Using Signs to Facilitate Vocabulary in Children With Language Delays

Lederer, Susan Hendler PhD, CCC/SLP; Battaglia, Dana PhD, CCC/SLP

doi: 10.1097/IYC.0000000000000025
Original Research/Study
ISEI Article

The purpose of this article is to explore recommended practices in choosing and using key word signs (i.e., simple single-word gestures for communication) to facilitate first spoken words in hearing children with language delays. Developmental, theoretical, and empirical supports for this practice are discussed. Practical recommendations for choosing first word–sign pairs from both functional communication and developmental lexical perspectives are provided. A critical reflection of existing word–sign recommendations is undertaken to sharpen clinical decision-making skills. Implementation strategies from language and sign intervention literature are included with examples.

Department of Communication Sciences and Disorders, Adelphi University, Garden City, New York.

Correspondence: Dana Battaglia, PhD, CCC/SLP, Department of Communication Sciences and Disorders, Adelphi University, 1 South Ave., Garden City, NY 11530 (dbattaglia@adelphi.edu).

The authors declare no conflict of interest.

Article Outline

THE EFFICACY of using simultaneous signs and verbal language to facilitate early spoken words in hearing children with language delays has been documented in the literature (Baumann Leech & Cress, 2011; Dunst, Meter, & Hamby, 2011; Robertson, 2004; Wright, Kaiser, Reikowsky, & Roberts, 2013). In their systematic review, Dunst et al. (2011) concluded that using sign as an intervention to promote verbal language is promising, regardless of the population served (e.g., autism spectrum disorder, Down syndrome, developmental delays, physical disabilities) or the type of sign language used (e.g., American Sign Language [ASL], Signed English). Theoretical support comes from developmental research on the gesture–language continuum (Goodwyn, Acredolo, & Brown, 2000; McCune-Nicolich, 1981; McLaughlin, 1998), as well as language-learning theories such as the socially-based transactional model (Sameroff & Chandler, 1975; Yoder & Warren, 1993) and the cognitively-based information processing model (Ellis Weismer, 2000; Just & Carpenter, 1992). In this article, we review the developmental, theoretical, and empirical research that supports using sign language as an intervention in clinical populations. We further apply research to the tasks of choosing early word–sign targets and implementing word–sign intervention.

Guidance on signing with children is readily available for parents and practitioners in popular parenting books (e.g., Acredolo & Goodwyn, 2009), children's board books (e.g., Acredolo & Goodwyn, 2002), and easily accessed websites (e.g., https://www.babysigns.com/; https://www.babysignlanguage.com/), as well as practitioner websites (e.g., the Center for Early Literacy Learning [CELL], 2010a, 2010b, 2010c, 2010d) and professional magazines (e.g., Seal, 2010). Although these works report translating research to practice, it must be noted they are without peer review (Nelson, White, & Grewe, 2012). For this reason, additional reflection on this topic is warranted.

Regarding recommendations on selecting a sign system, the aforementioned practice guidelines are in general agreement. Seal (2010) proposes the use of formal sign language signs (e.g., ASL) but accepts child modifications on the basis of motor skill. The Center for Early Literacy Learning (2010a, 2010b, 2010c, 2010d) uses a combination of ASL, ASL-modified, and homemade “baby signs.” Acredolo and Goodwyn (2009), the originators of the Baby SignsR program, added an ASL-only program in response to families who wish to teach universally consistent signs. Although no standard definition exists (Moores, 1978), ASL is a form of gestural communication utilized by individuals with profound hearing impairment (Nicolosi, Harryman, & Kresheck, 1996). American Sign Language is a distinct and formal language with an established system of morphology and syntax, different from that of spoken English. In ASL, some signs are iconic (i.e., how easily the sign visually resembles the concept it is trying to convey; Meuris, Maes, DeMeyer, & Zink, 2014) and motorically easy to produce, whereas others are not.

“Baby signs” are defined as stand-alone gestures made by infants and toddlers to communicate (Acredolo & Goodwyn, 2009; Acredolo, Goodwyn, Horobin, & Emmons, 1999). Baby signs are motorically simple, often generated by the toddler or created by the parent, and most often represent either an object or an activity (e.g., panting to represent “dog,” pulling at lower lip to represent “brush teeth”). Baby signs are also highly iconic. Iconicity has been discussed as a key factor in choosing early signs (Fristoe & Lloyd, 1980). Unlike ASL, baby signs are typically single words with no formal grammar.

Since Dunst et al. (2011) concluded that all sign interventions have value, we advocate here that in teaching isolated vocabulary (i.e., key words), homemade baby signs, formal ASL signs, and ASL-adapted signs all are appropriate as long as signs are iconic and consistent. Hereafter, these signs will be referred to as key word signs (KS) to differentiate them from any trademarked baby signs programs or ASL.

Published practice guidelines have further addressed how to choose word–sign pairs (Acredolo & Goodwyn, 2009; CELL, 2010a, 2010b, 2010c, 2010d; Seal, 2010). Although all agree that targets should be pragmatically functional and developmentally appropriate, none has systematically considered the research on spoken lexical development. Developmental lexical data are available (Fenson et al., 1994; Tardif et al., 2008), as are guidelines for choosing first spoken words (Holland, 1975; Lahey & Bloom, 1977; Lederer, 2002, 2011). These are important resources in choosing first word–sign pairs when the goal is to produce spoken words.

Finally, these research-to-practice guidelines provide useful information for intervention. Tips include the importance of gaining joint attention, pairing signs with spoken words, and the power of repetition within and across contexts, among others (Acredolo & Goodwyn, 2009; CELL, 2010a, 2010b, 2010c, 2010d; Seal, 2010). Collectively, these approaches combine the best of traditional language therapy with sign language intervention.

The purpose of this article is to integrate the aforementioned literature in an effort to guide clinical decision-making for young children with language delays in the absence of hearing loss. Specifically, this article will (a) review the developmental, theoretical, and empirical support for using signs to facilitate spoken words in children with language delays, (b) review guidelines for choosing first word–sign pairs, evaluate specific target recommendations, offer a sample lexicon, and (c) combine recommended practices in sign intervention and early language intervention.

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RESEARCH BASIS

Natural gestures have been defined as actions produced by the whole body, arms, hands, or fingers for the purpose of communicating (Centers for Disease Control and Prevention, 2012; Iverson & Thal, 1998). Natural gestures have been further categorized as either deictic or representational (Capone & McGregor, 2004; Crais, Watson, & Baranek, 2009; Iverson & Thal, 1998). Deictic gestures include pointing, showing, giving, and reaching and emerge between 10 and 13 months (Capone & McGregor, 2004). They are used to gain attention and change on the basis of the context. To illustrate, babies may use pointing for several functions and meanings, based on context. For example, a baby may point to a picture in a book to label a duck and point to a bottle to request it.

Representational gestures are used to express a specific language concept (e.g., nodding to signify agreement, waving to greet, and sniffing to signify “flower”) and, therefore, are not context-dependent. Representational gestures can stand alone. For example, if a child pretends to sniff a flower, and the flower is not present, the listener still knows what the child is attempting to communicate. These gestures begin to appear at 12 months (Bates, Benigni, Bretherton, Camaioni, & Volterra, 1979; Capone & McGregor, 2004).

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The gesture–speech continuum

Researchers studying gestures in young children have noted a continuum from prelinguistic gestures to first words (McLaughlin, 1998) to multiword combinations (Goodwyn et al., 2000), as well as concomitant milestones such as first symbolic/pretend play gestures and first words (McCune-Nicolich, 1981). Findings from longitudinal research in this area (Goodwyn et al., 2000; Rowe & Goldin-Meadow, 2009; Watt, Wetherby, & Shumway, 2006) have concluded that development of gesture predicts three critical early language-based domains: (a) lexical development (Acredolo & Goodwyn, 1988; Watt et al., 2006); (b) syntactic development in the transition to two-word utterances (Goodwyn et al., 2000); and (c) vocabulary size in kindergarten (Rowe & Goldin-Meadow, 2009).

Children with language impairments often have delays in gesture development (Luyster, Kadlec, Carter, & Tager-Flusberg, 2008; Sauer, Levine, & Goldin-Meadow, 2010). The nature of their gestural lexicons can be used to reliably predict who will and will not catch up in language development (i.e., late bloomers and late talkers, respectively; Thal, Tobias, & Morrision, 1991) and differentiate among those with various disabilities such as autism (Zwaigenbaum et al., 2005) and Down syndrome (Mundy, Kasari, Sigman, & Ruskin, 1995). In two recent studies, both teaching gestures directly to children (McGregor, 2009) and increasing parent use of gestures (Longobardi, Rossi-Arnaud, & Spataro, 2012) supported verbal word learning.

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Theoretical support

Two models of language acquisition, that is, the transactional model (Sameroff & Chandler, 1975; Yoder & Warren, 1993) and the information processing model (Ellis Weismer, 2000; Just & Carpenter, 1992) provide further support for pairing spoken words with representational gestures/signs (i.e., KS). The transactional model (Sameroff & Chandler, 1975; Yoder & Warren, 1993) posits that the language-learning process is reciprocal and dynamic. A child-initiated gesture invites an adult to respond. Children with language delays, who do not initiate or respond (either with gestures or words), risk diminished conversational efforts by adults, further compromising the language-learning experience (Rice, 1993). Kirk, Howlett, Pine, and Fletcher (2013) provided support for this model, reporting that the use of baby signs (vs. words alone) increased parents' responsiveness to their children's nonverbal cues in infants who are developing typically.

Information processing is a second model of language acquisition that may support the use of simultaneous speech/sign. This model places emphasis upon the importance of a child's cognitive processing abilities in the areas of attention, discrimination, organization, memory, and retrieval (Ellis Weismer, 2000; Just & Carpenter, 1992). Accordingly, deficits in any one process or task demand that exceed overall processing abilities will cause the system to break down.

Simultaneous speech/sign intervention can address information processing problems in at least four different ways. First, from a neurological perspective, while verbal language engages only the auditory cortex, sign engages both the visual and auditory cortices (Abrahamsen, Cavallo, & McCluer, 1985; Daniels, 1996). A child who has difficulty processing information by solely listening has the added opportunity to learn through the visual modality. This position is aligned with universal design for learning, in that educators and clinicians afford students with multiple means of representation, multiple means of engagement, and multiple means of expression (McGuire, Scott, & Shaw, 2006). Second, words are more fleeting than signs. Although a spoken word quickly fades from a child's auditory attention, gestures linger longer in the visual domain, thus providing more processing time (Abrahamsen et al., 1985; Gathercole & Baddeley, 1990; Just & Carpenter, 1992; Lahey & Bloom, 1994). Third, visual signs invite joint attention, an important prelinguistic precursor to communication development (Acredolo et al., 1999; Goodwyn et al., 2000; Tomasello & Farrar, 1986). The more signs presented, the more opportunities there are for the child to share attention and intention with the conversational partner. Fourth, both the sign and the word are symbolic. When used together, they essentially cross-train mental representation skills (Goodwyn & Acredolo, 1993; Petitto, 2000).

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Empirical support

Inspired by the theoretical and developmental rationales for using signs to facilitate spoken words, researchers have sought to obtain empirical evidence to support use of KS as an intervention strategy in children with language delays (Baumann Leech & Cress, 2011; Dunst et al., 2011; Robertson, 2004; Wright et al., 2013). Dunst et al. (2011) conducted a critical review of 33 studies on the influence of sign/speech intervention on oral language production. Studies included in their review were investigations of clinical populations including autism spectrum disorders, social-emotional disorders, Down syndrome, intellectual disabilities, and physical disabilities. Their review concluded that, regardless of the type of sign system used (e.g., ASL, Signed English), the use of multimodal cues (i.e., sign paired with spoken words) yielded increased verbal communication. It must be noted that a critical review of these studies reveals limited numbers of participants overall (1–21) and primarily single-subject, within-group designs. No randomized, between-group comparisons (the gold standard for empirical research) were identified in this review.

Baumann Leech and Cress (2011) utilized a single-subject, multiple baseline research design to compare two different augmentative alternative communication (AAC) treatment approaches (i.e., picture symbol exchange vs. [unspecified form of] sign) in one participant diagnosed as a “Late Talker” (i.e., a child with expressive language delays only). The participant learned spoken target words using both methods of AAC and generalized these words to different communicative scenarios. Although no difference was noted between AAC intervention strategies, sign (as one of the two strategies) did facilitate spoken language.

Robertson (2004) reported the results of a single-subject, alternating treatment study in which two late-talking toddlers were presented with 20 novel vocabulary words. Ten spoken words were paired with signs, whereas the remaining 10 served as controls. Both children learned all 10 signed words and carried them over to conversational speech versus learning only half of the nonsigned words.

Wright et al. (2013) studied the effect of a speech/sign intervention on four toddlers with Down syndrome exposed to enhanced milieu teaching (EMT; Hancock & Kaiser, 2006) blended with joint attention, symbolic play, and emotional regulation (Kasari, Freeman, & Paparella, 2006). After participating in 20 biweekly sessions, all four children increased their use of signs and spoken words. However, without a control group, it is not possible to infer a cause–effect relationship.

Given this promising empirical research base, coupled with developmental and theoretical support, the authors here conclude that use of KS as an intervention strategy is supported. Therefore, two questions remain: (1) How can research guide choosing first word–sign pairs? (2) What evidence-based strategies should be used to facilitate their production?

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HOW TO CHOOSE FIRST WORD–SIGN PAIRS

Choosing first signs, similar to choosing first words, must be based on a variety of both context and content concerns (Holland, 1975; Lahey & Bloom, 1977; Lederer, 2001, 2002, 2011, 2013). In relation to context, targeted word–sign pairs should be useful for communicating an array of pragmatic functions (i.e., the reason why we send a message). For example, children can request to have their needs met, protest to express displeasure, comment to express ideas, and ask a question to obtain information, to name a few of the many pragmatic functions possible (Bloom & Lahey, 1978; Lahey, 1988).

Word–sign pairs should be highly motivating and suitable for use during a range of activities and across settings (e.g., home, school; Lahey & Bloom, 1977; Lederer, 2013). Furthermore, they should be easy to both demonstrate and understand (i.e., highly iconic; Fristoe & Lloyd, 1980; Lahey & Bloom, 1977). In terms of content, rationales for choosing individual word–sign targets and a core lexicon should be derived from both general lexical development and child- and family-specific vocabulary needs. Finally, lexical variety, which lays the foundation for syntax, must be considered (Bloom & Lahey, 1978; Lahey, 1988).

Research to practice guidelines for choosing word–sign pairs provided by CELL (2010a, 2010b, 2010c, 2010d), Acredolo and Goodwyn (2009), and Seal (2010) place emphasis on the contextually-based aspects of language. Regarding content, Seal (2010) consulted developmental ASL research (Anderson & Reilly, 2002) and considered motor development. Acredolo and Goodywn (2009) referred to their own research on the natural development of Baby SignsR (Acredolo & Goodwyn, 1988). However, recommendations from the aforementioned experts do not systematically consider developmental spoken lexical research. Because the purpose of using signs with children with language delays is to facilitate first spoken words, the authors here conclude that the logical approach to selecting word–sign pairs is to identify the spoken targets first.

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Early lexical development

Early spoken word targets should be drawn largely from developmental lexical research (e.g., Benedict, 1979; Fenson et al., 1994; Nelson, 1973; Tardif et al., 2008). For a child with typical development, a majority of his or her first 20 words will be nouns, greetings, and “no” (Tardif et al., 2008). As a child's vocabulary approaches or exceeds 50 words, prepositions subsequently emerge (e.g., “up,” “down”), followed by action verbs (e.g., “go,” “eat”) and adjectives/modifiers (e.g., “more,” “all done,” “hot”; Bloom & Lahey, 1978; Fenson et al., 1994; Lahey, 1988). The lexicon at 50 words typically contains two-thirds of substantive words (i.e., objects or classes of objects expressed with nouns and pronouns such as names of people, toys, animals, and foods) and one-third of relational words (i.e., expressing relationships between objects using verbs, prepositions, adjectives, and other modifiers; Nelson, 1973; Owens, 2011). Late-talking toddlers (Rescorla, Alley, & Christine, 2001) and children with Down syndrome (Oliver & Buckley, 1994) have been reported to follow the same order of lexical acquisition as children developing language typically, but do so at a slower pace.

To help clinicians further facilitate semantic variety, Bloom and Lahey (1978) and Lahey (1988) developed a popular taxonomy to code substantive and relational words. They identified nine different early semantic categories of words and their meanings. Substantive words are contained in the category of existence, whereas relational words can be sorted into the following eight categories: nonexistence, recurrence, rejection, action, locative action, attribution, possession, and denial. Definitions and developmentally early verbal exemplars for each category can be found in Table 1.

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Recommendations for choosing word–sign targets

To begin, Lederer (2001, 2002, 2011) and others (e.g., Girolametto, Pearce, & Weitzman, 1996) recommend choosing a small set of 10–12 developmentally early targets representing a range of semantic categories to express a variety of pragmatic intentions. All exemplars in Table 1 meet these criteria. For children who have more significant language impairments, fewer targets should be selected.

As mentioned in the introduction of this article, recommended targets can be found in popular and professional publications (Acredolo & Goodwyn, 2002; Seal, 2010) and websites (e.g., https://www.babysignlanguage.com/; CELL, 2010a, 2010b, 2010c, 2010d). Since CELL (2010a, 2010b, 2010c, 2010d) and Seal (2010) chose their word–sign targets for special populations, we will use these to hone clinical decision-making skills. Specifically, we will reflect on their strengths and weaknesses in relation to (a) spoken lexical development, (b) representation of substantive and relational targets, and (c) variety within and across semantic categories. CELL's (2010a, 2010b, 2010c, 2010d) and Seal's (2010) targets appear in Table 2. We will conclude with a sample lexicon for clinical intervention.

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Spoken lexical development

The majority of the targets offered by CELL (2010a, 2010b, 2010c, 2010d) and Seal (2010) are words acquired early by children developing spoken language typically (Fenson et al., 1994; Tardif et al., 2008). (These are bolded in Table 2.) However, both lists include some targets that are acquired after 24 months. (These are not bolded in Table 2.) Targets that are starred in Table 2 did not appear in the database generated by Fenson et al. (1994). Finally, a denotation of “X” indicated that neither CELL (2010a, 2010b, 2010c, 2010d) nor Seal (2010) account for these targets.

In general, choosing words for language intervention that appear developmentally after 24 months is not recommended by the authors here. By the age of two years, toddlers who are developing typically have a vocabulary of approximately 200 words and are generating (at least) two-word combinations (Paul & Norbury, 2012). Given that the single-word lexicon is of approximately 50 words (Nelson, 1973; Owens, 2011), establishing a cutoff at two years of age provides a large enough pool from which to select developmentally early targets.

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Substantive–relational representation

Both CELL (2010a, 2010b, 2010c, 2010d) and Seal (2010) provide word lists that contain a majority of relational words. Choosing relational words for children with language delays is highly recommended because they can be used more frequently across activities and settings than substantive words (Lahey & Bloom, 1977). In fact, CELL (2010a, 2010b, 2010c, 2010d) recommends only one substantive word (“book”). Because substantive words are easier to learn than relational words (i.e., they are more easily represented; Bloom & Lahey, 1978; Lahey, 1988), the authors recommend building early lexicons that include both substantive and relational words, with a greater emphasis on the latter, as did Seal (2010).

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Semantic variety

Semantic variety refers both to within and across lexical category considerations. With respect to within category substantive words, first nouns include names of people, toys, foods, animals, clothes, and body parts (Fenson et al., 1994). Seal (2010) includes a sufficient semantic variety with people, toys, and food.

With regard to within category relational words, both CELL (2010a, 2010b, 2010c, 2010d), and Seal (2010) include a large number of verbs, similar to those seen in the first 35 ASL signs in young children who are deaf (Anderson & Reilly, 2002) but dissimilar in first word learners (Fenson et al., 1994; Tardif et al., 2008). Anderson and Reilly (2002) explain that these early verb concepts can be easily demonstrated with natural gestures (e.g., “clap,” “hug,” “kiss”). Spoken verbs are among the latest category of single words to be acquired (e.g., the first verb “go” appears at 19 months; the first nouns, “mommy” and “daddy” appear at 12 months; Fenson et al., 1994). Bloom and Lahey (1978) and Lahey (1988) explain that verbs are harder to learn than nouns because they are not always easily represented, permanent, or perceptually distinct from the noun (e.g., “eat” means someone is eating something). Because verbs are harder to learn, but easier to gesture, the authors here recommend including a minimum of two action verbs when building a KS lexicon.

Finally, with respect to variety of relational words across semantic categories, we need to look for exemplars from each of the early nine categories (Bloom & Lahey, 1978; Lahey, 1988). Inspection of CELL's (2010a, 2010b, 2010c, 2010d) and Seal's (2010) recommended targets reveals missing lexical items from certain categories as identified by an X in Table 2. According to Bloom and Lahey (1978), a first lexicon should include relational words from at least nonexistence, recurrence, rejection, action, and locative action.

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Making decisions

Table 1 provides the earliest acquired words in each semantic category. The bolded targets in Table 2, which are not seen in Table 1, provide additional word–sign targets for consideration. In addition to these recommended developmental targets, child “favorites” and family-specific vocabulary must be included. These are obtained through family interviews about child-preferred items (e.g., toys and foods), as well as alternative labels (e.g., people and foods), which have cultural significance to the family and the child. Rationales for including child-specific targets (e.g., Elmo) stem from individually motivating objects or events. Rationales for identifying culturally-guided (e.g., “ee-mah” for “mommy”) vocabulary foster positive rapport and respect (Robertson, 2007).

Taking spoken lexical development, substantive–relational representation, and semantic variety into account, Table 3 provides a sample first lexicon. These targets are adapted from Lederer (2002, 2011). Suggested KS descriptions are provided. The signs are derived from ASL and Baby SignsR. Users should modify as needed.

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STRATEGIES TO FACILITATE EARLY WORD–SIGN TARGETS

Many strategies that are effective in facilitating early spoken words can be expanded to include word-sign targets. Evidence-based practices for these shared objectives include the following: (a) focused stimulation (Ellis Weismer & Robertson, 2006; Ellis Weismer & Murray-Branch, 1989; Girolametto et al., 1996; Lederer, 2002; Wolfe & Heilmann, 2010); (b) Enhance Milieu Teaching (EMT) (Hancock & Kaiser, 2006; Wright et al., 2013); and (c) embedded learning opportunities (ELOs; Horn & Banerjee, 2009; Lederer, 2013; Noh, Allen, & Squires, 2009). In addition, evidence-based strategies for facilitating sign language also must be considered (Seal, 2010). Regardless of the teaching strategy being used, parents and professionals should always pair the spoken word with the KS in short, grammatically correct phrases or sentences (Bredin-Oja & Fey, 2013). The child's sign alone should be accepted fully with the assumption that it will fade once the spoken word emerges (Iverson & Goldin-Meadow, 2005).

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Focused stimulation

Focused stimulation is a language intervention approach in which a small pool of target words is preselected and each is modeled five to 10 times before another target is modeled (Ellis Weismer & Murray-Branch, 1989; Girolametto et al., 1996; Lederer, 2002; Wolfe & Heilmann, 2010). Repeating limited targets is supported by information processing theories, suggesting minimizing demands on the processing system (Ellis Weismer, 2000; Just & Carpenter, 1992). The target is presented in short but natural phrases/sentences to help build the concept linguistically. Other modes of representation to build the concept, such as pictures, signs, or demonstrations, are also used. In focused stimulation, the KS is repeated each time the target is spoken. No verbal or signed production is expected or overtly elicited from the child in the classic form of focused stimulation. Exposure alone has been proven sufficient to facilitate learning, using both parents (Girolametto et al., 1996) and professionals (Ellis Weismer & Robertson, 2006; Wolfe & Heilmann, 2010) as intervention agents. A study by Lederer (2001) demonstrated that parents and professionals collaborating in the use of focused stimulation were effective in facilitating vocabulary development. Table 4 provides a sample focused stimulation dialog for facilitating the word–sign target “eat.”

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Enhanced milieu teaching

Enhanced milieu teaching is a group of language facilitation strategies combining environmental arrangement to stimulate a child's initiation, responsive interactions, and milieu teaching. Examples of environmental arrangement include placing desired objects out of reach, providing small portions of preferred foods, giving the objects/activities requiring assistance (e.g., bubbles with the top sealed very tightly), or doing something silly (e.g., trying to pour juice with the cap still in place). Responsive interaction strategies include “following the child's lead, responding to the child's verbal and nonverbal initiations, providing meaningful semantic feedback, expanding the child's utterances” both semantically and syntactically (Hancock & Kaiser, 2006, p. 209). These strategies are designed to engage the child and scaffold language. Milieu teaching strategies include but are not limited to asking questions, providing fill-ins, offering choices, and modeling word–sign in increasingly more directive styles (Hancock & Kaiser, 2006).

Enhanced milieu teaching's theoretical basis comes from both behaviorist (Hart & Rogers-Warren, 1978) and social interactionist theories (e.g., transactional; Ellis Weismer, 2000; Just & Carpenter, 1992). Enhanced milieu teaching uses operant conditioning (i.e., antecedent, behavior, consequence; Skinner, 1957) in prearranged but natural contexts (Hart & Rogers-Warren, 1978). The antecedent can be either nonverbal or verbal.

Both parents and professionals have been shown to implement EMT effectively (Hancock & Kaiser, 2006). Similar to focused stimulation, collaborative use of EMT between interventionists and parents has been shown to produce the greatest impact on vocabulary expansion (Kaiser & Roberts, 2013). See Table 4 for a sample EMT interaction to facilitate the word–sign “eat.”

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Embedded learning opportunities

Although focused stimulation and EMT have been shown to help children generalize newly acquired vocabulary, they cannot address the issue of generalization alone. To help children both acquire and generalize new vocabulary, they need to be exposed to words and signs across activities and settings. This is made possible through systematic ELOs; Horn & Banerjee, 2009; Lederer, 2013; Noh et al., 2009). To plan for ELOs, professionals and families must work together to identify opportunities across the child's day in which the intended targets can be facilitated. Parents are made partners in the decision-making process for selecting targets and identifying multiple opportunities to facilitate these targets. See Table 4 for ELO opportunities to facilitate the word–sign target “eat.”

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Sign language strategies

In addition to traditional language facilitation strategies, recommended practices in teaching signs should be considered. Many of these practices are adapted from parents of young children who are deaf and learning ASL. Strategies include establishing joint attention such as tapping a child who does not respond to his name (Clibbens, Powell, & Atkinson, 2002; Waxman & Spencer, 1997) and keeping the sign in front of the child for the duration of the spoken word or phrase (Iverson, Longobardi, Spampinato, & Caselli, 2006; Seal, 2010). In addition, Seal (2010) suggests sitting behind children for hand-over-hand facilitation to help with perspective but also signing face-to-face so that children can see facial expressions and mouth movements. Like parents of children developing language typically, Seal (2010) encourages both parents and professionals to use “motherese,” that is, to present signs slowly, exaggerate their size, extend their duration, and increase their frequency.

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SUMMARY

Regarding recommended practices in implementing a word–sign intervention, this article extends the work of previous guidelines and specific word–sign recommendations (Acredolo & Goodwyn, 2002; Acredolo & Goodwyn, 2009; CELL, 2010a, 2010b, 2010c, 2010d; Seal, 2010). This article more systematically considers the roles of spoken language development, as well as language and sign facilitation strategies, in choosing and facilitating early word–sign targets. In addition to pragmatic context considerations embraced by reviewed researchers, early spoken lexical research must be consulted in terms of acquisition of specific words within and across a variety of semantic categories. This process will ensure creation of a diverse early lexicon necessary for communication in the present and the ultimate transition to syntax.

For children with language delays, combining signs with spoken words to facilitate spoken language has strong developmental and theoretical support. Empirical support is promising but more controlled studies are needed. Specifically, researchers must study larger numbers of participants and employ between-group designs, ideally using randomization of participants. In addition, the late talker population has received little attention with respect to word–sign interventions. Because research suggests that these children are the mildest of those with language delays and may even “catch up” without intervention (Paul & Norbury, 2012), it is important to ascertain whether a KS intervention program could speed up the process even further than language therapy without signs. Finally, given research that supports the use of parents as language facilitators (Girolametto et al., 1996; Hancock & Kaiser, 2006), an investigation of whether a parent-implemented home program using KS is warranted.

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children with language delays; key word signs; recommended practices; sign language

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