Project Activities
In this project, the research team examined the efficacy of EMT en Español using a randomized controlled trial, with child-caregiver dyads randomized into intervention and control groups. Assessments of children and caregivers were collected before the intervention began, immediately after the intervention ended, and at 6-month and 12-month follow-up time points. Analyses examined the impact of the intervention on observed vocabulary during child-caregiver interactions with caregivers and trained assessors, standardized child expressive and receptive language assessments, parent implementation of intervention strategies with their child in natural contexts and child diagnostic status at age 4 (DLD vs not DLD).
Structured Abstract
Setting
The study took place in homes and community settings where early intervention programs, funded by Part C of the Individuals with Disabilities Education Act (IDEA), in Tennessee. Families were located in urban and suburban areas of a moderately sized city.
Sample
Participants included 81 children aged 30-36 months and their Spanish-speaking caregivers. Children demonstrated significant expressive and receptive language delays at entry, with no additional disabilities. Children and caregivers were from low-income families. The majority (93%) of the caregivers were mothers; 75% of the caregivers had less than the equivalent of a high school education.
EMT en Español is the Spanish linguistic and cultural adaptation of Enhanced Milieu Teaching (EMT), a naturalistic language intervention that promotes the use of new language forms using environmental arrangement, responsive interaction strategies, language modeling and expansions, and systematic prompting procedures to teach functional spoken language. Therapists work with children in English and Spanish and teach caregivers in Spanish to use communication, interaction, and language support strategies in play, routines and book-sharing. EMT en Español is provided in Spanish and includes cultural and linguistic adaptations for Spanish-speaking children and families. The selection of child language targets followed typical Spanish language rules and development (e.g., taking into account that Spanish-speaking children acquire verb use and different inflections earlier than English-speaking children). There were a total of 36 sessions, half (18 sessions) consisting of two therapists working directly with the child (one provided 9 sessions in Spanish; one provided 9 sessions in English) and half (18 sessions) focused on caregiver training (5 sessions in- person at home; 13 sessions via zoom following a telehealth protocol).
Research design and methods
The intervention was evaluated through a randomized controlled trial in which child-caregiver dyads were randomized into the intervention or control group. Both groups continued to receive their usual services, but the intervention group had services supplemented with the EMT en Español. Therapists from the research team provided participants in the intervention group with 36 sessions of EMT en Español over a period of 6 months. Blind assessors collected child and caregiver assessment data at baseline, the end of the intervention, 6 months after intervention, and 12 months after intervention. Data on therapists' fidelity of implementation of the child intervention in English and Spanish and caregiver training were collected during 20% of sessions in the intervention phase. The data collected addressed the primary research questions about the effects of the intervention on expressive and receptive vocabulary during interactions and on standardized bilingual assessments; the effects on caregiver use of the trained intervention strategies, such as use of more rich language targets; and whether caregiver strategy use mediates the impact of the intervention on children's outcomes. The research team also examined longer-term effects on children's language and related school readiness skills, including executive functioning, and English as well as Spanish language skills. The costs of delivering the intervention were also examined. Family enrollment into the study occurred on a rolling basis over the first five years of the project; follow-up data were collected throughout the study, and final data analyses occurred in the final year.
Control condition
Families in the control condition received their current business-as-usual early intervention services, if any. These included the state's Part C program, Early Head Start, or no services. Families also received information about their child’s language development, toys and materials, and the parent manual (but no teaching or coaching) at the beginning of the intervention phase for the treatment group.
Key measures
For child language outcomes, the research team transcribed and coded two counterbalanced 20-minute adult-child interactions (one in in English and one in Spanish) with a trained assessor and two in Spanish with the child’s caregiver (a 5-minute book interaction and a 15- minute play interaction). The blind assessor administered the Receptive One Word Picture Vocabulary Test-Spanish Bilingual Edition and Expressive One Word Picture Vocabulary Test Spanish Bilingual Edition at each time point. The Bilingual English Spanish Assessment (BESA) was administered at the 12-month follow up to examine morphosyntax semantics and the combined language index score. For executive functioning, the research team administered the Behavior Rating Inventory of Executive Function-Preschool Version Spanish and direct child assessments, including the snack delay and Head-Shoulder-Knees-Toes task. Children were screened for eligibility on the Leiter-R and Preschool Language Scale-5th Edition Spanish. Fidelity of implementation was measured by coding videotaped intervention sessions to capture therapist use of EMT en Español in English and Spanish while interacting with the child, therapist teaching of the intervention strategies to caregivers, and caregiver use of intervention strategies during daily routines, play, and book sharing. Demographic information including family composition, caregiver education, and household income, as well as maternal depression were examined for potential use as covariates in analyses.
Data analytic strategy
Multivariate regression analyses were used to examine the immediate and longer-term impact of EMT en Español on children's language skills during the two 20-minute play-based language samples with a blind assessor, and caregivers' use of naturalistic language teaching strategies during caregiver-child interactions. Researchers used regression analyses to explore whether the intervention moderates the relationship between baseline conceptual expressive vocabulary skills and conceptual vocabulary skills at follow up. To examine whether parent use of intervention strategies mediates the impact of the intervention at follow up, the research team used mediation analysis with bootstrapping. To explore long-term effects of the intervention on school readiness skills (including standardized language assessments and executive functioning), the research team used multivariate regression.
Cost analysis strategy
The ingredients method was used to analyze implementation costs per child. Detailed records of all costs were compiled. Because exact costs of current Part C services needed to estimate comparative costs were not available, a summary of intervention costs and a general estimate of cost effectiveness were prepared.
Key outcomes
Key Outcomes: The main findings of this project, as reported by the principal investigator, are as follows:
- Children in the intervention group had higher numbers of rich language targets (English and Spanish combined) at immediate post-test, at the 6-month follow up, and at the 12-month follow up than children in the control group. The differences between groups were not statistically significant. However, the effect size at the 6-month follow up was moderate (d=.47) and approached significance (p=.08). There were no differences in conceptual receptive or expressive vocabularies between the treatment and control group at post, 6 months, or 12 months.
- There were significant effects of caregiver training on caregiver dosage post intervention and the significant effects maintained during follow up. Effect sizes in play interactions were d=1.06 at immediate post-test, d=.58 at 6-month follow up, and d=.69 at the 12-month follow up.
- Children in the intervention group scored significantly higher on the measures of children’s semantics, grammar, and morphological skills (BESA language index standardized score) than children in the control group, with a medium effect size of d=0.6 at the 12-month follow up. Based on classification outcomes, 8% control versus 45% of treatment children were no longer meeting DLD criteria at the 12-month follow up. In other words, children who received this intervention were five times more likely to no longer meet the clinical cutoff for DLD.
People and institutions involved
IES program contact(s)
Project contributors
Products and publications
Project website:
Publications:
ERIC Citations: Find available citations in ERIC for this award here.
Available data:
Data Set
Kaiser, A., Peredo, T. N., Mancilla-Martinez, J., & Durkin, K. (2025). EMT en Español: Early communication intervention for Spanish-speaking toddlers with language delays. Datasets t00, t01, t02, t03. LDbase. https://doi.org/10.33009/ldbase.1754422955.836f
Data Dictionary
Dillehay, K., Peredo, T. N., & Cisneros, G. (2025). EMT en Español RCT Data Dictionary. LDbase. http://ldbase.org/documents/b9f4d8a3-f759-487c-be22-a24aa509f635
Code for Observational Interactions and Natural Language Samples
Pak, N., Dillehay, K., Frampton, R., Asres, R., Cisneros, G., & Peredo, T. N. (2025). EMT en Español Coding Manual for Observational Caregiver-Child Interactions. LDbase. http://ldbase.org/documents/8950ed68-0420-44dd-96a8-a3afa44173c6
Additional project information
Parent Training Manual
Madero Ucero, A. P., & Peredo, T. N. (2025). EMT en Español Manual para Padres. LDbase. http://ldbase.org/documents/d4eae8c2-20b7-432b-aa2c-906a7c1851c4
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