Explicit Grammatical Intervent PDF

LSHSS
Clinical Focus
Explicit Grammatical Intervention

for Developmental Language
Disorder: Three Approaches
Catherine H. Balthazar,a Susan Ebbels,b,c and Rob Zwitserloodd
Purpose: This article summarizes the shared principles effective practices and support more widespread adoption
and evidence underpinning methods employed in the of syntactic interventions with school-age children.
three sentence-level (syntactic) grammatical intervention Conclusion: In each approach to syntactic intervention,
approaches developed by the authors. We discuss careful and detailed analysis of grammatical knowledge is
associated clinical resources and map a way forward for used to support target selection. Intervention targets are
clinically useful research in this area. explicitly described and presented systematically using
Method: We provide an overview of the principles and multimodal representations within engaging and functional
perspectives that are common across our three syntactic activities. Treatment stimuli are varied within a target
intervention approaches: MetaTaal (Zwitserlood, 2015; pattern in order to maximize learning. Similar intervention
Zwitserlood, Wijnen, et al., 2015), the SHAPE CODING™ intervals and intensities have been studied and proven
system (Ebbels, 2007; Ebbels et al., 2014, 2007), and clinically feasible and have produced measurable effects.
Complex Sentence Intervention (Balthazar & Scott, 2017, We identify a need for more research evidence to maximize
2018). A description of each approach provides examples the effectiveness of our grammatical interventions,
and summarizes current evidence supporting effectiveness encompassing languages other than English, as well as
for children with developmental language disorder ranging practical clinical tools to guide target selection, measurement
in age from 5 to 16 years. We suggest promising directions of outcomes, and decisions about how to tailor interventions
for future research that will advance our understanding of to individual needs.
A
n estimated 7% of the world’s children are affected in early childhood, but associated language problems persist
by developmental language disorder (DLD; into early adolescence and even adulthood (Conti-Ramsden,
Bishop et al., 2017; Norbury et al., 2016; Tomblin 2008; e.g., Law et al., 2009; Nippold et al., 2009), affecting
et al., 1997, 2003). While language difficulties vary by age, psychosocial (Clegg et al., 2005) and educational (Conti-
language, and functional context, problems with morphol- Ramsden, 2008) outcomes as well as employment prospects
ogy and syntax—the “grammatical” aspects of language— (Conti-Ramsden & Durkin, 2012; Conti-Ramsden et al.,
affect a large majority of these children (Fey et al., 2004; 2018; Law et al., 2009). With significant impact on func-
Leonard, 2014; Nippold et al., 2009). DLD may be diagnosed tioning documented across the life span, interventions for
children with DLD must address their needs at a variety of
ages and support language in academic as well as voca-
a tional and social realms.
College of Health and Human Services, Governors State University,
University Park, IL
The amount of evidence supporting effective gram-
b
Moor House Research and Training Institute, Moor House School & matical intervention procedures varies considerably depend-
College, United Kingdom ing upon language, age, and targets. The vast majority of
c
Language and Cognition, University College London, United Kingdom treatment studies are focused on English-speaking children
d
HU University of Applied Sciences, Utrecht, the Netherlands aged 7 years and under (Cirrin & Gillam, 2008; Ebbels,
Correspondence to Catherine H. Balthazar: CBalthazar@govst.edu 2014) and, as a consequence, primarily address English
Editor-in-Chief: Holly L. Storkel morphological features that are usually acquired in early
Editor: Amanda J. Owen Van Horne childhood, with less focus on the developmentally advanced
Received May 13, 2019
Revision received June 13, 2019
Disclosure: The intervention approaches described in this article were developed
Accepted November 7, 2019
and investigated by the authors. The authors do not have any financial interests
https://doi.org/10.1044/2019_LSHSS-19-00046 related to the intervention approaches. SHAPE CODING is a U.K.-registered
Publisher Note: This article is part of the Forum: Morphosyntax trademark to Moor House School & College, who is an employer of the second
Assessment and Intervention for Children. author.
226 Language, Speech, and Hearing Services in Schools • Vol. 51 • 226–246 • April 2020 • Copyright © 2020 American Speech-Language-Hearing Association
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syntactic skills needed by older children and adolescents activities, including visual analogies such as LEGO®1 bricks
(Nippold, 2010; Scott, 1988; Scott & Balthazar, 2010, 2013; to represent language structure as in the MetaTaal approach
Scott & Koonce, 2014). For the same reason, the approach (Zwitserlood, 2015); extensive visual coding of language
to grammatical intervention has overwhelmingly been on structures and rules using colors, shapes, and arrows as in the
use of methods that promote implicit learning, which is SHAPE CODING system (Ebbels, 2007); and explanation
presumed to be more natural and cognitively appropriate of language structures and how they support specific mean-
for children whose metalinguistic abilities are limited ings and functions as in CSI (Balthazar & Scott, 2018).
(Leonard, 2014). There is, however, a growing literature Metalinguistic teaching is used to fill in gaps in lan-
on the efficacy of several approaches to intervention for guage knowledge by making important syntactic informa-
treating grammatical deficits, particularly sentence-level tion overt, permanent, and available for examination and
grammar (syntax) in children with DLD, using explicit discussion (Ebbels et al., 2007) or to bypass or supplement
intervention procedures (Balthazar & Scott, 2018; Calder language functions presumed to be impaired (Calder et al.,
et al., 2018; Ebbels, 2014; Finestack, 2018; Finestack & 2018; Ebbels et al., 2014). The overall aim is for the child
Fey, 2009; Zwitserlood, 2015). to internalize the rule and then generalize use of the rule
The purpose of this article is to provide a summary through practice. Although an estimated 69% of U.S. clini-
of the principles and perspectives that are common across cians are using explicit instruction with school-age children
our three syntactic intervention approaches: MetaTaal (Finestack & Satterlund, 2018), metalinguistic instruction
(Zwitserlood, 2015; Zwitserlood, Wijnen, et al., 2015), to address linguistic targets has largely been rejected as a
the SHAPE CODING system (Ebbels, 2007; Ebbels et al., primary strategy with young children, whose metacognitive
2014), and Complex Sentence Intervention (CSI; Balthazar abilities are not well developed. However, a complete rejec-
& Scott, 2017, 2018). Each approach is described here tion of explicit methods with young children may not be
along with a summary of the evidence supporting its effec- justified. Finestack (2018) found that a combined implicit–
tiveness for children with DLD ranging in age from 5 to explicit approach produced a larger effect size than an
16 years. Our aims are to encourage the adoption of implicit-only approach, regardless of age, at least with
evidence-based syntactic interventions and to outline future respect to novel morpheme learning. In our syntactic inter-
research that will advance our understanding of effective ventions, explicit metalinguistic instruction is viewed as a
practices with school-age children with DLD. central feature rather than only a useful adjunct to implicit
intervention techniques, with demonstrable treatment
effects across a range of ages and targets and, to a lesser
Principles and Perspectives Guiding extent, multiple languages (e.g., Balthazar & Scott, 2018;
Syntactic Interventions Ebbels et al., 2014, 2007; Zwitserlood, 2015; see Table 1).
The MetaTaal, SHAPE CODING, and CSI ap- Findings that explicit teaching of grammatical rules
proaches to syntactic intervention were each developed to school-age children with DLD yields positive results are
independently, but they share a common set of assump- consistent with the procedural deficit hypothesis, which
tions, derived from a common evidence base and theo- stresses the relatively better skills in children with DLD of
retical perspective. What sets our sentence-level syntactic visuospatial memory and explicit learning in the context
interventions apart from other language intervention of relatively poorer implicit learning (Lum et al., 2012;
approaches are three factors: metalinguistic instruction, Ullman & Pierpont, 2005). The procedural deficit hypothesis
stimulus organization, and multimodal delivery. While claims that children with DLD are impaired at grammati-
each of our approaches has different methods, all three cal rule learning because of a deficit in their procedural
provide explicit instruction about language structure, orga- memory system. To compensate, they rely on their declara-
nize and present stimuli in a way that promotes implicit tive memory system. Accordingly, children with DLD may
learning, and support learning using visual and/or kines- be better able to learn grammatical rules when they are
thetic, in addition to auditory, representations of the taught explicitly (in declarative memory) and learning is
target structures. The origins of these principles are sum- enhanced by visual (or multimodal) support. A further
marized here in order to guide clinical decision making argument that is less often discussed in studies on meta-
for speech-language pathologists (SLPs) interested in devel- linguistic intervention is that, although children with DLD
oping sentence-level intervention plans and to provide appear to have poorer metalinguistic skills than typically
background for what we think are areas in need of further developing children (Kamhi & Koenig, 1985; Menyuk
study. et al., 1993), these skills do exist and can in fact be employed
successfully to remediate grammatical problems in a meta-
linguistic approach (e.g., Finestack, 2018). It is possible
Explicit Metalinguistic Instruction that the metalinguistic intervention also enhances metalin-
A key component of our syntactic interventions is guistic skills in children with DLD and serves as a mediating
explicit metalinguistic instruction, defined by verbal de-
scription, explanation, and feedback focused on form, the
functions of forms, and the manipulation of forms. This 1
LEGO® is a trademark of the LEGO Group of companies which
kind of instruction encompasses an array of instructional does not sponsor, authorize, or endorse this study.
Balthazar et al.: Explicit Grammatical Intervention 227

228
Table 1. Studies targeting grammar in children and adolescents with language disorders (Ebbels, 2014).
Language, Speech, and Hearing Services in Schools • Vol. 51 • 226–246 • April 2020
Age (years;months)
and number
Source and design of participants Language target Intervention Outcomes and magnitude of effectsa
Ebbels et al. (2007) 11;0–16;1 Production of verb SHAPE CODING system or a SHAPE CODING: Both intervention groups improved
RCT N = 27 argument semantic intervention significantly more than controls on verb argument
structure Direct 1:1, 1 × 30 min per week structure. (for the SHAPE CODING group vs.
for 9 weeks controls: d = 1.3, large effect size). Maintained
for 3 months. Generalized to control verbs.
Ebbels et al. (2014) 11;3–16;1 Comprehension of SHAPE CODING system The SHAPE CODING group showed significantly
RCT N = 14 coordinating Direct 1:1, 1 × 30 min per week more progress than waiting controls on targeted
conjunctions for 8 weeks conjunctions (d = 1.6, large effect size). Waiting
controls also made significant progress when
they too received intervention (d = 2.1, large
effect size). Generalized to TROG-2 assessment,
(d = 1.4, large effect size), but not to passives.
Maintained for 4 months.
Ebbels & van der Lely 11–14 years Comprehension SHAPE CODING system Three of four participants showed significant
(2001) N=4 and production Direct 1:1, 2 × 30 min per progress with comprehension and expression
Multiple baseline of wh-questions week (10 weeks for of passives. Two participants focused on
and passive passives, 20 weeks for comprehension of wh-questions and made
formation wh-questions) significant progress. All four focussed on
production of wh-questions and made significant
progress with subject questions. Two of four
made significant progress with object questions.
After 30 weeks, progress maintained for 2/3 on
passive comprehension and expression, 1/4 for
production of subject wh-questions, and 0/4 for
production of object questions.
Ebbels (2007) 11;8–12;9 Comprehension SHAPE CODING system Two of three children showed significant progress
Multiple baseline N=3 of dative and Direct 1:1, 2 × 30 min per week with dative; 2/2 showed significant progress with
comparative for 10 weeks comparative wh-questions.
wh-questions
Kulkarni et al. (2014) 8;11 and 8;10 Use of past tense SHAPE CODING system Participant A: stable baseline, then significant
Multiple baseline N=2 morphology Phase 1: 1 × 30 min per progress on sentence completion for treated
week with SLT for 10 weeks, and untreated verbs after Phase 1, and progress
plus 3.5 hr with TA for on conversation task only after Phase 2. No
Participant A and 0.5 hr change in control structure. Participant B:
with TA for Participant B. stable baseline, then significant progress with
Phase 2: SLT carried conversation after Phase 1, and progress in
out four sessions in class, sentence completion task only significant after
met with parents, and Phase 2. No change in control structure. Progress
carried out session at maintained for 6 weeks. For Participant B,
participants’ homes. generalization occurred to conversation during
Phase 1. Participant A needed generalization
therapy (Phase 2) for progress to generalize to
conversation.
(table continues)

Table 1. (Continued).
Age (years;months)
and number
SHAPE CODING system plus 2/3 made significant gains in targeted expressive
Calder et al. (2018) 6;2, 6;6, and 7;0 Use of past tense
systematic cueing hierarchy morphosyntax (–ed) After 5 weeks, some
Multiple baseline N=3 morphology
Direct 1:1 with SLT, 2 × 25 min decreased for 1/3 and further increased for
for 5 weeks 1/3. Generalized to TROG (2/3) and TEGI (3/3)
Calder et al. (2020) 5;10–6;8 Use of past tense SHAPE CODING system plus Most children showed significant improvement
Multiple baseline N=9 morphology systematic cueing hierarchy on trained verbs within (8/9, d = 0.9, large
Direct 1:1 with SLT, 2 × effect size) and between (7/9, d = 0.9, large
20–30 min per week for effect size) sessions and untrained verbs (7/9,
10 weeks, 50 trials per d = 0.8, large effect size). Progress maintained
session (1,000 in total) for 5 weeks.
Generalized to grammaticality judgment (d = 0.26,
small effect size) and standardized measures
of expressive grammar, SPELT-3 (8/9), but not
receptive grammar (1/9). Gains on control
measures not significant when participants
combined: 3s (1/9, d = −0.05, no effect); ’s
(2/9, d = 0.1, no effect).
Tobin & Ebbels (2019) 10–14 years with Singular vs. plural SHAPE CODING system Significantly more progress with intervention than
Balthazar et al.: Explicit Grammatical Intervention
Single-baseline design complex needs auxiliary or copula Direct 1:2 or 1:3, 2 × 20 min during baseline (d = 0.92, large effect size).
(including six with per week for 4 weeks Generalized from auxiliary to copula and
Down syndrome) vice versa.
N = 11
Ebbels (2007) 11–13 years Use of past tense SHAPE CODING system As a group, postintervention scores did not differ
Group study N=9 morphology in Direct group for 1:9, then 1:2 from preintervention scores, despite a large
comparing pre- writing for two children, 1 hr per effect size (d = 1.7). Six of nine children
and posttest week for 16 weeks + improved; two improved only after an additional
scores approximately 4 hr for paired therapy. Generalized to spontaneous
two children written work in class.
(table continues)
229

230
Language, Speech, and Hearing Services in Schools • Vol. 51 • 226–246 • April 2020
Table 1. (Continued).
Age (years;months)
and number
Balthazar & Scott 10;10–14;11 Production of Complex Sentence Intervention Written sentence combining pre–post improved
(2018) N = 30 complex Direct 1:1, 9 or 18 × 40–60 min significantly (η2 = .816; medium effect size); effects
Multiple-baseline sentences once or twice a week for differed for each sentence, with significant gains
design (adverbial, object 9 weeks on average for adverbial (SMDp = .91; large effect
complement, and size) and relative (SMDp = 1.00; large effect
relative clauses) size) clauses. Twenty-four participants (80%)
demonstrated a medium or large effect size on
at least one of the sentence types. Seven (23%)
of the participants achieved a medium or large
effect size on two sentence types; eight
participants (27%) achieved it on all three.
Similar gains in both the low- and high-dosage
groups. No generalization to written narratives.
Zwitserlood, Wijnen, et al. 9;3–12;8 Comprehension and MetaTaal Production of relative clauses via (written) sentence
(2015) N = 12 production of Direct 1:1, 10 × 30 min combining improved significantly with intervention
Single-baseline relative clauses twice a week for 5 weeks (r ranged between −.53 and −.60; medium
design effect size). Elicited production (without written
prompts) and comprehension of relative clauses
did not improve. Maintained for 3 months.
Zwitserlood (2015) 9;7–15;11 Comprehension MetaTaal Production of relative clauses via (written) sentence
Single-baseline N = 18 and production of Direct 1:1, 10 × 30 min combining improved significantly with intervention
design relative clauses twice a week for 5 weeks (r ranged between .40 and .50; medium size
effects). Elicited production (without written
prompts) and comprehension of relative clauses
did not improve. Maintained for 3 months.
Note. RCT = randomized controlled trial; TROG-2 = Test for Reception of Grammar (Bishop, 2003); SLT = speech-language therapist; TA = teacher aide; TEGI = Rice/Wexler Test of
Early Grammatical Impairment (Rice & Wexler, 2001); SPELT = Structured Photographic Expressive Language Test 3 (Dawson et al., 2003).
a
Effect sizes in each of these studies were reported for different language targets and outcome measures and using a number of different effect size metrics. While these values are
not directly comparable across studies, for illustrative purposes, we have provided effect size values and magnitude of effects where possible. Please refer to the original study
reports for technical information regarding effect size.

factor in their language gains. The idea that metalin- use many different stimulus sentences, rather than focus on
guistic ability and language knowledge are interrelated in mastering a limited set of stimulus sentences. All three of
this way is supported by a recent cognitive–linguistic model the syntactic interventions presented here facilitate rule in-
demonstrating that metacognitive and linguistic abilities duction by using many different exemplars of target forms,
have reciprocal mediating effects on performance (R. B. with varying vocabulary, including syntactic, semantic, and
Gillam et al., 2019; Montgomery et al., 2018). All three pragmatic variations found in different communicative
of our approaches thus use both contextual/inductive contexts (i.e., conversation, narration, exposition).
types of learning tasks and metalinguistic, explicit instruc-
tion designed specifically to prop up areas of cognitive– Multimodal Representations
linguistic weakness (such as long-term memory for language
knowledge) with areas that can be influenced therapeutically Language intervention activities can involve a number
(viz., language experience). of “modalities” for how clinicians present models and
stimulus items and how children provide responses. Our
approaches are designed to be “multimodal,” providing
Stimulus Organization: Priming, Density, combinations of auditory (aural/oral), visual (reading/writing,
and Variability shapes, colors), and kinesthetic (touching/moving) inter-
While we consider explicit instruction and deductive actions with the language material. The rationale for this
learning to be key parts of syntactic intervention, we also multimodal approach is to provide an optimal learning
view them as a bootstrap, not a replacement, for learning environment (Shams & Seitz, 2008) and to raise the level
that occurs implicitly. For this reason, our intervention of active participation, enjoyment, and motivation through
programs systematically organize treatment stimuli in order sensorimotor engagement (Sankey et al., 2010). Use of
to maximize inductive learning. Priming refers to the pre- multiple modalities of presentation and response can help
sentation of target forms (in higher density than found in circumvent any limited processing capabilities of the indi-
conversation), for increasing the likelihood that the target vidual channels (Birsh, 2005; Clark & Paivio, 1991). Each
forms will be subsequently produced (Leonard, 2011). of our approaches provides instruction in varied communi-
There have been no experimental studies that investigate cative and representational modalities.
structural priming in treatment of syntactic structures per se, Our syntactic interventions have been delivered using
but as Leonard (2011) concluded, what is known about stable visual representations found in written language,
priming should be considered when designing methods for but also with visual/kinesthetic analogies such as LEGO
fostering learning of sentence structures. This reasoning bricks. Visual representations should gradually be withdrawn
supports modeling and imitation activities that provide a to encourage internalization of the rule. Varied tasks within
higher density of the intended sentence types at the begin- a session (e.g., some paper based, some at the computer,
ning of a treatment session. some with pictures, some constructive, some discourse
While priming appears to be theoretically and practi- level) are included in order to help skills generalize across
cally important to prepare a child for learning a syntactic different communicative tasks and, importantly, to engage
pattern, increasing the density of models alone may not a student’s attention, so that they can sustain focus on
help (e.g., Proctor-Williams & Fey, 2007). It has been pos- metalinguistic and linguistic information.
ited that the type of task involved in the intervention can
interact with frequency of exposure to produce different Practical Considerations
effects (e.g., Kan & Windsor, 2010). Priming provided in a
context in which the learner is exposed to both the new Specifying Syntactic Targets
linguistic pattern and what it means may optimize learning Careful and detailed analysis of a child’s grammati-
(e.g., McGregor et al., 2007). Most related treatment cal knowledge is critical in order to support target selec-
studies have focused on word learning, not syntax, but the tion. Because the syntactic structures must be explicitly
findings highlight the potential problem with assuming that described and presented systematically, the clinician must
“more is better.” have a good understanding of grammar to identify which
Taken together, the current evidence makes it reason- specific areas the child is struggling to understand or pro-
able to anticipate that priming, combined with active attempts duce and which of these is most functional and important
to manipulate and use forms, particularly in meaningful in the child’s current circumstances. While individuals with
contexts, would be of benefit in teaching syntactic forms, DLD may never reach the same level of proficiency as
by increasing the density and frequency of exposures to a their peers when it comes to morphosyntactic language
level that students with DLD are likely to need in order to features (Rice et al., 2009), most will eventually “master”
learn. Finally, research on statistical learning principles the main syntactic and grammatical structures of the lan-
(cf. Plante & Gómez, 2018) indicates that we can expect a guage, at least to the extent that they do not present
positive effect of stimulus variability on language learning obvious problems in conversation. However, the later devel-
(e.g., Plante et al., 2014). Individuals with DLD may be oping types of complex sentences—namely, relative clauses
better able to induce an underlying syntactic rule if we not —often remain poorly understood and infrequently used
only make the pattern frequent and salient enough but also (particularly in writing) by older children with DLD

(R. B. Gillam & Johnston, 1992; Marinellie, 2004; Scott have been adopted in the majority of the research with
& Windsor, 2000). However, even those capable of pro- school-age children to date: the SHAPE CODING system
ducing later developing syntactic structures remain much (Ebbels, 2007; Ebbels et al., 2014, 2007), CSI (Balthazar
less likely to do so with the same frequency and level of & Scott, 2017, 2018), and MetaTaal (Zwitserlood, 2015;
sophistication typical of peers without DLD (Nippold et al., Zwitserlood, Wijnen, et al., 2015). None of the three
2009), particularly when faced with additional challenges approaches is prescriptive in nature, but rather, they each
such as unfamiliar content and tasks that are more com- provide a tool to help professionals make grammatical
plex due to interactions with other areas of weakness (e.g., rules visual and explicit when providing grammatical
reading fluency or handwriting; cf. Scott & Balthazar, 2010; intervention.
Scott & Koonce, 2014). The goal in this case is to extend
performance into those more troublesome contexts. None
The SHAPE CODING System
of our three approaches takes a position as to sequencing
targets according to a developmental order. Any recom- The SHAPE CODING system aims to help children
mended sequencing of targets will be presented in the de- with language disorders learn the grammar of English
scription of each approach. (although it is now being adapted for other languages), so
they can produce and understand longer and more com-
plex sentences and make fewer grammatical errors in their
Intervention Schedule spoken and written language. The SHAPE CODING
For older children whose language difficulties have system was developed by Susan Ebbels (a co-author of this
persisted into middle and high school, the issue of how article) at Moor House School & College, a specialist
much speech and language intervention should be delivered center in the United Kingdom for children with language
is an important one. Generally speaking, school clinicians disorders aged between 7 and 19 years. Within this context,
base their dosage decisions on local standards, which are there was a need for a system to support older children
designed to keep balance between caseload size, severity, with language disorders to learn more complex syntactic
and student availability. Syntactic treatment studies with structures than those usually targeted in younger children.
children like those in the target population have utilized The SHAPE CODING system combined elements from
once- or twice-weekly sessions of 20–60 min in length, over color coding systems used with younger children (the Colour
periods of time ranging from 5 weeks to 12 months, and Pattern Scheme [Lea, 1970] and Colourful Semantics [Bryan,
have been successfully delivered within that schedule, with 1997]) and extended them, particularly by using shapes
varying degrees of effectiveness depending on the target and arrows in addition to colors, to allow coding of much
structures and outcome measures. The gains demonstrated more complex syntactic structures than was possible with
in studies using treatment schedules in this range are en- those systems.
couraging, at least as a starting point. All three of our
approaches have been designed with practical feasibility of Components of the SHAPE CODING System
service delivery in mind; consequently, our evidence for The SHAPE CODING system has four main com-
effectiveness is grounded in schedules that could be adopted ponents: (a) shapes (for phrases, such as noun phrase, verb
within most treatment settings. Systematic investigation of phrase, and adjective phrase), which are linked with ques-
dosage as it relates to syntactic intervention in school-age tions such as “who,” “what doing,” “what like,” and “how
children with DLD has not yet been undertaken, but the feel”; (b) colors (for parts of speech); (c) single/double lines
evidence base, to date, provides a starting point for this (for marking singular and plural); and (4) arrows (for verb
type of work. Related factors such as distribution of learn- tenses).
ing episodes over time may be important and should be Shapes. Each shape groups words into phrases that
explored relative to syntactic interventions (cf. Ambridge answer a question such as “who,” “where,” and “what
et al., 2006; Riches et al., 2005). A comprehensive sum- doing” (see Figure 1 for examples and Table 2 for a
mary of evidence is available in Ebbels (2014), and we list of the shapes, their related question, and their syntactic
have adapted and expanded the table she provided to in- role).
clude all of our current studies. Table 1 provides effect sizes Colors. Colors are used for parts of speech and are
(when available) and magnitude of effects. Future studies associated with particular shapes (see Table 3). In some
using the same approaches, populations, and outcome shapes, a particular color word is required (e.g., a red word/
measures could compare different dosage variations against noun in an oval/noun phrase). However, additional words
the effect sizes described in the evidence base for our three can also appear; indeed, this is how sentence complexity is
approaches. built up. Colors may not always be used as this can be con-
fusing, especially when lots of words are included; in this
case, the words may just be written in black. The sen-
Approaches to Syntactic Intervention tences in Figure 1 are simple sentences, but the same pat-
The evidence base surrounding interventions designed terns could also be used for complex sentences with each
specifically to teach sentence-level structures has been shape containing many words. Figure 2 shows the same
growing. Here, we will focus on the three approaches that basic patterns but applied to complex sentences. Here, the
232 Language, Speech, and Hearing Services in Schools • Vol. 51 • 226–246 • April 2020

Figure 1. Simple sentences coded with the SHAPE CODING system.
colors are not used, or the internal structure, as the aim is to a tensed verb) and this has to match the time arrows on
show the overall meaning of the sentence. However, colors any “when” triangle.
and additional internal shapes could be included, if desired.
Lines for singular and plural. Noun–verb agreement Practicalities of Introducing and Using the SHAPE
is shown in the SHAPE CODING system by using double CODING System
lines under plural nouns and verbs and single lines under The SHAPE CODING system is a flexible tool that
singular nouns and verbs (see Figure 3). This helps avoid can be used to teach whichever aspect of morphosyntax is
errors such as “the boys is running,” as the noun and verb the current target for the child. Thus, the first step is for
must match in terms of single or double lines. A double the SLP to decide which area to focus on, and this will
red line in the oval noun phrase requires a double blue line depend on which specific areas the child is struggling to
in the diamond auxiliary or copula (which goes with “are” understand or produce and which of these is most func-
or “were”). If there are two entities in the oval (and hence tional and important in the child’s current circumstances,
two red lines in total, e.g., one under “boy” and one under for example, which will help the child communicate or access
“dog”), a double line is required in the diamond. This can and participate in lessons better. These decisions are sepa-
help prevent errors such as “the boy and his dog is run- rate from decisions about which methods to use. Once the
ning” as the single line under “is” does not match the two SLP has chosen a target, the SHAPE CODING system
red lines in the oval. may help them show the child how the rules for that struc-
Arrows. Verb morphology is indicated by underlining ture work. It is likely that only some aspects of the SHAPE
verbs (in blue) and using arrows (see Figure 4). Tensed CODING system will be required, depending on which
verbs have vertical arrows, with a vertical arrow in the middle structure is targeted, and only those aspects need to be
of the line for present tense and at the left-hand end for taught. Others can be added in later as other targets are
past tense. The progressive participle has a zigzag under introduced.
“–ing” to represent the continuous aspect. Children are The SHAPE CODING system is introduced to chil-
taught that every sentence must have “a down arrow” (i.e., dren using complete sentences, usually using structures they
Table 2. Shapes of the SHAPE CODING system.
Shape Related question(s) Syntactic role Color word required
Oval Who/what? External argument noun phrase (subject in active sentences) Red (often also pink)
Rectangle Who/what? Internal argument noun phrase (belongs inside other shapes) Red (often also pink)
Cloud What like/how feel? Adjective phrase Green
Semicircle Where? Usually prepositional phrase (preposition + internal argument NP) Often yellow
Hexagon What doing? Verb phrase Blue
Diamond Auxiliary, copula, modal verbs Blue
Triangle When?
Flag How?
Note. NP = noun phrase.

Table 3. Colors of the SHAPE CODING system.
Color Part of speech Examples Related shape
Red Nouns and pronouns dog, chair, he, him Ovals and rectangles
Pink Determiners and possessive pronouns the, a, his Often required with “red words” in ovals and rectangles
Blue Verbs sleep, snore Hexagons and diamonds
Green Adjectives small, sad Clouds
Yellow Prepositions on, under, beside Semicircles
Brown Adverbs slowly, fast Flags
Purple Coordinating conjunctions and, but, or
Orange Subordinating conjunctions when, if, because Often triangles
can already produce and understand. The starting point a question (e.g., “who”) and its answer (e.g., “the man,”
will depend on what structures are targeted, but given that “the dog,” or “Sam”). It is also important that the children
many grammatical targets for children with DLD involve do not think that each shape contains a single word, so a
verbs, the most common starting point is probably a simple next step may be to introduce subject–verb–object sentences
subject–verb sentence, for example, “the man is laughing.” (e.g., “the dog is chewing a bone”) and show that the answer
This would normally be introduced in the present progressive to the question “what is the dog doing” is “chewing a
(even if the child usually omits the auxiliary, this would bone,” thus more than one word. The rectangle may or
still be shown but would not be a focus in the initial stages). may not be put around “a bone” depending on whether the
The initial focus is for the child to understand that the SLP wants to focus on this (e.g., this may be desirable if
person or thing doing the action (“the man”) goes in the the focus will be on verb argument structure or increasing
oval and answers the question “who/what?”, while the ac- sentence length but may not be necessary if the focus will
tion (“laughing”) goes in the hexagon and answers the be on tense or agreement).
question “what doing?”. This can be done by turning shapes When teaching the child a new grammatical structure
around that have the question on the back and the phrase or rule, the following sequence may be used.
on the front, so that they see the direct connection between
1. The SLP introduces the target structure and gram-
the question and the answer. Laminated shapes work well
matical rule using the SHAPE CODING system and
for this, and the SHAPE CODING app also aims to rec-
demonstrates its meaning (often using small figures
reate this by flipping the shape following a long hold to
that can be placed on the relevant shapes and also
reveal the question. Omissions of determiners “the,” pos-
act out the meaning).
sessive pronouns “my,” or progressive endings “–ing”
are less important at this stage and can be a focus of later 2. Templates for that structure may be created using
intervention. the shapes, colors, arrows, and/or lines as appropri-
A key early step when using the SHAPE CODING ate to the target. These may be on paper or may be
system is for the children to understand the link between separate laminated shapes that can be written on or
Figure 2. Complex sentences coded with the SHAPE CODING system.

Figure 3. Noun–verb agreement using the SHAPE CODING 4. The adult/child acts out the other’s sentence using
system. small figures that can be placed on the oval and rect-
angle shapes to help work out which role they play
in the sentence (this is particularly important for
children whose targets involve comprehension, but
for those with expressive targets, this is also helpful
to show how their grammatical errors can affect
meaning).
5. Any errors that cause a change in meaning, or which
result in a pattern that does not match the sentence
template, are discussed and corrected.
6. The shape templates are removed, and the sentence
structure is produced and acted out if applicable.
The aim of this is for the child to internalize the
structures. Then, the shape templates are brought
back into view, and the accuracies of both production
and comprehension are checked with the template.
7. At the generalization stage, the adult may set up situ-
ations where the targeted structures are likely to be
used or where instructions including the target need
to be followed and then praise any use or correct
could be on a computer screen or on the SHAPE comprehension of the target, or correct errors by
CODING app. referring to the rules (e.g., “oops, you missed a dia-
3. The adult and child take turns to create sentences mond then” or “the dog was in the oval. So the dog
that match the shape template, either orally, or writ- is doing the action, not the cat”). The shape tem-
ten, or drawn on laminated shapes, or on the app. plates could be brought back if mentioning the rules
Suitable words that can go in different shapes could does not lead to correct production or comprehen-
be discussed in advance if these are not already avail- sion. A cueing hierarchy could also be used (see
able (as they are in the app), or the adult/child could Calder et al., 2018, 2020).
think of words on the spot. This is often preferable
if within the child’s capability as it is more creative Evidence Base for the SHAPE CODING System
and shows the flexibility and power of language, The effectiveness of the SHAPE CODING system
leading to sentences that are of interest or amusing has been investigated in a small but growing number of
to the child, which in turn leads to increased motiva- studies, which are summarized in Table 1. In contrast to
tion. While the app already has built-in suggested most interventions, these studies include some that focus
words for each shape, it is also possible to add custom on comprehension. The intervention studies include two
words of interest to the child. small-scale randomized controlled trials (RCTs; Ebbels
et al., 2014, 2007). In both of these, those children receiving
intervention using the SHAPE CODING system improved
Figure 4. Coding of verb tenses and time using the SHAPE
CODING system.
significantly more than controls who received intervention
on other areas of language. The first RCT involved 27 par-
ticipants with DLD aged 11–16 years (Ebbels et al., 2007),
investigated production of verb argument structure, and
compared 4.5 hr of intervention (30 min weekly for 9 weeks)
using the SHAPE CODING system (called “semantic–
syntactic therapy” in the study), with intervention focusing
on verb semantic representations. The progress of partici-
pants in these groups was compared with that of partici-
pants receiving a control intervention of equal intensity
and length on an unrelated area. Both methods were
based on detailed hypotheses regarding the underlying
reasons for the participants’ difficulties with verb argu-
ment structure, and both groups made significant prog-
ress in verb argument structure, unlike the control group.
Progress in the intervention groups also generalized to
nontaught verbs and was maintained 3 months after inter-
vention ceased.

The second RCT (Ebbels et al., 2014) involved CSI
14 participants with DLD also aged 11–16 years and focused
CSI (Balthazar & Scott, 2017, 2018) was developed
on comprehension of coordinating conjunctions (“but not,”
in order to help children with DLD aged 10 years and up
“neither nor,” “not only but also”) for 30 min weekly
meet the syntactic demands of the academic environment.
for 8 weeks (4 hr). The results showed those in the inter-
The aim of CSI is increased use and variety of complex
vention group improved their comprehension of the targeted
sentences, focusing on complexity created through subordi-
conjunctions significantly more than the waiting controls.
nate clauses. The CSI protocol teaches the three types of
The waiting controls had received equal amounts of inter-
subordinate clauses that account for the large majority of
vention on other areas of language, but when they too
complex sentences found in texts and in the spoken and
received intervention using the SHAPE CODING system
written output of mature language users: adverbial clauses,
focused on the target area, they then also made progress.
object complement clauses (clauses in object position), and
Progress also led to increased scores on the Test of Reception
relative clauses (Loban, 1976; Perera, 1984; Scott, 1988).
of Grammar (Bishop, 2003). Analyses of child-related factors
Each type of subordinate clause is taught in two-clause
(including nonverbal and visual processing abilities) revealed
sentences in order to maximize focus on the relationship
no significant predictors of response to intervention.
between the main and subordinate clauses. Each session is
Other smaller, less robust studies have also been
organized to provide explicit descriptions and practice in
carried out into the effectiveness of the SHAPE CODING
identifying and manipulating clauses. Contextualized prac-
system. Ebbels and van der Lely (2001) used a multiple
tice using material from curriculum-based texts and com-
baseline design and aimed to improve expression and com-
mon academic tasks is also included in order to expand
prehension of passives and wh-questions in four adolescents
and deepen conceptual foundations that contribute to func-
with DLD (aged 11–14 years). Three of the four participants
tional use and comprehension.
showed significant progress in both their comprehension and
production of passives after 10 hr of intervention. Interven-
tion on wh-questions lasted for 20 hr. Two participants had Adverbial Clauses
difficulties comprehending wh-questions preintervention, and In sentences with adverbial clauses, a subordinate
both showed significant progress in this area. All four par- clause is joined to a main clause, usually with a conjunc-
ticipants showed short-term progress with the production tion such as “although,” “while,” “whereas,” “because,”
of wh-questions, but only one participant maintained this “if,” “unless,” and so forth. Adverbial conjunction words
at a significant level by follow-up. The three partici- encode logical relationships. These types of clauses expand
pants who responded best participated in a follow-up on the verb in the main clause by adding information
study (Ebbels, 2007) targeting comprehension of the dative about relationships including time, cause, manner, or place.
construction (e.g., “the boy is giving the girl the rabbit”) The default position of an adverbial clause is after the
and comparative wh-questions (e.g., “what is bigger main clause (right-branching, e.g., “Student grades will be
than a cat?” vs. “what is a cat bigger than?”). All three re- posted tomorrow even though Professor Jones is on medi-
ceived intervention on datives, but only two received inter- cal leave”); however, adverbial clauses can be placed be-
vention for wh-comparatives due to a change of SLP. Two fore the main clause in order to emphasize it or to provide
of the three participants showed significant progress in transitions between sentences (left-branching, e.g., “Even
their comprehension of dative constructions. The third was though Professor Jones is on medical leave, student grades
hypothesized to have additional short-term memory diffi- will be posted tomorrow”). Left-branching adverbial
culties, which made progress on this area more difficult, clauses, also referred to as “fronted adverbials,” are later
due to the need to remember the order of three key nouns. developing and much more prominent in literate than con-
However, this participant made significant progress in com- versational language.
prehension of comparative wh-questions, as did the other The key features to explain are that (a) the adverbial
participant who was taught this structure. clause will tell more about the main clause, such as the
The majority of the studies of the SHAPE CODING time, cause, place, or manner of something that happened;
system have been with secondary-age children. However, (b) the adverbial clause will usually start with an adverbial
recent studies have investigated its effectiveness with younger conjunction; and (c) adverbial clauses often come after the
children with DLD for improving the use of the past main clause, but they can come before it, too. It is a good
tense (Calder et al., 2018, 2020; Kulkarni et al., 2014). idea to provide a list of the adverbial conjunction words to
Kulkarni et al. (2014) carried out a multiple baseline de- use during instructional activities.
sign with two children aged 8;11 and 9;4 (years;months)
and found significant gains after 5–8 hr of intervention. Object Complement Clauses
The studies by Calder et al. (2018, 2020) involved partici- A second type of subordination is an object comple-
pants aged 5;10–7;0 and combined the SHAPE CODING ment clause, in which the object of the main clause verb is
system with a systematic cueing hierarchy resulting in sig- a whole clause rather than just a noun phrase. These
nificant progress in the use of the past tense after 5 hr (2018) types of clauses often begin with “that,” but the word is
or 10 hr (2020) of intervention for the majority of the optional, and if taken away, the sentence is still grammati-
participants. cal. Other words that begin object complement clauses

include question words such as “what,” “when,” “who,” an object noun, and (d) that it usually starts with a relative
and “where.” Note that not all verbs with an argument pronoun. It is helpful to provide a list of the relative pronouns
structure including direct objects can “take” an object com- for the student to use during instructional activities.
plement and the ones that do tend to be verbs referring to
state of being or communicative acts (stative and reporta- Session Components
tive verbs, such as “be,” “let,” “tell,” “say,” and “exclaim”) The features of the target subordinate clause are first
or that code mental states (cognitive state verbs, meta- explained verbally with several examples shown in writing.
linguistic verbs) such as “think,” “know,” “conclude,” As the verbal explanation proceeds, the clinician marks
“decide,” and “predict.” This group of verbs is important the examples to indicate the features visually (see Figure 5).
in academic language because they allow writers to address After explanation, there are several additional examples for
processes, ideas, and opinions as objects. repetition and then a short reading with the target sentence
A list of verbs that take object complements, drawn types highlighted. There are then several practice activities,
from grade-level curriculum materials, can be a helpful including sentence identification, sentence deconstruction,
visual reminder during instructional activities. Since object and sentence combining, during which correct responses
complements take many forms, it may be also be helpful are scaffolded with gradually diminishing levels of clini-
to show the different patterns (see Balthazar & Scott, 2017). cian supports such as cues and models. A contextualized
An explanation could include telling the student that (a) some task completes the session, either sentence generation, pref-
verbs help us talk about feelings, thoughts, senses, and erence production, or cloze production. These last activities
mental activities; (b) these verbs can have object comple- focus on the meaning and function of the subordinate
ment clauses after them; (c) the object complement tells clauses, by either encoding ideas using the target sentence
“what”; and (d) there is more than one way to make an structure, contrasting meanings of alternate sentences,
object complement clause. or recalling and reproducing example sentences from a
longer text.
Relative Clauses Sentence repetition. In sentence repetition tasks,
Relative clauses, the third type of subordinate clause, several sentences with the target structure are presented
follow a noun and provide additional information about that for repetition. The student listens and then repeats. Usu-
noun. Typically, they begin with a relative pronoun (“that,” ally, three to five examples of the target pattern, drawn
“who,” “whose,” “which”), as in (1), but “that” can be from different topics and contexts, are developed for this
optional, and sometimes the clause is further reduced, as purpose.
in (2). Reading aloud. In a read-aloud activity, a short pas-
sage (between approximately 50 and 100 words) that con-
(1) Forty-five milligrams is the maximum daily intake that tains several exemplars of the target type of sentence can
is recommended by the Food and Drug Administration. be presented for the student and clinician to read aloud
(2) Forty-five milligrams is the maximum daily intake that together. The objective of this choral reading is to encour-
is recommended by the Food and Drug Administration. age fluent reading by providing adult support. This allows
Relative clauses can be classified into four types, for grade-level subject matter to be included without the
depending on their position in the main clause and whether student getting bogged down by her independent reading
the relative pronoun, which is always the head of the rela- level. The clinician reads expressively and at a normal to
tive clause, is the semantic subject or object of the sub- slow-normal rate, so that the student can keep up. If the
ordinate clause. When a relative clause modifies a subject student misses a word, it is usually self-corrected along the
noun, it interrupts the subject and verb, as in (3). These way, and the clinician can pause to allow self-correction.
are often called “center-embedded relatives,” and they are The target complex sentences should be reviewed after
among the later developing and more challenging types of reading, to briefly discuss what each added to the sentence
relative clauses for children with DLD, especially if they or how the subordinate clause related to the main clause.
have poor auditory memory. This is an opportunity to reinforce the relationship between
the type of complex sentence and how it is used to convey
(3) Almost all of the money that search engines make is particular meanings in connected discourse. The aim is
based on the keywords you type in.
to illustrate and prime the student with examples, not to
Relative clauses also vary in another important way, achieve perfect and complete comprehension.
namely, whether the relative pronoun replaces the subject Sentence identification. The aim of the identification
of the relative clause, as in (1), or the object, as in (3). activity is to teach the child about the key sentence features
Object relative clauses tend to be more difficult, because associated with the target subordinate clause. In sentence
the relative pronoun occurs in subject position of the clause identification, complex sentences can be presented on pa-
but actually replaces a noun in the object position that is per or on the computer, and the student highlights the
no longer visible. target subordinate clause (see Figure 6).
The key features to explain are (a) that a relative clause Sentence deconstruction. The aim of the deconstruc-
tells more about a noun, (b) that it always follows the noun tion activity is to assist the student in transforming the sub-
that it tells about, (c) that it can be after the subject noun or ordinate clause into its base form. Sentence deconstruction

Figure 5. Example of an explanation of visual codes for a relative clause, as presented in electronic format on a
computer screen.
begins the same way as sentence identification, but the Preference production. The preference production
main and subordinate clauses are pulled apart. These sen- task highlights meaning contrasts between pairs of sen-
tences can be presented on paper or on a word processing tences that are similar in structure. It requires the student
program or app (see Figure 7). Students either write out to integrate what they know about the world with the con-
the main clause and the subordinate clause on paper or cepts encoded by the various types of complex sentence
highlight and move these clauses into the appropriate slots clauses. The clinician presents two sentences that are almost
on a computer or tablet device. Deconstruction is particu- the same, except for one key word or phrase. The clinician
larly helpful for illustrating how relative clauses, which and student read the sentences aloud together and then
involve both pronominal replacement and often a change find and highlight the subordinate clause in each one. Then,
in word order, are constructed. the clinician will ask the student to think about what each
Sentence combining. Sentence combining also illus- sentence means and decide which one he or she agrees
trates the relationship and transformation involved in cre- with more, or which one is true, or which one makes more
ating a complex sentence. Two clauses are presented in a sense. Some clinician assistance is usually required to make
form that facilitates a student’s ability to easily rearrange the inferences necessary to decide which sentence is the
words to create their responses, such as movable strips of most sensible. It may also be necessary to explain vocabulary
paper or electronic media as with sentence deconstruction. words with which the student is unfamiliar; usually, a
The clinician helps the student start combining by building simple explanation or synonym will suffice.
the ideas behind the sentence and gradually guiding the Cloze production. A more advanced discourse-level
student into the desired sentence form. Grammatical, spell- production activity, which is more challenging because it
ing, and other errors are not viewed as incorrect for the taxes memory, conceptual, linguistic, and metalinguistic
purposes of this task. Only clause structure errors are di- resources simultaneously, is a cloze production passage. In
rectly corrected and discussed. All other errors are simply cloze production, the clinician prepares a short reading
corrected through modeling or recasting. passage that contains the target complex sentence type(s).
Sentence generation. Sentence generation can be ac- One copy is complete, and a second copy is modified to
complished in a number of ways. In the CSI protocol, we remove the target subordinate clause(s) and replace them
provided a brief, two- to three-sentence “story” and a main with blanks. This is easily done on a computer within a
clause followed by a blank, in order to elicit the subordinate word-processing program. Initially, the clinician and student
clause (see Figure 8). This process works well for all subor- read the first passage aloud together. Then, the complete
dinate clause types but is particularly useful for teaching version is removed, and the passage is again read aloud
object complement clauses. together, stopping where the blanks are. The student is
Figure 6. Example of a completed student worksheet used for the sentence identification task. The student’s
response is to highlight the target subordinate clause, in this case, a relative clause.

Figure 7. Example of a deconstructed sentence as presented in dosage on response to CSI. Thirty-one participants, aged
electronic format on a computer screen. The student has copied
each clause using a mouse to cut and paste each clause into
10–14 years, were treated for 9 weeks in either once-weekly
a “main clause and dependent clause” area, and then each is or twice-weekly 40- to 60-min sessions targeting complex
corrected to become an independent clause. sentences containing adverbial, object complement, and
relative clauses. At the end of 9 weeks, both groups dem-
onstrated an average 10–standard point gain (from an
average of 72–82) on the primary norm-referenced language
measure of the study, the Core Language Quotient of the
Clinical Evaluation of Language Fundamentals–Fourth
Edition (Semel et al., 2003), with the majority of the changes
accounted for by the Formulated Sentences subtest scores.
Performance on another primary outcome measure, the
then asked to provide a clause that fits in the blank and write complex sentence probes, also improved for the majority
or type it verbatim (or dictate it for the clinician to write). of participants (see Table 1); however, results differed by
The clinician should provide immediate feedback on the sentence type, with the largest effect sizes for adverbial and
response. Feedback can be both structural and semantic relative clauses. Significant pretreatment–posttreatment
(e.g., explaining whether the response makes sense). The cli- gains were not found on reading and writing measures.
nician and student can work together on a better response Participants in the higher dosage condition did not perform
and then reread, backing up a few sentences before the sen- significantly better than the comparison group; however,
tence with the filled-in target subordinate clause. the relatively short period of treatment overall (9 weeks)
and the fact that treatment targets were limited to two-
Evidence Base for CSI clause sentences, among other factors, leave many questions
Balthazar and Scott (2018) completed an early-phase regarding dosage unanswered. While these are not conclu-
efficacy study to assess treatment effects and the impact of sive results, they do suggest that one or two 1-hr sessions
per week of individual treatment aimed specifically at
Figure 8. Example of the sentence generation task.
complex sentences could produce meaningful gains.
MetaTaal
The MetaTaal approach derives from the program
“Grammar in Form and Color” developed in Denmark in
the early ’70s for children with severe hearing problems
(K. Thyme, personal communication, December 8, 2010).
This intervention program targeted morphosyntactic struc-
tures by using a metalinguistic and multimodal approach.
The program used LEGO bricks of various shapes and
colors to depict word classes and grammatical functions.
Building sentences with these LEGO bricks helped children
to understand and produce grammatical sentence struc-
tures. Thyme based her approach on Freunthaller (1937),
who developed a program that visualized grammar in
order to teach German and foreign languages to children
with severe hearing problems. Freunthaller’s basic idea was
that children with grammatical problems could learn mor-
phosyntactic structures with visual support and “pattern
practice.” Thyme’s program was never officially published,
but Van Geel (1973) translated and adapted the interven-
tion for Dutch children with DLD. The program became
quite popular in the Netherlands, and LEGO provided
special packages containing all the LEGO bricks needed to
work with the program. In later years, the interest in the
approach gradually waned, and the program was not devel-
oped further. The original versions of Grammar in Form
and Color only contained material to construct simple sen-
tences and coordinated sentences. Zwitserlood, Wijnen,
et al. (2015) further adapted the Dutch Grammar in Form
and Color program with LEGO bridges functioning as
connectors in order to build more complex sentences. This

new version was named “MetaTaal” and was evaluated in MetaTaal is a multimodal metalinguistic interven-
two quasi-experimental intervention studies targeting pro- tion program, making use of visual, tactile/kinesthetic, and
duction of relative clauses (Zwitserlood, 2015; Zwitserlood, motor channels to teach grammatical constructions explic-
Wijnen, et al., 2015). In these single-subject repeated-baseline itly to children with DLD. Children learn to build sentences
designs, complex sentences containing right-branching with LEGO bricks from left to right and are provided ref-
(sentence final) and center-embedded relative clauses erence sheets so they do not have to memorize the functions,
were selected as treatment goals. This choice was based colors, and sizes of the bricks. The first step is to build
on the results of a longitudinal study of children with simple, familiar sentences in order to learn the program.
DLD between the ages 6 and 10 years (Zwitserlood, 2014), The second step is to combine simple sentences into coordi-
which found 10-year-old children with DLD used fewer nated clauses (see Figure 9).
relative clauses (often containing more errors) than the In the next step, children learn that words can be moved
typically developing age-matched control groups. The ratio- or deleted from the sentence by construction of coordinated
nale behind choosing relative clauses as an intervention sentences with reduction (see Figure 10). When children get
goal was that, if such challenging targets could be reme- this idea, the next step in the program is to build subordi-
diated successfully, this would provide evidence that nate clauses, particularly relative clauses at the end of a
older children with DLD could still benefit from therapy. sentence. The LEGO bridge is placed in a vertical posi-
Current tendencies in the Netherlands to diminish direct tion, so that the relative clause is on a lower level than the
intervention for older children with DLD should consequently main clause (see Figure 11). Children also learn that they
be reconsidered. can leave out the relative clause and still have a correct
At this point, it is appropriate to elaborate somewhat sentence, which does not apply the other way around,
on Dutch relative clauses. Relative clauses appear to be because the word order (final position of the inflected
challenging for children with DLD in various languages verb) of the relative clause is not correct for a stand-alone
(Zwitserlood, van Weerdenburg, et al., 2015). The different sentence.
relative clause types and functions were already explained The last step in the program is to build center-
in the section on CSI; however, Dutch and English relative embedded relative clauses. Because the relative clause is
clauses differ in a number of ways. A first difference is that, positioned on a lower level, an extra bridge is used to re-
in English object relative clauses, the relative pronoun is turn to the level of the main clause (see Figure 12). This
optional, whereas in Dutch, it is obligatory. Second, in second bridge gets a small corner stone on top and is called
Dutch relative clauses, gender agreement between the head a “comma-bridge,” because in written Dutch, commas are
noun and the relative pronoun is required. The relative pro- usually placed between the inflected verbs of main and rel-
noun can take either the common gender form “die” or the ative clauses. This is the only instance that a LEGO brick
neuter gender form “dat.” A third difference relates to their does not correspond to a word in the sentence.
verb placement requirements. In Dutch, the finite verb al- A more detailed description of the MetaTaal program
ways takes the second position in main clauses but appears can be found in Zwitserlood, Wijnen, et al. (2015). All ther-
in clause-final position in subordinate clauses. Because of apy sessions contain several components, such as explana-
these verb placement requirements, Dutch-embedded relative tion of the meaning of the sentences, identification of certain
clauses with animate subjects and objects are not disambigu- sentence elements such as verb placement in main and rela-
ated by word order, as is the case in English. Such clauses tive clauses, conjunctions, and the relative clause position
can remain ambiguous between a subject relative clause in the sentence. Construction and deconstruction of the
reading and an object relative clause reading (4). Disam- sentences with the LEGO bricks constitute an important
biguation can be effected by morphosyntactic means (e.g., part of each session, and all sessions are concluded with a
subject–verb agreement, as in (5) or by pragmatic plausibil- game.
ity (6). Examples 4–6 originate from Zwitserlood, Wijnen,
et al. (2015). Subscripts for singular (SING) and plural Evidence Base for MetaTaal
(PLU) are provided to indicate where subject-verb agree- In the first MetaTaal intervention study (Zwitserlood,
ment is required in Dutch. Wijnen, et al., 2015), 12 children with DLD with a mean
(4) Het konijntjeSING (S), dat (S or O) de jager SING (S or O) ziet SING, zit in het gras. age of 11;2 participated (see Table 1). The children were
The rabbit that the hunter sees, sits in the grass all enrolled in a special school for children with DLD.
1st reading (SS): The rabbit (S), that (S) sees the hunter, sits in the grass. They all received 5 hr of individual protocolled therapy during
2nd reading (SO): The rabbit (S), (that) (O) the hunter sees, sits in the grass. 5 weeks (30 min, twice a week). Children were treated by
(5) Het konijntjeSING (S), dat (O) de jagersPLU (S) zienPLU, zit in het gras. their own SLP, who remained blind to the results from the
The rabbit that the hunters see sits in the grass five different criterion-referenced tasks used to measure rel-
Reading (unambiguous); The rabbit (that) the hunters see, sits in the grass. ative clause production and comprehension. All tasks were
(6) Het konijntje dat de jager op de korrel heeft, zit in het gras. administered by SLPs not involved in the intervention and
The rabbit that the hunter on the bead has, sits in the grass not familiar with the MetaTaal program. The children
Reading (unambiguous): The rabbit (S) (that) the hunter draws a bead on, completed three monthly baseline measurements prether-
sits in the grass. apy, followed by a measurement directly posttherapy and a
retention measurement 3 months later. During the baseline

Figure 9. Coordinated sentences built with LEGO bricks.
and retention period, the children did not receive therapy. executed, except for a small pilot study investigating the
Results showed that the children made significant progress feasibility of using MetaTaal to teach English as a foreign
on two out of three relative clause production tasks, but language to Dutch adolescents with DLD (Develing, 2018).
not on the comprehension task. Subsequently, this inter- Most SLPs working with MetaTaal are members of the
vention study was replicated with a group of 18 children MetaTaal Facebook and Google discussion groups. Mem-
with DLD, with a mean age of 12;9 (Zwitserlood, 2015). bers often report that children are motivated to work with
These children visited four different special schools for chil- the program and make good progress during treatment
dren with DLD in the Netherlands and received additional and also on standardized language measures.
special care because of behavioral problems. Four different
SLPs treated the children with the same protocolled inter-
vention program. They were also blind to the results of all Summary and Directions for Future Research
measurements until the study was finished. Results from
Evidence for use of the syntactic intervention
this replication study were similar to the first study, with
approaches discussed here, with a range of people with
significant gains on the production tasks and no gains on
DLD and for a range of grammatical structures, is slowly
the comprehension task. It is noteworthy that this somewhat
growing, but many areas remain to be investigated. All
older group of children scored higher during baseline
measurements and also obtained higher scores during three of our approaches could also be described as treat-
the posttherapy and retention measurements. Notably, ment “packages,” interventions that use a variety of tools
it was observed in both studies that the relative clause sen- and methods together (i.e., metalinguistic instruction, stim-
tence repetition task yielded no effect immediately post- ulus organization, multiple modalities, target selection,
therapy, but the children did improve between the last intervention schedule). These separate components have not
baseline measurement and the retention measurement. been teased apart, and we therefore do not know to what
This interesting finding suggests that learning of complex extent they contribute differentially to treatment effects;
grammatical structures may be protracted and that admin- however, it is not clear whether separating elements is fea-
istering retention measurements is important. sible or necessary in order to make progress in maximizing
Based on the promising results of both MetaTaal treatment effectiveness. Generally, the greatest need for
intervention studies, the MetaTaal program was expanded syntactic intervention research involves practical variables
with other subordinate clause types, in particular, adverbial that could be leveraged to promote greater success of chil-
clauses with conjunctions “omdat” (because) and “als…dan” dren with DLD and greater adoption of evidence-based
(if/when…then). With this addition, MetaTaal covers the practices by SLPs internationally.
most frequently used subordinate clause types in spoken
Dutch child language. Currently, the program is used widely Treatment Delivery
by SLPs in special education and private practices. To With a few exceptions, these interventions have been
date, no further MetaTaal intervention studies have been delivered using individualized one-on-one child/clinician
Figure 10. Coordinated sentence with reduction built with LEGO bricks.

Figure 11. Sentence built with LEGO bricks containing a right-branching object-subject-type relative clause.
models. Other service delivery options should be explored, Target Populations

including small groups, peer-assisted, and curriculum-based It is important to investigate the range of individuals
models. Utilizing other agents of intervention such as par- who are likely to benefit from syntactic intervention approaches
ents, classroom teachers, and other special educators to like ours. One factor that has to be investigated further is the
deliver and reinforce intervention could also be systemati- age of the children. A certain level of metalinguistic aware-
cally studied. ness seems to be a prerequisite for metalinguistic approaches.
However, we do not know from what age onwards children
can benefit from these approaches. Expanded treatment
Functional Impact studies that include not only children and adolescents with
To date, there is little information about the effects DLD but also those with comorbidities such as autism spec-
of our approaches long term on functional academic tasks trum disorder, mild intellectual disabilities, or hearing im-
(e.g., note-taking, reading comprehension, writing) or aca- pairment should also be considered; indeed, such research
demic and social outcomes (e.g., graduation from high has started with the SHAPE CODING system, but on a very
school, postsecondary degree completion, employment, small scale (Ebbels et al., 2014; Newton et al., 2017; Tobin
self-perception, socioeconomic status). The ultimate goal & Ebbels, 2019). MetaTaal is being developed to offer a ver-
of intervention is to build the types of language representa- sion for younger children, with more simple sentence frames,
tions that support children’s success outside of therapy. We expansion of the number of constituents/arguments, and more
need to determine what aspects of functioning are subject different types of coordinated sentences. Efforts such as these
to therapeutic changes and over what time span. need to be increased, and their efficacy needs to be researched.
Figure 12. Sentence built with LEGO bricks containing a center-embedded subject-subject-type relative clause.

Dosage investigated, and disseminated for use. A much more robust
Research on dosage in interventions for children with evidence base is needed supporting use of such methods for
DLD is rather limited (Proctor-Williams, 2009). Although collecting detailed information about children’s syntactic
Balthazar and Scott (2018) found no treatment advantage knowledge.
for a higher dosage group that received intervention twice
a week, the variations on dosage and their relationships to SLP Training and Resources
various possible outcomes and durations were very limited In order to effectively implement intervention ap-
in that study. In both MetaTaal intervention studies, the proaches as the evidence base expands, additional training
children were treated twice a week in a special education and intervention resources need to be developed and evalu-
setting, while the majority of the studies on the SHAPE ated. It is critical that SLPs have access to training that
CODING system were delivered once a week. While the provides a good knowledge base of grammar in their home
aforementioned studies as well as anecdotal evidence suggest language; for SLPs who work with multilingual children
that treatment once a week produces positive effects, much with DLD, it may be necessary to know this information
remains to be evaluated in terms of the optimal dosage for other languages spoken frequently in their countries.
for grammatical intervention. Systematic examination Currently, there are some training opportunities
of dosage factors such as stimulus frequency and density available for the three approaches presented here. For
should also be undertaken, in order to maximize inductive MetaTaal and the SHAPE CODING system, these include
learning based on statistical learning principles (Plante & 1-day courses (either face-to-face or online for the SHAPE
Gómez, 2018). CODING system) to equip SLPs, teachers, assistants, and
parents with the basic knowledge to be able to use the ap-
Measurement proach. However, the specialist knowledge of an SLP is
Because children with DLD are a heterogeneous group required to identify the grammatical targets and when
when it comes to language symptoms, there is a need for and how to move on to new targets. It is likely that others
appropriate measurement tools to help SLPs identify which will have difficulty implementing the system without the
children need this type of intervention and which areas of support of a trained SLP, even if they have attended a
grammar to target. We know that two children with the basic training course. Training in the SHAPE CODING
same overall scores on a comprehensive language test can system also includes more advanced levels aimed at
look quite different when patterns of language strengths SLPs (and specialist teachers with good knowledge of
and weaknesses are examined more closely. We are interested linguistics) needing to code and teach more advanced
in not only who can benefit but also, perhaps more impor- syntactic structures. CSI training workshops have been
tantly, who can benefit the most. Studies to date have provided on-demand but are not broadly or frequently
suggested that intervention might have the greatest impact available. Considerable work is needed to improve the
on children with the lowest performance; however, this availability and effectiveness of training for increasing
remains to be systematically studied under a variety of clinicians’ ability to identify and intervene with syntactic
operational definitions of “low performance” and “benefit.” targets.
In addition to identifying which children should re- Another area of future development is resources. The
ceive syntactic intervention, additional research and re- SHAPE CODING system has released an app, suitable
sources are needed to support comprehensive assessment of for use on both Android and Apple tablets. A CD of
grammatical problems so that specific targets can be selected printable resources is also available, and there are plans to
for individual children. Standardized language tests do not convert these into downloadable resources in the near future
provide clinicians with an in-depth analysis of morphologi- as technology continues to move forward. For MetaTaal,
cal or syntactic features. Current methods include language sets of LEGO bricks, the printed program, and criterion-
sample analysis (Heilmann, 2010) for assessing children’s referenced tasks are currently available, with a new version
spoken or written language and picture selection or sen- (under construction) for younger children with DLD and
tence repetition tasks to assess language knowledge and an app under development for use during therapy and at
comprehension. Balthazar and Scott (2017) advocate for home. The three approaches discussed here are developing
constructing criterion-referenced tasks and dynamic assess- in terms of the evidence base, training courses, and re-
ments in order to increase the specificity and ecological sources, and these three areas are rightly closely linked; as
validity of the assessment. Although published methods the evidence base develops, so training and resources can
such as these can be used or adapted for any age, lan- follow.
guage, or genre of language, it requires extensive clinician
knowledge and training, as well as preparation and analy-
sis, to make such adaptations and interpret the results. An Conclusion
increased number of ecologically valid and flexible mea- The purpose of this article has been to summarize
surement tools, such as the Coloring Book Test (Pinto & the reasoning and methods employed in three explicit gram-
Zuckerman, 2019), act-out tasks using toy figures (Ebbels matical intervention approaches and to map a way forward
& van der Lely, 2001), and real-time paraphrasing (Balthazar for clinically useful research in this area. Considering the
& Scott, 2014; S. L. Gillam et al., 2009), need to be developed, empirical basis for our syntactic intervention approaches,

we suggest that SLPs select specific syntactic targets based problems with language development: Terminology. The Journal
on careful and individualized analysis. Furthermore, we of Child Psychology and Psychiatry, 58(10), 1068–1080.
recommend the use of implicit learning principles in combi- Bryan, A. (1997). Colourful semantics: Thematic role therapy. In
S. Chiat, J. Law, & J. Marshall (Eds.), Language disorders in
nation with explicit metalinguistic instruction, accom-
children and adults: Psycholinguistic approaches to therapy
plished through intentional selection and organization of (pp. 143–161). Whurr.
stimulus materials and supported with learning activities Calder, S. D., Claessen, M., Ebbels, S., & Leitão, S. (2020). Ex-
presented in multiple modalities. Although treatment plicit grammar intervention in young school-aged children
scheduling and dosage evidence is sparse, we recommend with developmental language disorder: An efficacy study
an intervention schedule involving at least one individual using single-case experimental design. Language, Speech, and
30-min session per week. Moving forward, more efficacy Hearing Services in Schools, 51(2), 298–316. https://doi.org/
research is needed that investigates the optimal distribu- 10.1044/2019_LSHSS-19-00060
tion of learning episodes, includes languages other than Calder, S. D., Claessen, M., & Leitão, S. (2018). Combining im-
plicit and explicit intervention approaches to target grammar
English, and addresses a variety of types of language dis-
in young children with developmental language disorder. Child
orders. As the evidence increases, practical clinical tools Language Teaching and Therapy, 34(2), 171–189.
to guide target selection, measurement of outcomes, and Cirrin, F. M., & Gillam, R. B. (2008). Language intervention
decisions about how to tailor interventions to individual practices for school-age children with spoken language dis-
needs must also be developed and disseminated in order to orders: A systematic review. Language, Speech, and Hearing
maximize both the effectiveness of the intervention and Services in Schools, 39(1), S110–S137. https://doi.org/10.1044/
the adoption of syntactic interventions by clinicians around 0161-1461(2008/012)
the world. Clark, J. M., & Paivio, A. (1991). Dual coding theory and educa-
tion. Educational Psychology Review, 3(3), 149–210.
Clegg, J., Hollis, C., Mawhood, L., & Rutter, M. (2005). Devel-
opmental language disorders a follow-up in later adult life.
Acknowledgments Cognitive, language and psychosocial outcomes. Journal of
The Complex Sentence Intervention treatment protocol Child Psychology and Psychiatry, 46(2), 128–149. https://doi.
(Balthazar & Scott, 2018) was developed with the support of org/10.1111/j.1469-7610.2004.00342.x
Grant 1R15011165 from the National Institute on Deafness and Conti-Ramsden, G. (2008). Heterogeneity of specific language
Other Communication Disorders. The content of this article is impairment (SLI): Outcomes in adolescence. In C. F. Norbury,
solely the responsibility of the authors and does not necessarily B. Tomblin, & D. V. M. Bishop (Eds.), Understanding devel-
represent the official views of the National Institute on Deafness opmental language disorders (pp. 117–130). Psychology Press.
and Other Communication Disorders or the National Institutes of Conti-Ramsden, G., & Durkin, K. (2012). Postschool educational
Health. The second MetaTaal intervention study (Zwitserlood, and employment experiences of young people with specific
2015) was supported by a grant from SIAC Programmaraad- language impairment. Language, Speech, and Hearing Services
VerbindendVernieuwen. This article is part of the forum “Morpho- in Schools, 43(4), 507–520. https://doi.org/10.1044/0161-1461
syntax Assessment and Intervention for Children.” (2012/11-0067)
Conti-Ramsden, G., Durkin, K., Toseeb, U., Botting, N., & Pickles,
A. (2018). Education and employment outcomes of young
adults with a history of developmental language disorder. In-
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LSHSS

Explicit Grammatical Intervention

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Table 2. Shapes of the SHAPE CODING system.

Shape Related question(s) Syntactic role Color word required

Note. NP = noun phrase.

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Color Part of speech Examples Related shape

Figure 2. Complex sentences coded with the SHAPE CODING system.

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models. Other service delivery options should be explored, Target Populations

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