Language Nutrition for Language Health How to talk to children with - PDF document

Language Nutrition for Language Health How to talk to children with autism and developmental disabilities Heidi M Feldman MD PhD Stanford University 19th Annual Developmental Disabilities: An Update for Health Professionals March 5, 2020 iversity Disclosure • I have no financial disclosures and no conflicts of interest

Inspiration Classroom observations Clinical visits with families Learning Objectives: By the conclusion of this talk, participants will be able to • Define the components of Language Nutrition • Discuss methods for assessing the language environment of children • Contrast language nutrition for children who are typically developing and children with autism • Evaluate the impact of language nutrition on language development in autism • Advise parents of children with autism about how to talk to their children

Take home messages Nutrition is important for physical development 1. Language nutrition is important for language development 2. Language nutrition is important for language development in 3. children with autism Language Health in the Information Age

Language in the first 5 years ~500 words in their productive Narrative skills vocabularies ~50 words in their productive Word combinations, increasing First vocabularies grammar complexity, questions and gestures Recognizes First Preliteracy skills negations name words Birth 1 year 3 years 4 years 2 years Adapted from the Asmussen et al., 2019 Variable rates of development: Cross ‐ sectional data 600 Size of 400 Productive Vocabulary 200 0 16 18 20 22 24 26 28 30 Child age in months n = 4867, English ‐ speaking Frank, Braginsky, Yurovsky, & Marchman, 2016

Variable rates: Longitudinal data Number of different words Child age in months n = 108, English ‐ speaking Pan, Rowe, Singer, Snow, 2005 Variability in language development Caregiver education Caregiver occupation Maternal depression Family income Activities in the home School environment district

Variability in language development Caregiver education Caregiver occupation Maternal depression Family income Activities in the home School environment district Language nutrition

13 13 Terminology Baby talk Language Infant ‐ directed speech Nutrition Child ‐ directed speech Input Hart and Risley (1995) Meaningful Differences • Longitudinal study • 42 carefully selected US families • Children 7 ‐ 9 months to 3 years • SES based on parental occupation (upper, middle, lower, welfare) • Methods: Obtained about 1 hours/day of input; transcribed 1300 samples • Findings • 86 ‐ 98% child words in parent vocabulary • Dramatic differences in child vocabulary • Dramatic differences in parent input • Extrapolations to 30 million word gap

15 What comprises a nutritious language environment? ? Language nutrition 16 16 Quant i t y Qual i t y I nt eract i on • Responsiveness • Number of different words • Total words • Expansions • Sentence complexity • Total gestures • Joint engagement • Wh ‐ questions • Intrusiveness • Talking about past and future • Directiveness

18 Language learning opportunities vary

19 Advances in assessing language environments Old school New school 20 Diurnal variation – Adult Word Counts 1200 Adult Word 800 Counts in 10 min (AWC) 400 0 8am 12pm 3pm 8pm

21 Diurnal variation – Conversational Turns 30 Conversational Turns 20 in 10 min (CTC) 10 0 8am 12pm 3pm 8pm Time Language nutrition: key predictor of 22 22 language outcomes ● Pre ‐ term ● English ● Hard of hearing ● French ● Down Syndrome ● Spanish ● Specific Language Impairment ● Yucatan Maya Language Child Nutrition language

Autism Variability in trajectories in ASD Typical Typical/Mild delay Marked delay n = 106 Pickles et al,. 2017

Scoping review Language nutrition as prevention Type Prevention Define Example Primary Asymptomatic individual Vaccination Prevention gets treatment and never gets the condition Secondary Individual at early stage Mammography prevention gets treatment and develops mild form of condition Tertiary Individual with condition Early intervention prevention gets treatment and has a better functional outcome

Child ‐ directed speech in ASD • https://drive.google.com/drive/u/1/my ‐ drive Critical questions about language nutrition Question 1: Compared to language nutrition of healthy and typically developing children, what is the language nutrition to children with autism (and intellectual disability/global developmental delay)? Question 2: What is the strength of the association between features of the language input and child language outcomes in children with autism? Question 3: To what extent can intervention change/improve language nutrition and thereby improve child language outcomes?

Questions regarding language nutrition in ASD Question 1: Compared to language nutrition of typically ‐ developing children, what is the language nutrition to children with ASD? Language Nutrition TD/LangMatch ASD 30 30 Quantity Adult Word Counts in no differences the Home Quality Number of no differences different words Wh-questions More questions Fewer questions Sentence complexity More complex Less complex Interaction Directiveness Less directive More directive Joint engagement no differences Novel word teaching no differences

Language Nutrition TD/LangMatch GDD/ID 31 31 Quantity Adult Word Counts no differences at Home Quality Descriptions no differences Encouragement Less encouraging More encouraging Interaction Directiveness Less directive More directive Joint engagement no differences Tertiary Prevention: ID and ASD Question 1: Compared to language nutrition of typically ‐ developing children, what is the language nutrition to children with ID and children with ASD? Question 2: What is the strength of the association between features of the language nutrition and child language outcomes?

Language nutrition and children’s language outcomes in FXS High Sustained Responsivity Average Responsivity Predicted rate of different Low Sustained Responsivity words n = 55, children with FXS Age (months) Brady et al., 2014 Language nutrition and children’s language outcomes in ASD Language nutrition Direction with child language Positive relations with Sentence complexity Positive child language outcomes are seen… Commenting on child’s attention Positive Expansions of child language Positive 6 months, 1 year, 3 Engagement Positive years, and even up to Redirecting child’s attention Negative 16 years later! Telegraphic speech Negative

Tertiary Prevention: ID and ASD Question 1: Compared to language nutrition of typically ‐ developing children, what is the language nutrition to children with ID and children with ASD ? Question 2: What is the strength of the association between features of the language nutrition and child language outcomes? Question 3: To what extent can intervention change/improve language nutrition and thereby improve child language outcomes? Language nutrition RCTs – Child Outcomes ID and ASD: Roberts & Kaiser, 2011 ASD: Nevill et al., 2018 0 112.5 225 -225 -112.5 -1 0 1 Vocabulary raw mean difference, 95% CI Hedge’s g mean difference, 95% CI

Why modest effect size? • Children are enrolled in other services. Language nutrition must make a contribution over the other interventions. • In many studies, the intervention is minimal Few sessions • Parent education without child present • Limited modelling and feedback • • Interventions target one component of language nutrition rather than all 3 components • Choice of outcome measures: autism symptoms versus language features, structured language rather than communication, lack of functional outcomes Future Directions for Research • Conduct RCTs to establish that intervention can change language nutrition and that those changes cause improve outcomes • Create interventions of language nutrition that include improvements in quantity and quality of language input and quality of verbal interactions • Evaluate appropriate outcome measures in speech, language, and communication; goal of secondary/tertiary prevention • Employ interventions that follow recommended practices for language nutrition

Ingredients for successful interventions Model language nutrition Caregivers and Children Together Explicit Personal Training Sustained over time Alternative approach to improving nutrition Individualized Assessment Reassessment Customized Feedback

Clinical recommendations for families • Be warm and responsive, have fun • Provide the child with many words and gestures. Repeat those words frequently. • Follow into the child’s focus of attention. • Use full sentences, appropriate grammar • Avoid simplified speech • Avoid directing and prompting • Model, using many words in grammatical sentences • Encourage child’s comprehension 42 42 Clinical recommendations for families over time Use lots of words Present with warmth and responsiveness Add gestures 0 1 2 3 4 5 Child Age in Years e.g,. Rowe, 2012; Rowe & Goldin ‐ Meadow, 2008

43 43 Clinical recommendations for families over time Use lots of words Use a wide variety of different words Use grammatical sentences Present with warmth and responsiveness Ask questions Add Talk about the past and future gestures 0 1 2 3 4 5 Child Age in Years e.g,. Rowe, 2012; Rowe & Goldin ‐ Meadow, 2008 Questions? Comments?

Thanks!