To Gesture or not to Gesture? Paediatric Language Group 2014 Hello, my name is Jessica Waters and this is Mary Falco and we are presenting on behalf of the paediatric language EBP group.

The question for the year was... In children <3, does parent use of gesture result in faster acquisition of words compared to verbal input alone? Our clinical question for the year was ‘In children <3, does parent use of gesture result in faster acquisition of words compared to verbal input alone? This question came about following on from the topic we looked at last year which was risk factors and predictors for language difficulties in children under 5. The Early Language in Victoria or (ELVS) study highlighted that non-verbal skills were one of the strongest predictors of later language delay. Following on from this , we decided to find out more about gesture and its role in language development.

E3BP Types of Gesture Types of Gestures Parent use of gesture Child response Child use of gesture Parent response Deictic (pointing) Conventional (convey culturally appropriate gestures with prescribed gesture forms e.g. shaking a head sideways to convey negation, open palm for ‘give’, waving) Iconic - (convey actions and attributes e.g. cupped hands to indicate roundness of a ball)natural sign, all gone/drink) Other Tally Number of Deictic gestures used by parents Number of Deictic gestures used by children Number of conventional gestures used by parents Number of conventional gestures used by children Number of iconic gestures used by parents Number of iconic gestures used by children After doing our first round of CAPs, we came across several studies that reported on different types of gestures children and parents use. We realized that we often didn’t pay close attention to types of gestures and particularly parental use of gesture. For this reason, we decided to look at some of the kids on our caseload and see how clinicians were observing the use of gesture by both parents and children. Everyone in our group analysed a 5 minute interaction between a child and parent in a non structured play activity. The literally generally splits into these types : They looked at Deictic gesture for example pointing at the television Conventional gestures – these convey culturally appropriate gestures with prescribed gesture forms e.g. shaking a head sideways to convey negation, open palm for ‘give’ or waving ‘bye’   Iconic gestures – these convey actions and attributes e.g. cupped hands to indicate roundness of a ball or the natural sign for all drink Gestures can be used for different functions. Some gestures are reinforcing meaning the information provided in the gesture is the same as the verbal production e.g. pointing at the ball and saying ‘ball’. Supplementary gestures add information for example saying ‘kick’ and pointing at the ball’ to express ‘kick the ball’ The feedback following these observations was that this task helped clinicians in our group to be more aware of gestures that the child was using. Although we know gesture is important and it is often analysed, for most people it was not indepth and was sometimes overlooked during a time limited assessment. Group members also commented that it made them be more aware of what gestures the parents used when interacting with their children and how children responded to gestural input.

What did we find? Naturalistic observations of parent- child interactions Longitudinal studies Few ‘intervention’ studies The majority of the studies we came across were naturalistic observations of parent-child interactions that looked at parent and child use of gesture. These studies gave us information about the relationship between gesture and language. Some studies were longitudinal and went as far as giving predictive value. As expected however, very few studies were intervention studies that could tell us about impact of parental gesture on child language development.

The relationship between gesture and language development Relationship between child use of gesture and early vocabulary development Small and reliable tendency for gestures to develop earlier than first words (Goodwyn & Acredolo, 1993) At 14-16 months children use more gestures than speech (Ozcaliskan, 2005) Gesture and speech increase over time. Significant increase in number of gestures between 14 and 24 months (Ozcaliskan, 2009) Many of the studies we looked at confirmed what we already knew - We know that there is a relationship between child use of gestures and early language development. Several studies looked at how gesture and speech change over time in typically developing children. -Children typically use gestures before they speak and the earlier a child points at a particular object, the earlier they will produce a verbal label for it. --In children 14-16 months, children used more gestures than words and also used their gestures to convey a greater array of meanings than they could with their words -Both gesture and speech increase over time and there is a significant increase in the number of gestures children use between 14 and 24 mo

The relationship between gesture and language development Gesture + Speech combinations increase following first words Supplementary gesture-speech combinations precede first words Drop in gesture use from 26 mo as preference for verbal modality (Ozcaliskan 2005 & 2009) -Once children begin to use first words, gesture and speech combinations increase. -Initially children’s gesture speech combinations are reinforcing in function (eg. They point at the car and say ‘car’). Soon after they become supplementary and use gesture to convey information that they cannot convey with words alone eg. Say ‘Dad’ and point at shoes, trying to convey ‘Dad’s shoes’ -In the Ozcaliskan study children used gesture and speech combinations for several months to convey information that they could not produce entirely in speech -These supplementary gesture-speech combinations were a pre-cursor to 2 word combinations -From 26 months on, studies found there was a drop in gesture and gesture-speech use and a preference for the words only which makes sense

The relationship between gesture and language development Relationship between parent use of gesture and child use of gesture and language Parents produce models for different types of gestures and gesture-speech combinations they want their child to use Between 14-26 months, the type of gestures children use mirror that of their parents Parent use of gesture often has a different role to child use of gesture (Ozcaliskan, 2005) Evidence for a ‘gestural motherese’ (Ozcaliskan 2005 & 2013) There are several studies that have looked at parental use of gesture and it’s role in influencing child gesture and language. -Ozcaliskan and several other studies have found that parents naturally produce models for different types of gestures and gesture-speech combinations they want their child to use. So if they want their child to learn the word for car, they might point at a car and say the word. We talked about how there are different types of gestures: deictic gestures, conventional gestures and iconic gestures. Studies have shown that the number of different types of gestures that children use tends to approximate their parents over time. Ozcaliskan 2005 looked at maternal gesture and child gesture at 3 age points (child at 14, 18 and 22 months. They found that when the children were aged between 14-22 months, Pa’s produced mostly used deictic gestures, followed by conventional gestures and then by iconic gestures. Children at this age were found to follow a similar pattern. The children showed increased responsiveness to iconic gestures from 26 months which was associated in an increase in their parent’s iconic gesture production This study also looked at the function of the gestures that parents and children use. It was found that parents tended to use more reinforcing gestures (eg. Saying ‘look at the bear’ and pointing) or clarifying what is conveyed in speech (saying ‘look at it’ and pointing at the bear), in comparison to supplementary gestures where they are adding on new information with the gesture. In contrast, the children tended to use more supplementary gestures and increased their use of supplementary gestures with age. In several studies it was discussed that children tend to use supplementary gestures as an intermediary step or as a way to help them learn words and linguistic constructions, whereas the function of the parents gestures is to provide a model for what they would like them to say -. -It has been suggested that there is evidence for a gestural motherese – similar to motherese in speech - meaning that parents naturally produce higher rates of simpler gesture forms (eg pointing), conveying simpler information than they would if conversing in gesture with adults. Several studies have found that mothers gestured at a lower rate and produced simpler gestures involving mostly points at objects or conventional gestures (eg. Shaking head for ‘no’) and fewer iconic gestures

The relationship between gesture and language development Relationship between parent use of gesture and child use of gesture and language Mothers use of pointing when child 16 months old correlated with child vocabulary size at 20 months. Maternal pointing at 20 months also correlated with child’s gesture production at 20 months (Iverson, 1999) Parent using more gesture = child using more gesture (Rowe et al, 2009) Iverson in 1999 looked at children at 16 and 20 months of age interacting with their mother. At 16 months the mothers production of pointing gestures correlated significantly with child vocabulary size. At 20 months maternal pointing significantly correlated with child’s gesture production. -Rowe also showed that the parent using more gesture resulted in the child using more gesture. In 2009 Rowe looked at a group of 14 month old children interacting with their parents and then reviewed children’s language skills at 54 months. He found that parents from a higher socio economic status used more gesture with their children and children whose parents used more gesture with them used more gesture themselves. It was also found that a child’s use of gesture at 14 months impacted on their vocabulary at 54 months.

Gesture as a predictor of language development Development of gestures and receptive vocab in the second year of life have good predictive value for poor language at 2 (Suvi Stolt, 2014) At 14 months of age child use of gesture is a predictor of vocabulary at 42 months (Rowe et al, 2008) The effect of SES on child vocab at 54 months is impacted upon by the child’s use of gesture at 14 months (Rowe et al 2009) There are several articles which gave us information about how gesture could be a predictor for language development. Suvi Stolt in 2014 conducted a longitudinal study in low birth weight children and studied the development of gesture between 9months and 15 months of age and its predictive value for language skills at 2. There was a significant correlation between the number of gestures used and receptive language at 2:0 in the low birth weight group. The predictive value of gestures was good when measured at 15 months, however weak receptive vocab at 15 months was a stronger predictor of poor language skills at 2 years. This suggests that the development of gestures is best assessed after 12 months and that measures of gesture and receptive vocab combined provide a good indication of language performance at 2 years. Rowe et al (2008) studied 54 parent-child dyads. It was a naturalistic study observing parent child interactions between 14 and 34 months. They found that parents who produced more gesture types with their 14 month old children have children who produce more gesture types at that time. The children who produce more gesture meanings at 14 months have larger verbal vocabularies at 42 months. Later in 2009 Rowe found that parents from higher SES groups used gesture to convey a broader range of meanings compared with parents of children from lower SES groups. The effect of SES on child vocabulary at 54 months is impacted upon by the child’s use of gesture at 14 months

Gesture to foster parental responsiveness Child sign vocabulary is positively associated to mothers attunement to child affect. More signs in child’s vocabulary = more attuned mothers were to changes in child affect Sign training intervention increased maternal response to child distress cues (Valotten, 2012) Several of the articles looked at the impact of gesture on parental responsiveness. Vallotton in 2012 included 29 families in 2 groups from low income families and/or children at risk of developmental delay. Parents in the intervention group were trained in use of infant signs. They found that child sign vocab was positively associated to their mothers attunement to their affect. The more signs the child had in their vocab the more attuned mothers were to the changes in the child’s affect. The sign intervention didn't change their mothers responsiveness to their child’s social skills but it did increase maternal response to child’s distress cues.

Gesture to foster parental responsiveness In children aged 10-24 months mothers translation of child gestures = positive impact on language acquisition. Mothers translation of child gesture increases likelihood of the words becoming part of the child’s spoken vocabulary (Goldin –Meadow & Goodrich, 2007) Goldin –meadow, goodrich (2007) looked at 10 typically developing children in a longitudinal study beginning from 10 months to 24 months. – in children aged 10-24 months mothers translation of their childs gestures was found to make a positive impact on their child’s language acquisition. When mothers translated child gesture into words those words were significantly more likely to become part of their child’s spoken vocabulary.

Gestural input for improving language development Sign input from parents fosters receptive language development Sign input from parents significantly improves expressive language at 15 and 24 months of age (19, 30 and 36 approaching significance) More gesture = more for caregivers to respond to = more rapid language development Goodwyn, Acredlo and Brown (2000) Most of the articles we have looked at were naturalistic studies where there was no direct intervention. We did however find a few studies which controlled for the amount of gestural input that children received... Goodwyn, Acredlo and Brown (2000) looked at 103 children aged 11-36 months involved in a longitudinal design. Children were randomly allocated into a sign training group (ST), non-intervention control group (C) and verbal training group (VT) The families given key toys/objects and a picture book and taught how to use them in everyday interactions with their child to target 5 key words. Sign training group parents signed and used words. The verbal training group parents just labelled objects/verbs Results indicated that there was a difference between receptive language scores between 30 and 36 months between the Sign Training and control the difference however it was not significant Expressive language scores for children in the Sign Training group were significantly higher than the control group at 15 and 24 months with 19, 30 and 36 months approaching significance. It was hypothesised in this paper that symbolic gesture may be related to more rapid language development because of how the adult responds to the child who is using gesture. For example if the child flaps his arms when he sees a ‘bird’ the adult is more likely to elaborate or confirm the child’s comment by saying ‘look a bird’ ‘look at him flying away’ as opposed to the child who does not initiate the exchange by flapping his arms. Therefore the 14 month old with 10 words and 10 gestures can elicit caregiver responses to twice as many things as he could without the gestural symbols.

Gestural input for improving language development Acquisition of new words for children with and without SLI is improved with... slower speaking rate the use of gesture with spoken language No significant effects for changing stress Use of gesture improves comprehension Ellis Weismer (1993) Ellis Weismer also studied if gestural input affects language development. 16 children in kindergarten, 8 with a specific language impairment and 8 without were divided into 2 groups and taught novel words under 3 conditions – stress, rate and visual (gesture) Results indicated that the acquisition of novel words for all children in the study (with and without SLI) were significantly affected by alterations in speaking rate and by the use of gesture accompanying spoken language. There were no significant effects for stress changes in the groups. It was also found that children in both groups demonstrated significantly better comprehension of words when the words were taught with a gesture.

Clinical bottom line Gesture is good for... Improving expressive language skills Fostering receptive language skills Promoting parent child responsiveness Is best measured early in the second year as a predictor of language development Gesture is a precursor to first words and gesture + sign is a precursor to combinations There must be underlying cognitive skills in place to develop gesture (memory, categorisation and symbolisation) Our clinical bottom line is that... -Gesture is good for improving expressive and receptive language – we know that parental gesture can facilitate child use of gesture and that a child’s use of gesture can be a predictor for future vocabulary development. We can therefore assume that using gesture is an important clinical tool to help children learn a new concept or language skill -As mentioned, there are studies to suggest that a child’s use of gesture can improve parents responsiveness to the child’s affect -Gesture is best measured early in the second year as a predictor of language development -Gesture is a precursor to first words and gesture + sign is a precursor to combinations. Child use of gesture is an important part of the language learning context and children practice gestures and gesture-speech combinations that they see their parents produce as a way of practicing new semantic meanings. -We know that there must be underlying cognitive skills in place to develop gesture (memory, categorization and symbolisation)

Relevance to Practice Parental responsiveness Low SES groups Best to assess gesture after 12 months Gesture + verbal input = best outcome for language development From now on we will be thinking about .... - The relationship between gesture and parental responsiveness. The more signs children use the more attuned parents will be to their affect. - Low SES groups - gesture should be looked at in low SES families as we know that parents from low SES groups use less gesture and in turn their children produce less gesture. Is best measured after 12 months of age as it will have a better predictive value - Teaching gesture with language will result in a better outcome for children’s expressive language skills and may also improve their receptive language skills.

References 2014 CAP’s completed O’Toole & Chiat (2006) Symbolic functioning and language development in children with Down Syndrome Vallotton (2012) Infant signs as intervention? Promoting symbolic gestures for preverbal children in low-income families supports responsive parent-child relationships, Early Childhood Research Quarterly, 2012, 401-415 Goodwin, Acredolo & Brown (2000) Impact of Symbolic Gesturing on Early Language Development Ozcaliskan & Goldin-Meadow (2005) Do parents lead children by the hand? Goodwyn & Acredolo (1993) Symbolic Gesture vs Word Goldin-Meadow, Woodrich et al (2007) Young children use their hands to tell their mothers what to say

References Rowe& Goldin-Meadow (2009) Differences in early gesture explain SES disparities in child vocabulary size at school entry Ozcaliskan S. & Goldin-Meadow, S (2009) When gesture speech combinations do and do not index linguistic change Iverson, J.M., Capircio, Longobardi E., Caselli M. Gesturing in mother-child interactions Stolt S., Makila, A. et al (2014) The development and predictive value of gestures in very-low-birth-weight children: a longitudinal study Weismer (1993). The influence of prosodic and gestural cues on novel word acquisition by children with SLI Background reading: Ozcaliskan & Dimotrova (2013 How Gesture Input Provides a Helping Hand to Language Development, Seminars in speech and language, 34, 4

2014 Topic: TBC – Watch this space! jessica.waters@sswahs.nsw.gov.au maryfalco@lifestart.org.au Thanks to the group this year, Exciting new topics – coming soon, if you want to join please email jess or Mary .