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Principles for School-Age Language Intervention: Insights from a Randomized
Controlled Trial
Article in ASHA Leader · January 2010
DOI: 10.1044/leader.FTR1.15012010.10
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American Speech-Language-Hearing Association
January 19, 2010 Issue : Feature
Principles for School-Age Language
Intervention: Insights from a
Randomized Controlled Trial
see also: References
cite as: Gillam, R. & Frome Loeb, D. (2010, January 19). Principles for School-Age Language Intervention: Insights
from a Randomized Controlled Trial. The ASHA Leader.
by Ronald Gillam & Diane Frome Loeb
During the 1990s, Michael Merzenich and Paula Tallal worked together to create a computerized language
intervention program called Fast ForWord-LanguageTM (FFW-L, Scientific Learning Corporation, 1998).
The design of the FFW-L program was based on scientific discoveries about auditory processing disorders
(e.g., Tallal & Piercy, 1974) and training protocols that had resulted in neural changes in nonhuman primates
(e.g., Jenkins, Merzenich, Ochs, Allard, & Guic-Robles, 1990; Recanzone, Merzenich, & Jenkins, 1992).
Merzenich and colleagues (2002) have suggested that these strategies should be used in intervention with
humans because they have been proven to drive brain remodeling in animals, and neuroplasticity-based
training principles are being applied in many areas of speech and language rehabilitation (e.g., Ludlow et al.,
2009). The neuroplasticity-based training principles underlying FFW-L (Byl, Merzenich, & Jenkins, 1996;
Fitch & Tallal, 2003) are summarized in Table 1 [PDF]. Whether or not the neuroplasticity-based training
principles of FFW-L are necessary components of language intervention can now be assessed in light of new
evidence from a randomized controlled trial.
Randomized Controlled Trial
We conducted a large-scale randomized controlled trial (RCT) that compared the language outcomes of
FFW-L to another computer-assisted instruction intervention, clinician-directed language intervention, and a
non-intervention condition that focused on academic enrichment (Gillam et al., 2008; Loeb et al., 2009). The
study was designed to answer a theoretically driven question: Does an intervention that employs auditorytemporal training with neuroplasticity-based procedures result in unusual improvement on measures of
auditory processing, language, and literacy skills in children with specific language impairments?
The RCT included 216 school-age children with language impairments from nine school districts in Texas
and Kansas. The participants were randomly assigned to one of four conditions.
FFW-L consisted of seven computer games that target auditory discrimination, memory for speech, and
grammatical comprehension. The activities in the FFW-L games followed the behavioral principles of
discrete trials teaching (Brown-Chidsey & Steege, 2004). A signal to attend was followed by a
discriminative stimulus that prompted a mouse-click response. Correct responses were rewarded by points,
jingles, and extra animations on the computer screen. The auditory stimuli in FFW-L were modified in ways
that prolonged segments and differentially amplified particular frequencies (Nagarian et al., 1998). The
extent of the auditory modifications and the difficulty of the stimulus items were constantly adapted in
response to the children's response accuracy.
The other three conditions were similar to FFW-L in that they were delivered on an intense daily schedule
and children were required to attend carefully to the instructional activities, received feedback about the
correctness of their responses, and received rewards for successful responses and participation. The three
conditions also differed from FFW-L in several ways (see Table 2 [PDF]).
Individual language intervention (ILI) compared FFW-L to a functional communication approach.
Clinicians provided one-to-one language intervention in a quiet room. The ILI activities were not repetitive.
Instead, ILI intervention promoted multiple opportunities for therapeutic discourse (e.g., growth-relevant
recasts, focused stimulation, scaffolding) during conversations about children's literature (Gillam &
Ukrainetz, 2005; Hoggan & Strong, 1994; Loeb, 2003). Clinicians did not tally each correct response; they
tracked children's progress by rating the level of clinician effort and the level of child responsiveness for
each activity.
Computer-assisted language intervention (CALI) assessed the importance of modified speech. Like the
FFW-L exercises, the CALI modules targeted auditory discrimination, memory for speech, and grammatical
comprehension. The CALI games followed a discrete trials presentation pattern similar to the one used in the
FFW-L games; none of the CALI modules, however, contained modified speech.
Academic Enrichment (AE) was designed to be an attention control. Children played academically
oriented computer games that focused on reasoning, mathematics, social studies, and science but were not
designed to teach language skills to children with language impairments.
Study Outcomes
The participants were tested before treatment, immediately after treatment ended, and three and six months
post-treatment. Children received a battery of auditory processing, language, and literacy
measures that included a backward masking task (Marler, Champlin, & Gillam, 2001), the Comprehensive
Assessment of Spoken Language (CASL; Carrow-Woolfolk, 1999), the Test of Narrative Language (TNL;
Gillam & Pearson, 2004), the Comprehensive Test of Phonological Processing (CTOPP; Wagner, Torgesen,
& Rashotte, 1999), and the Woodcock Reading Mastery Test-Revised (WRMT-R; Woodcock, 1987).
We hypothesized that FFW-L and/or CALI would promote auditory processing and phono-logical
awareness, and that ILI would enhance abulary, grammar, and narration skills. We expected minimal change
in the children in the AE group.
The results were surprising. Children in all four groups improved significantly on auditory processing,
language, and phonological awareness measures immediately after treatment, and continued to improve for
the next six months. Over the course of the study, the CASL scores of more than 70% of the children in each
group either moved into the normal range or improved beyond the 95% confidence interval of their pretest
scores (Gillam et al., 2008). Across all analyses, results suggest that very different kinds of languagelearning experiences can offer a wide range of auditory processing, language, and phonological awareness
benefits to children with specific language impairments.
Core Components
The researchers who created FFW-L argued that interventions incorporating neuroplasticity-based training
principles (Table 1 [PDF]) cause brain changes that result in unusual gains on measures of auditory
processing, language, and literacy (Byl, Merzenich, & Jenkins, 1996; Fitch & Tallal, 2003; Merzenich et al.,
1996). The results of our RCT suggest that not all eight principles of neuroplasticity training are necessary.
The intervention in all four conditions was provided on an intense daily schedule, promoted active attention,
provided immediate feedback, and rewarded effort and success. Even though we did not collect direct
measures of the children's neurophysiological changes, it is realistic to assume that changes in behavior are
tied to neurophysiological changes (Tallal & Gaab, 2006). It is possible that one or a combination of these
principles led to the kinds of brain changes that influence improvement of the children's language skills.
The four treatment conditions did not share the principles of repetitive stimuli, item-by-item tracking of
correct responses, adapting the difficulty of the stimuli, or modified speech. Therefore, these components of
intervention do not appear to be necessary parts of language intervention programs that result in significant
changes in auditory processing and language. Highly repetitive teaching, tracking the correctness of every
response, systematic adaptation of difficulty levels of activities, or auditory modification of stimuli may
influence language learning; however, they do not appear to be necessary components of successful
language intervention programs. Four components of language intervention were associated with successful
auditory processing and language outcomes for children across the four conditions in our study: intensity,
active attention, feedback, and rewards.
Intensity
All the RCT conditions were delivered on the same intense schedule: 100 minutes per day, five days per
week for six weeks. To gain a general sense of the importance of the intensity component, we compared the
pre-test and post-test CASL standard scores from the children in our study to pre-test and post-test standard
scores on the Test of Language Development Primary (3rd edition) from a large group (n=156) of same-age
children (Tomblin, personal communication) who had participated in a longitudinal epidemiological study in
Iowa (Tomblin et al., 1997; Tomblin et al., 2003). On average, children in the Iowa study received speech
and/or language intervention in public school settings twice each week for 20-minute sessions for two years
(an approximate total of 48 hours). The children in our study received 1 hour and 40 minutes of intervention
five days per week for six weeks (a total of 50 hours) followed by some intervention in school settings (12
hours on average).
Figure 1 [PDF] depicts the outcome comparisons. The improvement made by the children in our RCT over
six months was approximately five times greater than the improvement made by children from the Iowa
epidemiological study in two years. These comparisons suggest that intense intervention schedules may be
more beneficial than less intense intervention schedules.
A recent survey by Brandel (2009) found that most school-age children with language impairments receive
intervention twice a week for 20-minute sessions, regardless of severity or diagnosis. Only a small number
of SLPs use block scheduling, which allows for more intensive intervention. Given the importance of
intensive treatment, school clinicians may want to explore options for block scheduling in their districts.
Alternative solutions such as providing language intervention before or after school and in summer school
programs offer clinicians other means for providing intensive remediation.
Active Attention
Children learn more when their attention is directed at the learning experiences that are being presented
(Erickson, 2008). LaBerge's (1995) model of attention involves preparatory, selective, and maintenance
processes. FFW-L promoted all three kinds of attention. Children received an attention signal before every
item to make sure that they were looking at the screen and ready to listen (preparatory attention). They were
then rewarded for making accurate perceptual judgments (selective attention) and for completing a number
of items in a specified period of time (maintenance of attention).
The other three conditions promoted primarily selective attention and maintenance of attention. The ILI
clinicians and aides who were monitoring the CALI and AE conditions encouraged children to return to
tasks if they stopped responding or began talking about topics that were not related to the immediate
activities. Results suggest that procedures that focus on children's attention by delivering a pre-attentive
signal and/or that promote selective attention and maintenance of attention more generally have the potential
to yield similar beneficial effects.
Feedback
In all of the trial conditions, children received some form of feedback as to whether their responses were
correct. In FFW-L, CALI, and AE, the feedback for correct answers was musical or visual rewards. The
feedback for incorrect responses was either a mildly noxious sound (such as the "clunk" in the FFW-L circus
sequence game) or an indication that the response was wrong followed by an opportunity to repeat the trial.
The feedback from the ILI clinicians was less systematic. Sometimes clinicians told children if their answers
were right or wrong and explained why (e.g., "That's right. You remembered to name the boy in your
story."). Often clinicians provided indirect feedback that took the form of expansions or recasts (e.g., Child:
"Him's going over there." Clinician: "Yes, he is going over there."). Although the type of feedback differed,
children in each condition received information about the correctness of their responses.
Rewards
Most models of learning recognize the importance of internal motivation and the benefits of rewards for
appropriate behavior. In the computer conditions, the children received animated reinforcement designed to
keep them interested and motivated. In the ILI condition, the SLPs smiled at the children when they
responded correctly and told them they were doing well. All of the children received tangible rewards as
well. We kept charts for each child with daily stickers and prizes at the end of the week. In all four
conditions, there were rewards for attending and responding correctly to questions or directions and for
maintaining acceptable behavior during the course of an entire session.
Research to Practice
Merzenich and colleagues (2002) have shown that teaching that employs a set of neuroplasticity-based
training strategies drives brain remodeling in animals. It has been suggested that these behaviorally based,
discrete-trial training procedures are necessary to bring about brain-based changes that lead to language
development in children with language impairments.
The results of our randomized controlled trial suggest otherwise. In our study, four different languageteaching conditions yielded similar gains in auditory processing and language skills. Four aspects of
neuroplasticity-based intervention (highly repetitive stimuli, tracking correct responses, adapting difficulty
levels, and use of modified speech stimuli) were part of one or two conditions—but not all four—and appear
to be unnecessary elements of successful language intervention.
Four other aspects of intervention (a daily intense schedule, promoting active attention, providing immediate
feedback, and rewarding effort and success) were part of each study intervention condition. Although more
research needs to be done to identity the critical attributes of successful language intervention, it appears that
there are sound theoretical and practical reasons for clinicians to consider incorporating aspects of intensity,
attention, feedback, and rewards in their intervention programs.
We question the assumption that it is best to base intervention procedures for children on teaching principles
that have been shown to result in neurological change in rats and monkeys. As Gillam (1999) noted earlier,
there are real differences in the kinds of mental functions that children and monkeys perform. Intervention
procedures should take advantage of children's capacity for symbolic representation, grammar, and
reasoning through language. It makes sense to engage children in language-learning experiences that are
matched to their interests, typical activities, linguistic and conceptual functioning, and informationprocessing abilities.
Our results suggest that neural reorganization that promotes language development can result from a variety
of interventions in which highly motivated children have multiple opportunities to respond to challenging
and accomplishable tasks within intensive programs.
Ronald Gillam, PhD, CCC-SLP, holds the Raymond L. and Eloise H. Lillywhite Endowed Chair in
Speech-Language Pathology in the Department of Communicative Disorders and Deaf Education at Utah
State University. His research focuses on information processing, language assessment, and language
intervention for school-age children. Contact him at ron.gillam@usu.edu.
Diane Frome Loeb, PhD, CCC-SLP, is an associate professor in the Department of Speech-Language-
Hearing: Sciences and Disorders and the Intercampus Program of Communicative Disorders at the
University of Kansas. Her research interests include language development and disorders, intervention
methods and efficacy, sociolinguistic issues, and intervention with indigenous children. Contact her at
dianelo@ku.edu.
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