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5-2016 The ffecE t of Baby Sign on Early Language Development for "At-Risk" Populations Sarah S. Anderson St Cloud State University, [email protected]
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The Effect of “Baby Sign” on Early Language Development for “At-Risk” Populations
By Sarah S. Anderson
A Thesis
Submitted to the Graduate Faculty of
St. Cloud State University
in Partial Fulfillment of the Requirements
for the Degree of
Master of Science
in Communication Sciences and Disorders
May 2016
Thesis Committee: Dr. Sarah Smits-Bandstra, Chairperson Dr. Rebecca Crowell Dr. Amy Knopf EFFECT OF BABY SIGN ON LANGUAGE FOR “AT-RISK” POPULATIONS 2
Abstract
The purpose of this case study was to examine the effect of exposure to symbolic gestures or
“Baby Sign” on the development of joint attention, receptive and expressive language of children from low socioeconomic backgrounds, including culturally/linguistically diverse children aged 9 to 20 months. Two child-parent dyads participated in the program. Both were enrolled in the local “Head Start” (Reach-Up) program. The MacArthur Bates, Preschool Language Scales-4
(PLS-4) and video-recorded interactions with the primary caregiver were used to assess the effectiveness of Baby Sign parent-training to facilitate early language development. Results of the Preschool Language Scales-4 and the MacArthur Bates identified improved both receptive and expressive language in “at risk” (low socioeconomic and culturally diverse backgrounds) infants exposed to Baby Sign. In addition, qualitative data collected by parent interview revealed significant barriers to service delivery for early language facilitation, particularly for culturally/linguistically diverse children from low socioeconomic backgrounds.
EFFECT OF BABY SIGN ON LANGUAGE FOR “AT-RISK” POPULATIONS 3
Acknowledgements
We would like to thank the staff at Reach-Up of St. Cloud for their collaborating during this study, and undergraduate student, Julia McClung, for her assistance during data collection and analysis. We would also like to thank St. Cloud State University Office of Sponsored Programs
Student Research Grant Award. Finally, we would like to thank our family and friends without which this study could never had existed.
This study is dedicated to the child that lost his life during the process of this study. EFFECT OF BABY SIGN ON LANGUAGE FOR “AT-RISK” POPULATIONS 4
Table of Contents
Chapter I: INTRODUCTION ...... 7 Chapter II: METHOD ...... 17 Chapter III: RESULTS ...... 22 Chapter IV: DISCUSSION ...... 28 Chapter V: CONCLUSION ...... 36 References ...... 37 Appendixes ...... 46 Appendix A ...... 47 Appendix B ...... 48 Appendix C ...... 50 Appendix D ...... 54 EFFECT OF BABY SIGN ON LANGUAGE FOR “AT-RISK” POPULATIONS 5
List of Tables Table 1 ...... 23 Table 2 ...... 24 Table 3 ...... 25 Table 4 ...... 26 Table 5 ...... 27 Table 6 ...... 32
EFFECT OF BABY SIGN ON LANGUAGE FOR “AT-RISK” POPULATIONS 6
List of Figures
Figure 1 ...... 15
EFFECT OF BABY SIGN ON LANGUAGE FOR “AT-RISK” POPULATIONS 7
Chapter I: INTRODUCTION
Recently, research has been directed to improving the quality of early childhood care to build and develop socio-linguistic foundations and promote overall learning (Levickis,
Girolametto, & Reilly, 2014). Early intervention, particularly before age 6, has been established in literature for communication skills, because of a “critical period” of brain development at that time (Uylings, 2006; Werker & Hensch, 2015). The irrefutable beneficial effects of early intervention for communication skills has been demonstrated in auditory rehabilitation
(Campbell, Macsweeney, & Woll, 2014), autism (Webb, Jones, Kelly, & Dawson, 2014), intellectual disability (Fujinaga, Shinagawa, Watanabe, Ogihara, Sasaki, & Hori, 2005), and children “at risk” due to low socioeconomic status (Colmar, 2014).
A rising issue for early childhood centers developed for families from low socio- economic status (SES) backgrounds is the culturally and linguistically diverse (CLD) families whom they serve. For example, over 17% of children enrolled in the St Cloud “Reach-Up” program are from CLD families. Of that percentage 58% have no receptive or expressive
English and the remaining 42% have only a “moderate” proficiency in English (Storm, personal communication). Male infants and toddlers of this population are known to be at higher risk for developing a language delay or disorder (Campbell, Dollaghan, Rockette, Paradise, Feldman,
Shriberg, & Kurs-Lasky, 2003; Letts, Edwards, Sinka, Schaefer, & Gibbons, 2013). Several researchers have hypothesized this discrepancy may be because females develop at a more accelerated rate than males.
Early childhood programs attempt to meet the needs of linguistically diverse families in a functional way to promote a strong linguistic foundation. For example, when there is a prominent language amongst the class of preschoolers that isn’t English, Head Start employs a EFFECT OF BABY SIGN ON LANGUAGE FOR “AT-RISK” POPULATIONS 8
staff member that is a native speaker of that language to help promote the children’s first language (L1). There is irrefutable evidence that promoting the development of the L1 in a language learner helps to develop their second language (L2) (David, 2005; Murphy, 2014).
These programs would also benefit from an early intervention strategy to promote a strong communication foundation within their infants and toddlers, no matter their first language.
The purpose of this research project is to investigate whether the implementation of Baby
Sign, is an effective early language facilitation program for low SES infants and toddlers from
CLD backgrounds.
Baby Sign History
The National Institute on Deafness and Other Communication Disorders (NIDCD) (2014) defines American Sign Language (ASL) as a “complete, complex language that employs signs made by moving the hands combined with facial expressions and postures of the body.”
According to NIDCD, ASL is primarily used by people in North America that associate themselves with the Deaf1 and hard-of-hearing community. Within the past decade there has been an increase of use of a simplified version of ASL with the targeted use as a means of early communication with infants and toddlers (Nelson, White, & Grewe, 2012). There have been several labels to refer to this method such as; deictic gesturing, symbolic gesture, sign training, and Baby Sign. For the purposes of this research paper we will refer to this method as Baby
Sign.
Mueller, Sepulveda, and Rodriquez (2013) defined Baby Sign as facilitating communication of normally developing hearing infants by early exposure to sign language.
Primarily, there is a use of functional everyday signs (i.e. cookie, water, more, all-done) that are
1 When the word “deaf” is capitalized (e.g. Deaf) it is a representation of someone who is deaf and associates themselves with Deaf culture (i.e. other Deaf individuals, uses American Sign Language as a primary mode of communication). It is also known as being “big D deaf.” EFFECT OF BABY SIGN ON LANGUAGE FOR “AT-RISK” POPULATIONS 9
produced by a primary caregiver during optimal exposure times (e.g. feeding time and play time). This production is initially done with the expectation of not having the sign immediately reproduced by the child, but introduced as a symbol for an action and/or word. Over time, and repeated use of the symbol by the caregiver within context-rich interactions, the child can easily employ these Baby Signs, either separate from or in conjunction with verbalizations as a means of communication.
Minnesota Head Start Association
The Minnesota Head Start Association Inc. established in 1987. The Administration for
Children and Families is a federally operated program that was established nation-wide in 1991 to provide quality childcare for families from low SES backgrounds to support infant and toddler development. This federally operated program was established to identify and overcome issues impacting the development of children within low SES populations. One program they have established is providing affordable quality childcare for people with limited financial means.
This is important due to the lack of resources available for children of low SES background and the negative impact it can have on their development (Levine, & Zimmerman, 2010).
Reach-Up of Central Minnesota in conjunction with the Minnesota Head Start
Association (MHSA) was established in 1979. This program specifically targets at risk families with infants and toddlers to provide and facilitate support that is fundamental to early socio- linguistic development. According to the Glossary of Education Reform the term “at risk” encompasses any student that is considered to have a higher probability of academic failure
(Great Schools Partnership, 2014). Children from low SES tend to have limited exposure to language (i.e. books, magazines, verbal language input) effecting their language development
(Clearfield & Jedd, 2013). EFFECT OF BABY SIGN ON LANGUAGE FOR “AT-RISK” POPULATIONS 10
The goal of Reach-Up is to facilitate the development in children across all areas (e.g. motor, cognitive, language, social, behavior) to ensure a successful transition to school. Within the infant and toddler curriculum there are opportunities for sensory experiences, literacy exposure, cognitive decision making, fine and gross motor activities, and communicational attempts (Minnesota Head Start Association Inc., 2014). This curriculum was specifically designed to address the areas of common deficits found for infants and toddlers from CLD and/or low SES families, in particular, language delays.
Implications of Low SES and CLD for Early Language Development
It has been noted that children from a low SES background are at risk for developing a language delay (Clegg & Ginsborg, 2006). It is believed that, due to a lack of parental education, in combination with minimal resources, children experience a language-impoverished environment (Clegg & Ginsborg, 2006). Common resources and experiences not available to
CLD or low SES children include, but are not limited to, literacy materials such as picture books, social interactions with other children within their peer groups, appropriate verbal parental interactions, and motor and sensory stimuli such as age-appropriate toys.
Researchers Letts, Edwards, Sinka, Schaefer, and Gibbons (2013) described the marked differences in language development in children from a low SES background compared to their middle-high SES peers. They found characteristics of less developed phonological inventory and early literacy skills (i.e. page turning, finding the title) in children from low SES background.
They reasoned that when the maternal figure’s education level is of high school equivalent or lower, a child’s language is more likely to fall behind. They further argued that, “any negative influence of low SES on early language development may then indirectly affect the child’s life- long educational prospects.” EFFECT OF BABY SIGN ON LANGUAGE FOR “AT-RISK” POPULATIONS 11
In agreement with this research, Downing and Ollila (1977) reported that children from low SES typically have less exposure to speech, writing, and/or print until they enter school.
The authors stated that when children aren’t exposed to speech, writing, and/or print at home at a young age they don’t develop necessary pre-literacy skills as a foundation for learning to read and consequently fall behind.
In addition to low SES, it has been noted that children from CLD backgrounds are at risk for language delays (Clifford, Rhodes, & Paxton, 2014). People of this population typically have limited resources to support their dual language learning children, and it has been found that few parents in this population are aware that programs exist to help facilitate dual language learning
(Woolfenden, 2014).
Bilingual language learning is considered a risk factor not specifically because of the complexities of learning two spoken languages simultaneously, but the diverse conditions the child may experience while this dual language learning is occurring (Kohnert, 2008). Researcher
Kathryn Kohnert (2008) describes potential risk factors such as: age when dual language input first occurs (e.g. easier to acquire when exposed during infancy), the environments in which language exposure is taking place (i.e. home, television, school), the ‘social prestige’ and community support given for both languages (i.e. if one language is considered more useful), if these languages share any commonalities (i.e. both are romantic languages), and the specific purpose these languages serve (e.g. communication in public vs. home).
Typical language developmental milestones are met in multi-linguistic populations, consistent with their monolingual peers, as long as there is a strong foundation in the L1 (Janet,
2009) and environmental support is evidenced (Bohman, Bedore, Peña, Mendez-Perez, &
Gillam, 2010). However, the problem lies when typical English Language Learners (ELL) are EFFECT OF BABY SIGN ON LANGUAGE FOR “AT-RISK” POPULATIONS 12
not as proficient at English as their monolingual peers causing academic difficulties especially in grades pre-k through second grade (Paradis, Emmerzael, & Duncan, 2010; Lindholm-Leary,
2014).
Typical Language Developmental Milestones
Language acquisition has a typical developmental pattern that corresponds to a child’s age. Milestones of language acquisition can be broken down to three major areas: pre-linguistic
(birth to 18 months), emergent (18-36 months), and developing (2-5 years of age; Paul &
Norbury, 2012). For the purposes of this study, we will focus on the milestones that correspond to the later pre-linguistic stage, and the early emergent stage.
From birth to 8 months infants evidence perlocutionary speech acts consisting of vegetative sounds, cooing, laughing, quasi-resonant nuclei, vocal play, canonical and reduplicated babbling (Chapman, 2000; Miller, 1981; Gordon-Brannan & Weiss, 2007). By the time an infant reaches 11-18 months of age (locutionary speech acts) they should have the ability to comprehend 3-50 words and should also be producing their first true words. When an infant/toddler reaches approximately 24 months of age they are producing at least 50 words and up to 300 words expressively (Chapman, 2000; Miller, 1981; Gordon-Brannan & Weiss, 2007).
When discussing the role gestures play in relation to language development, researchers
Goodwyn, Acredolo, and Brown (2000) discussed that “the onset of intentional communication is signaled by a small set of gestures which essentially launch the child into purposefully communicating with others.” Gestures used for the intentional communication, or deictic gestures, begin to occur as a language milestone around 10 months of age (Bates, 1976; Bates,
Benigni, Bretherton, Camaioni, & Volterra, 1979; Goodwyn et al., 2000). With the onset of
‘deictic gesturing’ and the lack of fine motor control necessary for proficient verbal EFFECT OF BABY SIGN ON LANGUAGE FOR “AT-RISK” POPULATIONS 13
communication, there are several months, in infancy, where intentional communication and verbal ability are disjointed. With the complexities involved in spoken language development there seems to be a supplementation of gesturing by infants/toddlers as a means to communicate
(Goodwyn et. al, 2000).
Importance of Symbolic Gesture
When a child points to an object a caregiver doesn’t disregard this action as one of little importance. Just the opposite, the caregiver recognizes this as a communication attempt, and goes through a trial and error series to understand what the child may be referring to. The use of gesturing as a pre-linguistic and emergent means of communication is one that should not be overlooked rather, substantiated as a way to promote overall communication in infants and toddlers. Iverson and Goldin-Meadow (2005) reported
Gestures that children produce early in language development provide a way for them to
communicate information that they cannot yet express verbally, offering children a
technique for referring to objects before they have words for those objects (p. 367).
Bates, Thal, Whitesell, Fenson, and Oakes (1989) explain that by the age of 18 months the majority of children have come to the realization of the symbolic meaning of words, that words can be used to represent objects in the world. By promoting the use and understanding of gestures a caregiver is facilitating information that aids in the acquisition of verbal communication. Goodwyn et al. (2000) proposed that, just as crawling serves as a critical stepping-stone to walking, gestures serve the same purpose for speaking.
Bates et al. (1979) viewed gestures as a variant of symbolic communication and that when communication was attempted intentionally, utilizing ‘conventional signals,’ it is a
‘process that precedes, correlates with, and hence possibly contributes to the emergence’ of EFFECT OF BABY SIGN ON LANGUAGE FOR “AT-RISK” POPULATIONS 14
language. Based on the evidence and research of the authors reviewed above, the main premise of this paper is that promoting the use of symbolic gesture through utilizing Baby Sign will facilitate a child’s intentional expressive attempt at communicating, and furthermore their spoken vocabulary.
Constructivist Theory
It has been theorized that one way children acquire linguistic knowledge is from exposure to environmental input (Boyd & Goldberg, 2009; MacWhinney, 2004; Piaget, 2002; Ratner,
2013). This theory has several names but is most frequently called the Constructivist approach
(a.k.a. Interactionist or Empiricist approach). According to Owens (2012) a communication base is established first, namely nonverbal communication (e.g. gestures), then a child is able to build upon that framework to eventually communicate verbally. This building occurs over time with environmental exposure (i.e. caregiver input). This theory is primarily attributed to Jean Piaget and Lev Vygotsky who theorized that more information could be obtained through child play
(Pass, 2007; see figure 1). EFFECT OF BABY SIGN ON LANGUAGE FOR “AT-RISK” POPULATIONS 15
Figure 1
Diagram of Piaget and Vygotsky’s Constructivist Theory
Information from Figure 1 obtained from: Pass, S. (2007). When Constructivists Jean Piaget And Lev Vygotsky Were Pedagogical Collaborators: A Viewpoint From A Study Of Their Communications. Journal Of Constructivist Psychology, 20(3), 277-282. doi:10.1080/10720530701347944
Piaget (2002) explains that thought development is consecutive to a child’s language development. It has been theorized, and found to be sound, that this development is accomplished through social opportunities and language possibilities that are provided to the child through adult models (Veneziano, 2013). The child is then able to acquire these models through exposure, and eventually use in their verbal repertoire. It is anticipated that the results of the current study will provide supportive evidence to support this theory of early language development.
Previous Studies
Goodwyn, Acredolo, and Brown (2000) explored the effect of simple gestures with 11- month old infants on early language development. Infants (n = 103) were randomly assigned into
Sign Training (ST), Verbal Training (VT) and Control conditions. Pre-intervention assessments using the MacArthur Bates Communicative Developmental Inventory (Fenson et al., 2007) and vocalization frequency during a caregiver/child 15-minute play session showed no significant EFFECT OF BABY SIGN ON LANGUAGE FOR “AT-RISK” POPULATIONS 16
group differences. Caregivers in the ST group implemented symbolic gestures (e.g. fish, flower) daily while VT caregivers targeted specific words (e.g. kitty, doggy). After 25 months it was found that the ST experimental group significantly outperformed other groups in all areas of language. Other studies have also found similar beneficial outcomes of implementing Baby Sign during infancy on language development (Bates’ et al., 1989; Iverson & Goldin-Meadow, 2005;
Mueller’s et al., 2014).
Objective
Mueller and Sepulveda (2014) reported that the popularity of Baby Sign is increasing despite a lack of “empirical” research supporting its use. Although there are many claims to the benefits of incorporating Baby Sign as an alternative mode of communication for a child, there is still a need for more research to substantiate these claims. In particular there is a paucity of research regarding the effectiveness of early intervention strategies for low SES or CLD populations (Kohnert, 2008).
Therefore, the primary objective of this research paper was to investigate whether the implementation of Baby Sign is an effective early language facilitation program for low SES infants and toddlers from CLD backgrounds.
Research Hypothesis
Based on the Constructionist Approach theoretical framework proposed by Boyd &
Goldberg (2009) it was predicted that infants, from “at-risk” populations, exposed to Baby Sign during a critical period of linguistic development would demonstrate an improved receptive and expressive vocabulary relative to matched controls.
EFFECT OF BABY SIGN ON LANGUAGE FOR “AT-RISK” POPULATIONS 17
Chapter II: METHOD
Research Design
Originally, the study was devised as a mixed experimental design with both within-group and between-group comparisons. Interpretive statistics (ANOVA comparisons) were planned to compare the results for parent-child dyads randomly assigned to experimental (Baby Sign) vs. control conditions (fine motor skill training). Due to unforeseen difficulties with participant recruitment and mortality, the study became a case study (see Discussion).
Screening Criteria
Infants participating in this program were screened by the Reach-Up staff with the Ages
& Stages Questionnaires and Ages & Stages Questionnaires: Social Emotional (Squires,
Twombly, Bricker, & Potter, 2009), as well as regular hearing/vision screenings. Participants had ongoing developmental assessment by the Teaching Strategies Gold (Heroman, Burts, Berke &
Bickart, 2010) performed by Reach-Up staff.
Participants were excluded if they did not meet the age criteria specified and/or if the parents did not agree to sign the participation waiver. Participants were not excluded from the study if found to have previous use of Baby Sign, more than one language spoken in the home, multiple (3 or more) ear infections prior to the study, or any language/developmental delays.
Participants
Participants were families participating in the Reach-Up Head Start of Minnesota program. Participants self-selected by responding to flyers distributed by the director, teachers, or home visit staff. Written informed consent was obtained and all participants were treated according to ethical treatment of vulnerable human participant guidelines established by St
Cloud State University (Appendix A). Three parent-child dyads passed the screening criteria and EFFECT OF BABY SIGN ON LANGUAGE FOR “AT-RISK” POPULATIONS 18
began the study. Data from one of the parent-child dyads was excluded because the dyad withdrew from the study before completion.
Participant 1 (P1). P1 was a multi-cultural male of African American and Caucasian decent, and had English spoken by both parents in the home. The mother reported to have delivered P1 at full-term with no complications during pregnancy or birth. Prior to the study P1 had met all developmental milestones, had no significant health related problems, and had no immediate (mother/father) family history of speech/language difficulties. P1 had previous exposure to the following Baby Signs: milk, mom, dad, and ball.
Participant 2 (P2). P2 was a multi-cultural male of Caucasian and Hispanic
(Ecuadorian) decent, and had English spoken by the mother and English/Spanish spoken by the father in the home. The mother reported to have delivered P2 at full-term with no complications during pregnancy or birth. Prior to the study P2 had achieved all developmental milestones, had no significant health related problems, and had no immediate (mother/father) family history of speech/language difficulties. P2 had no previous exposure to Baby Signs.
Tasks and Procedures
Both the initial and post-training evaluations were completed by a graduate student in a speech-language pathology program, and supervised by a licensed speech language pathologist certified by the American Speech Language Hearing Association. Assessments were completed in a small quiet room with both caregiver and the child present.
Baseline Measures. To assess the comparability of both participants at the beginning of the study, both participants were compared on several demographic variables and baseline language and communication measures similar to the study previously done by Goodwyn,
Acredolo and Brown (2000). Demographic variables included birth order, sex, and EFFECT OF BABY SIGN ON LANGUAGE FOR “AT-RISK” POPULATIONS 19
maternal/paternal education (4 – pt scale: 1 = high school or less; 2 = some college; 3 = college graduate; 4 = post-graduate work). The language measures at 10 months of age included: participant history screening form (see Appendix B), maternal report of verbal and gestural vocabulary (MacArthur Bates Communicative Developmental Inventory or CDI; Fenson et al.,
2007), the infants’ auditory comprehension and expressive communication from a standardized assessment (Preschool Language Scale – 4th Ed. [PLS-4]; Zimmerman, Steiner & Pond, 2002), and a measure of vocalization, joint attention, and communication attempt frequency during a
10-minute play session.
The reliability and validity of the standardized, norm-referenced measures are well established (Mancilla-Martinez, Pan & Vagh, 2011; Qi & Marley, 2011). Previous studies examining early language acquisition have employed both the PLS-4 (Volden et al., 2011) and the CDI (Mancilla-Martinez, Pan & Vagh, 2011; Reilly et al., 2009) and found significant differences on these assessment instruments after an intervention. No significant comprehensive differences were found between P1 and P2. At the end of the initial assessment parents of P1 and
P2 scheduled their training session2.
Baby Sign Training. Parents completed an initial 30 minute seminar and, jointly with the Primary Investigator (PI), designed a daily practice routine for implementation of the training at home. The seminar included a video of the PI explaining the importance of early language development and tips for implementing the Baby Sign (e.g. get down on the child’s level, be sure to have the child’s attention, show child an item out of child’s reach, produce the sign with its verbal counterpart simultaneously, wait for response from infant, produce sign/word again assisting infant in production of sign, and then give infant item being withheld). After the video
2 P2 was assessed in the Spanish versions of the MacArthur Bates and PLS-4 for any discrepancies across languages. No discrepancies were found between English and Spanish for P2. EFFECT OF BABY SIGN ON LANGUAGE FOR “AT-RISK” POPULATIONS 20
the PI reiterated the process, and asked the parent to explain the process to verify understanding.
Five signs, unique to each child, were selected by the parent and the PI jointly for each parent- child dyad to practice. Signs selected were words/signs that were not previously produced by the child, but signaled a commonly occurring message in the child’s daily routine (e.g. all-done, more, milk). Parents were given a book of common Baby Signs, which included their five signs as well as others (Briant, 2004). Each target Baby Sign was highlighted within the book for easy referral. Parents were asked to demonstrate production of all of the five signs, and also demonstrated the implementation of one sign to check for understanding of process. When completed, the PI explained the parent log (see Appendix C) and established with parents the optimal times of day and frequency of implementing each sign (i.e. feeding time, play time, 3-5 times daily per sign were suggested). Parents and the PI then established the most convenient day/time to call for bi-weekly phone interviews (i.e. during infant nap time).
Qualitative and Quantitative Phone Interviews. Parents were contacted bi-weekly during the 14-week training period to ensure they were maintaining the training protocol.
During this conversation a list of specific questions were asked (see Appendix D). The first interview was preformed one week post-training. The interview collected information about parent feelings and perceptions of the training program, as well as frequency and implementation of Baby Signs.
Post-Training Evaluation. At the conclusion of the 14-week training period both participants completed a 60-minute post-training evaluation. The post-training evaluation included re-administration of the PLS-4, the CDI, and a 10-minute video-recorded free play session with the caregiver. EFFECT OF BABY SIGN ON LANGUAGE FOR “AT-RISK” POPULATIONS 21
Dependent Variables. Dependent variables of performance on the task included scores on the CDI and PLS-4 as well as the number of vocal attempts, sign attempts, joint attention, and total communication attempts within the 10-minute play sample.
Speech samples were video and audio recorded, and all types of communication attempts were analyzed off-line3 by the PI. The PI counted the total number of each type of attempt for each minute of interaction. A second rater (BR), blind to the conditions of the study, also analyzed the recordings in one-minute intervals. Percentage agreement was calculated between the two raters for 25% of the samples to determine inter-rater reliability and to minimize investigator bias.
3 Not in real time. EFFECT OF BABY SIGN ON LANGUAGE FOR “AT-RISK” POPULATIONS 22
Chapter III: RESULTS
A total of 3 parent-child dyad participants were recruited to participate in this study. Due to attrition, 1 participant dyad left the study, the remaining 2 dyads continued the study in its entirety. Both participants were initially screened at 9-months 24-days old.
Screening Results
Based upon previously discussed criteria during the screening process (see Methods), it was deemed that both participants were appropriate subjects for this study. The following data was collected through: parent interview, 10-minute play sample, CDI, and the PLS-4. After initial qualitative data was collected, ongoing data was collected through bi-weekly parent phone calls. P1 conducted re-assessments 14-weeks post-intervention using the same assessments from the initial assessment. Due to scheduling complications, P2 was re-assessed 16-weeks post- intervention.
Pre-Post Percentiles for CDI
Analysis was conducted using the results acquired through the use of the CDI. The CDI assesses the child’s current abilities through the use of Early Words (e.g. Phrases Understood,
Words Understood, and Words Produced), and Actions and Gestures (e.g. Total Gestures). The results are then represented through a percentile rank when compared to other same-aged peers.
Both participants’ results from pre-intervention and post-intervention are depicted below (see
Table 1). EFFECT OF BABY SIGN ON LANGUAGE FOR “AT-RISK” POPULATIONS 23
Table 1
Pre-Post Intervention Results for CDI
Participant Category of Language Pre- Post-Intervention Change Intervention Percentile (+/-) Percentile P1 Part I: Early Phrases 35% 55% +20% Words Understood Words 60% 65% +5% Understood Words 65% 80% +15% Produced Part II: Total 65% 85% +20% Actions and Gestures Gestures P2 Part I: Early Phrases 50% 75% +25% Words Understood Words 65% 45% -25% Understood Words 55% 55% No Produced change Part II: Total 40% 45% +5% Actions and Gestures Gestures
Both participants showed a percentile rank increase between 20-25% in Phrases understood, and 5-20% in Total Gestures used when analyzed with the CDI.
Pre-Post Standardized Scores and Percentiles for PLS-4
Analysis was conducted using the results acquired through the use of the PLS-4. The
PLS-4 assesses the child’s current abilities in subtests entitled Auditory Comprehension,
Expressive Communication, and Total Language Scores. The results are then analyzed and represented through standardized scores (SS) and percentile ranks when compared to other same- aged peers. Both participants’ results from pre-intervention and post-intervention are depicted below (see Table 2). EFFECT OF BABY SIGN ON LANGUAGE FOR “AT-RISK” POPULATIONS 24
Table 2
Pre-Post Intervention Results for the PLS-4
Participant Category of Pre- Post- Pre- Post- Language Intervention Intervention Intervention Intervention SS SS Percentile Percentile Rank Rank P1 Auditory 93 117 32 87 Comprehension Expressive 98 120 45 91 Communication Total Language 100 121 50 92 Score P2 Auditory 103 109 58 73 Comprehension Expressive 97 113 42 99 Communication Total Language 100 113 50 81 Score
Both participants showed an increase in standard score on receptive (Auditory
Comprehension) language (P1 increased 24 points and P2 increased 6 points), Expressive
Language/Communication (P1 increased 28 points and P2 increased 16 points), and Total
Language Scores (P1 increased 21 points and P2 increased 13).
Pre-Post Analysis of Video-Recorded Interaction Samples
Analysis was conducted using the number of vocal attempts, sign attempts, joint attention, and total communication attempts within the 10-minute play video recorded samples.
A rater (BR), blind to the study, was trained in the video recording analysis (e.g. vocal attempts, sign attempts, and joint attention). BR’s results were then compared to the PI’s analysis results.
This comparison is depicted below (see Table 3). EFFECT OF BABY SIGN ON LANGUAGE FOR “AT-RISK” POPULATIONS 25
Table 3
Results of 10-minute Communication Sample
# of Joint Attention Rater Occur- Rater # of Vocal Consist- Sign rences > 2 Consist- conversational Video Rater Attempts ency Attempts seconds ency turns > 2 Julia (Blind P1V1 Rater) 52 96.29% 0 14 85.70% 2 P1V1 Sarah 54 96.29% 0 12 85.70% 3 Julia (Blind P1V2 Rater) 18 94.40% 0 13 94.40% 3 P1V2 Sarah 17 94.40% 0 13 94.40% 2 P2V1 Sarah 5 N/A 0 10 N/A 0 P2V2 Sarah 15 N/A 1 (reach) 10 N/A 0
Neither of the participants showed change in joint attention, sign attempts, or number of conversational turns greater than two. P1 showed a decrease in vocal attempts from approximately 53 to approximately 18, whereas, P2 showed an increase of vocal attempts from 5 to 15. However, we do not consider these vocal attempts to be significant. Rather they match appropriately to participants’ activity choice during the 10- minute segment (e.g. P1 Video 1 pulling items from a box/bin and handing them to parent, P1 Video 2 walking items from one room to the next, P2 Video 1 book reading with parent, P2 Video 2 removing items from a box/bin and showing them to parent).
Interview Results
Scheduled interviews were initially set up to take place bi-weekly to help reinforce the continued use of the targeted intervention, identify barriers, and monitor progress made. It was found during each interview that both participants reported the intervention as going “good.” It was also found that both participants would recommend this form of intervention to other EFFECT OF BABY SIGN ON LANGUAGE FOR “AT-RISK” POPULATIONS 26
parents. P2 reported this intervention as being “an easy way to communicate with your child before they can talk…very cool to have that communication already.” Both participants reported the results of the intervention being “exciting” to watch, and beneficial to their child’s ability to receive and express communicatively. Additionally, both participants found that intervention was most efficient during feeding time and it provided more opportunities for models of the signs. Lastly, both participants referred to the positive benefits of explaining how their child was communicating with others (i.e. signing to friends and family). P1 reported that her family was
“really impressed by him being able to sign.”
P1. P1 participated in 5/7 phone interview opportunities. Due to several barriers (i.e. participant’s phone disconnected, unavailable to answer the phone, unable to return phone call) two phone interviews did not take place. A portion of the results collected during the interviews are reported in the table below (see Table 4).
Table 4
Results of P1 Phone Interviews
Date Avg. #of times Ideal time to Avg. # of signs Signs produced with or signs were model signs attempted by without vocalization? modeled child 6-17 3-5x per day Feeding/play 1 Without 7-1 3-5x per day Feeding/play 3 Without 7-27 3-5x per day Feeding 4 With 8-12 2-3x per week Feeding 4 With 9-3 2-3x per week Feeding 5 With
P1 showed a notable increase in the average number of signs attempted and production of signs with vocalization. P1 also showed a decrease in the number of models provided overtime
(3-5x per day to 2-3x per week). EFFECT OF BABY SIGN ON LANGUAGE FOR “AT-RISK” POPULATIONS 27
P2. P2 was able to participate in 6/7 phone interview opportunities. Due to several barriers (i.e. unavailable to answer the phone, unable to return phone call) one phone interview did not take place. Quantitative results collected during the interviews are reported in the table below (see Table 5).
Table 5
Results of P2 Phone Interviews
Date Avg. #of times Ideal time to Avg. # of signs Signs produced with or signs were model signs attempted by without vocalization? modeled child 7-17 3-5x per day Feeding 1 Without 7-31 3-5x per day Feeding 2 Without 8-16 1-3x per day Feeding 4 With 8-31 3-5x per day Feeding 3 With 9-18 2-3x per week Feeding 4 With 10-2 1-3x per day Feeding 4 With
P2 showed a substantial increase in the average number of signs attempted and production of signs with vocalization. P2 also showed a decrease in the number of models provided overtime (3-5x per day to 1-3x per day).
While working with culturally and linguistically diverse populations, several barriers were experienced or reported during phone interviews that hindered compliance with the research protocol. Some of these barriers experienced during this study included: life- threatening domestic violence, inability to maintain/follow through with intervention, insufficient time, mental health issues, insufficient safety, and/or insufficient housing.
EFFECT OF BABY SIGN ON LANGUAGE FOR “AT-RISK” POPULATIONS 28
Chapter IV: DISCUSSION
The results of the present study support the research hypothesis that infants, from “at- risk” populations, exposed to Baby Sign during a critical period of linguistic development would demonstrate an improved receptive and expressive vocabulary relative to matched controls. In addition, these results also support the constructivist theory suggesting that one way children acquire linguistic knowledge is from exposure to environmental input (Boyd & Goldberg, 2009;
MacWhinney, 2004; Piaget, 2002; Ratner, 2013).
Research Design
Due to unforeseen difficulties with participant recruitment and mortality the study became a case study. Some of the strengths of conducting a case study include: getting a more thorough understanding of the participant’s emotional and environmental needs instead of just the notation of exhibited behaviors, as well as the allowance for creativity and innovative therapy approaches. In addition, case studies can be used as a basis for theory in clinical application, and they allow for direction in further research (Portney & Watkins, 2009).
However, as with any study design, case studies have several drawbacks as well. Some drawbacks of utilizing a case study include difficulty justifying that the outcomes of the study were solely produced from the experimental variable, and not from an outside variable. For example, a case study design does not allow control for improvement due to maturation.
However, utilization of the norm-referenced PLS-4 assessment test allowed comparison of participants with same-age peers to, at least partially address this confound. With larger studies it is easier to determine the effectiveness of treatment based on the magnitude of participant outcomes. When the participant size is smaller there is more to be justified when providing EFFECT OF BABY SIGN ON LANGUAGE FOR “AT-RISK” POPULATIONS 29
supportive evidence for the experimental variable outcome (i.e. listing all possible variables and how they impact the study results; Portney & Watkins, 2009).
Initially, we had anticipated having a larger subject size (6-12 subjects), but had challenges recruiting participants within our criteria and experienced attrition. Had we known prior to our study the participant size would result in two parent-dyads we would have implemented a single-subject experimental research design with multiple baselines across subjects because of the strengths of this design. Within a multiple baseline design, by providing and removing treatment for a length of time, researchers have an opportunity to observe the effects that therapy provides. In addition, this type of research design provides the ability to rule out any other subsequent, non-therapy behaviors that may be affecting the outcome (Morgan &
Morgan, 2009).
CDI
Support for the research hypothesis was evidenced by the notable increase in receptive and expressive language outcomes captured by the CDI. Results of the CDI Early Words showed an increase of percentile rank for both participants (P1, 20%; P2, 25%) in Phrases Understood, and an increase of percentile rank for Total Gestures when compared to same-aged peers (P1,
20%; P2, 5%). These results mirror those found in previous research (Goodwyn, Acredolo, &
Brown, 2000; Suanda & Namy, 2013).
However, it should be noted that there was a decrease in the Words Understood percentile rank for P2 (25%) on the CDI, which was not consistent with the results of previous research (Suanda & Namy, 2013).
This difference could be accounted for in several ways. For example, this effect may be due to the parents’ habitual use of phrases with the determiner/pronoun “that” with their child EFFECT OF BABY SIGN ON LANGUAGE FOR “AT-RISK” POPULATIONS 30
versus specific words (i.e. “bring me that” vs. “bring me the ball”). Parent 2 reported in interviews that she was, at times, unsure if her child knew the specific words, but she was confident in knowing that her child understood phrases clearly at the post-intervention assessment. The results for single words understood may not be representative to P2’s skill level at the time. A clinician-administered vocabulary test/screening may have been useful as a supplement to parent reported treatment outcome measures and may have captured different results for this area of development.
PLS-4
Results of the PLS-4 expressive and receptive language showed a substantial increase in standard scores by both participants on Auditory Comprehension (P1 increased 24 points and P2 increased 6 points), Expressive Communication (P1 increased 28 points and P2 increased 16 points), and Total Language Scores (P1 increased 21 points and P2 increased 13). Language improvements found on standardized tests were also found by the information collected during continued bi-weekly phone interviews. Results from these two data sources support the research hypothesis and constructivist theory. These results are similar to those found by researchers
Goodwyn, Acredolo, and Brown (2000). For example, these researchers also found that there was a significant increase in receptive and expressive language when compared to both of their control groups (verbal training and non-intervention).
Video-Recorded Interactions
Results of the 10-minute video showed that both participants had no change in joint attention, sign attempts, or number of conversational turns greater than two. P1 showed a decrease in vocal attempts from approximately 53 to approximately 18, whereas, P2 showed an increase of vocal attempts from 5 to 15. Vocal attempts captured in one 10-minute video pre and EFFECT OF BABY SIGN ON LANGUAGE FOR “AT-RISK” POPULATIONS 31
post-treatment did not appear to reliably reflect participants learning or the experimental effect.
Rather, communication attempt frequency tended to correspond to participants’ activity choice during the 10- minute segment (e.g. P1V1 pulling items from a box/bin and handing them to parent, P1V2 walking items from one room to the next, P2V1 book reading with parent, P2V2 removing items from a box/bin and showing them to parent).
The finding that short videos were not optimal measures for detecting experimental effects is not unexpected. Researchers Goodwyn, Acredolo, and Brown (2000) also indicated that the information collected during their video play segments was insightful, but did not indicate any significant change for participants in the earliest age group. They concluded, however, that more reliable data and significant changes in communication behavior during infant video-recorded play was for subjects 24-months of age or older. This finding suggests that parent interview and report may serve as more valid and reliable measures of communication change of over time for children younger than two. This finding also suggests that a range of different measures, including clinician-administered standardized tests, parent report, and video are necessary to get a true picture of child communication changes.
Interview Results
The research hypothesis was also supported by the information collected during bi- weekly phone interviews. These results were similar to those found by researchers Goodwyn et al., 2000). Goodwyn et al. (2000) reported that subjects in their “sign training” group out preformed their same aged subjects in their control group in receptive, expressive, and non- verbal communication (p. 94-96).
Results of the bi-weekly phone interview showed a noteworthy increase in the average number of signs attempted and production of signs with vocalization with both P1 and P2. Both EFFECT OF BABY SIGN ON LANGUAGE FOR “AT-RISK” POPULATIONS 32
participants also showed a decrease in the number of models provided over time. This indicated that the number of models needed for the participants to successfully engrain the newly acquired signs decreased as the signs became more habitual and generalized. Results indicated that the ideal modeling time for both participants over time was during feeding. This could be due to the direct one-on-one attention received by the participants, and their parents’ ability to hold the participants’ attention for a length of time. This finding indicated that future interventions planned for children of this age in the home may consider implementing/training strategies around regular home routines such as feeding.
Implications for Future Studies
Data acquired through phone interviews, and entering the home, also suggested several barriers to the study when working with at-risk populations (e.g. phone being disconnected, not always modeling signs daily, life threatening domestic violence, insufficient time). These results had important implications for future studies to consider when working with these populations
(see Table 6)
Table 6
Implications for Future Studies
Concerns While Entering Loss and Mandated Reporting Barriers the Home Primary Investigator safety Child safety Domestic violence Disarray and disorder in the home Mandated Reporting of abuse and Housing relocation (e.g. food remnants and clothing on neglect the floor) Aggressive behavior from family Loss of life Phone disconnection members
EFFECT OF BABY SIGN ON LANGUAGE FOR “AT-RISK” POPULATIONS 33
Disconnected Phone. In one instance, the PI attempted to call P1 several times over a 2- week period where the P1’s phone services were disconnected. This instance affected the ability to collect data effectively (both qualitative and quantitative). In addition, this experience appeared to initially cause some embarrassment for P1’s mother the next time the PI was able to make contact. The PI expressed to her that “these things happen,” which reassured the mother, but it could be something that could negatively impact future studies (i.e. attrition).
Concerns While Entering the Home. In another instance, the PI and an assistant went to a participant’s home. This home was overwhelmingly in disarray. It was difficult for the PI the assistant to find a place to sit due to the abundance of toys, clothing, food remnants, and garbage that littered the floor. This did not seem to upset the children and/or parents, but it did make it difficult for the PI and the assistant to assess, train, and collect data affectively. It was difficult to ensure standardized/regulated assessment conditions. The participant would play with toy items that were not brought by the PI/assistant, and the participant would put food items into their mouth that had been sitting on the floor for an undetermined amount of time. The
PI/assistant would assist the parent often by removing the food items, and asking if they could move some toys/clothes to an area out-of-reach. However, future researchers should be aware of these potentials issues, and devise a plan in case they run into similar issues.
There were moments of concern for the investigators when the PI and assistant entered a participant’s home. The PI followed the protocol of calling someone, to let them know where they were going, how long they would be gone, and that they would call when the PI was out of the home. This was done for the safety of the PI and assistant. The participants lived in areas that were known to have frequent crime, and safety was important to consider. Additionally, several participants’ mothers had significant others with a history of aggressive behavior. Future EFFECT OF BABY SIGN ON LANGUAGE FOR “AT-RISK” POPULATIONS 34
studies should consider a similar protocol for investigators’ safety, and have a system in place for immediate assistance if in danger (i.e. texting an outside source to call the police).
There were moments of concern for the participants when the PI entered the home. One of these concerns was due to the older siblings being physically aggressive towards the participants (i.e. pushing, pulling, hitting, throwing toys). There were several instances where the parent needed to interfere on the participant’s behalf. These situations were potentially fatal, and were not always swiftly remedied by the observing parent. Lastly, one participant’s parent
(not involved in the study) had a known history of aggression and drug use. Even though this parent was not a part of the household at the time, it is important to consider in case that parent should return. It should be recommended that researchers be prepared for situations in which mandated reporting are necessary.
Loss and Mandated Reporting. Researchers should also be prepared for the loss of a participant. Due to the risk of domestic abuse and heightened stress in these populations it is important for researchers to know that there is a chance were their participant could be physically harmed and/or die. During the course of this study one potential participant lost their life due to domestic abuse. This event happened 3 days prior to the PI going into the infant’s home. Throughout the study the PI had grown to know the participant and their family well.
The news of the death was devastating.
It is important for future researchers to consider the possibility of domestic abuse, infant neglect, and harm done to the investigators. The safety of the research team and participants should not be taken lightly, and the investigators should know where to go if they should need to seek other professional help (i.e. police, counselor, social work professionals). EFFECT OF BABY SIGN ON LANGUAGE FOR “AT-RISK” POPULATIONS 35
Barriers. Additional qualitative results found during the phone interview, and throughout the study, indicated several barriers while working culturally and linguistically diverse populations. These barriers made it difficult and/or impossible for participants to access early intervention services during this study. While some experienced a majority of the barriers listed, all experienced at least three: life threatening domestic violence, participant resident relocation, financial difficulty, child care, transportation, inability to maintain/follow through with intervention, insufficient time, mental health issues, insufficient safety, and/or insufficient housing. These barriers were significant findings to consider for any further research conducted with similar populations.
Continued Research. The results found by this study have multiple implications, and provide numerous areas of continued research. It is recommended that more research be conducted in this area with more participants, longer duration, and additional measures.
Additional research may include a team approach including other professions such as social work, physical and occupational therapy, and/or applied behavior analysts. In addition, with longer duration, it is recommended that literacy should be another targeted area to be included in a longitudinal study.
EFFECT OF BABY SIGN ON LANGUAGE FOR “AT-RISK” POPULATIONS 36
Chapter V: CONCLUSION
In summary, the results of this study support the research hypothesis that implementation of Baby Sign as a form of early language development intervention for “at-risk” populations can be beneficial to the infants/toddlers. More and more, early childhood center programs are developed for families from low SES and CLD populations. Within these populations early intervention is crucial for optimal language development. Results of this study further substantiate the advantages found in the implementation of Baby Sign as a form of early intervention for receptive and expressive language in infants of “at-risk” populations. However, it is recommended that further, and more extensive, research be conducted to study the long-term benefits of such an intervention within this population. EFFECT OF BABY SIGN ON LANGUAGE FOR “AT-RISK” POPULATIONS 37
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Appendixes EFFECT OF BABY SIGN ON LANGUAGE FOR “AT-RISK” POPULATIONS 47
Appendix A EFFECT OF BABY SIGN ON LANGUAGE FOR “AT-RISK” POPULATIONS 48
Appendix B
Early Development Research Screening Form
Investigators: Sarah Anderson, M.S. Candidate, St Cloud State University Julia McClung, B.S. Candidate, St Cloud State University Sarah Smits-Bandstra, Assistant Professor, St Cloud State University
Participant Screening Form to be filled out with Primary Caregiver
Date: ______
Name of Child: ______Child’s Date of Birth: ______
Name of Caregiver: ______
Gender: Male Female Email: ______(optional)
Telephone: Home: ______
Address: ______
Current Profession: ______Highest Education Level:______
Medical/Developmental History
1. Did your child have difficulty learning to hold their head up, sit up, make sounds, reach and grab, crawl, or eat? Yes No
If yes, please describe______
2. Do you have any concerns about your child’s hearing or vision?
If yes, please describe______
3. Is your child seeing a doctor regularly or taking any medication(s) for a disease or disorder? Yes No
If yes, please list them______EFFECT OF BABY SIGN ON LANGUAGE FOR “AT-RISK” POPULATIONS 49
4. Has your child ever had seizures, epilepsy or fits? Yes No
5. Has your child even been in the hospital for a serious injury or illness (car accident, head injury, meningitis, high fever)? Yes No
If yes, please describe ______
6. To the best of your knowledge, did you or the child’s father ever have difficulty learning to speak or learn in school as a child? Yes No
If yes, please describe______
7. . Is English your native language? Yes No
If not, what is/are your native language/s ______
8. What languages are spoken to the child?
9. What language do you plan to use for the training?
10. Do you know any type of sign language? Yes No
If yes, please describe______
ٱ No ٱ Do you use sign language with your child? Yes .11
If yes, please describe______
12. Do you or another person work with the child to improve their hand strength and skill? Yes No
If yes, please describe______
EFFECT OF BABY SIGN ON LANGUAGE FOR “AT-RISK” POPULATIONS 50
Appendix C
Baby Sign Log
Models While Response From Models Response Days Eating/Feedi Child During Play From Child ng Monday Tuesday
Wednesda
y Thursday WEEK1 Friday Saturday Sunday Monday Tuesday
Wednesda
y Thursday WEEK2 Friday Saturday Sunday Monday Tuesday
Wednesda
y Thursday WEEK3 Friday Saturday Sunday Monday
Tuesday Wednesda
y WEEK4 Thursday Friday
EFFECT OF BABY SIGN ON LANGUAGE FOR “AT-RISK” POPULATIONS 51
Saturday Sunday
EFFECT OF BABY SIGN ON LANGUAGE FOR “AT-RISK” POPULATIONS 52
Models While Response From Models Response Days Eating/Feedi Child During Play From Child ng Monday Tuesday
Wednesda
y Thursday WEEK5 Friday Saturday Sunday Monday Tuesday
Wednesda
y Thursday WEEK6 Friday Saturday Sunday Monday Tuesday
Wednesda
y Thursday WEEK7 Friday Saturday Sunday Monday Tuesday
Wednesda
y Thursday WEEK8 Friday Saturday Sunday EFFECT OF BABY SIGN ON LANGUAGE FOR “AT-RISK” POPULATIONS 53
EFFECT OF BABY SIGN ON LANGUAGE FOR “AT-RISK” POPULATIONS 54
Models While Response From Models Response Days Eating/Feedi Child During Play From Child ng Monday Tuesday
Wednesda
y Thursday WEEK9 Friday Saturday Sunday Monday Tuesday
Wednesda
y Thursday
WEEK10 Friday Saturday Sunday Monday Tuesday
Wednesda
y Thursday
WEEK11 Friday Saturday Sunday Monday Tuesday
Wednesda
y Thursday
WEEK12 Friday Saturday Sunday EFFECT OF BABY SIGN ON LANGUAGE FOR “AT-RISK” POPULATIONS 55
EFFECT OF BABY SIGN ON LANGUAGE FOR “AT-RISK” POPULATIONS 56
Models While Response From Models Response Days Eating/Feedi Child During Play From Child ng Monday Tuesday
Wednesda
y Thursday
WEEK13 Friday Saturday Sunday Monday Tuesday
Wednesda
y Thursday
WEEK14 Friday Saturday Sunday Monday Tuesday
Wednesda
y Thursday
WEEK15 Friday Saturday Sunday Monday Tuesday
Wednesda
y Thursday
WEEK16 Friday Saturday Sunday EFFECT OF BABY SIGN ON LANGUAGE FOR “AT-RISK” POPULATIONS 57
EFFECT OF BABY SIGN ON LANGUAGE FOR “AT-RISK” POPULATIONS 58
Appendix D
Phone Interview Template for Baby Sign Group 1. How have things been going (open-ended)? 2. How many times per day would you say you model each sign? a. < 3 times per day (how often per week) b. 3 – 5 times per day c. 6 – 9 times per day d. 10 times or more per day 3. When do you model each sign? a. During feeding b. During play c. During both feeding and play d. Other (explain) 4. Has your child made any attempts to communicate with Baby Sign? a. If yes, continue with questions b. If no, skip to question 11 5. Which sign/s has your child used? 6. Did they use the sign after it was modeled or spontaneously? 7. Were they using the sign appropriately to the context (i.e. the sign MORE when asking for more of something)? 8. Was/were the sign/s used with vocalization or without vocalization? 9. Where were you when your child used the sign/s (i.e. at home)? 10. How did you respond to their use of Baby Sign?
11. How have you been feeling about the Baby Sign program? 12. How do you feel about the number of signs you are training with? a. Too many (explain) b. Too few (explain) c. Just right 13. How do you feel about the functionality of the signs (i.e. do they fit with the needs of your child)? 14. How do you feel about using Baby Sign with your baby? 15. Would you recommend using Baby Sign to other parents (explain)?