or, by its more formal title:

Grammatical concepts of English: Suggested order of intervention

Have you ever asked the following?

“I know that I still need to work on grammar with older kids with DLD to ensure academic success, but what rationale should I have for selecting targets?”
 
“How do I decide what order to tackle the many areas of grammar that need support?”
 
“Is there any evidence to help me decide whether I should work on passives or relative clauses or adverbial clauses first? They all seem important—and hard!”
​

We're (finally!) ready with some answers. Enjoy.

The following Ask TISLP and its accompanying spreadsheet were created by Susan Ebbels, SLT, PhD and Amanda Owen Van Horne, PhD, CCC-SLP. Additional content support provided by Karen Evans, MA, CCC-SLP and Hilary Nicoll, BSc, SLT.

SLPs posing questions like this are rightly worried about maximizing academic and functional outcomes for children with DLD in the face of limited evidence to guide target selection for grammatical goals once children reach school age. As far as we are aware, no systematic studies have yet been completed that show which order of intervention is most effective, no matter how you measure efficacy (most likely to lead to the greatest immediate progress, most likely to lead to the greatest gains through generalization (e.g., Rvachew & Nowak, 2001; Owen Van Horne, Fey, & Curran, 2017)).
​

Evidence about the sequence of grammar treatment can be inferred WITHIN an area but not ACROSS areas

Within any given area (e.g., Questions), there is typically some preliminary evidence to suggest that some things should be learned before others (e.g., Y/N questions before Wh- questions), but across areas (e.g., Questions vs. Conjoining), there is rarely a clear ordering and two reasonable people (including the authors of this Ask TISLP!) might disagree. Indeed, the same SLP might make different decisions for different children as they consider the impact of each child’s specific difficulties with comprehension or production on their functioning in the classroom, playground, at home or when interacting with the wider community. This depends not only on the child’s profile but also on the topic areas being covered in that child’s class currently and the structures needed to interact successfully with others.

​Well, now what? Guessing time? No—because even though the evidence is limited, there’s still plenty of reason to predict that some things logically could or should be taught before others.
 
And because we know clinicians need some strategies now, we’ve shared our best guess at a likely order of treatment within each of several syntactic domains (main clause structure, noun phrases, negation, questions, adverbials, conjoining, agreement, tense/aspect, complement clauses, passives, relative clauses) in the tables available here. 

The first tab of the spreadsheet provides an overview of all the areas covered within each domain of morpho-syntax. If you hover your cursor over an item, you will see a pop-up note with a definition and/or example of that structure. Each column on the first tab then has its own tab (also linked from the column headings), which provides the same order with more details, including more examples of each structure type, any prerequisite structures, and notes about things to consider. In principle, an SLP could start at the top of any given column/tab and work their way down that tab and feel like they have some logical order of prerequisite skills through which they are passing that is either grounded in the typical development literature, or the typical development literature plus our own personal experience teaching children these targets. 

However, working straight down a single tab alone is unlikely to be the best strategy as areas near the top of most tabs are likely to be more functional and important than areas lower down most other tabs. Thus, switching from one tab to another, or indeed, combining targets across tabs may be the best approach.
 
What the color-coding means: The purpose of the colors is to aid decisions about how to order or combine across tabs, though we view these color-coded divisions as somewhat more disputable. 

• Red: foundational. Get these basic components in place before teaching anything else.
• Amber, Green, Blue: cross-domain groupings for things that might warrant attention before moving onto the next color block.

For example, an SLP working on amber areas of tense and aspect (e.g., is+VERB+ing) might want to teach grammatically correct who and what questions (also amber, who/what is VERBing?) before teaching third-person singular -s (green) or perfect tense (green). Some areas, like adverbial (e.g., he fell BECAUSE she tripped him), or complement clauses (e.g., he thought she tripped him on purpose), are often thought of as late-developing, but in fact are present in very young typically developing children’s speech and thus are also coded amber. Other elements within the same column may be primarily observed in literate language (e.g., thus, nevertheless, although).  Thus, we would encourage an SLP to not just proceed in lockstep down any individual column/tab, but rather to consider what else of that same color might need to be taught looking across the other columns/tabs before proceeding across color boundaries.

Some precursor skills may be required or may help link two areas of grammar 

In some cases, we can say that children must master certain precursor skills before being able to attempt a particular target (e.g., auxiliaries and copulas before Y/N Questions) because logically you need to be able to say am, is, or are before you can say Is she running? or Are you happy?.  Similarly, being able to use a wh-question word meaningfully by itself (Where?) may precede being able to use that wh-question word in a well-formed question; or understanding and use of temporal adverbs (before, after) ought to precede work on temporal adverbial clauses (before we eat dessert, we should eat dinner). In the more detailed tabs for each area, in addition to listing targets in a logical sequence, we also indicate when a skill from another tab is required to be successful. Occasionally we indicate the need for semantic or conceptual foundations (e.g., time concepts before tense), though there is a need to attend to conceptual underpinnings in general. We have tried to differentiate between REQUIRED precursors and recommended ones, though we note that this is based on logic, our own clinical experience, or intuition rather than empirical research evidence.

Remember: If you identify a target you’d like to work on, also check out its prerequisites. These are its logical precursors.

​Consider targeting academically relevant syntax goals even if morphology isn’t yet perfected

​Though it is common to work on pronoun case and verb morphology prior to working on compound and complex sentences, there may be reasons to move on to other targets prior to mastery. Examination of Brown’s stages shows that typical children are advancing their use of complement clauses and coordinated/adverbial clauses while still making errors in tense and agreement (Brown, 1973). Tense and agreement can show a particularly protracted course of development in children with DLD (Rice, Wexler, & Herschberger, 1998), even with intervention (Rice, Hoffman, & Wexler, 2009).
 
Thus one might want to target improved use of verb morphemes while also targeting syntactic goals such as the use of complement clauses (also called nominal clauses). For example, “mom said she put my homework in my folder” might be a critical thing to communicate and could be successfully communicated even if morphology is in error as long as embedding is intact (e.g., Mom say her put my homework here (points to folder)). Expressing cause-effect (me angry because he push me), if-then (if lunch money at home, you be hungry), before-after (before go school, I lose jacket), what someone said (Sally asked  I come her house after school), thought (I think we go today), desired (I hope we play together) or perceived (I see her car gone and no one at home) all require using embedded clauses and are critical for developing relationships and understanding school culture.
 
Teaching clause structure alongside morphology can help ensure that kids can communicate ideas associated with false belief (I thought…. but...) or reported speech (she said that...) (Durrleman & Delage, 2020) or introduce strategies for clause combining to allow conditional (If-then) or causal (because, so) concepts to be communicated. Two strategies exist: 

1. Always have both a target that hinges on morphology and a target that does not rely on morphology at any given time.
2. If a child seems ‘stuck’ and no longer making progress on a morphological target, consider moving on to a syntactic target or a different morphological target and cycling back later on.

At the same time, introducing morphological targets may be necessary for progress in many areas (e.g., negation, questions, passives), as shown by the notes about firm prerequisites in the detailed tabs.

​Comprehension of grammatical structures is at least as important as production

Successful interaction with others and access to the curriculum in the classroom depends both on being able to understand what others say or write and being able to clearly express yourself in speech and writing. We cannot assume that children who produce certain grammatical structures can also fully understand them. They may be producing strings of words they have previously heard without full understanding of the structure. Many children use context to help their comprehension, but when this is removed or limited, comprehension may break down. So, a child being quizzed by a teacher may not understand the difference between did you push Pete? and did Pete push you? leading to confusion about who was the guilty party.
 
It is vital that SLPs check children’s comprehension and production. Factors that support production may be different than the factors that support comprehension. Nonetheless, when working on a particular area of grammar it may be most efficient and effective to work on both comprehension and production together. For example, the SLP says a target sentence (e.g., the cow is pushing the horse) and the child acts it out with toy figures and then the child produces another sentence using the same structure (e.g., the cat is chasing the dog) and the SLP acts it out. This reinforces the meaning of the structure, the importance of the word order and works on both comprehension and production together. Indeed, a final stage may be for the SLP to deliberately “make errors” in their comprehension and production to see if the child can spot these errors, with the eventual aim of the child being able to spot their own errors and self-correct them. In the detailed tabs, we especially call attention to places where comprehension is likely to lag behind production or require special attention.

​Generalization across structures is limited

We also know that kids with DLD show limited generalization across structures. In work with young children using recasting as the therapy technique, Wilcox and Leonard (1978), for instance, showed that children learn each wh-word plus auxiliary combination individually and Curran and Owen Van Horne (2019) found that preschool and kindergarten children learned because adverbial clauses but did not generalize to other types of causal adverbial clauses. Explicit instruction or intervention with older children may result in generalization within structures more than the implicit approaches frequently used with younger children. Tools like visual cues (as are employed in the SHAPE CODING™ system) highlight how grammatical forms are similar and serve similar functions within the sentence frame, which may lead to better generalization to items with the same (Ebbels, van der Lely & Dockrell, 2007) or similar structures (Tobin & Ebbels, 2019). Nonetheless, ensure that a child has learned all aspects of a new structure before marking it as mastered.

​Focus on functional implications in your grammar goals and be flexible!

​This Ask TISLP and the linked tables were constructed in response to questions about working with school-age kids with DLD, but we have ultimately provided a broader view of interlocking goals in the area of grammar and syntax. Knowing what to target for school-age children can be difficult because they have made good progress on many of the ‘basics’ and now need support to master the nuances of literate and academic language. These aspects of grammar are areas even experienced SLPs may feel unsure of and need to brush up on in order to provide best supports.  Ongoing efforts to support SLP metalinguistic awareness, knowledge and confidence of interventions in these areas are available through SHAPE CODING™ program.
 
Each area is likely to require concentrated intervention in order to see sustained progress that is maintained over time. This is effortful and some structures may never be targets for some children due to the need to address competing priorities such as vocabulary or pragmatics. Clinicians should set intervention priorities based on functional impact linked to the child’s age and ability level and continuously revise these goals in consultation with the child, their parents, and their teachers. An adolescent or young adult may need the ability to engage with written language in academic texts, job contracts, and civil discourse. A younger child may need the oral language of the classroom and the playground the most. This is not to say that a younger child does not need access to complex syntax, however (Curran, 2020) or that an older child does not need to revisit tense and agreement (Nippold, Nehls-Lowe, & Lee, 2020).  An SLP should feel empowered to move beyond the order set forth in these tables in order to flexibly match the order of intervention to the particular functional needs of the individual young person and to educate others about the importance of different aspects of grammar and syntax for academic and professional success.

Notes and addenda:

This spreadsheet is for the English language. But what about the various dialects of English? Will everything hold up, regardless of dialect? Dr. Amanda Owen Van Horne and our topic area expert, Dr. Kyomi Gregory, provide a little further discussion on that here:

The short of it is:
Pretty much all of the syntax stuff is still okay across most English dialects. Morphology, however, gets trickier, e.g. with African American English (AAE), Southern White English (SWE), etc.

The longer answer is:
The examples and ordering given were developed with Mainstream American English (MAE) and British English data in mind because those are the dialects for which we have the most available data currently. Data from assessment and formal linguistics suggest that many syntactic frames appear to be dialect neutral—that is, they are produced using largely the same structure and in largely the same contexts in both MAE and, say, African American English (AAE), but the morphology is not (Zurer Pearson, 2004). Clinicians should double-check that individual forms are realized the same across dialects though. For instance, although all forms of English employ nonfinite complements, the way infinitival to within that structure varies (i.e., MAE: he wants to go home; AAE: he want go home; Riviere, Oetting & Roy, 2018). Main clause structures, adverbial clauses, complement clauses, passives, and relative clauses are frequently dialect-neutral targets.

Other forms, such as tense, agreement, negation, questions, and noun phrase agreement, are termed contrastive forms because they distinguish between two dialects. Complex verb forms (perfect tense) are contrastive between British English and MAE. Third-person singular-s, use of BE, and use of past tense are contrastive between MAE, SWE, and AAE. This doesn’t mean that contrastive morphological targets should be avoided, but rather that care should be taken to benchmark production against use by TD children who are the same age and speak the same dialect as the child. For instance, AAE speakers use tense less often than SWE speakers. But also, within each dialect, children with DLD use tense less often than TD speakers (Oetting, Berry, Gregory, Rivière, & McDonald, 2019). These forms may be produced differently when combined with other forms (e.g., negation, questions). A clinician should get familiar with the child’s dialect before deciding on how to order these forms across columns and how heavily to emphasize precursor skills. Comprehension of both the dialect variation spoken in the client’s culture and MAE is important given the literature on the role that academic language plays in literacy development (Puranik, Branum-Martin, & Washington, 2020). Thoughtful attention to how the child’s dialect is realized and the functional needs of the child is critical for ethical practice.
 

**2021 Update!**

Can't get enough? Well, have we got good news for you. Dr. Ebbels and her team are still hard at work on this resource, and since the publication of this version, they've put out an updated edition which, in addition to a few minor changes, levels up the grammar fun with a scoring system and more resources to help plan the order of targets to hit in therapy. Find the updated spreadsheet and this how-to video starring Dr. Ebbels. 

Associated links

Grammar Spreadsheet (Excel version)
Grammar Spreadsheet (printable version)

Cite as 

Ebbels, S., & Owen Van Horne, A. (2020). Grammatical concepts of English: Suggested order of intervention. The Informed SLP. https://www.theinformedslp.com/review/the-grammar-guide-you-never-knew-you-always-wanted

Disclosures

Authors of this Ask TISLP were paid for their contribution.
​The SHAPE CODING™ program, mentioned above, was created by author Susan Ebbels and her employer, Moor House School & College, receives financial compensation from training and resources. 

Works cited - see here