Research Article

Folia Phoniatrica
et Logopaedica Received: March 14, 2023
Folia Phoniatr Logop 2024;76:245–263
Accepted: September 1, 2023
DOI: 10.1159/000534022 Published online: October 25, 2023

Efficacy of a Self-Directed Video-Based

Caregiver-Implemented Language
Programme
Xin Qi Winnie W.H. Ng Gigi H.K. Tsang Carol K.S. To
Academic Unit of Human Communication, Development and Information Sciences, Faculty of Education, The
University of Hong Kong, Hong Kong, Hong Kong SAR

Keywords 60% in both stages was noted. Significantly higher post-

Parent-training · Self-directed learning · Language facilitation training knowledge scores were found in groups 1 and 2.
techniques · Efficacy General but nonsignificant growth in use of parallel talk and
gesture, and significant gains in children’s vocalization in the
training arm were observed. Conclusion: The self-directed
Abstract video-based training programme would be useful in im-
Introduction: Caregiver-implemented language pro- parting information to caregivers. However, the modest
grammes are effective for alleviating early language diffi- improvements in the use of LFTs suggested direct coaching
culties. This study examined the efficacy of a self-directed appeared to still play a significant role in enhancing the
video-based caregiver-implement language programme in actual implementation of LFTs. Further investigation on a
Chinese families. Method: This study consisted of two larger scale is required to evaluate the effectiveness of the
stages. In stage 1, 31 caregiver-child dyads (typically de- training programme for promoting the wider use of this
veloping children) completed the training programme mode as a preventive measure. © 2023 S. Karger AG, Basel
(group 1) in the form of six video-based training modules. In
stage 2, 28 caregiver-child dyads (children with language
difficulties) receiving active speech therapy were randomly Introduction
assigned to the training (group 2) and control arms (group
3). Group 2 received the same training as group 1 in addition Childhood speech and language disorders are public
to their regular therapy while group 3 was kept as status health concerns as early difficulties in this area have been
quo. Caregivers completed a quiz on their knowledge of associated with long-term negative impacts on individ-
language facilitation techniques (LFTs) and submitted uals’ education, self-esteem, socialization, and psycho-
caregiver-child interaction videos at the start and end of the social development [1–3]. These problems were found to
training. Outcome measures included programme com- be unevenly distributed across the social spectrum and
pletion rate, quiz scores, and use of LFTs and children’s more prevalent among children from lower socioeco-
communication skills in the videos. A pre-post design and a nomic backgrounds, highlighting the needs for universal
between-group design were adopted in the stage 1 and 2 preventive services in relation to the socially disadvan-
studies, respectively. Results: A completion rate of about taged population [4]. If left untreated, they can also turn

karger@[Link] © 2023 S. Karger AG, Basel Correspondence to:

[Link]/fpl Carol K.S. To, tokitsum @ [Link]
into a long-term societal issue [5–7]. Efficacy of early involves SLTs working with caregivers, teachers, or other
intervention of the difficulties has been well-supported in potential intervention agents, and less on direct inter-
the literature with high-quality evidence from both cross- vention with children concerned. Under this model, a
sectional and longitudinal studies [8–10]. The interven- large number of caregiver-implemented language pro-
tions are based on strong theoretical underpinnings of grammes have been constructed. Caregiver-implemented
communication and language acquisition, as well as programmes have been documented as an effective way to
language disorders. Studies have been demonstrated that enhance caregivers’ responsiveness and their use of
these interventions result in significant improvements in language facilitation strategies that improve the quantity
child’s speech and language abilities and long-term and quality of linguistic input [17–21]. Most parents are
outcomes [11]. found to have an intuitive ability to learn and apply these
Traditional speech and language intervention are often naturalistic skills to their daily interactions which in turn
delivered through direct services to clients on a one-to- enhance their children’s language ability [19, 20]. For
one basis in healthcare settings such as clinics or schools. children with late language emergence, i.e., children who
Speech language therapists (SLTs) may independently may be at risk at developing long term language prob-
design a context that can maximize individual children’s lems, Rescorla and Dale [22] suggested that knowledge in
performance within sessions [12]. The one-to-one nature language facilitation strategies empowers the parents to
would allow the clinician’s management of complex cases modify daily routines and input to fit their children’s
and ensure child’s privacy, and at the same time focus on needs accordingly and bolster their sense of self-efficacy
easing the impairment of individual children. However, in tackling the long-term problems brought about by
natural exposure to the language, peer interactions, and language impairment. For example, The It Takes Two to
diverse type of communication partners may have been Talk Hanen programme is an example of a parent-
missed. The importance of the communicative and implemented intervention designed for children with
pragmatic functions of language may have been played language difficulties [23]. In this programme, parents are
down in such intervention mode [13]. taught to adopt a child-centered approach and to use
Service delivery models have been evolved to better interaction-promoting and language-modelling strate-
serve clients more effectively and efficiently, and to gies. Overall, positive results were reported in terms of
benefit more people with diverse needs. Public health parental responsiveness, quality and quantity of parent-
administrators proposed the “pyramid of needs” model to child interactions. The effectiveness of these parent-
explain how to approach the needs of the population [6, implemented programmes was not only reflected in
14, 15]. This model comprises three levels: universal, the significant gains of caregivers’ knowledge and skills,
targeted, and specialist. The bottom level of the pyramid but also in child’s outcomes including verbal output and
is the universal level which aims to serve the entire social communication skills [19, 20, 24–26]. In studies
population. In this level, preventative and proactive comparing between the effects of parent-implemented
measures are used to reduce the possibility of secondary language interventions which clinician-implemented
and future problems from emerging. The second level is interventions, none reported parent-implemented in-
the targeted level where moderate-intensity and short- tervention to be less effective than the latter [20, 27].
term interventions are provided to targeted groups who Recent systematic reviews on parent-implemented in-
are at risk for a particular problem. The highest level, the terventions also highlighted the long term and stronger
specialist level, refers to the provision of intensive, in- generalization effect brought by parent-implemented
dividualized interventions for specific speech and lan- programmes over clinician-led therapy and further
guage disorders with the aim of lessening the impact of supported that parent-implemented language pro-
the existing impairments. Research by Gascoigne [14] has grammes should be more seriously considered as a key
emphasized that SLTs should play a role across all three service delivery model rather than just an alternative [20,
levels within various settings. However, based on this 27–29].
pyramid, the traditional intervention provision model
may not be sustainable or adequate to meet the needs of
the majority because it relies on qualified clinicians as the Language Facilitation Techniques
sole intervention agents [16].
The consultation model has been developed as an Various language facilitation techniques (LFTs) have
alternative to the traditional model of speech and lan- been reported to be effective in parent-mediated inter-
guage intervention. The consultation model basically ventions [30–32]. Capone and McGregor [33] suggested

246 Folia Phoniatr Logop 2024;76:245–263 Qi/Ng/Tsang/To

DOI: 10.1159/000534022
that gestures can be used as an important scaffold for children with disabilities, findings indicated that the
advancing children’s language, and also cognition in increased complexity of parental language input had a
general. Before children can communicate verbally, positive impact on language development in children
gesture is an important communication means between with autism spectrum disorder (ASD) [46]. Besides
them and the communication partners. Even infants are caregiver’s language input, their reaction style to the
found to be able to attend to and imitate gestures that child’s behaviour is also important. Being responsive by
adults used in the environment [34, 35]. In addition, giving prompt and contingent responses is a key com-
parental gesture use was found to be able to predict ponent of a reciprocal parent-child interaction because it
concurrent infant gesture uses and language skills and supports infants’ pragmatic understanding that language
also more than 2 years later [36, 37]. Thus, it is essential to is a means that allows intentions to be socially shared
promote parent’s use of gesture during daily commu- [47]. Parents are therefore encouraged to observe the
nication and social interactions with their child. children’s behaviour, focus on the same activity, and
Parents are also encouraged to provide various verbal respond to the child contingently, rather than directing or
linguistic models appropriate to the children’s level instructing the children regarding what to do or say [48].
during interactions. When parents tailor language input
to their children’s current language ability within their
zone of proximal development, that is, just one step ahead The Hong Kong Context
of the children’s current level, the language learning
process can be facilitated [38]. Paul and Norbury [39] Despite the documented advantages of parent-
summarized several indirect language stimulation tech- implemented language facilitation interventions and
niques. Self-talk and parallel talk are two strategies used to availability of parent training programmes, they have
provide verbal descriptions related to a child’s focus of primarily been developed and carried out in western
attention. Self-talk involves describing the caregivers’ cultures. They have not yet been widely implemented or
own actions, which parallel talk includes providing tested in usual care in some non-western areas including
commentary on what the child is doing in the immediate Hong Kong. Public speech language therapy services
context. Research has shown that when parents of autistic started in the Hong Kong since around the 1990s and
children, who were minimally verbal, provide language expanded rapidly since then. Traditional one-to-one
input that follows their child’s current focus of attention, direct individual therapy, however, is still the domi-
the children’s language learning can be enhanced and nant form of local intervention [49]. The limited uptake
positive outcomes can be seen in later language com- of the parent-implemented programme in usual care
prehension and production ability [40]. Imitation is might indicate that there are obstacles or gaps at the
another useful LFT for parents of young children with client, clinician, or organizational levels [50].
emerging language. Contingent imitation by adults In traditional Chinese culture, people hold a strong
promotes young children’s learning of imitation when no belief that education is very important – one’s education
pressure is placed on them to speak [41, 42]. In addition, level determines one’s social status and occupation. Thus,
imitation of infants’ verbal responses was associated with teachers who bear the commitment to teach students have
the increase in infants’ spontaneous vocalizations [43]. a high status in society. These concepts and values can
Besides exact imitation, parents are also encouraged to also be seen in the clinical setting. Parents regard SLTs as
expand their children’s preceding utterances by adding the teachers who have a significant role in teaching their
more phonetic details, enriching semantic content, or child and developing their abilities. This may be a reason
providing further syntactic context. Notably, maternal why direct therapy to clients concerned has been accepted
use of expansion has been observed to be associated with as the dominant service delivery mode of speech therapy
the timing of children achieving significant expressive in Hong Kong.
language milestones [44]. Similarly, the technique of There are also a number of practical factors have been
extension, in which parents extend children’s utterances suggested to be vital to the successful caregiver engage-
by offering additional and semantically relevant com- ment and involvement in children’s learning and reha-
ments, has been demonstrated to be facilitative to chil- bilitation. Socioeconomic status has been repeatedly
dren’s syntactic skills development, especially those op- shown to be related to lower level of attendance and
erating at or beyond the word combination stage [45]. In involvement in parenting programmes in the literature
a meta-analysis exploring the relationship between pa- [51]. Disadvantaged parents reported a number of lo-
rental utterance length and language outcomes among gistical and time constraints due to work schedule,

Efficacy of Self-Directed Video Learning Folia Phoniatr Logop 2024;76:245–263 247

Program DOI: 10.1159/000534022
multiple childcare, transportation, and financial condi- participating in self-directed online learning modules.
tions as reasons why they chose not to participate in Results of a randomized control trial study that inves-
parenting programmes [52–56]. These reported con- tigated the effectiveness of a self-directed learning pro-
straints also existed in the Hong Kong context where gramme for parents of children with ASD showed gen-
dual-earner families with children are very common [57]. erally positive treatment effects for both parent and child
In many of these families, both parents have long working [69]. These positive findings suggested that technology-
hours and/or nonstandard work schedules such that these based self-directed parent training intervention can be
parents may need to work across the typical daytime also a potential intervention option for children with
span, and childcare service for younger children is not as early language difficulties, in particular in mass-scale
elaborated as in some other countries. The lack of flex- prevention programmes targeting a wider population
ibility in parents’ work schedules and insufficient support in the community [70].
is detrimental to their participation in the interventions
for their children who need special support. As a result,
parents’ attendance and inability to complete of home Purpose of the Study
practices were pinpointed as the major obstacle of parent
training programmes and the problems were particularly The current study aimed to examine the feasibility
prominent among parents with below-average education and efficacy of a self-directed video-based caregiver-
level and public health awareness [58]. Because of these implemented language programme in Hong Kong. The
constraints, this intervention mode was sometimes self-directed learning model in the present study meant
considered as having low cost-effectiveness. Thus, tailor- that there was no use of instructors to provide feedbacks
made intervention programme with an innovated de- and caregivers were expected to learn at their own pace.
livery method may be an option for families who must The whole study consisted of two stages involving dif-
work full-time or have other younger children to care for ferent participant groups and objectives. The stage 1
in the family. study took place before the stage 2 study. The preliminary
results and experience obtained in the stage 1 study
provided the basis for the stage 2 study.
Use of Technology in Parent-Implemented Programmes The stage 1 study aimed to explore the acceptability
and effect of this self-directed programme on families
Given the gap in parents’ engagement and the avail- with children who have no clinical concerns. The par-
ability of the evidence-based parent training pro- ticipants represent the bottom level of the “pyramid of
grammes, modifications may be needed to increase the fit needs,” i.e., the universal level [14]. We examined if
of the intervention to the target population or culture caregivers can benefit from this mode of service in terms
while protecting scientific integrity as much as possible of the gains in knowledge and actual behaviours
[59]. Technology has opened up a powerful solution to (i.e., LFTs) and children’s communication skills. The
accommodate individual parents’ needs such as irregular stage 2 study extended the stage 1 study onto families with
schedule. Researchers and clinicians have explored in- children having language difficulties to examine the
novative ways with the use of technology to enhance the programme application on the target group level of the
cost-effectiveness of delivering parent training. By in- “pyramid of needs” [14]. Method and results of the stage 1
corporating self-directed learning methods, services de- study will be presented and discussed followed by the
livered through internet-based technologies are promis- stage 2 study.
ing in addressing the varied client-level constraints and
increasing service access [60, 61]. Self-directed learning
methods assume that the learning target can be oper- The Stage 1 Study
ationalized. Caregivers can learn the knowledge and skills
at their own pace, and independently modify their own All the participants in the stage 1 and stage 2 studies
behaviours [62]. Such learning methods have been were recruited via a non-governmental organization
proven to be effective in supporting parents to acquire (NGO) in Hong Kong. The NGO provides services to
intervention strategies [63] and improving children’s different social groups in the territory, including general
language and communication outcomes [64–66]. public (e.g., preschool centres) and those with special
Hamadet al. [67] and Wainer and Ingersoll [68] found needs and developmental difficulties (e.g., rehabilitation
significant increase in parents’ knowledge of ASD after services).

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DOI: 10.1159/000534022
Table 1. Demographic characteristics
of the participants who completed the Characteristics Group 1 (n = 31) Group 2 (n = 14) Group 3 (n = 14)
study
M (SD) or n (%) M (SD) or n (%) M (SD) or n (%)

Child’s age (months) 17.4 (3.2) 31.43 (11.52) 39.07 (16.55)

(range: 12–14) (range: 13–53) (range: 12–57)
Child’s sex
Male 23 (74.1) 9 (64.3) 9 (64.3)
Female 8 (25.9) 5 (35.7) 5 (35.7)
Parent’s age
26–35 years 16 (51.6) 4 (28.6) 5 (35.7)
36–45 years 14 (45.2) 9 (64.3) 9 (64.3)
46 years or above 1 (3.2) 1 (7.1) 0
Monthly household income
$10,000–$29,999 1 (3.2) 8 (57.1) 5 (35.7)
$30,000–$59,999 10 (32.3) 4 (28.6) 7 (50.0)
$60,000–$99,999 14 (45.2) 2 (14.3) 2 (14.3)
>$100,000 6 (19.4) 0 0
Parental education
Primary 0 1 (7.1) 0
Secondary 0 9 (64.3) 8 (57.1)
Tertiary 31 (100) 4 (28.3) 6 (42.9)
Child’s diagnosis
Dev. delay n/a 0 2 (14.3)
Prematurity n/a 3 (21.4) 5 (35.7)
Others n/a 11 (78.6) 7 (50.0)

Participants Setting and Training

The first group of participants consisted of 31 dyads of The self-directed training was designed to be a stand-
typically developing children and their caregivers (group alone programme and easy for non-professionals. That
1). Inclusion criteria for parents were (a) being a native is, parents should be able to access to the materials
Cantonese speaker, (b) being a parent of a child at the age without specific training or knowledge. In Hong Kong,
of 12–24 months old, (c) being the primary caregiver of smartphone penetration rate of the age group
the participating child, and (d) have no history of di- 25–64 years old had reached 98.95% in 2020 [71]. The
agnosed speech and language difficulties or psychological programme was therefore designed to be delivered via
disorders. Their children in this age range were required mobile devices.
to: (a) acquire Cantonese as their native language and (b)
have no history of diagnosed developmental disorders. Development of Training Materials
Their language level ranged from single words to word Five LFTs were selected to be the training targets,
combination. namely, (1) “Gesture,” (2) “Observe,” (3) “Imitation,” (4)
Table 1 provides an overview of the demographic “Self-talk and Parallel talk,” and (5) “Expansion and
characteristics of the 31 parent-child dyads in group 1. Extension.” These strategies were generally considered
On average, the children were 17.4 months old, and 23 culturally acceptable and appropriate in Chinese (c.f., van
of them were boys. The majority of the parents were Kleeck, 1994). However, the use of these LFTs among
under the age of 45 years old, and all the participants Chinese population still awaits more evidence. Table 2
in this group were mothers. Additionally, most summarizes the definitions and provides examples of
caregivers held a high level of education and reported these LFTs.
relatively high household income. This trend may be Based on these five LFTs, five video clip modules were
attributed to the fact that many of these caregivers developed by the research team. Each module lasted for
were associated with a private child-care centre op- about 3 min. A script without jargon for each module was
erated by the NGO. constructed by the second and the last authors. Definition

Efficacy of Self-Directed Video Learning Folia Phoniatr Logop 2024;76:245–263 249

Program DOI: 10.1159/000534022
Table 2. Language facilitation techniques described in the programme

Technique Definition Example

“Gesture” Incorporate gestures when talking to the child Caregiver waves hands and says, “Bye-bye”
“Observe” Observe the child’s behavior and attention focus and follow the The child attempts to get a toy that is placed
child’s lead far away
Caregiver observes the child’s behavior, gets
the toy for the child and plays with it together
“Imitation” Repeat the child’s immediate vocalization or verbalization The child says, “Ball”
without any modification Parent says, “Ball”
“Self-talk and Self-talk: Describe the parent’s own actions Parent opens a box and says, “I am opening
parallel talk” a box”
Parallel talk: Describe the child’s actions and related context The child plays with a toy car
Parent says, “You are pushing the car”
“Expansion Expansion: Elaborate the child’s utterance by adding phonetic The child says, “car red”
and information to child’s vocalization. For verbal children, semantic Parent says, “It is a red car”
extension” and/or syntactic details are added to make it a more acceptable
form
Extension: Add a new remark that is semantically related to the The child says, “Baby cry”
child’s utterance Parent says, “Because the baby is hungry”

of terms, explanations with evidence, and appropriate programme including assignment submission (video
reactions in hypothesized scenarios were described. An recording of parent-child interaction) at specific time
introduction video clip was also developed. It described points and participation in the simple quizzes via an
the programme’s background, how children learn the online platform. Upon written consent, parents were
language, factors influencing language development, and requested to provide their demographic information by
provided an overview of the LFTs to be taught in each filling out a questionnaire.
module. Including the introduction module, the training During phase II (i.e., baseline) before any intervention,
packing consisted of six modules, and all the video clips each parent was requested to record three video re-
were in animation form. After several rounds of modi- cordings (duration of 3 min each) of their typical daily
fications with reference to the language use and com- interactions with the participating child at home using
prehensibility to non-professionals, the draft script was their smartphones. The basic instructions regarding
further proofread by the practicing SLTs in the NGO. The the videotaping equipment, communicative context/
final script was then passed to an animation production scenarios (e.g., meal time, playing toys, or share book
designer who interpreted the script into a visual plot and reading), camera angles, and the control of noise levels
prepared graphics and animation, and inserted the voice had been explained in the workshop. The workshop
narration. The clip was then evaluated and finalized by information, a calendar summarizing the video recording
the SLTs. In addition to the video clips, a quiz containing submission days, and all the contact details were precisely
10 multiple-choice questions was constructed by the two described in a physical booklet which was distributed to
authors who were both SLTs in relation to the content of the parents during the workshop. The video recordings
the video clips (see online suppl. material at [Link] needed to be submitted to the investigator via a mobile
org/10.1159/000534022). This was used as a measure of communication application (WhatsApp Messenger
caregiver’s knowledge. or WeChat) within 1 week after attending the
workshop. Each parent also needed to complete the
Procedures online quiz on their mobile devices at the end of the
There were three phases in the stage 1 study. During workshop (see Setting and Training above). Upon sub-
phase I, all the parents attended a 30-min live workshop mission of the baseline video recordings, the participants
in the NGO, in which the background and procedures of started their training (i.e., video training programme).
the parent training programme were presented. The They received six training video clips, one at a time,
workshop highlighted the required commitments to the in form of a hyperlink via a mobile communication

250 Folia Phoniatr Logop 2024;76:245–263 Qi/Ng/Tsang/To

DOI: 10.1159/000534022
application. Once the parents received the link, they can capturing procedures. The second videos were chosen
watch the video anytime. Each training video clip was over the last one because the children and the parents
followed by two true or false questions to reflect their were less likely to be away from the camera view in the
comprehension of the current training contents. If an former. Therefore, focussing on the second video en-
incorrect answer was given, a correct answer was provided hanced later analysis and coding.
with an explanation automatically. The participants then Verbal and nonverbal productions by the participating
received the next training video clip after answering parent-child dyad were transcribed and coded. Each fully
questions related to the previous video clip. The first three intelligible parental utterance, with or without a simul-
video clips were sent within 1 month, with a 6-day interval taneous gesture, was assigned a turn number. If a verbal
in between. The remaining three video clips were sent in response and/or gesture was immediately repeated with
the next month, with a 4-day interval in between. The no intervening activity or utterance that was considered a
mothers were asked to adopt the techniques described in repetition and was not assigned a separate turn number
the videos in their everyday interactions with their children. [72]. Furthermore, only the first utterance in rote
Phase III started 2 weeks after the completion of video counting and song-singing was given a turn number. Any
training programme. The parents completed the online incomplete responses resulted from self-interruptions or
quiz, which was the same as the one they had completed overlapping speech were also not assigned turn numbers.
before the training. Then, within 1 week after the com- A verbal response or an utterance was defined as “any
pletion of the quiz, they recorded three additional 3-min sequence of words and/gestures that is preceded or fol-
videos of their interactions with their participating chil- lowed by a silence, a change of conversational turn, or a
dren at home (i.e., post-training video). The instructions change in intonation patterns” (Iverson et al., 1999, p.61).
were the same as those given in the baseline condition. The verbal utterances were then coded following a de-
vised coding scheme (see Table 3) [30, 73–76]. The
Measures following behaviours were coded, including (1) imitation,
A set of measures were administered. In order to (2) self-talk, (3) parallel talk, (4) expansion, (5) extension,
evaluate the changes in the parents and the child’s per- (6) directive, and (7) open-ended question.
formances after the programme, a pre-/post-test design Most of the descriptions were straight-forward for
was adopted. coding but some instances of parallel talk and directive
were alike. To differentiate parallel talk and directive, the
Acceptability timing of the utterance had to be considered. An utter-
Participants’ acceptability towards the programme was ance was coded as parallel talk only if it was produced
measured in terms of programme completion rate which during and referred to the child’s action; if the utterance
was reflected by the percentage of participants who was produced before or after the child’s action, it would
completed the training out of the total number of par- be coded as a directive as it was not contingent.
ticipants who gave their written consent in the initial live Gesture is defined as a movement of a part of the body,
workshop. A high completion rate would indicate that followed by a pause of movement or relaxation of the
parents generally accepted such a training model. body part [77]. Three types of gestures, including deictic,
conventional, and representational, were included in the
Caregiver’s Knowledge of LFTs coding [78].
Parents completed the same quiz comprised of Efficacy of the targeted strategies was measured by
10 multiple-choice questions at baseline and post- different outcome proxy described based on the coding
training. Number of the correctly answered items was system (see Table 4). An increase in the frequency counts
used as the knowledge outcome indicator. of these measures indicated an increase in parental use of
the strategies taught except that directive was used as a
Caregiver’s Verbal Behaviours proxy to counter-represent the measure of “Observe”
Three baseline and three post-training videos of strategy. This was because excess directives accounted for
parent-child interaction were recorded at home. Specif- parental intrusiveness, for which the strategy of “Ob-
ically, the second video in each set of three was selected serve” aimed to minimize [79]. The frequency of open-
for analysis. The three videos were recorded in a se- ended question was included as a control measure which
quential manner. The first videos were not chosen be- was not introduced in the programme and different from
cause a number of them showed artefacts due to technical the taught techniques. Minimal effect on this control
problems when parents were not yet familiar with the measure would be expected.

Efficacy of Self-Directed Video Learning Folia Phoniatr Logop 2024;76:245–263 251

Program DOI: 10.1159/000534022
Table 3. Coding for caregivers’ verbal behaviors

Verbal Description Example

response

Imitation Caregiver imitates exactly the child’s prior vocalization or • Child says, “Baba.”
verbalization Caregiver says, “Baba.”
• Child says, “Ball.”
Caregiver says, “Ball.”
Self-talk Caregiver describes their own preceding, ongoing or upcoming act • Caregiver throws the ball and says, “I am
throwing a ball.”
• Caregiver says, “I will throw the ball to
you”, and then she throws the ball.
Parallel talk Caregiver describes the child’s preceding or ongoing act, or objects, • Child plays with a ball.
people, or activities related to the context that the child’s paying Caregiver says, “You are playing with a
attention to ball.”
Expansion Caregiver adds one or more vocalizations or words to the child’s • Child says, “Ba.”
preceding word approximation or verbalizations Caregiver says, “Babi.”
• Child says, “Car.”
Caregiver says, “Push the car.”
• Child says, “I want juice.”
• Caregiver says, “You want some juice,
don’t you?”
Extension Caregiver adds new information to the child’s preceding • Child says, “Drink juice.”
verbalizations Caregiver says, “The juice tastes good.”
Directive Parent instructs the child to perform a particular action • Caregiver says, “Get that toy for me.”
Open- Caregiver asks a question that has to be answered using more than • Caregiver asks, “Why do you feed the
ended one word baby?”
question • Caregiver asks, “What are you doing?”

Adapted and modified from Hancock et al. (2016) and Paul and Norbury (2012).

Table 4. Outcome proxy for each of the target strategies study was defined as words and word approximations
that were directed to the caregivers and served as at least
Technique Outcome proxy (frequency) one of the communicative functions (i.e., behaviour
regulation, social interaction, joint attention) [80].
Targeted
Use of gesture Gestures
Observe Directive (a counter proxy) Coding Reliability
Imitation Imitation Caregivers’ and children’s behaviours were transcribed
Self-talk and parallel talk Self-talk and coded manually by the second author based on the
Parallel talk coding scheme. To assess inter-rater agreement in coding,
Expansion and extension Expansion
two students studying Speech and Hearing Sciences at the
Extension
University of Hong Kong independently coded 10% of
Non-targeted the randomly selected video transcriptions (six videos,
Open-ended question Open-ended question
including both caregivers and child’s responses). The
overall inter-rater reliability was 87.7%. All disagreements
were resolved through discussion. To assess intra-rater
Children’s Communication Ability reliability, one of the students coded 10% of the video
Children’s verbal communication skills were measured transcripts (six videos) after the first coding with an
by calculating the frequency of verbal production within interval of at least 5 days. The overall intra-rater reliability
the 3-min video. Child verbal production in the stage 1 was 93.9%.

252 Folia Phoniatr Logop 2024;76:245–263 Qi/Ng/Tsang/To

DOI: 10.1159/000534022
 Table 5. Baseline and post-training frequency count of caregivers’ behaviors in the stage 1 study

Behavior Baseline Post-training p value F(1,30) Effect size (partial η2)

M (SD) M (SD)

Gesture 3.677 (4.628) 4.548 (5.328) 0.004** 9.601 0.242

Imitation 0.871 (1.056) 2.000 (1.949) 0.002** 11.029 0.269
Self-talk 3.871 (3.500) 4.90 (3.995) 0.200 1.718 0.054
Parallel talk 16.581 (7.196) 22.258 (6.511) 0.002** 11.535 0.278
Expansion 0.452 (0.995) 0.774 (1.359) 0.194 1.767 0.056
Extension 0.225 (0.884) 0.129 (0.718) 0.325 1.000 0.032
Directive 16.355 (10.021) 10.903 (8.068) 0.001** 12.441 0.293
Open-ended question 2.806 (2.960) 2.84 (3.277) 0.956 0.003 0

**p < 0.01.

Results of the Stage 1 Study Child’s Behaviours

The frequency of children’s verbal responses in post-
Programme Completion Rate training [M (SD) = 9.322 (8.451)] was similar to baseline
Among the 50 eligible parents who had attended the condition [M (SD) = 7.935 (6.31), F(1, 30) = 1.116,
initial workshop and provided written consent, six p =0.299, partial η2 = 0.036].
dropped out before the training commenced and 13
dropped out during the training. The remaining 31
participants completed the entire training programme, Discussion of the Stage 1 Study
and so the overall completion rate was 62%. There were
no significant differences between the participated and About 62% of the caregivers completed the entire
the withdrawn groups in terms of child’s birth order, programme in the Stage 1 study. It is noteworthy that
caregivers’ age, and household monthly income (p > there was no dropout during the release of videos 5
0.05), but a significant difference in child’s sex (t(42) = and 6. The high retention in the later part of the
2.89, p = 0.006) with more girls in the withdrawn programme may reflect that the participating care-
group. givers accepted the format of the video training
programme and were willing to spend time on
Caregivers’ Knowledge watching the videos and finished the programme. The
The caregivers obtained a significantly higher score in completion rate was found to be comparable to other
the post-training phrase [M (SD) = 8.23 (1.36)] compared online parent training programmes reported in the
to the baseline condition [M (SD) = 5.19 (1.17); literature. For example, Tayloret al. [81] implemented
t(30) = −8.62, p < 0.001], and this difference demon- an internet-based intervention with coaching based on
strated a large effect size, d = 2.40. the Incredible Years parenting programme, to help
promote behavioural change in parenting skills. The
Caregivers’ Skill reported completion rate was 66%, which was similar
Post-training frequency of gesture, imitation, and to the 65% for the face-to-face group intervention in
parallel talk were significantly higher than those in community settings reported by Horwood et al. [82].
baseline. Effect sizes measured with partial eta squared However, it was worth noting that all the caregivers
range from 0.242 to 0.278 and were considered large. enrolled in the stage 1 study obtained a high education
There was also a significant reduction in the post-training level. Educated parents had been found to have a
frequency of directive with a large effect size of 0.293. In higher level of self-efficacy and might show more
contrast, the frequency of self-talk, expansion, and ex- awareness regarding their own child’s development
tension between baseline and post-training period were [83], and reflected in their commitment in their
similar. The change of open-ended question which was participation in parent training programmes. Socio-
not taught in the programme was not significant economically disadvantaged parents of young children
(Table 5). on the other hand showed a low programme

Efficacy of Self-Directed Video Learning Folia Phoniatr Logop 2024;76:245–263 253

Program DOI: 10.1159/000534022
participation rate (39%) in a preventive face-to-face The Stage 2 Study
parent training [55]. All-in-all, the caregivers’ pro-
gramme completion rate in the stage 1 study was The stage 2 study sought to address the following
satisfactory and provided initial evidence regarding research questions: (1) For caregivers of children with
caregivers’ acceptability in Hong Kong. language impairment, was the video-based caregiver-
The low baseline quiz scores reflected that care- implemented intervention programme developed in
givers might lack of the knowledge regarding the study 1 effective in increasing their knowledge and skills
importance of language input. Significant increase in of using language facilitation techniques? (2) For children
the post-training performance showed that mothers with language impairment, was caregivers’ language fa-
were able to learn the principles of language facilita- cilitation mediated from the programme effective in
tion strategies through just watching videos. This self- improving their communication skills?
directed learning model appears to be sufficient for
supporting adult parents to acquire child interaction Participants
knowledge. The participants in the stage 2 study consisted of
The results of the study also indicated that parents children with language difficulties and their caregivers.
were also found to be able to apply the techniques when Children’s language difficulties may be associated with
interacting with their children, as demonstrated by the other medical diagnoses including global developmental
significant change in their use of gestures, imitation, delay and prematurity. Their language level ranged from
parallel talk, and directive before and after training. no single word to emerging word combination. They were
However, the changes of self-talk, expansion, and ex- receiving active speech therapy intervention during the
tension appeared to be minimal. It might be possible that study period. Inclusion criteria for children were: (1)
these techniques were more complex than the others. No having an utterance length below two, (2) being con-
significant changes were found in the frequency of asking sidered as having expressive language difficulties by an
open-ended question which was a control measures. The SLT, and (3) having Cantonese as a native language.
unchanged frequency of the untaught strategy and the Exclusion criterion was the diagnosis of ASD. This was
growth of some of the targeted strategies provided sup- because the focus of the language facilitation strategies
port that the observed change was a training-induced and the games described in the modules did not specially
effect. On the other hand, there were no significant cater for the ASD characteristics. For caregivers, inclusion
changes in children’s verbal behaviours after the training. criteria were (1) being the primary caregiver of the
It may be possible that gains were realized in terms of participating child and (2) speaking Cantonese as a native
other nonverbal behaviours and vocalizations. Therefore, language and the primary language used with their
use of nonverbal behaviours and vocalizations will be children. All these caregivers did not attend other parent
included in the stage 2 study. language training programme during the study period.
In general, the video-based self-learning parent model The demographic characteristics of the 28 caregiver-
was found acceptable to general Chinese caregivers in child dyads in groups 2 and 3 are also summarized in
Hong Kong, at least those with higher education level. No Table 1. For group 2, children in group 2 had an average
culture-specific barriers were observed during the im- age of 31.43 months, with 9 boys and 5 girls. Meanwhile,
plementation. The caregivers showed certain gain in the mean age of the children in group 3 was 39.07 months,
mastery of the skills discussed in the videos. The positive consisting of 9 boys and 5 girls. In both groups, the
findings supported that this new mode of parent training majority of the parents were under 45 years old, and all
can be developed into an accessible and easy parent participants were mothers. However, unlike the stage 1
training programme to impart knowledge has potential to study, caregivers’ education levels and household in-
become an accessible and easy-to-use parent training comes were more evenly distributed in these groups.
programme. Such a programme could help impart
knowledge and basic parent-child communication Randomization and Allocation Concealment
technique to parents and facilitate children’s language Participants in the stage 2 study were further divided
growth at a preventive level, leading to better develop- into two arms: (1) the group who participated in the video
mental outcomes. The preliminary results also merit an training programme during the study period (group 2) on
extended study on caregivers with more diverse attributes top of their regular speech and language therapy, and (2)
and those families with children having early language the control arm who only received the speech and lan-
difficulties. guage therapy as status quo and did not participate in the

254 Folia Phoniatr Logop 2024;76:245–263 Qi/Ng/Tsang/To

DOI: 10.1159/000534022
video training programme during the study period social interaction, and joint attention [84]. For between-
(group 3), but they were allowed to access to the pro- group comparisons, ANCOVAs were conducted with
gramme after the study period. post-training performance as the dependent outcome
The speech and language therapy these participants variable, group as the between-group measures, and
received during the study period were direct individual baseline performance as the covariate. When the trends of
therapy focussing on the child. Although home practice the changes follow the expectation, i.e., the training arm
was given to caregivers after each therapy session, (group 2) shows more robust changes than the control
caregivers were not directly trained on their language arm (group 3), training-induced effect could be claimed.
facilitation skills as indicted by the SLTs in the NGO.
Prior to baseline data collection, a random allocation Coding Reliability
sequence composed of the numbers “1” and “2” was Caregivers and children’s behaviours were first tran-
generated by using a computer programme; the numbers scribed and coded manually by the third author based on
represented the two training conditions. Immediately the coding scheme developed in the stage 1 study. The
after the submission of baseline videos, which finalized whole dataset was then recoded independently by the first
the list of participants, the caregiver-child dyads were author, who was a doctoral candidate in Speech and
allocated randomly according to the sequence to the Hearing Sciences during the study and is very experi-
training (group 2) or control arm (group 3). enced in coding caregiver-child interaction. This second
coder was blinded to the group membership of the
Procedures parent-child dyads using Interact-9 [85] on a second-by-
There were four phases in the stage 2 study. The second basis. To assess inter-rater agreement in coding,
general procedures in phases I, II, and III are the same as intraclass correlation coefficients (ICCs) [86] were cal-
those in the stage 1 study except that the face-to-face culated for the measures of imitation, self-talk, parallel
workshop in phase I was replaced by an introductory talk, expansion, extension, directive, open-ended ques-
video which aimed to further enhance the accessibility of tions, and child’s vocalization, and verbalization. ICCs of
the programme. The content of the video corresponded to all the measures ranged from 0.743 to 0.897 except ex-
that in the live workshop and included the background tension for which the ICC was 0.645. The overall inter-
and the procedures of the study. Similar to group 1, each rater reliability was good indicating that the coding
caregiver in group 2 and group 3 (1) received the physical scheme was clear and reliable. Coding by the second
booklet, (2) filled out a written consent and an online coder was used for the analysis.
demographic survey, (3) completed the same quiz, (4)
recorded and sent three videos (duration of 3 min each) of
their interaction with their children via a mobile com- Results of the Stage 2 Study
munication application to the investigator a week before
receiving the introductory video, and (5) submitted three Programme Completion Rate
post-training videos after the completion of the pro- Among the 49 eligible parent-child dyads who consent to
gramme. Children in group 2 and group 3 continued to participate in the study, 11 did not respond upon contacting
receive therapy in the NGO as status quo during phase II. later or actively withdrew from the study. Nine dyads did not
Caregivers of group 2 received the programme as submit pre-training videos. Of the remaining 29 participants,
scheduled while group 3 received the access to the 28 completed the video training and submitted baseline and
programme after the study period in phase IV. post-training video recordings. The programme completion
rate in the stage 2 study was 57% (28/49) which was slightly
Measures and Analysis lower than the stage 1 study (62%).
The same set of caregiver and child measures used in
the stage 1 study was administered in the stage 2 study Caregivers’ Knowledge Acquisition
except that children’s vocalization, and gestures in a Group 2 demonstrated significantly higher post-
communicative act were also included in addition to training quiz scores than the control group after con-
verbal production as child’s outcomes. A communicative trolling for baseline quiz scores [group 2: baseline M
act in the stage 2 study was counted when it fulfilled both (SD) = 1.92 (1.71), post-training M (SD) = 6.38 (2.47);
the following conditions: (1) conveyed via verbalization, group 3: baseline M (SD) = 5.15 (1.46), post-training M
vocalization, or gesture, and (2) demonstrated commu- (SD) = 4.62 (1.98); F(1, 25) = 5.30, p < 0.05, partial η2 =
nicative functions which included behavioural regulation, 0.187].

Efficacy of Self-Directed Video Learning Folia Phoniatr Logop 2024;76:245–263 255

Program DOI: 10.1159/000534022
Table 6. Baseline and post-training frequency count of caregivers’ and children’s behaviors in the stage 2 study

Behavior Group 2 (n = 11), M (SD) Group 3 (n = 11), M (SD) Comparison

baseline post baseline post dfs F p value

Caregiver outcomes
Gesture 9.272 (4.496) 11.000 (6.943) 11.272 (11.217) 11.182 (7.534) 1, 23 0.060 0.809
Imitation 1.363 (1.120) 1.273 (2.054) 1.000 (1.897) 1.818 (2.639) 1, 23 4.378 0.050*
Self-talk 3.182 (3.371) 1.636 (2.501) 2.000 (2.191) 1.636 (1.859) 1, 23 0.002 0.967
Parallel talk 2.182 (2.750) 2.818 (4.875) 1.545 (2.018) 0.636 (1.027) 1, 23 1.649 0.214
Expansion 0.818 (1.328) 0.909 (1.446) 1.364 (2.157) 1.000 (1.612) 1, 23 7.28 0.793
Extension 0.182 (0.405) 0.091 (0.302) 0.091 (0.302) 0.000 (0.000) 1, 23 1.087 0.310
Directive 8.636 (4.822) 10.364 (7.619) 7.455 (6.624) 6.636 (6.637) 1, 23 1.248 0.278
Open-ended questions 2.273 (2.412) 2.273 (2.494) 2.273 (3.438) 2.182 (2.228) 1, 23 0.010 0.921
Child outcomes
Verbalization 7.909 (9.534) 14.273 (13.469) 10.455 (14.088) 11.364 (12.651) 1, 23 1.697 0.206
Vocalization 4.818 (3.516) 6.000 (5.119) 2.091 (2.468) 0.636 (1.286) 1, 23 5.813 0.024*
Gesture 3.091 (3.208) 1.364 (2.203) 3.182 (4.936) 1.182 (1.662) 1, 23 0.057 0.813

*p at or < 0.05.

Preliminary Analyses of Baseline Performances Children’s Communication Skills

One-way ANOVA was computed for the baseline No significant training effect on children’s verbal
measures of caregiver and child outcome variables to production [group 2: baseline M (SD) = 7.91 (9.53), post-
examine the baseline between-group difference. Other training M (SD) = 14.27 (13.37); group 3: baseline M
than the control group (group 3) showing significantly (SD) = 10.45 (14.088), post-training M (SD) = 11.36
lower baseline levels of child vocalization than the (12.651)] and gestures [group 2: baseline M (SD) = 3.09
training group (group 2) (F(1,20) = 4.79, p < 0.05), there (3.208), post-training M (SD) = 1.36 (2.203); group 3:
were no differences on any other measures of the out- baseline M (SD) = 3.18 (4.936), post-training M (SD) =
come variables (i.e., parents’ use of LFTs, child’s ver- 1.18 (1.662)] were observed. However, there was a sig-
balization, and use of gesture) between two groups. nificant growth in children’s vocalization in the training
arm [group 2: baseline M (SD) = 4.82 (3.516), post-
Caregivers’ Behaviours training M (SD) = 6.00 (5.119); group 3: baseline
Among the video recording submitted by the caregivers, M (SD) = 2.09 (2.468), post-training M (SD) = 0.064
six of them did not meet the requirements of at least 3-min (1.286); F(1, 23) = 5.813; p = 0.028; partial η2 = 0.202].
long and involved the participating caregiver. These videos
were excluded. Eleven video recordings from each of the
training and control groups were analysed. The descriptive Discussion of the Stage 2 Study
statistics of the baseline and post-training performances of
the training and control arms were summarized in Table 6; The stage 2 study explored the efficacy of the self-
Figures 1a–h displayed the changes of the parental responses directed video-based for enhancing the LFTs of caregivers
in the baseline and post-training of the training and control with children having language difficulties among Chinese
groups. It is worth noting that the scales of these graphs were families in Hong Kong. Programme completion rate was
different. The pattern of changes varied across behaviours. In 57%. Like group 1, group 2 caregivers who also received
general, the mean frequency of parallel talk and gesture of training demonstrated a significant improvement in their
the training arm increased from baseline to post-training. quiz scores, implying that even nonprofessional care-
However, the increase did not reach statistical significance givers are able to learn new knowledge via self-directed
when compared to the control arm. Unexpectedly, the learning. Yet, the actual implementation of the knowledge
control arm used the strategy of imitation more often than gained onto practice involved another level of compe-
the training group and the difference is reaching statistical tency because none of the growth of the caregivers’ be-
significance (p = 0.05). Finally, the training group showed haviours of the training arm showed significant change
similar changes in the untaught strategies. when compared to the control arm. Significant gains in

256 Folia Phoniatr Logop 2024;76:245–263 Qi/Ng/Tsang/To

DOI: 10.1159/000534022
 a b

c d

e f

g h
1
(For legend see next page.)

Efficacy of Self-Directed Video Learning Folia Phoniatr Logop 2024;76:245–263 257

Program DOI: 10.1159/000534022
children’s vocalization were observed in the training arm LFTs indicated that some caregivers might find these
but not verbal and gesture use. As expected, changes of strategies easier to apply than the others. Parallel talk
the non-targeted control behaviour of open-ended could be initiated easily in the context without drawing
question of the two groups before and after training much attention to a child’s language ability. The child
was not significant. demonstrated certain actions, the parent supplied the
verbal descriptions for the child, and parallel talk is like
Completion Rate and Changes in Quiz Scores speaking for the child. Use of gesture to augment what the
The programme completion rate of the stage 2 study caregivers are talking about is also relatively straight-
was slightly lower compared to the stage 1 study. It is forward. That may explain why some caregivers can apply
worth noting that several caregivers in stage 2 study the strategies and resulted in the general growth.
required multiple reminders (text messages or phone Other techniques did not show any positive trends.
calls) to submit their video recordings, while the sub- The limited use of these LFTs may be related to the
mission by caregivers in the stage 1 study was generally on complexity of these techniques and children’s low lan-
time. However, the number of reminders sent was not guage level. Kaiseret al. [96] pointed out that during
recorded in the present study. Previous studies showed parent training, parents have to go through several
that parental involvement in child’s educational activities learning stages before learning an advanced technique.
is predicted by parental self-efficacy [87], a factor which is Mastery of single-episode techniques such as parallel talk
influenced by education level and parenting stress [83]; is the prerequisite of acquiring successive corrective
other challenges such as child’s developmental issues also models. Parents may need to wait for and be alert to the
negatively affect parental self-efficacy [88, 89]. Compared child’s production when they use the advanced strategy.
to the stage 1 study, caregivers in the stage 2 study who In addition, they have to be familiar with their children’s
managed a child with speech and language difficulties current language development and possess certain level of
showed a lower education level as a group. It might be awareness regarding language structures so as to provide
possible that mothers in the stage 2 study experienced slightly more advanced language models that are within
higher parenting stress [90, 91]. The higher stress level their child’s zone of proximal development [97]. These
and the more varied parental education backgrounds may techniques may be demanding to the general population
affect their parental efficacy, which may in turn lead to a and self-directed learning via video watching alone is
less involvement and requirement of multiple reminders insufficient to support their learning. Moreover, chil-
to support their participation [92–95]. Yet more sys- dren’s weak verbal ability also contributes to the limited
tematic analysis is needed to support this claim in future use of some advanced strategies such as extension and
study. expansion. Some children were still approaching single-
Like results in the stage 1 study, the significant word stage and produced vocalization which may not
between-group effect in post-training quiz scores indi- allow caregivers to apply the advanced techniques such as
cated that the participating caregivers were able to learn extension. These results imply that selection of the ap-
knowledge from watching the training modules without propriate techniques for children at different language
coaching. This attested that videos were generally suffi- levels is also an important consideration in practice.
cient to improve the knowledge of language facilitation in Unexpectedly, the control arm used imitation more
caregivers with diverse education backgrounds and can be than the training arm. Imitation has the pedagogical value
considered a useful part of parent-training programmes. in aiding children to learn language. However, without
receiving the training, it was not likely that parents in the
Changes in Caregivers’ and Child’s Behaviours control arm realized this function and repeated what the
A different picture was observed when considering the child said. Instead, their imitation may be considered as a
transfer of knowledge into practice. Only general but not feedback to the child to continue the flow of conversation.
significant increase in the frequency of parallel talk and Direct imitation is the simplest way to provide feedback
gesture were observed. The specific growth in these two when compared to other types of responses. Along with

Fig. 1. a Changes of caregivers’ use of gesture before and after expansion before and after training. f Changes of caregivers’
training. b Changes of caregivers’ use of imitation before and use of extension before and after training. g Changes of
after training. c Changes of caregivers’ use of self-talk before caregivers’ use of directive before and after training.
and after training. d Changes of caregivers’ use of parallel talk h Changes of caregivers’ use of open-ended question before
before and after training. e Changes of caregivers’ use of and after training.

258 Folia Phoniatr Logop 2024;76:245–263 Qi/Ng/Tsang/To

DOI: 10.1159/000534022
the general decreasing trends were observed in the fre- carefully assess both caregiver and child behavioural
quency of other strategies in the control group, this may changes is essential when evaluating language interven-
be the reason for the significant growth of imitation in tions to fully understand their effectiveness.
this group.
Based on the raw frequency, caregivers in both groups
used a large amount of directive where they instructed the Overall Conclusion and Clinical Implications
child to perform certain actions. This may be related to
the cultural characteristics of parenting practice among Caregiver-implemented language training pro-
Chinese. For example, Chinese American parents taught grammes are a relatively new mode of training when
their preschool children in more structured and formal compared to traditional direct individual training in
ways, and were more directive [98]. The slight reduction Hong Kong. The current study further included the self-
in group 1 may suggest that the practice is malleable. The directed learning element with the use of video clips in
introduction of the “Observe” strategy as a substitute of developing a caregiver-implemented programme, aiming
directive command to children appears to be useful in to address the constraints of the caregivers. The signifi-
guiding the caregivers to wait and follow the child’s lead cant growth in the quiz scores supported the use of this
while not affecting cultural appropriateness or accept- mode in enhancing caregivers’ knowledge. The self-
ability among Chinese caregivers [99]. Yet, additional directed learning nature possesses the advantage of
coaching and feedbacks sessions may be required to saving the commute cost to workshop venue and allowing
reinforce and consolidate its use in practice, especially for flexible individual schedules when compared to face-to-
caregivers of children with confirmed needs. face training. The inclusion of technologies can also
Similarly, caregivers in both training and control arms increase caregivers’ motivation and satisfaction to self-
showed relatively frequent use of “Gesture” even during learning. The accessibility of mobile devices and the
baseline. They may have learned the skills from their regular recent pandemic that have reduced certain face-to-face
speech therapy sessions or they were just sensitive to the activities may further expedite this mode of training as
difference in the verbal language demand and children’s part of the training programme around the world. In
language skills and therefore tended to use gestures to addition, the gains also revealed that Chinese caregivers
maximize their communication success [100]. Again, the were able to acquire certain “Western-based” LFTs and
general growth in the training arm was nonsignificant. Our effectively implemented them with their children.
analyses did not include breakdown analysis of the types of The programme completion rate was satisfactory
gestures. It may be possible that caregivers mainly used among Group 1 caregivers of typically developing chil-
deictic gestures but not conventional and representational dren. However, there was a slightly lower completion rate
gestures. Future studies can explore if caregivers’ use of the among group 2 and group 3 caregivers, who were caring
latter two can in fact benefit from training. for children with language delays. A number of factors
Finally, significant changes in the child’s vocalization were found to relate to parents’ programme completion
were observed in the training group indicating a large rate. For example, the novelty of the programme format,
effect size. However, the nonsignificant improvement in the initial expectations regarding its content or relevance,
caregiver’s use of LFTs may reflect the variability of the and other commitments [101]. Specifically, caregivers in
measures based on 3-min video sample of unstructured group 2 and group 3 showed lower household income
activities, which may not capture all aspects of the implying that they would be less resourceful. In addition,
caregiver’s behaviour that were critical to supporting the the commitment to caring for children with language
child’s language development. It is possible that the delays may have made their participation to the pro-
significant gains in vocalization were a pooled effect from gramme even more challenging. Research by Morris and
the sum of the positive changes in caregiver behaviours. Bellon-Harn [102] suggested that when working with
The lack of significant changes in the child’s verbal parents from low-SES backgrounds, communication
production and gesture use may suggest that children adjustment, technical support and adapting the timeline
were more likely to vocalize in response to the improved can be beneficial because these assistances could poten-
parental input, even changes in these were not imme- tially enhance programme engagement and completion
diately apparent. Further research is needed to confirm rates among caregivers facing additional challenges.
these speculations and to better understand the complex Moreover, the positive changes in the caregivers’ be-
interactions between caregiver behaviours and child’s haviours in the training group did not reach statistical
language development. Using multiple measures and to significance. This implies that a self-directed learning

Efficacy of Self-Directed Video Learning Folia Phoniatr Logop 2024;76:245–263 259

Program DOI: 10.1159/000534022
mode may only be useful as an enrichment programme Personalized coaching and feedback on caregivers’
for parents of typically developing children at emerging technique implementation from professionals should
language stage without specific clinical concerns and as a be included in order to further examine the feasibility
universal prevention measure in the public health and the cost-effectiveness of the programmes.
“pyramid of needs” model. The training programme,
however, may not substantially improve quantity and
quality of parent’s language input for children with Acknowledgments
language impairment and parents from diverse back-
grounds. Interventions on targeted and specialist levels in This manuscript was based on part of the honours theses
written by the second and the third authors and supervised by the
the model may demand higher professional human re- last author. The authors thank the Hong Kong Christian Service
source involvement, and possibly higher dose, in order to for the assistance in participant recruitment. We are grateful to all
induce useful changes in parents’ use of LFTs. According children and parents who participated in the study.
to the adult learning model, learners’ active engagement
and external support in the process can be facilitative.
Caregivers would learn best and more efficiently when Statement of Ethics
coaching is available [103]. The self-directed component
can pair with certain level of tailor-made and specialist This study protocol was reviewed and approved by Human
Research Ethics Committee of Faculty of Education, the University
level support for even better outcomes, especially for of Hong Kong [HREC’s Reference Number: EA1803062].
complex techniques and caregivers of children with
language difficulties [104].
Conflict of Interest Statement
Limitations and Future Directions The authors have no conflicts of interest to declare.

The current study had a small sample size with no

control group that did not receive any form of inter- Funding Sources
vention for comparison. For future studies, a larger
dosage in a longer time frame should be included to tap This research was supported by the Small Project Fund, the
University of Hong Kong awarded to C.K.S. To.
on the long-term effect of such a programme on
children with language impairment. Factors that may
affect the efficacy of the programme, like diverse SES
Author Contributions
status, parental stress level, self-efficacy, pre-training
parenting skills level, should be taken into consider- Xin Qi contributed to the data coding, validation, and prep-
ations. Comprehensive and sensitive measurements aration of the final draft. Winnie Ng and Gigi Tsang took part in
including standardized assessments should be used as conceptualization, data collection, data coding and original draft
parent and child’s outcome measures. In addition, we preparation. Carol To contributed to the overall conceptualization,
mainly investigated the change in caregivers’ and research design, literature review, data interpretation, and prep-
aration of the manuscript and its revision.
children’s behaviours but did not include caregivers’
attitude and satisfaction as the outcome measures.
Focus group discussion with all the participating
caregivers would be particularly useful in modifying the Data Availability Statement
programme content or procedures for caregivers having Data generated and analysed during this study are included in
children with and without communication difficulties this article. Further enquiries can be directed to the corresponding
because they would have different concerns and needs. author.

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