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Enhancing Children's Communication Through Parent-

implemented Language Therapy
a
Silvia Romero-Contreras
a
Universidad Autnoma de San Luis Potos, Mxico
Published online: 17 Jul 2015.

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To cite this article: Silvia Romero-Contreras (2015) Enhancing Children's Communication Through Parent-implemented Language
Therapy, Childhood Education, 91:4, 274-282, DOI: 10.1080/00094056.2015.1069157

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Enhancing Childrens
Communication Through

photo: izuboky/Shutterstock
Parent-implemented
Language Therapy
Speech and language delays disproportionately affect children living in poverty or
growing up in conflict- or violence-affected contexts. These situations undermine
childrens efforts to form close parental and caregiver attachments, which are
crucial to typical development of language. When children are identified as
language delayed, parents and caregivers may find that confusion, stigma,
frustration, or inexperience can prevent the parent-child interactions that so
effectively promote language development. In this article, the authors sought
to improve learning outcomes for language-delayed children through parent-
implemented therapy. Parents who were instructed in language therapies felt
empowered and confident to continue employing the strategies they learned with
their children at home.

By Silvia Romero-Contreras
Universidad Autnoma de San Luis Potos, Mxico

274 \ Childhood Education

 I
n Western cultures, adults often
consider children as conversational
partners from a very early age.
Most adults, when interacting with
infants and toddlers, pause after
each utterance to allow time for
a response even before the child
is able to engage in true conversation (Pan
& Snow, 1999). Face-to-face conversation is
the first kind of extended discourse children
experience. As children become better
conversational partners, they also progress
in their development of the phonological,
morpho-syntactic, and semantic sub systems
(Pan & Snow, 1999). Children use their
everyday experiences to build up their
knowledge about the world and about
language through the construction of event
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representations. These event representations
include rules about their own behavior
and the behavior of others; since events are
goal oriented, the participants intention is
a key organizing principle for the child in
constructing this knowledge (Nelson, 1986).
Bruner (1983) provides evidence about
how mothers interact in rule-governed
interactions with their children as young
as three months of age. Exposure to
these interactions facilitates language
development through various scaffolding
photo: izuboky/Shutterstock
mechanisms. Maternal input, according
to Bruner, is finely tuned to the childs
communicative abilities and is elaborated
based on the childs response, a process of
reciprocal negotiation, and maternal cultural
expectations regarding child development.
Bruner calls this complex mechanism the
language acquisition support system (LASS).
Children with a language delay or disorder
may fail to provide the responses expected
by their mothers or primary caretakers,
causing the LASS to be disrupted and
reducing childrens opportunities to develop
language at their full potential.
The Training Program in Communicative
Interaction (EIC, Entrenamiento en
Interaccin Comunicativa, Romero, 2008)
empowers parents as co-therapists to
support their childrens cognitive and
linguistic development through strategies
of communicative mediation that restore
the LASS. With the support of a consultant,
participating families stimulate their
childrens language development by
applying therapeutic play strategies
at home. During the program, they also
keep a journal, respond to inventories, and
videotape therapeutic play sessions with
their child at least once a month.
To date, the author and her colleagues
have worked with over 80 families from
various Mexican states. The families have
succeeded in enhancing their childrens
communicative, cognitive, and language
skills. Some of these cases have been
documented and previously reported
(Romero, 2008; Romero-Contreras & Gmez,
2013). In this article, the results obtained
with a group of nine families (children ages
2 years, 2 months to 6 years, 7 months)
are presented. Seven of the children were
diagnosed with Down syndrome (DS), one
with agenesis of the corpus callosum (ACC),
and one with West syndrome (WS).
Parent-implemented
Language Therapy
When a child has a disability or
developmental delay, parents modify their
expectations and forms of interaction,
which distorts the communication flow and
thus the language development process
(Johnson-Glenberg & Chapman, 2004). These
changes in stimulation occur as parents
experience reduction in or lack of a childs
responsiveness to parents attempts to
interpret his utterances, leading to a feeling
of powerlessness and alienation and/or
communicative distortion.
Parent intervention in language therapy
using a naturalistic approach has been
found to be a powerful way to improve the
language development of children with
primary and secondary language disorders.
In interventions using this approach, a spe-
cialist advises parents on the use of com-
municative strategies to promote language
development during everyday interactions
(Grcia, 1999; Grcia & Del Rio, 2000). A
meta analysis conducted on 18 research re-
ports, involving children with and without
Author Note: The author wants to acknowledge the
collaboration of the following undergraduate and graduate
students in this work: Alma Viridiana Hermosillo-Mendoza,
Gloria Elena Gmez-Martnez, Jorge Omar Martnez-Jimnez,
Luca Aguilar-Orozco, Elizabeth Rocha-Zavala, and Andrea
Sard-Aguilar.
July/August 2015 / 275

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intellectual disability ages 18-60 months,
showed that parent-implemented interven-
tion was more effective than interventions
in all language measures and more effective
than therapist-implemented intervention in
receptive language and expressive syntax
(Roberts & Kaiser, 2011). Providing parents
guidelines for conducting rich and engaging
interactions with their children, following a
model called EMT (enhanced milieu teach-
ing), showed positive effects in language-
impaired children when compared to a non-
treatment group; parents in the treatment
group improved their communicative skills
when compared to parents of both language-
impaired and typically developing children
(Roberts & Kaiser, 2012).
Psycholinguistics demonstrates that
children acquire language through
communication and that language cannot
be taught. Language must be promoted
through a supportive communicative
environment that allows for the childs
active participation (Ygual & Cervera, 1999).
By empowering parents to stimulate their
childrens language development, they
will learn to take advantage of everyday
situations and employ strategies that
promote interaction habits that help develop
communicative competence (Ygual &
Cervera, 1999).
Parent-child interactions vary, depending
on the tasks they perform together. For
example, differences in the behavior of
276 \ Childhood Education
photo courtesy of author
adults and children have been identified
when assembling puzzles, reading a story,
or during free play (Adamson, Bakeman,
Deckner, & Romski, 2009; De Falco, Esposito,
Venuti, & Bornstein, 2008), depending
on how familiar they are with the task
(Goodsitt, Raitan, & Perlmutter, 1988) and
on the task complexity (McNaughton &
Leyland, 1990; Rogoff, Ellis, & Gardner,
1984). In advising parents, it is important
to help them recognize these changes and
develop appropriate strategies.
Adults should take into consideration the
current and potential levels of language and
communicative competence of the child.
This means negotiating and providing
enough support to make further progress in
the childs development. The main objective
of the adult should be guiding the child so
that he or she can ultimately understand
and use decontextualized language (Hupp,
Munala, Kaffenberger, & Wessell, 2011).
Stimulation must be conducted at the childs
current communicative level or slightly
above to promote development.
In interactions with children experiencing
language delays, such as children with
Down syndrome, adults tend to adopt a
directive style (i.e., to control the childs
behavior) (Grcia & Del Rio, 2000). This
directivity may be a response to the childs
passivity in interactions or an outcome of
a parents desire to provide instruction.
Some studies show that the more structured,
 difficult, and novel the task is for the child,
the more likely it is for the adult to adopt a
directive style (Gonzlez, 1996).
One goal in working with parents of
children with language delays or disorders
should be to promote child initiation of
pragmatically appropriate interactions
(Grcia & Del Rio, 2000). Thus, it is
necessary to transform the expectation that
parents value the communicative relevance
of their childrens interactions more than the
clarity of their speech.
Method
Participants
The present study reports results of
implementing the EIC program with
nine families. At the beginning of the
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strategies they learned with their children
and with their advisors support. Families
practice the strategies with their children
at home for 20 minutes a day, five days a
week, videotaping at mid-month in order
to receive feedback. They also keep a diary
and fill out a parent report on the childs
language, typically using the MacArthur
Inventory of Communicative Abilities
(Jackson-Maldonado, Bates, & Thal, 1992a,
1992b). Parents are trained in three main
areas: quality of the interaction (QA), co-
construction of play-routines (PR), and
communicative strategies (CS).
Quality of Interaction. Based on
MacDonald and Carrolls (1992) ecological
model for adult-child interactions, parents
are trained to promote a balanced, matched,

intervention, the target children were responsive, non-directive, and emotionally

between 2 years, 2 months and 6 years, 7
months; eight were boys and one was a
girl. All children but two had a diagnosis of
Down syndrome, one boy (age 2;3) had West
syndrome, and another boy (age 2;7) had
agenesis of the corpus callosum. All families
enjoyed middle-level or mid-high level
socioeconomic status.
Procedure
The EIC program consists of eight monthly
eight-hour sessions. In the first part of
each session, parents attend a workshop
to learn about the strategies that will be
implemented during the following month.
In the second part, families practice the
attached interaction with their children.
Co-construction of Play Routines. Parents
are trained to understand the differences
between adult and child play perspectives
(Bruner, 1984; Garvey, 1981) and the stages
of child play (Westby, 1980), to take a
child-oriented perspective when playing
with their children, to promote the co-
construction of appropriate play routines
when interacting with their children, and to
elaborate on play routines once they have
been established in the interaction.
Communicative Strategies. After an
overview of the milestones and stages of
language development (Romero-Contreras,
1999), parents are introduced to a series

Mean and Standard Deviation (SD) of Play Session Indicators

Baseline Mid-program End-of-program
Indicators (n = 12) (n = 12) (n = 12)
7.83 8.92 11.00
INT
(1.64) (1.88) (1.28)
9,33 13.17 12.00
PLAY
(4.19) (1.85) (3.46)
7.08 8.33 8.42
COM-Q
(2.20) (1.07) (1.00)
8.58 9.67 12.09
COM-N
(6.00) (3.85) (4.81)

INT = quality of interaction, PLAY = play co-construction, COM-Q = quality of communicative strategies, COM-N =
quantity of communicative strategies
Table 1

July/August 2015 / 277

 of communicative strategies divided into
three groups to promote communicative
interaction, world knowledge, and code
knowledge. These strategies were developed
based on studies on motherese, child-
directed speech, and whole language
therapy (Bruner, 1983; Norris, 1996; Romero,
1996; Romero-Contreras, 1994, 1999). All
these strategies and resources are explained,
demonstrated, and rehearsed with parents,
who also learn to analyze their progress
based on specific criteria, observation
checklists, and rubrics. The program
encourages families to work together in
small groups (two or three families with
children at similar developmental stages)
to review the materials, watch and analyze
their videos, and support their learning
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through constructive feedback. The advisor
keeps in touch with parents through e-mail
to offer feedback and answer questions
between sessions. Enrollment in the program
requires the commitment of at least one
parent throughout the program.
Data Collection and Coding
Parents were separately videotaped playing
with their children (mother-child; father-
child) at the beginning of the program
(Session 1) to collect the baseline data.
Two more videotaped play sessions were
analyzed and compared to the baseline;
these videotapes were drawn from those
sent every month to the advisor to monitor
the familys progress, one from a mid-
Figure 1
278 \ Childhood Education
program session and one from one of
the last two sessions. The selection of the
comparison play sessions was made based
on availability, as not all parents were able to
conduct the play sessions every month, due
to child sickness or other constraints, and
the material quality (sound and image) of
the video was not always adequate.
Four measures were calculated for each
play session: quality of interaction, play
co-construction, quality of communicative
strategies, and quantity of communicative
strategies.
Quality of interaction was measured on a
three-point scale (1 = poor, 2 = fair, 3 = good)
for four criteria: balance, match-responsive-
ness, low-directiveness, and emotional at-
tachment. The maximum possible score for
this indicator is 12 points.
Play co-construction was measured
considering the level of adjustment of the
adult to the childs abilities regarding:
the overall play stage, the use of objects
(real, similar, or pretend), the number and
sequence of actions involved, the ability
to negotiate the goal of the game (from
no negotiation to active involvement in
planning a game), and the type of event
represented in the play (everyday, rare,
imaginary). For each of these five criteria,
the rater had to identify the level at which
the child was able to participate and the
level at which the adult was interacting
and compare them to establish whether the
adult was at the childs zone of proximal
 development (3 = good), close (2 = fair), or
far away (1 = poor). The maximum possible
score for this indicator is 15 points.
Quality of communicative strategies was
measured considering the adults level of
adjustment to the childs communicative,
world knowledge, and linguistic abilities. To
establish the level of adjustment, the childs
abilities in each criterion were classified in
one of five stages and compared to the adult
input to establish whether the adult was at
the childs zone of proximal development
(3 = good), close (2 = fair), or far away (1 =
poor). The maximum possible score for this
indicator is 15 points.
Quantity of communicative strategies
was measured counting the variety of
communicative strategies used by the adult
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Two independent raters analyzed all
videotapes and discussed discrepancies until
an agreement was reached. Additionally,
childrens language development was
measured using the number of words
reported as comprehended and the words
reported as produced in the MacArthur
Inventory of Communicative Abilities
(versions I and II). Parents filled out the
inventories at the onset of the program
and every month thereafter. Inventories
corresponding to the same month of the play
sessions selected were used for the analysis.
Results
In all nine families, at least one parent
became actively involved in the program. In
three families (Allan, Mark, and Roger [all

to promote the childs interaction (such as
eye contact, interpreting childs actions,
joint attention), world knowledge (such as
use of visual supports, making comments
or descriptions about present objects), and
linguistic abilities (such as parallel talk,
recasting, expansions, modeling). Twenty-six
strategies were taught to the parents (eight
for interaction, four for world knowledge,
and 14 for linguistic abilities).
childrens names are pseudonyms]), both the
mother and the father actively participated
and sent in their monthly videos, so six
videos for each of these families were
analyzed. For the remaining six families,
only three videos per family were analyzed.
A total of 36 play sessions (12 baseline, 12
mid-program, and 12 end-of-program) were
analyzed. In all families but one, the mother
became actively involved. Table 1 shows

Correlations Between Play Session Indicators and Childrens Language Measures

Play Session Language Measures
Indicators Comprehension Production
Rho Spearman .716 **
.531*
INT Sig. (bilateral) .002 .011
N 16 22
Rho Spearman .614 *
.507*
PLAY Sig. (bilateral) .011 .016
N 16 22
Rho Spearman .619* .476*
COM-Q Sig. (bilateral) .011 .025
N 16 22
Rho Spearman .380 .628**
COM-N Sig. (bilateral) .147 .002
N 16 22
INT = quality of interaction, PLAY = play co-construction, COM-Q = quality of communicative strategies,
COM-N = quantity of communicative strategies

Table 2

July/August 2015 / 279

 the mean and standard deviation of parent
measures for each of the three moments.
All indicators show some increase
between the baseline and the data collected
during the program. The shaded areas on
Table 1 show where these differences were
significant: between baseline and end-
of-program for quality of interaction and
between baseline and mid-program for play
co-construction. These differences were
calculated using non-parametric statistics
(Mann-Whitney U), as the sample is too
small (INT B-E. U = 35.5, p = .031; PLAY
B-M. U = 11.0, p < .001).
Child language measures (reported words
comprehended and produced at the begin-
ning, at the middle, and at the end of the
program) are presented in Figure 1. Some
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children made little or no progress on either
measure (Allan and Mark); others showed
progress only in comprehension and very
little progress in production (Simon and
Ivan); three children made progress both in
comprehension and production (Emma, Jake,
and Joe); and comprehension was not mea-
sured for two children (Roger and Danny)
who started at high levels of production
(parents were given the second version of the
MacArthur inventory, which only asks for
words produced). For two children (Simon
and Danny), two measures are missing, as
their parents did not fill out the Inventories.
The results obtained for the play sessions
280 \ Childhood Education
were correlated with the words reported as
comprehended and the words reported as
produced on the inventories for the same
month. No significant correlations were
found when the whole sample was entered
into the analysis. Further exploration of the
data revealed two discrepant cases (Allan
and Mark). Although their parents were
very committed to the program and made
great progress in all areas measured, the
childrens linguistic development showed
very little or no progress.
Once these cases were removed from the
analysis, significant correlations emerged
between play session indicators and
language measures (see Table 2). The highest
correlations were found between quality of
interaction and comprehension and quantity
of communicative strategies and production.
Quantity of communicative strategies
was the only play indicator showing no
correlation with comprehension.
Conclusion
Providing parents of children with
language disorders effective tools to adjust
their language input to their childrens
communicative development offers them the
opportunity to understand the mechanisms
of communication, to become part of the
re-habilitation process, and to ensure its
continuity. Most children with language
disorders undergo long periods of therapy in
photo courtesy of author
 which parents are only marginally involved.
Parent-implemented therapy presents both
benefits and challenges. Parental learning
and empowerment, increased periods of
effective stimulation, and improvement of
parent-child communicative interactions are
among the most important benefits. All of
these also contribute to increasing quality of
early childhood services.
Adjusting the program demands
to account for parents daily life
responsibilities, their expectations, and their
personal and professional backgrounds
can be challenging. While the participating
families in this study were all very
committed to their childrens well-being
and development, many found the program
to be overly demanding in terms of the
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activities they were asked to conduct and
the emotional investment they experienced.
Nevertheless, they were able to overcome
these constraints and remained involved
throughout the whole program.
The results obtained with this group
show that parents can learn to control their
communicative and linguistic input and
provide a more adequate stimulation for
their children with language delays. Some
parents commented that they used the
strategies learned with their other children
and they were teaching the strategies to
their older children and to other relatives
or professionals (teachers, occupational
therapists) who spend significant time
with the child. This suggests that as
parents become involved in childrens
treatment, both the quality of services and
the outcomes are enhanced; parents not
only become more effective in promoting
childrens communicative development,
but also increase childrens opportunities
to receive adequate stimulation in their
interactions with others.
The correlations found between the
play session indicators and the childrens
language measures suggest that the program
has a positive effect on childrens outcomes;
this, however, cannot be categorically
asserted due to the design of the study,
which includes limited cases and no control
group. The two children who showed a
discrepant pattern compared to the rest of
the group indicate that the program needs
to be revised and adapted to the needs of
low-performing individuals. One possible
modification could be to increase the length
of the program, as these children were
among the youngest and also the most
affected by their condition. These results
shed new light on ways to improve early
childhood intervention programs. The
fact that the parents did improve their
communicative abilities is encouraging, as
they will continue stimulating their children
and communicating with them.
All parents in this group were motivated
to continue using the strategies learned
during the program and agreed to continue
group meetings to support their learning.
Working with parents offers professionals
a new and broader perspective on the
relevance of communication for establishing
meaningful and powerful relationships.
In this program, the families and their
communicative encounters are at the center
of the process. Witnessing their growth
and improved mutual understanding is a
gratifying experience.
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