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Research
Communication Disorders Quarterly

An Exploratory Study of “Quantitative

34(4) 199­–209
© Hammill Institute on Disabilities 2013
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DOI: 10.1177/1525740112473146
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Feedback on Adult Language Production

Dana Suskind, MD1, Kristin R. Leffel, BS1, Marc W. Hernandez, PhD1,

Shannon G. Sapolich, BA1, Elizabeth Suskind, BS1, Erin Kirkham, MD2,
and Patrick Meehan, MSW3

Abstract
A child’s early language environment is critical to his or her life-course trajectory. Quantitative linguistic feedback utilizes
the Language ENvironment Analysis (LENA) technology as a tool to analyze verbal interactions and reinforce behavior
change. This exploratory pilot study evaluates the feasibility and efficacy of a novel behavior-change strategy, quantitative
linguistic feedback, to influence adult linguistic behavior and, as a result, a child’s early language environment. Baseline LENA
outcome measures (i.e., adult word count [AWC] and conversational turn count [CTC]) were obtained from a diverse
sample of 17 nonparental caregivers and their typically developing children (charges) ages 10 to 40 months. Caregivers
participated in a one-time educational intervention focusing on enriching a child’s home language environment, interpreting
feedback from the baseline LENA recordings, and setting language goals for the following session. Post-intervention, six
additional LENA recordings were obtained weekly to measure linguistic behavior. Caregivers showed a significant and
prolonged increase from mean baseline to mean postintervention AWC and CTC as measured by LENA–AWC: mean
difference = 395 words per hour, 31.6% increase, t = 3.29, p < .01; CTC: mean difference = 14 turns per hour, 24.9% increase,
t = 3.54, p < .01. Preliminary results indicate that a one-time educational intervention combined with quantitative linguistic
feedback may have a positive effect on caregiver language output, thus enhancing the child’s language environment. This
study represents an initial step in the development and evaluation of a novel behavior-change strategy. We propose that
quantitative linguistic feedback will add significantly to the arsenal of clinical and research tools used to evaluate and enrich
a child’s early language environment.

Keywords
speech and language therapy, parent education, specific language impairment (SLI)

Background
A child’s early language environment is critical to his or her
life-course trajectory (Forget-Dubois & Dionne, 2009; Law
& Rush, 2009; Phillips, 2011). Language exposure not only
bears an obvious relationship to a child’s linguistic devel-
opment but also significantly influences a child’s overall
cognitive and educational achievement (Hart & Risley,
1992, 1995; Huttenlocher, Vasilyeva, Cymerman, & Levine,
2002; Kashinath, Woods, & Goldstein, 2006). Hart &
Risley’s landmark study demonstrated a significant correla-
tion between the number of words a child hears by age 3
and his or her ultimate IQ and academic success. Equally
compelling is the literature linking the qualitative aspects
of language exposure, including complexity of speech,
adult-to-child interaction and responsive caregiving, with a
child’s ultimate educational outcome (Bornstein, Tamis-
LeMonda, Hahn, & Haynes, 2008; Huttenlocher, Haight,
Selzer, & Lyons, 1991; Kaiser & Hancock, 2003a, 2003b;
Landry, Smith, Swank, & Guttentag, 2008; Landry, Smith,
Swank, & Miller-Loncar, 2000; Reilly et al., 2010; Snow,
1972). This research demonstrates clearly that a qualita-
tively and quantitatively rich early language environment is
paramount for a child to realize his or her linguistic poten-
tial and, ultimately, life-course potential as well.
Disparities in early language environments, along with
their profound lifelong consequences, have been
demonstrated in children with developmental disabilities
1
University of Chicago, IL, USA
2
University of Washington, Seattle, USA
3
University of Michigan, Ann Arbor, USA
Corresponding author:
Dana L. Suskind, Department of Pediatrics and Otolaryngology,
University of Chicago, 5841 S Maryland Ave., mc 1035, Chicago, IL, USA.
Email: dsuskind@surgery.bsd.uchicago.edu

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200 Communication Disorders Quarterly 34(4)
such as autism, children with intellectual disabilities, chil-
dren with hearing loss whose parents are hearing, and chil-
dren with specific language impairments (SLI), as well as
children of low socioeconomic status (SES; DesJardin &
Eisenberg, 2007; Hammer, Tomblin, Zhang, & Weiss, 2001;
Hoff & Tian, 2005; Huttenlocher et al., 1991; Meadow-
Orlans, 1997; Reilly et al., 2010; Rowe, 2008; Spencer &
Gutfreund, 1990). These populations have been demon-
strated to have significantly reduced quantitative and quali-
tative parental linguistic input. As such, it has been estimated
that children living in poverty will have heard 30 million
fewer words by age 3 compared with their more affluent
peers (Hart & Risley, 1995). This gap in linguistic input
mirrors an academic achievement gap that is evident from
the first day of school and persists throughout adulthood
(Phillips, 2011). Children with hearing loss in particular,
regardless of SES, have been shown to have significant dis-
parities in language experiences when compared with nor-
mal-hearing peers. In low-SES children, language disparities
are most often associated with less exposure to and facility
with academic language (Snow, 1972). For children with
hearing loss, however, it is the fundamental development of
listening and spoken language that is at risk.
Clinical interventions for children who have speech and
language delays often target the adult caregiver as the cata-
lyst for improving the child’s language development (Kaiser
& Hancock, 2003a; Kashinath et al., 2006; McWilliam,
2001; Pickston, Golbart, Marshall, Rees, & Roulstone,
2009; Reese, Sparks, & Leyva, 2010; Roberts & Kaiser,
2011). As the primary contributors to their child’s language
environment, adult caregivers are able to enrich their child’s
home language environment throughout the child’s day.
This family-centered approach is fundamental to the feder-
ally funded early intervention programs for young children
with disabilities (Individuals With Disabilities Education
Improvement Act of 2004, 2003). While the intervention
literature focuses primarily on parental caregivers, the lit-
erature also supports the incorporation of nonparental care-
givers (NPCs; Giurolametto, Weltzman, & Greenberg,
2003, 2004; Milburn, 2011). Intervening with NPCs is an
important method for improving the child’s language envi-
ronment as NPCs care for the majority of 0- to 4-year-old
American children; 77% of children of employed mothers
received care from NPCs in 2010 (Table FAM3.A. Child
care: Primary child care arrangements for children 0–4 with
employed mothers by selected characteristics, selected
years 1985–2010).
The literature strongly supports the potential for improv-
ing the child’s language outcome via the adult caregiver
(Roberts & Kaiser, 2011). In a meta-analysis of 18 parent-
implemented language interventions, Roberts and Kaiser
found significant improvements in receptive and expres-
sive language skills of children 18 to 60 months of age
(Roberts & Kaiser, 2011). Although the interventions had
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varied approaches, philosophies, and target populations,
overall Roberts and Kaiser found that, with relatively mod-
est training, parents successfully implemented language
interventions, which in turn positively affected children’s
receptive and expressive language. Most interventional
approaches that Roberts and Kaiser reviewed included a
broad “social communication focus,” with linguistic strate-
gies designed to be integrated into daily routines (Roberts
& Kaiser, 2011). The two most common linguistic
approaches aimed to affect “what the parents say” and
“how much the parents say” (Roberts & Kaiser, 2011).
Interventions also sought to enhance parent–child interac-
tion via increased parental responsiveness to the child’s
attempts to communicate.
Despite the generally positive outcomes, Roberts and
Kaiser (2011) identified a number of weaknesses in the
interventions reviewed. They found a lack of detailed
descriptions of the interventions, resulting in an inability to
pinpoint the intervention components that correlated with
specific language improvement (Roberts & Kaiser, 2011).
In addition, many studies failed to accurately assess care-
giver intervention uptake, sustainability of caregiver lan-
guage behavior change, or the necessary child intervention
dosage, for example, frequency and length of intervention
program (Roberts & Kaiser, 2011). Furthermore, the pri-
marily middle-class study participants raised the question
of external validity and generalizability of results.
These shortcomings mirror a similar concern in the over-
all health promotions literature, where studies of complex
behavioral interventions often lack clarity in descriptions of
behavioral strategies used (Michie, Johnston, Francis,
Hardeman, & Eccles, 2008). It has been suggested that the
modest behavioral effects often found in interventions are
linked to this lack of transparency and well-defined behavior-
change strategies used in these interventions (Michie,
Fixsen, Grimshaw, & Eccles, 2009). In response to these
limitations, the health promotions field has advanced a tax-
onomy of theoretically based behavior-change techniques
(Michie et al., 2011). Michie et al. have proposed a compre-
hensive group of 40 discrete evidence-based behavior-
change techniques, which they term CALO-RE1 taxonomy.
The CALO-RE taxonomy of strategies is not specific to a
particular behavioral intervention type (e.g., smoking or
weight loss) but is, rather, a methodological tool that can be
generalized to any health promotion intervention. The ulti-
mate goal is to eliminate the ambiguities of interventional
strategies so the specific factors and their specific effects in
an intervention are understood. The literature provides
compelling evidence that incorporating these theoretically
based behavior change techniques into health promotion
interventions is essential to stimulating sustainable behavior-
change and advancing the science of behavior change
(Abraham & Michie, 2008; Michie et al., 2005; Michie,
Jochelson, Markham, & Bridle, 2009).
Suskind et al. 201
Aims
It is with appreciation for the critical need for theoretically
based behavior-change strategies in caregiver-directed lan-
guage interventions that we describe our preliminary pilot
testing of a novel, multifaceted behavior-change strategy
we call quantitative linguistic feedback. This strategy has
been developed to facilitate changes in language behavior
of adult caretakers and to quantify the impact and sustain-
ability of intervention in adult linguistic behavior. It is
designed to be incorporated into and enhance any existing
caregiver-directed interventions.
The theoretical underpinnings of quantitative linguistic
feedback are Bandura’s social cognitive theory (SCT), the
theory of planned behavior (TPB), self-determination the-
ory (SDT), and the health belief model (HBM; Ajzen,
2001; Ajzen, Brown, & Carvajal, 2004; Bandura, 1997;
Vansteenkiste & Sheldon, 2006). These theories of behavior
change must be factored into the development of successful
behavioral intervention techniques (Michie et al., 2008).
Guided by such theories, we developed quantitative linguis-
tic feedback with a multifaceted approach that includes a
mechanism by which adults can set and respond to goals
(TPB and goal setting), utilize cues for action or external
prompts for behavior change (HBM), recognize the
improved language environment they are providing for
their child, and develop a sense of competency and auton-
omy in facilitating their child’s development (SCT).
TPB describes “intention” as a critical determinant of
behavior. Health intention is, itself, determined by beliefs
and attitudes about treatment (e.g., medication efficacy and
adverse effects), subjective social norms (e.g., concern with
the opinions of others), past experience (e.g., previous
experience with similar programs), and perceived behav-
ioral control and self-efficacy (Hagger, Chatzisarantis, &
Biddle, 2001). Attitudes, both favorable and unfavorable,
will affect intention and, ultimately, action and adherence,
or the lack thereof (Ajzen, 1996; Hagger, et al., 2001; White
& Wellington, 2009). Quantitative linguistic feedback
encompasses intention by incorporating goals to be set and
accomplished, and, most critically, engages caregivers as
goal setters.
HBM maintains that “readiness” to change behaviors is
“activated” by motivational feedback and “cues to action”
(Janz, Champion, & Stretcher, 2002). External prompts are
cues to action, which in turn stimulate behavior change. In
quantitative linguistic feedback, “cues to action” are the
Language ENvironment Analysis (LENA) data that provide
concrete evidence of a child’s language environment and
patterns of change.
Finally, Bandura’s SCT recognizes self-efficacy―the
“belief in one’s capacity to organize and execute the courses
of action required to produce given attainments”―as criti-
cal for the success of all interventions (Bandura, 1997).
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Bandura writes that a sense of self-efficacy is essential any
time a parent is to take action on behalf of a child’s educa-
tion or health status, or act as a child’s teacher and advocate.
DesJardin and Eisenberg (2007) also found that caregiver
self-efficacy is strongly related to the linguistic skills of
young children with hearing loss. Self-efficacy is also asso-
ciated with more sophisticated language strategies, such as
open-ended questioning and parallel talk, which are in turn
correlated with improved language outcomes (Hughes &
Demo, 1989; Johnston-Brooks, Lewis, & Garg, 2002;
Raikes & Thompson, 2005; Wolf et al., 2007).
Given these theoretical foundations, the parent-directed
educational intervention was designed to (a) review the
importance of a child’s early language environment in rela-
tion to later language proficiency, (b) understand how the
LENA measures certain critical aspects of this environment
(i.e., adult word count [AWC], conversational turn count
[CTC], TV Time [TVT]), and (c) discuss strategies to help
parents enrich their child’s language environment.
The technological centerpiece of quantitative linguistic
feedback’s behavior-change intervention is the LENA
System. The LENA is an innovative recording device that,
along with its accompanying computer software, can be used
to automatically capture and analyze a child’s home language
environment (Oller, 2010). The LENA quantifies the number
of words to which a child is exposed and the number of con-
versational turns the child takes with adult(s) over a continu-
ous 16-hr period (Gilkerson & Richards, 2008). The LENA’s
quantitative outcome measures are then presented to caregiv-
ers, providing them with concrete feedback about where need
for greater language exposure exists and where improvement
has been made. Thus, the LENA’s value is not simply for
scientific quantification but for providing feedback to the
adult caregivers. In collaboration with a therapist, caregivers
can clearly see a snapshot of the home language environ-
ment, consider their role within it, discuss opportunities to
enrich that environment, and importantly, chart and track
progress toward enrichment. In other words, the quantitative
outcome measures are utilized as a type of “biofeedback”
used for goal setting and measuring progress toward those
goals. Thus, this quantitative linguistic feedback can be used
to reinforce traditional approaches used in a wide variety of
language-development focused interventions.
Quantitative linguistic feedback is a multifaceted tech-
nique for behavior change that may work through a number
of different mechanisms as described in the CALO-RE tax-
onomy (Michie et al., 2011). For adult caretakers, quantita-
tive linguistic feedback offers a mechanism by which they
can set and respond to goals, utilize cues for action or exter-
nal prompts for behavior change (e.g., reviewing LENA
outcome measures), and recognize the improved language
environment they are providing for their child. It also instills
a sense of competency and autonomy in facilitating their
child’s development.
202 Communication Disorders Quarterly 34(4)

Our initial work evaluating quantitative linguistic feed- Table 1.  Nonparental Caregiver Characteristics.
back’s feasibility and efficacy in improving adult quantitative
Nonparental caregiver n %
language behavior is presented here. We hypothesized that
quantitative linguistic feedback would result in a significant Education 17 –
increase in AWC and CTC as measured by the LENA.  GED 2 12
Subsequent efforts will focus on demonstrating a correspond-   High school diploma 2 12
ing qualitative improvement, sustained linguistic change, as   Some college 4 23
well as methods for incorporating this novel strategy into   Four year college degree 9 53
existing interventions. Ultimately, the technique of caregiver-   Nanny school 2 12
directed, quantitative linguistic feedback holds the promise Race/Ethnicity 17 –
for significantly improving child language outcomes.   African American 2 12
 Asian 1 6
 Hispanic 3 19
Method and Procedures  Caucasian 10 63
  Did not state 1 6
Design
Primary language 17 –
 English 12 71
The study used a prospective case-crossover design involv-
 Other 5 29
ing two baseline recordings followed by a single educa- Language spoken with child 17 –
tional intervention and six postintervention LENA feedback  English 12 71
recordings. This exploratory pilot study was conducted  Other 5 29
with a group of NPCs who were chosen because of their   Other language spoken 3 to 6 hours/day 1 20
extensive, focused, and consistent periods of time with the   Other language spoken 1 to 3 hours/day 2 40
children in their care.   Other language spoken <1 hour/day 2 40

Participants
NPCs. Nineteen English-speaking NPCs caring for typi-
cally developing children were recruited for this study. Of
the 19 recruited NPCs, 17 (90%) completed the study and
are included in the present analysis. One NPC dropped out
secondary to pregnancy, and another withdrew due to
scheduling difficulties prior to obtaining baseline record-
ings. A table of NPC demographics is shown in Table 1. All
NPCs were women and ranged in age from 23 to 53 years
(M = 33.1, SD = 10.1). Their education levels ranged from
GED to 4-year college degree, with approximately half
having a 4-year degree (n = 9; 53%). Two NPCs (12%)
received specialized child care training (i.e., nanny school).
Ten NPCs (59%) were Caucasian, with the other 6 repre-
senting a range of races and ethnicities, including African
American (n = 2; 12%), Asian (n = 1; 6%), and Hispanic (n
= 3; 18%). Nearly one third of the NPCs (n = 5; 29%)
spoke English as a second language. On average, NPCs
had 9 years of experience caring for children (SD = 7,
range = 2–28) and a range of 2 months to 3 years caring for
the child in this study (M = 1 year, SD = 9 months). Five of
the NPCs (n = 5/17, 29%) cared for at least one other child
simultaneously with the child in the study.
Children and families. Seventeen families participated in this
study: 10 girls (n = 10; 59%) and 7 boys (n = 7; 41%). Ages
ranged from 10.5 to 40.3 months (M = 20.4 months). In
families with multiple children, 1 child between the ages of
10 and 42 months was eligible for inclusion in the study.
Eight children (47%) had one sibling, with four of the sib-
lings younger and one older. One child (6%) had two sib-
lings, with one younger and one older (see Table 2). Five
children received primary care from their mothers (9%),
1 child from his or her NPC (6%), 10 from their mothers and
NPCs (9%), and 1 from his or her mother and father (6%).
All children were from two-parent households with
annual incomes of US$100,000 or more. One parent had
an associate’s degree, whereas the rest of the parents in
the study had a 4-year college degree or higher. Forty-one
percent of parents (n = 14) had attained doctorate degrees.
Eleven families responded as Caucasian (65%), three as
Asian (18%), two as multiethnic (12%), and one family
declined to state (6%). All families spoke English as the
primary language at home. Five were bilingual, but
reported that they spoke their second language less than
1 hr per day.
Materials and Procedures
Recruitment. English-speaking NPCs caring for typically
developing children were recruited through professionals at
the University of Chicago and the surrounding area via
email, online postings, and word of mouth. NPCs were paid
US$100 for completion of the study. Informed consent was
obtained from parents and NPCs. The consent forms
included an agreement that parents would not know or ask
for their NPC’s results or feedback.

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Suskind et al. 203

Table 2.  Family Characteristics. the shirt containing the LENA device. The LENA device
records up to 16 hr of audio, and requires a minimum of
Child n %
12 hr of data for complete and accurate processing. Because
Sex 17   the NPCs all worked less than 12 hr per day, they were
 Male 7 41 instructed to keep the device turned on for the maximum
 Female 10 59 recording duration and to write down the timestamp present
Number of siblings 17   on the digital display when their interaction with the child
 0 8 47 ended for the day (i.e., when they left the child’s home or
 1 8 47 when the child was put to bed). NPCs each made a total of
 2 1 6 eight recordings during the course of the study: two base-
Level of education   line recordings prior to intervention and six postbaseline
Mother 16 – recordings. We used the average of the two baseline record-
  Four-year college degree 6 37.5 ings as their baseline measure.
  Master’s degree 4 25
  Doctorate degree 6 37.5
Educational intervention. After baseline recordings were
Father 16 –
completed, each NPC participated in a language-focused
  Associate’s degree 1 6
educational intervention lasting approximately 1 hr at the
  Four-year college degree 5 31
  Master’s degree 2 13
child’s home. This session included information on child
  Doctorate degree 8 50 language development, along with tips for increasing their
Race/Ethnicity 17 – talk and conversational turn-taking with the child. The edu-
 Asian 3 18 cational session was conveyed via a short PowerPoint pre-
 Caucasian 11 65 sentation, and included the following core components: (a)
 Multiethnic 2 11 review of the importance of a child’s early language envi-
  Did not state 1 6 ronment (i.e., connection between caregiver linguistic input
Mother employed 16 – and a child’s language and educational success), (b) discus-
  At home 1 6 sion of LENA and its target measures (i.e., AWC and CTC),
  Outside home 15 94 (c) review of caregiver baseline LENA recordings, and (d)
Primary caregiver 17 – discussion of strategies to enrich a child’s early language
 Mother 5 29 environment and raise LENA measures through talking
  Nonparental caregiver 1 6 more and increasing conversational turns with a child.
  Mother and nonparental caregiver 10 59
  Mother and father 1 6 Quantitative linguistic feedback. The research assistant then
provided the NPCs with their individual LENA linguistic
feedback from the baseline recordings, and facilitated the
Demographic and home language survey. NPCs and one par- NPCs’ understanding of the LENA feedback reports and
ent from each family completed a demographic survey, goal setting for the following recordings. LENA feedback
which included items about race, ethnicity, education, and reports included raw numbers, percentiles, and graphic rep-
household income. The instrument also included a home resentations of mean hourly AWC and CTC. Intervention-
language survey, which included questions about typical ists discussed with NPCs specific results, methods for
daily schedules, the amount that the child talked, the amount increasing AWC and CTC, and goal setting for upcoming
that NPCs and parents spoke to the child, and the amount of recordings. In addition, NPCs demonstrated ability to accu-
time children were exposed to TV during a typical day. rately interpret and understand feedback at the end of the
interventional session.
Interventionists. Two graduate-level research assistants After the educational intervention, NPCs made record-
involved in the development of the 1-hr educational inter- ings once weekly for 6 weeks and received their LENA
vention performed all interventions. Training and practice feedback results halfway between each recording session.
occurred with the principal investigator (Suskind) prior to No active discussion or goal setting was performed by the
commencement of interventions. interventionist beyond providing the results in paper form.

Recording procedure. At the start of the study, NPCs were

each given a LENA digital language processor designed to Data Processing
be worn by the child in the front pocket of a specially made Data were uploaded from the LENA recorders into a study
t-shirt. At the beginning of each recording day, NPCs wrote computer. All data were then processed into counts by
down the recording start time and then placed on the child LENA ADEX software. Audio recordings were discarded

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204 Communication Disorders Quarterly 34(4)

to protect the privacy of the participants per IRB-approved Table 3.  Family and Nonparental Caregiver Language
research protocol. Language-related outcomes were Characteristics.
assessed on three main measures: AWC, CTC, and child
Self-reported language behaviors n %
vocalization count (CVC). Naptime as well as NPC-child
interaction start and end time parameters were set using the Estimation of time spent conversing with child
information NPCs provided in their initial surveys and on  Parent 15 –
their daily recording time sheets. A computer script was    Less than average 0 0
written to filter recordings during nap periods. Once fil-    Average 1 7
tered, all counts were then standardized by total relevant    More than average 11 73
interaction time and were expressed as either words per    Much more than average 3 20
hour (wph) or turns per hour (tph).   Nonparental caregiver 17 –
   Less than average 0 0
   Average 7 41
Statistical Analysis    More than average 5 29
   Much more than average 5 29
Repeated measures ANOVAs were conducted for each of
Estimation of volume of child speech  
the four LENA measures (i.e., AWC, CTC, CVC, and TVT),
 Parent 16 –
with Time (postintervention Sessions 1, 2, 3 to 6) as the
   Less than average 2 12
within-subject variable, to determine whether there were
   Average 3 19
significant differences among postintervention recording    More than average 7 44
time points. No significant differences were found for any of    Much more than average 4 25
the four LENA measures. As such, the counts for each of the   Nonparental caregiver 17 –
six postintervention time points were averaged to create a    Less than average 0 0
single postintervention score for each of the four LENA    Average 7 41
measures. Paired t tests were then carried out to compare the    More than average 5 29
pre- and postintervention mean standardized counts.    Much more than average 5 29
Estimation of 50 word vocabulary  
 Parent 16 –
Outcomes and Results    Yes 9 56
Home Language Survey    No 7 44
  Nonparental caregiver 17 –
NPCs and parents were asked to rate the amount that the    Yes 12 71
child talked on a 5-point scale from much less than average    No 5 29
to much more than average. Their responses are shown in
Table 3, with 10 NPCs (59%) and 11 parents (65%) rating
their children as above-average talkers. When asked how
much they conversed with their child, a majority of parents recordings were made 4.8 days apart on average (SD = 7.5,
(n = 11; 73%) stated they talked to their child more than range = 1–33). Because of the Hawthorne effect, the aver-
average. One parent (7%) rated herself as average. Three age of the two baseline measures was to make pre- and
parents (20%) rated themselves as talking to their child postintervention comparisons (Wolfe & Michaud, 2010).
much more than average. In response to the same question, Indeed, AWC was marginally significantly higher for the
7 NPCs (41%) responded that they talked to the child an first baseline session than for the second (M difference =
average amount, whereas 5 (29%) thought they talked more 413 wph, 28.4%, t = 2.25, p < .04). In contrast, the CTC
than average, and the remaining 5 (29%) reported talking baselines did not differ significantly (M difference = 12
much more than average. tph, 19%, t = 1.64, p < .12) nor did the CVC baselines (M
Overall, NPCs and parents reported low amounts of child difference = 26 vph, 10.4%, t = 1.71, p < .11). The six
television exposure. NPCs reported that the television was on postbaseline recordings were made from 1 to 89 days post-
from 0 to 3 hr per day while they were with the child (M = 0.8 intervention (M = 25 days, SD = 19 days). The average
hr, SD = 0.9 hr). Similarly, parents reported watching 0 to 3 interval between postintervention recordings was 8 days
hr of television per day at home (M = 1.24, SD = 1.02). (SD = 6 days).

TVT overall. The TVT recorded in the child’s aural environ-

LENA Outcome Measures ment during waking hours was low for all children in the
Caregivers contributed two recordings at baseline prior to study, with an average of 22.8 min at baseline (range =
intervention and six postbaseline recordings. Baseline 1–63 min, SD = 16.1 min). Mean amount of TVT did not

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Suskind et al. 205
Figure 1.  Adult word count baseline and postintervention
averages in words per hour.
Figure 2.  Adult word count in words per hour at baseline and
6 weeks post-intervention.
differ significantly between baseline and postintervention
recordings (M difference = 0.57 min, 2.5% decrease, t =
0.14, p < .89).
AWC overall. As seen in Figure 1, mean AWC from postint-
ervention recordings was significantly higher than mean
AWC at baseline (M difference = 395 wph, 31.6% increase,
t = 3.29, p < .01). Figure 2 shows AWCs at baseline and at
each of the six postintervention sessions.
CTC overall. The mean postintervention CTC was signifi-
cantly greater than the baseline average, shown in Figure 3
(M difference = 14 tph, 24.9% increase, t = 3.54, p < .01).
Figure 4 graphs CTCs at baseline and at each of the six
postintervention sessions.
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Figure 3.  Conversational turn count baseline and
postintervention averages in turns per hour.
Figure 4.  Conversational turn count in turns per hour at
baseline and 6 weeks post-intervention.
Conclusion and Implications
Discussion
The primary goal of our exploratory pilot was to evaluate
the novel behavior-change strategy of quantitative lin-
guistic feedback and its effect on adult linguistic behav-
ior. Our study comprised an initial 1-hr educational
session, six weekly LENA recordings, and the use of
quantitative feedback from those recordings to improve
language outcomes. The significant increases seen in
adult quantitative language output for AWC and CTC
indicate the potential of the quantitative linguistic feed-
back technique to inform adults to motivate them to
modify their interactions with children and provide a
richer language environment.
206 Communication Disorders Quarterly 34(4)
Pedometers offer a useful analogy for understanding the
quantitative linguistic feedback technique and clarifying its
impact. Pedometers provide a quantified, easily grasped
conceptual framework for behavior change; hence, the
health promotion concept of “10,000 steps a day” (Shape
Up America, Get Up and Go! 10,000 Steps a Day, 1994).
Behavior-change literature evaluating the pedometer as a
form of quantitative feedback shows that pedometers have
been very successful in encouraging sustained physical
exercise and movement in all populations, including low-
income individuals (Clarke et al., 2007; Duru, Sarkisian,
Leng, & Mangione, 2010; Strath et al., 2011). Adults are
rarely conscious of their own “word count,” even if they
understand its impact on their children’s development. With
LENA feedback technology, as with pedometers, they can
see the language environment they provide for their child,
begin to understand their critical role, and make appropriate
behavioral changes. Although the LENA feedback is not
instantaneous like the pedometer, it gives adults unprece-
dented insight into and concrete appreciation of their child’s
language environment and overall development.
However, an enriched early language environment
requires more than a purely quantitative measure. It is a
complex interplay of rich qualitative language and respon-
sive behaviors. Linguistic feedback is designed to signifi-
cantly increase adult language quantity to provide a
foundation on which qualitative behavioral strategies may
be layered. It is the combination of quantity and quality in a
child’s early language environment that will lead to optimal
cognitive and educational outcomes.
We view quantitative linguistic feedback not as a “silver
bullet” but rather as a strategy to increase the effectiveness
of behavioral interventions. As an effective addition to clin-
ical therapy sessions, it can provide parents and therapists
additional proof of behavioral change. Analyses of LENA
audio recordings can also provide greater insight into the
qualitative changes. The LENA technology’s ease of use
and automated software processing make it ideal for inclu-
sion in all caregiver-directed interventions involving lan-
guage feedback. Although privacy protections maintained
under IRB protocols for this pilot precluded qualitative
analysis by requiring the deletion of audio recordings,
future projects will include such evaluation.
This pilot study has demonstrated the potential of quan-
titative linguistic feedback, laying the groundwork for its
continued iterative development as an evidence-based
behavioral approach. Quantitative linguistic feedback may
also have an even greater role in areas such as individual
therapy. Because of the wide diversity of client populations
and the limited insight therapists may have into individual
home environments, they are often forced to use a general-
ized therapeutic approach rather than one tailored to the
specific family. This is especially true regarding the child’s
early home language environment. The LENA may allow
Downloaded from cdq.sagepub.com at UNIV OF WISCONSIN OSHKOSH on June 8, 2015
therapists to gain greater understanding of a family’s base-
line linguistic style so they can personalize their clinical
approach. In addition, the LENA provides ongoing infor-
mation to therapists with regard to their clients’ therapeutic
uptake. Just as personalized medicine lets oncologists indi-
vidually adapt therapeutic regimens to specific cancer char-
acteristics, so also does quantitative linguistic feedback
provide insights that help therapists provide the appropriate
therapy to each patient.
Quantitative linguistic feedback may also be a valuable
tool for the greater scientific community. As Roberts and
Kaiser (2011) noted, advancing the science of evidence-
based behavioral interventions requires transparency of
strategies used and quantifiable outcome measures of
parental behavioral uptake to quantify intervention dosage.
Quantitative linguistic feedback is a concrete behavioral
strategy that corroborates fidelity of implementation of
interventional strategies as well as gauges parental behav-
ioral uptake. Although a current limitation of the linguistic
feedback is its lack of qualitative measurement, in future
studies, the LENA’s audio recordings may be analyzed for
qualitative changes as well. This pilot represents only the
beginning in the iterative development and testing of this
novel multifaceted approach. The results of this study sug-
gest that the LENA has the potential to be a valuable addi-
tion to the world of speech and language intervention.
Considerations
The study was limited in three areas: participant sample,
potential Hawthorne effect, and variance accounted by the
educational intervention. Although our sample size was
small, we were encouraged by the ability to demonstrate a
statistically significant increase in our selected adult lan-
guage parameters. In addition, caregivers with and without
a college education appeared responsive to the behavioral
strategy. We plan to investigate with a larger sample size
the issues of external validity related to the inclusion of
NPCs as opposed to parents. We hypothesize that parents
will be more invested and motivated for behavioral change
when it is their own child who benefits.
An important issue to consider is that of overall linguis-
tic implications, in terms of the sustainability of the linguis-
tic behavior change and the true nature of this effect on a
child’s early language environment. There is the issue of the
“Hawthorne effect,” which states that individuals positively
modify their behavior when they are knowingly being
observed. An individual’s knowledge that one is being
recorded and will be receiving feedback may result in care-
givers increasing linguistic input only during the recording
times. Quantitative linguistic feedback will never entirely
avoid this issue, although sustaining increased talk for a
10-hr recording day is much less likely than being on best
behavior during the 1-hr videotaped session typical in most
Suskind et al. 207
intervention studies. In addition, the NPCs in our study
knew that their employers would not have access to their
results. To address this limitation, future studies will include
greater number of LENA recordings to habituate caregiver
response as well as LENA recordings without feedback to
assess sustainability of behavioral change.
Finally, the 1-hr educational intervention and initial
baseline LENA feedback were inseparable in this study. We
are unable to isolate the impact of the LENA feedback from
the educational session on NPC behavior recorded over the
six remaining recordings. However, the behavioral litera-
ture has shown that lack of continued feedback results in
attenuation of effect. We suspect that quantitative linguistic
feedback was responsible for the sustained changes in the
AWC and CTC. To address this limitation, in future studies,
we will experimentally manipulate the number of times
caregivers are provided with quantitative linguistic feed-
back after the educational intervention. Future embedding
of quantitative linguistic feedback into established interven-
tions, inclusion of a control group and analyses of child out-
comes will also help address these limitations and confirm
the effects of intervention.
Conclusion
Enhancing a child’s early language environment represents
an extraordinary opportunity to affect the life trajectory of
a child. Pilot testing of the innovative behavioral strategy—
quantitative linguistic feedback—demonstrates its potential
for stimulating changes in adult language behavior. Because
of these encouraging results, we will continue the develop-
ment and study of this promising strategy.
Declaration of Conflicting Interests
The author(s) declared the following potential conflict of interest
with respect to the research, authorship, and/or publication of this
article: The LENA recorders used in this study were on loan from
the LENA Foundation.
Funding
The author(s) disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article: The
authors received internal funding from the Department of Surgery
at the University of Chicago as well as funding from the Hemera
Foundation.
Note
1.  CALO-RE is an acronym for “Coventry, Aberdeen and London
Refined.”
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