Parents as Interveners: Does it really work?

By Lauren Lowry
Hanen Staff Member and Clinical Writer

This article is taken from Wig Wag, a member-only newsletter for Hanen Certified professionals. For more information on Hanen Programs and becoming Hanen Certified, visit www.hanen.org/membership.

Many speech-language pathologists have questions about training parents to become their child;s primary language facilitator. They ask whether:

• parents are really as effective at intervening with their child as clinicians are?
• parents can have an impact on all aspects of their child’s language (including receptive language and syntax?)
• all children with language impairments benefit from parent-implemented intervention (including children with developmental delay, autism and Specific Language Impairment (SLI)?)

Megan Roberts and Ann Kaiser of Vanderbilt University undertook a “meta-analysis”, in which the results of several small studies that have examined parent-implemented intervention were combined. The purpose was to evaluate the effects of these interventions and answer the questions listed above.

How Parents Influence their Child’s Language in Typical Development

“The Effectiveness of Parent-Implemented Language Interventions: A Meta-Analysis” (Roberts & Kaiser, 2011) begins with a discussion about the relationship between parent-child interaction and child language development. The authors cite research which shows that parents affect their child’s language development in the following ways:

• greater amounts of parent-child interaction result in larger child vocabularies
• maternal responsiveness affects the timing of expressive language milestones
• the quantity of child-directed speech is linked to the size of a child’s vocabulary
• the quality of input (e.g., diversity of words, syntactic complexity) affects the size of a child’s vocabulary
• parents’ use of supportive language learning strategies predicts a child’s verbal skills (e.g., highlighting the relationship between objects and actions, expanding and recasting the child’s utterances)

What Studies Show about Parents of Children with Language Impairments

Just as maternal responsiveness affects children with typical language development, so it affects expressive and receptive language development in children with language impairments and developmental disabilities. However, Roberts and Kaiser (2011) report that studies show some differences in the ways parents interact with their child when the child has a language impairment.

Compared to parents of typically developing children:

• parents of infants with communication difficulties spend half as much time interacting with their infants
• parents of children with SLI engage in less conversation with their children
• mothers of children with language impairments tend to be less responsive and label items less frequently
• parents of children with language impairments use fewer language support strategies (such as recasts and expansions)

These findings speak to the “bi-directional influences of children on parents and parents on children” (Roberts & Kaiser, 2011, p. 181). Not only do parents have an effect on their child’s language development, but a child’s communication capacity appears to influence the input he receives from his parent.

Why Conduct a “Meta-Analysis” on the effects of parent-implemented interventions?

Several single-subject studies have shown that parents are able to learn language intervention strategies, and that this improves their child’s language skills. However, there have been few reviews of studies using group designs, and two reviews mentioned by the authors looked at parent-implemented intervention for specific groups of children ― children with language impairment without intellectual disability (ID) and children with autism, respectively (Law, Garrett, & Nye, 2004; McConachie & Diggle, 2007).

Roberts and Kaiser identified the need for a meta-analysis of studies that “includes all children with language impairment, including children with ID, autism spectrum disorders and children with primary language impairment” (p.183). Ultimately, the authors undertook this review since it allowed for, "...comparative analyses of the effects of parent-implemented language intervention on subgroups as well as identification of common outcomes of parent-implemented language intervention across children with different types of language impairments." (p.183)

The Meta-Analysis

Roberts and Kaiser included 18 studies in their meta-analysis. These studies:

• utilized a group design with control group (controls were either “non-treatment”, “therapist-delivered intervention", or “business as usual” community services)
• included young children, averaging between 24-36 months (age range: 15-77 months)
• looked at relatively short interventions, most of which were between 10-13 weeks and offered less than 26 total hours of parent training
• taught strategies such as responding to child communication, balancing adult-child turns, using language models

The “Hanen Parent Program” (now known as It Takes Two to Talk®) was the most frequently studied intervention, comprising 8 out of the 18 of the studies in the meta-analysis. Roberts and Kaiser’s review included measures of seven language constructs:

• overall language
• expressive language
• receptive language
• expressive vocabulary
• receptive vocabulary
• expressive morpho-syntax
• rate of communication

The Results

Kaiser and Roberts organized their results around six key questions:

1. Do parent-implemented interventions positively affect child language outcomes?
Yes. “Parent-implemented intervention had positive, significant effects on [children’s] receptive and expressive language skills, receptive and expressive vocabulary, expressive morpho-syntax, and rate of communication when compared to a control group” (p.192).

2. Is intervention more effective when delivered by a parent?
Yes, for some language constructs. While there was no significant difference between intervention delivered by parents or therapists for the most part, parents were more effective when targeting receptive language and expressive syntax.

3. Which child language outcomes have the largest effects?
Expressive morpho-syntax had the largest effect size, although no single language construct was significantly larger than another.

4. Do the effects of parent-implemented interventions differ for children with and without intellectual disabilities?
No, except for expressive vocabulary (there was a larger effect size for expressive vocabulary for children without ID). For the majority of language constructs, though, there were no differences in outcome effects for these two groups of children.

5. Does the type of language measure impact the magnitude of the effects?
No. Roberts and Kaiser looked at whether measuring via parent report or observational measures influenced the effects, and no significant difference was found. This means that the effects of intervention were not just the “result of changes in parental perceptions of their children’s language skills, which might have been reflected in parent report measures” (p. 194).

6. Do parent-implemented interventions positively affect parent use of language intervention strategies?
Yes. “Parent training had a positive impact on parents’ responsiveness, use of language models, and their rate of communication” (p.194).

Are we on the right track?

Roberts and Kaiser’s meta-analysis validates The Hanen Centre’s commitment to offering group training in order to help parents learn to be their child’s primary language facilitator. Their analysis confirms that “parent-implemented language interventions are an effective early language intervention for young children with language impairments” (p. 197) and that the time required to provide this training is not excessive.

The majority of interventions in Roberts and Kaiser’s meta-analysis included fewer than 26 hours of parent training (ranging from 9 to 36 hours). This is the “equivalent to 1 hour of parent training per week for 6 months” which “.... is a relatively small amount of direct intervention... given the magnitude and consistency of the effects on child language outcomes”

Note that while the authors average out the training at one hour per week for six months, the sessions of most group training programs are two or more hours each, reducing the length of the intervention by half in many cases. This certainly makes a case for training groups of parents, versus seeing parents and children individually. All Hanen Programs for parents involve fewer than 26 hours of parent training sessions, ranging from 10 hours (for the Target Word Program™) to 20 hours (for It Takes Two to Talk and More Than Words® Programs), with sessions being 2 - 2.5 hours.

While there is additional time spent preparing and planning group sessions in Hanen Programs, this result still validates the time required to train parents. For example, if an SLP/T takes 110 hours in total to lead It Takes Two to Talk, that averages to just under 14 hours per child - far less than would be spent on individual therapy.

This meta-analysis provides strong validation for supporting parents as language facilitators. The field of speech-language pathology often lacks clear evidence for its treatments. However, this meta-analysis provides indisputable evidence that training groups of parents to facilitate their child’s language is effective for all groups of children with language impairment and for a variety of language outcomes. Clearly, parents know their child best and are the ones most motivated to help their child. As clinicians, our task is to advocate for parent-implemented early language intervention so that we can empower parents to help their own children.

References

1. Girolametto, L., Pearce., P., & Weitzman, E. (1996). Interactive focused stimulation for toddlers with expressive vocabulary delays. Journal of Speech and Hearing Research, 39, 1274-83.
2. Law, J., Garrett, Z., & Nye, C. (2004). The efficacy of treatment for children with developmental speech and language delay/disorder: A meta-analysis. Journal of Speech, Language, and Hearing Research, 47, 924–943.
3. McConachie, H., & Diggle, T. (2007). Parent implemented early intervention for young children with autism spectrum disorder: A systematic review. Journal of Evaluation in Clinical Practice, 13, 120–129.
4. Pepper, J., & Weitzman, E. (2004). It Takes Two to Talk: A Practical Guide for Parents of Children with Language Delays. Toronto: The Hanen Centre.
5. Roberts, M., & Kaiser, A. (2011). The Effectiveness of Parent-Implemented Language Intervention: A Meta-Analysis. American Journal of Speech-Language Pathology, 20, 180–199.

The Hanen Centre is a Canadian not-for-profit charitable organization with a global reach. Its mission is to provide parents, caregivers, early childhood educators and speech-language pathologists with the knowledge and training they need to help young children develop the best possible language, social and literacy skills. This includes children who have or are at risk for language delays, those with developmental challenges such as autism, and those who are developing typically.

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