SLP 671 Quiz 2
When should we be concerned about late-talkers? (video)
- 1st words around 12 months of age -if child is not producing words by 18 months or only has handful, seek advice from doctor to see if hearing loss or developmental difficulties -for most LTs, no other problem other than child not speaking -looked at children 18 months with no words or limited words: -most late talkers were fine by 4 -2 predicting factors: 0 if they had problems with producing And predicting words 0 come from families with long term problems -reasonable to reassure parents if they don't have other language difficulty, good comprehension, and no family history -if they come from families where there is a history then it could be a risk factor
Longitudinal Course/Outcomes for LLE
-50%-70% of children with LLE are reported to catch up to peers and demonstrate normal language development by late preschool and school age -prevalence of language impairment at the age of 7 years was 20% for children with a history of LLE compared with 11% for controls (1 in 5 have LD by 7) -Although many children with LLE perform within the normal range on expressive and receptive language measures by kindergarten, their scores on such measures continue to be lower than those of children with a history of typical language development, matched for socioeconomic status -school-age children identified as demonstrating LLE also demonstrated: 0lower scores at 5 on language measures that tap complex language skills, such as narrating a story 0poorer performance on measures of general language ability, speech, syntax, and morphosyntax at the age of 7 years 0poorer performance on reading and spelling measures at ages 8 and 9 years 0lower scores on aggregate measures of vocabulary, grammar, verbal memory, and reading comprehension at the age of 13 years 0lower scores on vocabulary/grammar and verbal memory factors at the age of 17 years
LATE TALKERS CAN BECOME CHILDREN WITH LANGUAGE DISORDER OR LATE BLOOMERS
-Not all LTs eventually meet their same-age peers in language performance -Some LTs persist in their language delay and receive a diagnosis of a Language Disorder in elementary school -Language disorder is a diagnostic category in DSM-V. It refers to children who have difficulty acquiring and using language that is not attributed to sensory, mo- tor, genetic, cognitive, or other factors. -Late bloomers are LTs who do converge on average language performance, accord- ing to formal tests of language, as they approach school-age. However, late bloomers perform significantly below their same-age peers without a history of late talking
WHY EARLY INTERVENTION AND THE USE OF PARENT-IMPLEMENTED INTERVENTION?
-A parent-implemented intervention revolves around social interaction -In addition to a small vocabulary, LTs are described as serious, withdrawn, and less socially competent -LTs are also more dependent on adults for both initiating and responding in conversations, even when compared with younger children who are matched for vocabulary size -deficits in social engagement abilities are a part of the most impaired communication profiles they identified in LTs -parents adapt their communication style to fit the LT's social engagement presentation. Caregivers tend to become more directive instead of directed by their child's interests. -A parent-implemented intervention balances the interaction style in the caregiver- child dyad -a parent-implemented intervention shows greater effect sizes in expressive vocabulary growth when compared with other treatments -Parent-implemented intervention maximizes carryover of new skills including a new interacting style. -The parent-implemented intervention model dovetails well with ASHA's policy on a family-centered practice, addresses environmental risks, and maximizes protective factors against late talking -the Hanen Parent Program improved: 0 Receptive and expressive language skills, generally 0 Receptive and expressive vocabulary, specifically 0 Expressive grammar, specifically 0 Rate of communication -a parent-implemented intervention was applied to school-age children with Language Disorder. Improvements were observed in: 0 Verbal initiations 0 Sentence length 0 Child-to-parent utterances -Epigenome refers to chem- ical modifications to genes that result from negative and positive experiences
LATE TALKING IS A RISK FACTOR FOR PERSISTENT LANGUAGE DISORDER
-Late talking is a risk factor for persistent Language Disorder into the school-age years and the risk extends to reading disorder -For the LT, there is late emergence of vocabulary growth. Once growth is initiated, the growth curve follows a typical trajectory for some early language skills, but remains significantly below age expectation throughout childhood -After 4 years of age, the child with Language Disorder transcends a small vocabulary size to include difficulty with word retrieval, grammar, figurative language, and larger linguistic units of discourse -Grammatical impairments have become a clinical marker of Language Disorder, specifically, failing to mark verb tense and agreement by elementary school -Individual growth analysis of LTs with familial history of language impairment revealed a delay in emergence and slow growth of tense marking before 3 years of age in comparison with other LT peers. -Sentence formulations remain simple rather than complex in the child with Lan- guage Disorder -LTs who became children with Language Disorder presented with: 0A deceleration in grammatical development 0A premature ceiling in grammatical skill -LTs also come to literacy with uneven and weak spoken language development. -On functional MR it was found that by elementary school, children with a history of late talking, when identifying a word to match a picture, showed reduced engagement of various neural areas -the reason for lack of early identification is not yet known, but its suggested that, in addition to the late emergence of vocabulary, a second path to Language Disorder might be the toddler-preschooler who has timely emergence but a slowed rate of language after that.
DLD what we know Diagnosis and assessment
-Longitudinal studies consistently demonstrate stability in language status from school entry, with greater instability when children are identified in the pre-school years -about 40% of children identified with language delay by age 4 have spontaneously resolved by school entry -Early language skills predict small amounts of variance in later language ability and therefore universal screening is not recommended as it is not reliable enough and identifies too many false positives Risk factors associated with persistent DLD include: 0Family history of language or literacy deficits 0Socio-economic disadvantage 0Poor maternal education 0Lower non-verbal cognitive abilities 0Early developmental delays -DLD in the classroom may be difficult to notice if the child is quiet & able to follow the actions of other children in the classroom, without truly understanding the language or instructions. Teachers are more likely to notice obvious speech problems and/or behaviour difficulties, difficulties learning core curriculum content, and problems with learning how to read. -Speech-language therapists are the primary professionals charged with assessment and diagnosis of DLD in the UK, though a multi-disciplinary team may be required for differential diagnosis of an associated biomedical condition. Associated conditions may include: autism spectrum disorder (ASD), sensori-neural hearing loss, neurodegenerative conditions, brain injury, acquired epileptic aphasia in childhood, genetic conditions such as Down syndrome, cerebral palsy, intellectual disability Diagnosis of DLD requires the following: 0The child has significant language deficits relative to age expectations that create obstacles to communication or learning in everyday life 0The child's language problems are persistent and unlikely to resolve by five years of age 0The problems are not associated with a known biomedical condition, as listed above -Diagnosis will involve parent/carer interview of family history, observation of the child's language and communication strategies in everyday contexts, and direct assessment of language skills using standardised assessment. -Tomblin proposed that assessment focus on the EpiSLI criterion: five composite scores representing performance in three domains of language (vocabulary, grammar, and narration) and two modalities (comprehension and production) -clinicians may rely more heavily on omnibus tests of language, and measures of narrative ability have been shown to have good prognostic ability -Cut-off scores on these measures are arbitrary, though typically children scoring in the lowest 7-10% on two or more composite scores are identified as having DLD -Test scores should be compared to functional impact
DLD Prevalence
-Prevalence estimates of DLD may vary depending on the severity criteria for language, and whether or not non-verbal ability is used as an exclusion criterion. -The functional impact of DLD was evident in that only 12% of children identified as having DLD met early curriculum targets. -While clinical reports suggest more boys are affected, epidemiological studies have not identified sex differences in prevalence. This suggests that girls may be under-identified in community settings. DLD rarely occurs in isolation and children with DLD are at increased risk for a range of co-occurring conditions including: 0Attention deficit hyperactivity disorder (ADHD) 0Motor deficit (e.g. Developmental Co-ordination Disorder) 0Reading disorders (including both dyslexia and reading comprehension deficits) 0Speech sound disorders 0Social, emotional, and behaviour problems -In adolescence, children with DLD are twice as likely as peers without language disorder to experience internalising, externalising, and ADHD-type psychopathologies and approximately 1/3 of adolescents referred to tertiary child and adolescent mental health services have previously unidentified language disorder (Cohen et al., 1998). -From school entry DLD is persistent and characterised by parallel rates of language growth relative to peers -As a consequence, there is currently little evidence that children with DLD are able to narrow the language gap with typically developing peers. -Young people with DLD are therefore more likely to leave school with fewer academic qualifications and may experience on-going problems with employment, intimate relationships, and mental health
LLE Signs and Symptoms
-Signs and symptoms among monolingual English-speaking children with late language emergence (LLE) are often based on parent-report measures -MAIN SIGNS: 0an expressive vocabulary of fewer than 50 words 0no two-word combinations by 24 months of age -It is essential to review these criteria at regular intervals (e.g., every 6 months) to assess language growth and to determine if language skills fall outside of developmental trajectories and whether the child demonstrates LLE -consider other language development factors including: 0rate of vocabulary growth 0speech sound development 0emerging grammar 0language comprehension 0social language skills 0use of gestures 0symbolic play behaviors -when compared with toddlers of the same age with typical language development, late talkers may demonstrate: 0phonological differences once they do produce their first words, including less complex/mature syllable structures, lower percentage of consonants correct, and smaller consonant and vowel inventories 0delayed comprehension and use of symbolic gestures for communication 0use of shorter and less grammatically complex utterances—particularly for toddlers with expressive and receptive delays 0comprehension of fewer words -Research also suggests that delays and differences in babbling before the age of 2 years can predict later delays in expressive vocabulary, limited phonetic repertoire, and use of simpler syllable shapes -LLE may be an early indicator of language impairment -Receptive language skills, expressive vocabulary size, and socioeconomic status appear to be the best predictors of language outcomes
Children With LLE Versus Late Bloomers
-Some researchers distinguish a subset of children with LLE as late bloomers -Late bloomers are children with LLE who catch up to their peers. -At the onset, it is difficult to distinguish children with LLE from late bloomers because this distinction can be made only after the fact. -Some research suggests that there may be some early difference: 0late bloomers used more communicative gestures than age-matched children with LLE who remained delayed, thereby compensating for limited oral expressive vocabularies 0Late bloomers also were less likely to demonstrate concomitant language comprehension delays when compared with children who remain delayed
LLE Causes
-The causes of late language emergence (LLE) in otherwise healthy children are not known. However, several variables are thought to play a role. Child Risk Factors: 0Gender—Boys are at higher risk for LLE than girls 0Motor development—Children with LLE were found to have delayed motor development (in the absence of disorders or syndromes associated with motor delays) when compared with typically developing children 0Birth status—Children born at less than 85% of their optimum birth weight or earlier than 37 weeks gestation were found to be at higher risk for LLE 0Early language development—language abilities at 12 months appear to be one of the better predictors of communication skills at 2 years Family Risk Factors: 0Family history—Children with LLE are more likely to have a parent with a history of LLE 0Presence of siblings—Children with LLE are less likely than children without LLE to be an only child; these findings may reflect decreased maternal resources available to the child 0Mother's education and socioeconomic status (SES) of the family—Lower maternal education and lower SES of the family are associated with higher risk for LLE; maternal education and family SES are thought to be related to the amount of support (resources) available to the child for language learning -For children younger than 18 months, screen media use (other than video chatting) is discouraged -Infant exposure to certain types of media was associated with lower language scores, although the relationship between media and language development is not fully understood -Early identification and intervention can mitigate the impact of risk factors -Therefore, it is important for speech-language pathologists to recognize these risk factors when identifying LLE and considering service delivery options.
Development Language Disorder (DLD) Introduction
-The lack of consistency in terminology has been directly linked to poor public awareness of DLD -The CATALISE recommended the term DLD to denote a problem with language that stems from atypical developmental processes (as opposed to acquired brain damage, as in stroke or head injury) and to convey the serious nature and potential long term consequences of language deficits -DLD includes SLI, but allows for more variable non-verbal cognitive abilities -Including 'disorder' in the diagnostic label also provides consistency with other neurodevelopmental conditions such as 'autism spectrum disorder' or 'attention deficit hyperactivity disorder'. Phonology/speech sounds: -Children with phonological deficits may fail to distinguish between certain speech sounds, such as 't' and 'k', so that 'cat' is produced as 'tat'. -some error patterns are atypical, but most errors resolve by the time children are 4-5 years old -Persistent phonological deficits may reduce intelligibility of speech and difficulties identifying and manipulating speech sounds within words (phonological awareness) is associated with difficulties learning to read. Grammar/syntax: -Grammar is often a disproportionate area of deficit for children with DLD. -Comprehension of sentences can also be affected, especially when word order does not convey who did what to whom: For instance, there may be difficulty understanding sentences like 'the boy was chased by the girl' as children with DLD may interpret this as the boy doing the chasing Semantics: -Children with DLD often have difficulties learning new words. -They may therefore have limited vocabularies and the words they do know may not have the same depth of understanding seen in children with typical language development Discourse and Pragmatics: -Discourse refers to longer stretches of connected language, like conversation and narrative -Children with DLD very often have deficits in narrative and may find it difficult to maintain the thread of conversation -Pragmatic deficits may manifest as poor at turn-taking in conversation, maintaining the topic of conversation, or being able to repair conversations that breakdown by asking for clarification. -Pragmatics may also refer to the comprehension and use of linguistic forms that rely on context to disambiguate meaning, for example, non-literal language like metaphors and idioms, or making an inference
ABANDONING THE WAIT-AND-SEE APPROACH
-The position of the American Academy of Pediatrics is that children under 3 years of age are to be referred from the pediatrician's office for further developmental and medical evaluation if a toddler fails developmental screening -Under this initiative, children receive screening, referral and follow-up for developmental milestones -Standardized screening of developmental milestones occurs at 9, 18, and 30 months of age, as well as when a concern is expressed by a caregiver or is evident to the medical professional at well-child appointments. -Medical and medically aligned health researchers advocate abandoning the wait-and-see approach -New directions in brain and behavioral sciences, and the availability of large population samples, endorse referral for further evaluation, but not a wait-and-see approach, when it comes to children who are late to talk -ASHA's position is that access to communication is fundamental to all children from birth and even those at-risk, and advocate that interprofessional practice is the best approach to improving outcomes. -When considering referral for a LT, opt to refer for evaluation and potential intervention knowing that early intervention may result in long-term, positive outcomes for the child.
WHY WAIT AND SEE?
-The wait-and-see approach has been subject to debate -The origins of this approach include fear of harms in identifying children as possibly delayed. -Harms include extra time, increased effort, and anxiety associated with further testing of the child. However, speech-language pathologists report that care- giver stress can already be ongoing from anxiety that their child is not talking when expected, or from parents who differ in opinion on the issue -parent child relationship = negatively affected by late talking -Diagnostic labeling has also been suggested as a potential detriment -The US Preventive Services Task Force found no studies and, therefore, had insufficient evidence to make a recommendation regarding the potential harms (or benefits) of screening, referral, or intervention for speech-language disorders in young children -this approach may also hinge on the perception that late talking is largely "self-correcting" because a majority of LTs are viewed as simply late blooming. 3 problems with this thinking: 0First, although late bloomers seem to catch up on standardized test performance, late bloomers present a weaker endowment for language and related abilities 0Second, late talking is a significant risk factor for Language Disorder (Language Disorder is heritable.) 0Third, unerring predictors remain elusive in differentiating late bloomers from the child with Language Disorder, particularly from screening alone.
Late Language Emergence (LLE) Overview
-children from 2 to 4 years of age -LLE = a delay in language onset with no other diagnosed disabilities or developmental delays in other cognitive or motor domains. -diagnosed when language development milestones are below age expectations -referred to as "late talkers" or "late language learners." -may have expressive language delays only, or they may have mixed expressive and receptive delays -may be at risk for developing language and/or literacy difficulties. LLE may evolve into other disabilities, such as social communication disorder, autism spectrum disorder, intellectual disability, learning disability, or attention-deficit/hyperactivity disorder. -to make a differential diagnosis, consider hearing loss and monitor the child's global development as well as cognitive, communication, sensory, and motor skill development.
DLD What we know Causes
-common perception is that DLD results from poor parenting and a lack of appropriate language input during development, however it is in fact a much more complicated picture. -There is strong consensus that DLD is heavily influenced by genetic factors; Numerous studies have shown that while non-identical twins may differ radically in their language skills, identical twins tend to be much more similar in language ability. -Of course, there can be some variation in the severity and persistence of DLD in identical twins, indicating that non-genetic factors (such as chance experiences, differences in school or peer experiences, illness, etc.) affect the course of disorder, but it is unusual to find a child with DLD who has an identical twin with typical language. -The recognition that genetic factors play a role also informs us about environmental circumstances. -Many children with DLD will grow up to be adults with DLD -they will likely have lower levels of literacy and educational attainment -although there is considerable evidence that DLD is more common in children from socio-economically disadvantaged backgrounds, this likely reflects both genetic and environmental vulnerabilities
DEFINING THE LATE TALKER
-defined by an early language delay despite typical cognition, normal sensory and motor systems, and the absence of genetic or neurologic disease -A sluggish start to vocabulary acquisition is more likely to be transient if it occurs in isolation and is identified before 18 months of age. -In contrast, toddlers are more likely to persist in language delay the older they are when identified -screening for language delay has become the standard between the ages of 24 and 30 months of age.
DLD background
-diagnosed when a child's language skills are persistently below the level expected for the child's age -language deficits occur in the absence of a known biomedical condition, such as autism spectrum disorder or Down syndrome, and interfere with the child's ability to communicate effectively with other people -Expressive language is characterised by non-specific words and short simple sentences to express meanings -understanding of language (receptive language) is also a challenge -Aspects of language may be variably impaired and include: 0Phonology (speech sounds) 0Semantics (vocabulary) 0Syntax (grammar) 0morphology (endings on words that express grammatical relationships, like past tense -ed in English) 0Discourse (narrative, conversation) 0Pragmatics (social communication, inferencing, figurative language) -exact cause of DLD is not known, but it is likely that there are several interacting genetic and environmental factors, rather than one single identifiable cause. -Behavioral interventions are the most common approach to treating DLD, but there is no cure for DLD
LLE expressive, recessive, and mixed delays
-expressive: show delayed vocabulary acquisition and often show delayed development of sentence structure and articulation -recessive/mixed: show delays in oral language production and in language comprehension. -Children with LLE who have receptive and expressive delays are at greater risk for poor outcomes than children with LLE whose comprehension skills are in the normal range
LATE BLOOMERS HAVE WEAK ENDOWMENT OF LANGUAGE ABILITY
-late bloomers perform within age limits—many times within a low average performance range, on formal tests after having a slow start to vocabulary -a weak endowment for language is observed throughout childhood -This weaker endowment for language is reflected as a gap in test performance between late bloomers and typical peers that does not narrow or close, nor does it sort out individual differences -The gap between these 2 groups spans a variety of language skills including: Vocabulary, Verb morphology, Syntax, Reading, & Narrative -Late bloomers show slow maturation of neural processing, which is observed in event-related potential (ERP) responses to speech as early as 3 years of age through 5 years -Although the typical child shows a higher proportion of ERP signals in the frontal neural region, late bloomers do not. -By age 6 years, group differences in ERP responses disappear, but the gap between the late bloomers' and typical peers' test performance does not close -Social skills, executive function, and behavior regulation rely on prior language achievements. -late bloomers tested within the average range for language, but late bloomers had: Greater executive function problems, More emotional and behavioral regulation problems, & Fewer social skills
ASCERTAINING RISK FOR LATE TALKERS GUIDES EARLY PREVENTION
-no single reliable predictor has been found -Family history and being male most consistently emerge as being associated with late talking and/or Language Disorder -The presence of a comprehension delay in conjunction with expressive delay at 24 months also tends to be associated with persistent Language Disorder. -heredity played a greater role in a LT exhibiting a Language Disorder. 2 important predictors of the LT who then persisted with Language Disorder at 4 years of age were: 0Poor comprehension at 20 months of age 0The parent's inability to repeat nonwords when the child was 20 months old children reared at lower SES levels were more likely to be LTs than children from higher SES levels. How- ever, other variables mediated the effect of SES and those included: 0 Birthweight 0 Quality of parenting and childcare 0 The child's own approach to learning Protective factors were: 0 Informal play activities 0 Shared book activities between infant-adult dyads
Wait-and-See Approach: SCREENING IN THE PEDIATRICIAN'S OFFICE
-serves an important public health function -Early language screening is often the conduit to diagnosing primary disabilities such as autism or hearing impairment -early screening also identifies language delay as a primary diagnosis in its own right: Fewer than 50 words at 24 months of age, for example, can be a valid reflection of language delay and general neurodevelopmental problems -Late talking children in study: 0Presented with more middle ear ventilation disorders 0Reported more family histories of language disorders -Late talking children fell into 4 groups with language delays comparable in socioeconomic status (SES), family history of language disorders, and hearing health: (n 100 0Expressive language delay only (n=61) 0Mixed receptive and expressive language delay (n=17) 0Language delay with cognitive impairment (n=18) 0Autism (n=4) -Autism diagnosis = eligible for treatment, BUT ONLY language delay can be debated eligibility -Decisions depend on percent delay or standard deviation scores on formal testing, as well as other developmental domains affected
DLD What we know Treatment
-treatment for DLD is variable and many common approaches lack a sound evidence base. -Service delivery may be focused on 'tiers' or 'levels' of intervention, including Universal approaches designed to benefit all children -Targeted interventions that may be aimed at children with less severe deficits and carried out by non-specialist providers -Specialist services in which SLTs provide direct and/or individualised treatments to children with the most-significant needs -Large scale, high-quality randomised controlled trials are still relatively uncommon in the field and this makes it difficult to assess clinical efficacy -Children's language will improve over time, and without controlled studies, it can be hard to know how much of observed change is down to a specific treatment approach -In general, trials show significant, positive treatment effects for direct interventions with specific language targets including vocabulary, expressive grammar, and some elements of narrative and discourse -Receptive language skills appear much more resistant to treatment -Large scale studies of targeted language interventions show more variable outcomes and at best, modest treatment effects -children with DLD can learn aspects of language that they are specifically taught, but this learning rarely generalises to other aspects of language or other academic/developmental skills -In addition, changing a language trajectory remains challenging and is likely to take considerable time and on-going effort
DLD Areas of uncertainty
-we are still a long way from understanding how various genetic risk factors influence brain development, how differences in brain development affect learning, and why these differences would have disproportionate effects on language learning -Nor do we fully understand how genetic and environmental influences interact to yield the heterogeneous profile of DLD that we see. -We don't know whether or how language disorders could be prevented, in part because early assessment of language is less reliable and therefore not strongly predictive of later language ability -Prioritizing the under-5s could therefore result in treating large numbers of typically developing children and divert precious therapy resources from children with persistent language learning needs. On the other hand, resolving language disorder after the age of 4 is challenging. We need to know if there is an optimal age to intervene, and whether there may be periods later in development when intensive intervention may be particularly beneficial. -children with DLD are at increased risk for poor social, emotional, and behavioural outcomes -We don't understand the mechanisms that underpin this risk but school failure, variable education provisions, poor peer negotiating skills, and poor emotion recognition/regulation are all potential candidates -we urgently need to know how children with DLD access 'talking therapies' and what modifications to standard psychological treatments are required to ensure maximum benefit for children with DLD and their families. -Our intervention evidence base is improving all the time, but we are still a long way from understanding what kinds of interventions work best, when, and for whom. -We do not know the impact of common co-occurring conditions, such as general cognitive deficits, attention deficits, motor deficits, on response to treatment, or whether improvements in language functioning generalise to other aspects of development -Providing the dosage necessary to make significant change in language proficiency remains an on-going challenge given limited therapeutic resources. -Robust studies of on-line or computerised interventions for language are almost non-existent and urgently needed to evaluate whether such approaches could supplement face-to-face interventions.
Late Talkers Why the Wait-and-See Approach Is Outdated
A wait-and-see approach delays referral of a child for further developmental evaluation when s/he fails a language screening in toddlerhood. The view that most late talkers "catch up" seems to be outdated because they do not necessarily meet their same-age peers in all aspects of development. Late talking can also impact early socialization and school readiness, and can place some late talkers at risk for life-long disability. Interprofessional education and practice supports early referral for late talkers who are at- risk. Advances in the science of brain development, language development and disorders, and epigenetics support early identification and intervention, not a wait-and-see approach for late talkers. -approach can occur for various reasons: 0a lack of knowledge in bilingual development has led nurses to delay referrals. 0as a SLP, there is a gap between what is known about LTs and their outcomes when deciding on referral of a child for further evaluation 0One alternative to the wait-and-see approach is to refer an LT to a state's early intervention program. IPP is well- established in the early intervention system under Part C of the Individuals with Dis- abilities Education Ac -there will be at least 2 professionals working with a LT including: Audiology, Medicine, Nursing, Occupational therapy, Physical therapy, Psychology, Speech-language pathology, & Teaching
LLE Protective Factors
protective factors that may buffer children and families from factors that place them at risk for later language and learning problems: 0reading and sharing books with infants daily 0providing informal play opportunities 0being cared for primarily in childcare centers compared with all other forms of care The National Joint Committee on Learning Disabilities also identifies a number of protective factors: -access to pre-, peri-, and postnatal care - access to learning opportunities, such as 0exposure to rich and varied vocabulary, syntax, and discourse patterns 0responsive learning environments that are sensitive to cultural and linguistic backgrounds 0access to printed materials 0involvement in structured and unstructured individual/group play interactions and conversations 0engagement in gross and fine motor activities 0access to communication supports and services as needed.
