Interactive Book Reading to Accelerate Word Learning by Children With SLI
Phase: NA
Conditions: Specific Language Impairment
Sponsor: University of Kansas

Official Title: Interactive Book Reading to Accelerate Word Learning by Children with SLI 
 
Grant #: R01DC012824 
 
NCT#: NCT01829360 
 
Date: October 18, 2019 
 
 
 

Purpose. The goal was to determine whether interactive book reading outcomes for children with SLI 
were affected by manipulation of dose (i.e., the number of exposures to the target word during a book 
reading session) and dose frequency (i.e., the number of repeated book reading sessions) and 
whether pre-treatment factors predicted treatment response variation. 
 
Participant Selection. Kindergarten children are recruited through community language screenings, 
referrals from speech-language pathologists, or advertisements. At first contact with an interested 
family, an informed consent document and background questionnaire are provided. The background 
questionnaire gains information about demographic characteristics of the child/family and assesses 
some of the inclusionary/exclusionary criteria. 
 
Exclusionary Criteria: a child is excluded from participation if he/she:  
(1) speaks more than one language, as determined by background questionnaire;  
(2) has a health history indicating neurologic or other disorders that would exclude a diagnosis of SLI 
(e.g., autism), as determined by background questionnaire. 
 
Inclusionary Criteria: children will  
(1) be at least 5-years-old and in/eligible for kindergarten, as determined by background questionnaire; 
(2)  pass a hearing screening;  
(3) have nonverbal IQs at or above the 16th percentile on the Reynolds Intellectual Assessment Scale-2 
to rule out cognitive deficits;  
(4) have a Core Language Score at or below the 9th percentile (standard score = 80, 1.3 SD below 
mean) on the CELF-4 to document language impairment;  
(5) score at or below the 9th percentile (standard score = 6) on the semantics subtest of the DELV or 
the word classes subtest of the CELF–5 to document a vocabulary deficit. Score cut-offs are based 
on classification accuracy reported in the manuals (when reported).  
 
Procedural flowchart. Is shown in the following multi-page figure. Each major procedure is described below. 
 
Standardized Testing: Once informed consent is attained, standardized tests are administered to assess 
inclusionary criteria and gain additional information to further characterize the participants and potentially 
predict their performance in treatment. 
 
• 
Pre-Session 1 
o Signed consent form (could be completed at Session 1) 
o Completed background questionnaire (could be completed at Session 1) 
• 
Session 1 
o CELF-4: Core Language Subtests (inclusionary criteria) 
o CTOPP-2: Phonological Awareness – Elision subtest (further characterize participants) 
• 
Session 2 
o DELV Semantic subtest (inclusionary criteria) 
o CELF-4: Word Classes subtest (inclusionary criteria) 
o CTOPP-2: Phonological Awareness – Sound Matching subtest (further characterize 
participants) 
• 
Session 3 
o Hearing screening (inclusionary criteria) 
o RIAS (inclusionary criteria) 
o CTOPP-2: Phonological Awareness – Blending subtest (further characterize participants) 
o CTOPP-2: Phonological Memory subtests (further characterize participants) 
o GFTA-2: Articulation (further characterize participants) 

 

o  
 

 

 

 

 
Randomization. Once children have met all criteria to be included in the study, they are randomized to one of 
the 4 treatment arms, shown in the next figure. Treatment arm randomization also includes assignment of Set 
A and Set B books to each treatment. Stratified randomization was used such that children with DELV 
standard scores 6 and higher are randomized separately from children with DELV scores 5 and lower because 
it was hypothesized that treatment outcomes would differ based on the ability to quickly learn new words, as 
indexed by the DELV. 
 
Treatment. See https://asha.figshare.com/articles/Dose_Dose_Frequency_Storkel_et_al_2019_/9745181 
Supplemental Material S4. Treatment scripts for each treatment condition and each word set for the treatment 
protocol (session-by-session list of activities and treatment scripts) corresponding to each arm and word set. 
 
Outcome Measures.  
 
Primary outcome measure: Definition task. As in our prior preliminary clinical trial (Storkel, Voelmle, et 
al., 2017), the primary outcome measure was a definition task. We chose a definition task for two reasons: (1) 
to afford comparison to our past research with this treatment to determine whether continuing changes to the 
treatment improve outcomes; (2) to ensure that the treatment is helping children establish the rich word 
knowledge needed to support a variety of linguistic tasks. Although this task sets a high bar for word learning, 
our past research shows that it is sensitive enough to detect changes between different treatment conditions. 
The definition task was administered before treatment, immediately following the conclusion of each treatment, 
and 2 weeks following the conclusion of each treatment  
 
Research assistants administer the task across two sessions with 15 Set A and 15 Set B words tested 
in each session. For each word, the child received the prompt, “Tell me what [word] means.” Prompts were 
pre-recorded and presented with computer software so that pronunciations of the words were consistent 
across tasks. Children’s responses were audio recorded and transcribed for later scoring. The children first 
hear three practice words (bed, ball, candy), which were words likely to be known by them to ensure that they 
understood the task. Then, the 30 target words are presented in random order along with familiar words (n = 
10, e.g., chair, teacher, apple). In terms of training the testers, all testers are shown how to use the computer 
software and the recording device. Testers practice administering the definition test to other trained testers 
until they are comfortable with the equipment and protocol. Testing script is available at 
https://asha.figshare.com/articles/Dose_Dose_Frequency_Storkel_et_al_2019_/9745181 Supplemental 
Material S7 Testing script. 
 
The definition scoring procedures from our prior preliminary clinical trial (Storkel, Voelmle, et al., 2017) 
are used. In the prior study, the research team followed the procedures of McGregor, Oleson, Bahnsen, and 
Duff (2013) and consulted dictionaries to create a scoring rubric that listed common elements of an accurate 
and complete definition for each word (e.g., pouted = negative emotion + lips/face). Possible scores were: 0 
points for an incorrect or absent definition (e.g., pouted = face), 1 point for an appropriate use of the word in a 
sentence (e.g., pouted = pouted because you don’t want to eat and your mom makes you) or for a vague 
definition (e.g., pouted = cry), 2 points for a conventional definition containing at least one critical element but 
lacking other critical elements (e.g., pouted = mad), and 3 points for a complete and accurate definition 
including all critical elements (e.g., pouted = feel mad and push your lips out). Two raters independently score 
each response following the rubric guidelines. The raters compare their scores and resolve disagreements 
through consensus.  
 
In the analyses, children’s definitions scored as 2 or 3 (i.e., a partially or completely accurate definition) 
are counted as correct and definitions scored as 0 or 1 (i.e., incorrect definition, absent definition, correct use 
of a word in a sentence, or vague definition) are counted as incorrect. This was done to afford comparison to 
prior studies (Justice et al., 2005; Storkel, Voelmle, et al., 2017).  
 

 

Secondary outcome measure: Interim definition. Learning also is tracked during treatment. The 
research assistant who provides the treatment prompts children to provide definitions or name the target words 
at four points during each treatment. The words are assessed in a fixed order while the child views the pre-
reading pictures for each word. The research assistant asks, “What does [word] mean?”. Specific feedback iss 
not provided but the correct definition always iss provided after the child’s response regardless of the accuracy 
of the response. This is shown in the scripts at 
https://asha.figshare.com/articles/Dose_Dose_Frequency_Storkel_et_al_2019_/9745181. Definition responses 
were scored by two independent raters unaware of children’s treatment assignment following the procedures 
described above.  
 
Secondary outcome measure: Interim naming. For naming prompts, the research assistant shows the 
child the post-book reading picture without the orthographic label and asks a question meant to elicit the 
phonological form of the target word (e.g., “What is the lightning doing?” to elicit flashing). Specific feedback is 
not provided but the correct orthographic label and context sentence always are provided after the child’s 
response regardless of the accuracy of the response. This is shown in the scripts 
https://asha.figshare.com/articles/Dose_Dose_Frequency_Storkel_et_al_2019_/9745181. Naming responses 
were scored as correct or incorrect. Correct responses included the word itself (e.g., glared), the word in its 
bare form or with a different ending (e.g., glare, glaring) or an acceptable phonological substitution of the word 
(e.g., gwaring, judged on an individual basis). One independent judge scored naming responses and scores 
were verified by another judge. 
 
Summary of the Design. The preceding figure provides a summary of the design. Upon meeting the selection 
criteria, children were randomized to 1 of 4 treatment arms. Pre-treatment definition testing was conducted for 
all 60 words, as indicted by the white box in Figure 1. Treatment 1 then was initiated for 30 words (Set 1 words 
with Set A or B being randomized to Set 1 or Set 2). Set 1 words were tested via naming and definition tasks 
four times during Treatment 1, as indicated by asterisks in in the figure. Upon completion of Treatment 1, all 60 
words (Set 1 and Set 2) were tested immediately and 2-weeks after treatment via the definition task. Note that 
Set 1 words have received treatment but Set 2 words have not yet received treatment and serve as untreated 
control words. Treatment 2 was then initiated for the remaining 30 word (Set 2 words). Set 2 words were tested 
via naming and definition tasks four time during Treatment 2, as indicated by the asterisks in the preceding 
figure. Upon completion of Treatment 2, all 60 words (Set 1 and Set 2) were tested immediately and 2-weeks 
after treatment via the definition task. Note that Set 2 words have just received treatment, whereas Set 1 words 
received treatment much earlier. Thus, for Set 1 words, these test points indicate longitudinal maintenance of 
learning following 5-12 weeks of treatment on a different word set. 
 
Data Analysis Strategy. A series of multilevel longitudinal models were evaluated using SAS Proc Mixed to 
describe the change in number of Set 1 and Set 2 words accurately defined over seven test points: pre-
treatment, 36 exposures in Treatment 1 (i.e., last Treatment 1 session), immediate post-Treatment 1, 2-week 
post-Treatment 1, 36 exposures in the second treatment (i.e., last Treatment 2 session), immediate post-
Treatment 2, and 2-week post-Treatment 2. Because the number of exposures varied for the interim definition 
tests, only the 36-exposure interim definition test data, which was consistent for all treatment conditions, were 
used.  We expected significant slopes for Set 1 words during Treatment 1 when they were the target of 
intervention.  We had no hypotheses about whether Set 1 words would decline or would be maintained after 
Treatment 1 ended and monitoring continued during Treatment 2.  We expected non-significant slopes for Set 
2 words during Treatment 1, when those words were not the focus of intervention, and significant slopes for 
Set 2 words during Treatment 2 when they were the target of intervention. Because the number of words 
defined were counts, the natural log of the words defined was modeled resulting in a model equivalent to a 
generalized linear mixed model with a negative binomial link function.   
 
The significance of fixed effects was evaluated using Wald tests, and the significance of random effects was 
evaluated using likelihood ratio tests and information criteria between models with the same fixed effects.  We 
evaluated models with time coded as days since the start of intervention as well as categorically by 
intervention point. The categorical model fit the data better. The final categorical coding of time is shown in 
Table 7. Because there were two treatment phases (Treatment 1 vs. Treatment 2) with different expectations 
for change in Set 1 versus Set 2 words in each phase, we examined a piecewise model of change in which the 
change related to the first treatment phase (i.e., pre-treatment, 36 exposures in Treatment 1, immediate post-

Treatment 1) was described by one linear slope and change related to the second treatment phase (i.e., 2-
week post-Treatment 1, 36 exposures in the second treatment, and immediate post-Treatment 2) was 
described by a second linear slope. This allows the slope for each word set to differ across each phase, as 
predicted.     
 
Results. Results are reported fully in Storkel, H. L., Komesidou, R., Pezold, M. J., Pitt, A. R., Fleming, K. 
J., & Romine, R. S. (2019). The impact of dose and dose frequency on word learning by kindergarten 
children with developmental language disorder during interactive book reading. Language, Speech, 
and Hearing Services in Schools, 50, 518–539. https://doi.org/10.1044/2019_LSHSS-VOIA-18-0131 -
- open access 
 
Summary of Results. Results showed that children with DLD learned a significant number of words 
during treatment regardless of the dose and dose frequency format, but that significant forgetting of 
newly learned words occurred in all formats once treatment was withdrawn. Individual differences in 
word learning were related to CELF Core Language and CELF Understanding Spoken Paragraphs 
scores. 
 
Conclusion. When administered at an adequate intensity, variation in the dose and dose frequency of 
interactive book reading does not appear to influence word learning by children with DLD. Although 
interactive book reading continues to show promise as an effective word learning intervention for 
children with DLD, further development is needed to enhance the effectiveness of this treatment 
approach.