​Is syntax the broccoli of speech–language pathology training?
​Probably for some of us…but it is time for that to change!

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​As SLPs, we can hear a lateral lisp or a distorted /r/ from a mile away given our expertise in speech and articulation. Why can’t we do the same with syntactic errors? In my own clinical experience, the most powerful syntax intervention tool I have available to me is actually my own knowledge on the topic. Due to my “fluency” in syntax, I can quickly identify tricky sentences based on their grammatical structures and then provide appropriate scaffolding. The research is clear that students with specific language impairment (SLI) and developmental language disorder (DLD) have persistent grammatical deficits. Further, these language deficits heighten their risk for many negative long-term outcomes including academic underachievement, limited occupational options, incarceration, and sexual assault, among others. We are the specialized professionals who need to step in and help. Our job begins much earlier than the provision of therapy. We have a responsibility to identify the children who will benefit most from our syntax interventions.
 
The vast majority of students with SLI/DLD are unidentified for clinical services by school-entry and the picture does not improve as time goes on (Tomblin et al., 1997). Unfortunately, we know that SLPs play a role in this under-identification issue and, thus, we have an obligation to address it ourselves. We over-rely on omnibus assessments (e.g., CELF, CASL); we often use assessments lacking in key psychometric properties; and, when doing domain-specific follow-up testing, we tend to gravitate towards vocabulary assessments rather than morphosyntax/syntax (Betz, Eickhoff, & Sullivan, 2013; Fulcher-Rood, Castilla-Earls, & Higginbotham, 2018; Spaulding, Plante, & Farinella, 2006). All of which is not in alignment with evidence-based practice. Omnibus language assessments, while convenient, do not provide the depth and breadth of the impacted morphosyntactic and syntactic structures in the SLI/DLD population. What can we do to change this? Self-analysis of our routine language-based diagnostic practices is a great place to start. Select omnibus language measures with sufficient sensitivity/specificity for diagnostic purposes and carefully consider which domain-specific assessments you administer in order to thoroughly explore potential grammatical deficits. Thorough domain-specific testing is imperative, as you will see below, since it allows you to identify an individualized profile of morphosyntactic and syntactic deficits, which guides intervention design. Suggested assessment tools include the Test of Early Grammatical Impairment (free here), the Structured Photographic Expressive Language Test-3rd edition, and sentence-level subtests tapping complex sentence knowledge (e.g., formulating sentences, grammatical judgements, sentence combining). Complement your standardized assessments with transcribed language samples to gather data on how your students use language, and grammar specifically, in functional contexts.
 
Here is where the story gets bleaker and, because of that, here is why having a strong knowledge-base of syntax and strong evidence-based assessment practices are crucial for intervention desgn: syntax does not have many pre-packaged intervention options out there for school-aged students. Ebbels’ 2014 review of grammar interventions is a great place to start learning. Overall, the author concluded that grammar intervention is effective, especially for students without receptive impairments. 
***You may be thinking, “Wait, I have almost no students on my caseload without receptive language impairments.” Hmm…remember our discussion about evidence-based assessment practices above? Perhaps those are some of the students that we are missing… 

​The following is a list of the reviewed grammar intervention targets (Ebbels, 2014); see the individual papers listed in the review to dig into the relevant topics more deeply:  ​

​While implicit approaches (e.g., recasting, focused stimulation) have been documented to be effective for preschool, explicit approaches (metalinguistics) are most promising for school-aged children (Ebbels, 2014). Keep in mind that the majority of grammar interventions stem from efficacy research. That is, research conducted under ideal environmental circumstances to identify whether the treatment has potential. Thus, your clinical expertise in general treatment implementation (e.g., managing your environment, student engagement, scaffolding) remains an important intervention ingredient. Below you will find introductory information on two interventions. These are not the only interventions available; rather, they are examples to help you step into this area of practice and to see that syntax intervention is not all that overwhelming once familiar with the concepts. Both intervention examples share the same core constructs—explicit teaching and metalinguistics (i.e., engaging students in their own thinking about language).
 
Argument Structure  What is this, you might wonder? Let’s have a quick refresher. Verbs play a central role in sentence processing. They dictate how many arguments are required in a sentence and what roles those arguments play. Using the sentences in the figure below, the verb stuff contains 3 arguments with 2 being obligatory/required—the noun phrase you; the noun phrase the toys/box; and the prepositional phrase in the box or the adjunct (i.e., optional) phrase with the toys. Children with SLI/DLD are known to make errors including the omission of required arguments or incorrect use of arguments (e.g., “The lady is filling the sweets into the jar", Ebbels, van der Lely, & Dockrell 2007, p. 1332).
 
Ebbels, van der Lely, and Dockrell (2007) completed a randomized control trial on shape coding for improving argument structure knowledge in children with SLI/DLD. Shape coding is a metalinguistic intervention using “a combination of shapes, colors, and arrows to ‘code’ phrases, parts of speech, and morphology, respectively” (p. 1331), as shown in the figure below. The authors provide you with a shape code key (i.e., which phrase type corresponds to which shape/color), the corresponding question shape, and some example shape coded sentences. ​Using a shape template, the child and clinician work together to act out and observe the various verbs in action using provided manipulatives. The observer creates a matching sentence using the shape template and the actor judges the accuracy of that sentence. Then, they switch roles. Results revealed significant improvement as compared to a control group in the use of argument structure after only 4.5 hours of therapy. The gains were maintained at a 3-month follow-up and generalized to untrained verbs. Ebbels and colleagues have documented effectiveness of shape coding for other grammatical targets too, such as past tense -ed, passives, and wh-questions.

Complex Sentences  While much research has documented complex sentences as an area of deficit in production and comprehension for students with SLI/DLD, we are quite limited in the treatment options available to us. Balthazar and Scott (2018) recently revealed that targeted intervention can improve three types of complex sentences. While their study population included kids aged 10 to 14 years, intervention targeting complex sentences can and should begin earlier. The acquisition of complex sentences begins in the preschool years (Diessel, 2004) and research has shown that children with SLI/DLD are at risk for delayed development, less frequent usage, and more prone to errors from the very beginning (e.g., Owen & Leonard, 2006). The complex sentence types targeted in Balthazar and Scott (2018) included:

These three sentence types comprise a large majority of the sentence types that school-aged children, adolescents, and young adults encounter in academic language. Examples of the targeted complex sentences can be found in the appendix of the research article and the authors outline the various treatment activities included in the intervention. Sessions were 40 to 60 minutes in length and were conducted either once or twice per week, although they did not find an advantage for the twice per week group. Direct teaching included discussion of sentence type definitions and structural characteristics, what they contribute to sentence meaning, ways to identify the sentence type in texts, and how to differentiate them from other sentence types. Activities included practice with sentence repetition (priming), sentence identification, decomposing complex sentences into simple sentences, combining/generating complex sentences from simple sentences, and contextualized activities (e.g., clause hunts within passages, cloze productions). See two example tasks below:
Conclusion For the school-aged population, targeted explicit and metalinguistic intervention is effective for students with SLI/DLD in relatively short treatment time frames. Keep in mind that both studies reviewed here included a sample restricted to SLI such that nonverbal IQ was within normal limits; generalizability of effects may differ within a larger DLD caseload with varying nonverbal IQ and concomitant conditions. Additionally, Ebbels’ (2014) review of grammar interventions suggested that efforts be spent determining which grammatical targets require intervention, reinforcing that our understanding of linguistic concepts and thorough grammatical assessment are imperative. A common intervention component across these two studies is focused and targeted instruction on a particular part of the grammar. The first step in intervention is determining the student’s individual linguistic profile. Knowing which structures to target based on thorough assessment will make syntax intervention much more natural to implement. Just as you know exactly when/how to scaffold and elicit an improved /r/ within treatment, you will additionally know when/how to scaffold and elicit an omitted third person singular -s or which complex sentences will likely be tricky while reading. You will encounter other grammatical deficits on your caseload besides those reviewed here. I direct you to The Syntax Handbook: Everything You Learned About Syntax…But Forgot, 2nd edition (Justice & Ezell, 2002), “The Language Characteristics of Specific Language Impairment” chapter from Leonard’s book Children with Specific Language Impairment (2014), and The Acquisition of Complex Sentences (Diessel, 2004), which are excellent resources for more in-depth learning.
 
Although we may be limited in the school-aged syntax interventions available to us, do not be hesitant to move forward! Take pride in the fact that we are the professionals who are most prepared to help students with syntactic deficits. Research shows that individual SLPs play a significant role in language-based treatment outcomes (Farquharson, Tambyraja, Logan, Justice, & Schmitt, 2015); the more prepared you are in this area of clinical practice, the more effective you can be for your students. Increasing your syntactic knowledge will allow you to use the many clinical tools you have accumulated in other treatment domains.
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June 2018
Answer provided by: 
Claire M. Selin, M.S., CCC-SLP
Doctoral student at the University of Kansas and Director of Language & Literacy at Children’s Therapy Services
Follow Claire on Instagram, Facebook, & Twitter ​to learn more about her research and clinical practice
  • Balthazar, C. H., & Scott, C. M. (2018). Targeting Complex Sentences in Older School Children With Specific Language Impairment: Results From an Early-Phase Treatment Study. Journal of Speech Language and Hearing Research, 61(3), 713–728.
  • Betz, S. K., Eickhoff, J. R., & Sullivan, S. F. (2013). Factors influencing the selection of standardized tests for the diagnosis of specific language impairment. Language, Speech, and Hearing Services in Schools, 44(2), 133–146. http://doi.org/10.1044/0161-1461(2012/12-0093)
  • Diessel, H. (2004). The acquisition of complex sentences. (Vol. 105). Cambridge University Press.
  • Ebbels, S. (2014). Effectiveness of intervention for grammar in school-aged children with primary language impairments: A review of the evidence. Child Language Teaching and Therapy, 30(1), 7–40. http://doi.org/10.1177/0265659013512321
  • Ebbels, S. H., Van Der Lely, H. K., & Dockrell, J. E. (2007). Intervention for verb argument structure in children with persistent SLI: A randomized control trial. Journal of Speech Language and Hearing Research, 50(5), 1330–1349.
  • Farquharson, K., Tambyraja, S. R., Logan, J., Justice, L. M., & Schmitt, M. B. (2015). Using hierarchical linear modeling to examine how individual SLPs differentially contribute to children's language and literacy gains in public Schools. American Journal of Speech-Language Pathology, 24(3), 504–14. http://doi.org/10.1044/2015_AJSLP-14-0055
  • Fulcher-Rood, K., Castilla-Earls, A. P., & Higginbotham, J. (2018). School-Based Speech-Language Pathologists' Perspectives on Diagnostic Decision Making. American Journal of Speech-Language Pathology, 1–17.
  • Justice, L. M., & Ezell, H. K. (2002). The syntax handbook: Everything you learned about syntax--but forgot.
  • Leonard, L. B. (2014). Children with specific language impairment.
  • Owen, A. J., & Leonard, L. B. (2006). The Production of Finite and Nonfinite Complement Clauses by Children With Specific Language Impairment and Their Typically Developing Peers. Journal of Speech, Language, and Hearing Research, 49, 548–571. http://doi.org/1092-4388/06/4903-0548
  • Spaulding, T. J., Plante, E., & Farinella, K. A. (2006). Eligibility criteria for language impairment. Language, Speech, and Hearing Services in Schools, 37(1), 61–72. http://doi.org/10.1044/0161-1461(2006/007)
  • Tomblin, J. B., Records, N. L., Buckwalter, P., Zhang, X., Smith, E., & O’Brien, M. (1997). Prevalence of specific language impairment in kindergarten children. Journal of Speech Language and Hearing Research, 40(6), 1245–1260. http://doi.org/10.1044/jslhr.4006.1245