Clinical Practice Guideline: Report of the Recommendations, Communication Disorders, Assessment and Intervention for Young Children (Age 0-3 years)
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CHAPTER III

• General Approach for Identifying and Assessing Young Children with Communication Disorders
• General Considerations in Identifying and Assessing Young Children with Communication Disorders
• The Parent's Involvement in the Assessment Process
• The Professional's Involvement in the Assessment Process
• Cultural Considerations and Linguistic Variations
• Chapter III (continued)

Most experts agree that it is important to identify children with developmental delays or disorders as early as possible. Intervention at earlier stages in the child's development may have a greater chance of reducing the short-term and long-term negative consequences of these disorders (Guralnick, 1998).

Language delay is the most common type of developmental problem seen in preschool age children (Rescorla and Schwartz, 1990). Depending upon the level of delay that is considered abnormal, studies suggest that from three to ten percent or more of children in the 2 to 3 year old range may have a communication delay (Rescorla and Schwartz, 1990). Some authors report that children with communication disorders make up from 25% to 50% or more of young children eligible for early intervention programs (McLean and Cripe, 1997; Goodman, 1998).

Early identification and early intervention may be especially important for young children with significant communication disorders (McLean and Cripe, 1997). The assessment of language in children under age 3 is challenging, however, since there is considerable variability in the rates at which children develop language skills. Moreover, the dividing line between typical and delayed language is not always clear.

Typical communication development

Communicative behaviors begin at birth and evolve over time. Communication is integral to all aspects of a child's development, and the quality of the child's communication has a long-term impact on socialization and on learning.

An important aspect of communication includes the reciprocal interaction of the infant/young child with others. The form of communication varies with a child's age and developmental status. During the first year of life, the child's communication involves hearing, physical contact, body movement, gesture, facial expression, and vocalization. During the child's second year of life, it is common for the child to develop individual spoken words. The typical child's language development is often quite rapid leading to the use of two-word combinations and a great increase in vocabulary. During the third year, vocabulary usually continues to increase rapidly, and the child uses increasingly complex elements of language.

The role of the parents in identification and assessment

Every aspect of the assessment process for young children with communication disorders involves the parents in a variety of ways. Parents have an important role in helping to monitor the development and health of their child. Parents and other caregivers (potentially including grandparents, babysitters, and family day care providers) are the richest source of information about a child's development.

Information provided by the parents and other caregivers may lead to the early identification of possible problems. At a later stage, information provided by the parents is crucial to an adequate assessment of the child's communication.

Parents are often present during the assessment sessions, and observation of child-parent interactions is an important aspect of assessment. Parents also have an important role in helping professionals make decisions about assessment and treatment goals for the child. Because parents play a critical role in the identification and assessment process, there is a need for parents to understand communication development in young children. Informing and involving the parents provides an opportunity for them to be active participants in the care of their child.

Cultural considerations and linguistic variation

Communication is embedded within a cultural context. For many families, English may not be the primary or the only language spoken in the home. Multilingualism and other linguistic variations, such as various dialects, within a home and other care environments may affect the way in which the child learns each language. For children from a bilingual or multilingual home, the early expression of language is likely to vary somewhat from that seen in children raised in a monolingual environment. This difference in language is not a deficit.

The acquisition of two languages by children reared in bilingual or multilingual homes can occur sequentially or simultaneously. Simultaneous bilingual language learning occurs when a child learns two or more languages in infancy from the onset of language. This usually occurs when the child develops two languages before the age of 3 years. Bilingual children may become aware of using two languages as early as 15 months and as late as 3½ years.

In the early acquisition of bilingualism, the children use vocabulary words to indicate a concept in one or the other language. As the children develop the use of morphology and grammar between the age of 2-3 years, the two languages develop; however, the syntactic systems may remain undifferentiated for a while. After the age of 3 years, children are typically able to use the appropriate syntax and grammar to express themselves in each language. Thus, the acquisition of language in bilingual or multilingual homes by children from age 0-2 can be expected to progress at a rate similar to that of children reared in monolingual homes. Although the number of controlled studies is limited, it is generally held that there is no difference in the pace of language acquisition between monolingual and bilingual children in simultaneous language acquisition (Langdon and Cheng, 1992).

Appropriate assessment of communication and identification of communication disorders can be challenging in young children from a bilingual/multilingual home. A distinction can be made between what is typical development for the child's language and cultural environment, versus a difference resulting from the influence of learning a second language, versus a true disorder.

Appropriate assessment of a child's communication development will take into account the languages and dialects spoken within the child's home and other places of care as well as the culture of the child and the family. While a variety of standardized tests are available for Spanish speakers, there are no tests available for many other increasingly common languages such as Korean, Chinese, and Russian.

General Considerations in Identifying and Assessing Young Children with Communication Disorders

Recommendations

The importance of early identification

1. It is important to monitor communication development and to assure that hearing is normal in all children from birth. Communication is integral to all aspects of development and has a long-term impact on socialization and on learning. [D2]

2. It is important to identify and treat communication disorders as early as possible. [D2]

3. It is important that all persons involved with young children understand:

• the typical course of communication development

• the signs of difficulty with communication

• the interaction of the various developmental domains (communicative, hearing, social, cognitive, motor, and adaptive) in the typical course of a child's development

• steps to take when concerns are identified [D2]

The importance of accurate assessment and diagnosis

4. Making an accurate diagnosis of communication disorder is complex, especially for children under 3 years of age, so it is important that all professionals involved in helping make the diagnosis of communication disorder are knowledgeable and experienced in working with infants and young children. [D2]

Considerations in deciding on assessment strategies, materials, and settings

5. It is recommended that the setting of the assessment be appropriate to the developmental stage of the child and be comfortable for both parent and child. [D2]

6. It is recommended that assessment materials and strategies reflect developmentally appropriate practice with infants and young children. [D2]

Reporting findings of the assessment to parents

7. It is recommended that the reports of professionals who assess children with suspected communication disorders include:

• results presented in language that is understandable to the family and other professionals dealing with the child

• information about how the child's level of communication skills may affect other developmental areas

• strengths and limitations of the assessment tools or process

• results that are useful for developing intervention goals [D2]

8. It is important for professionals to consider how the assessment process and results will impact the family. [D2]

Recommendations

1. It is important for all parents of young children to receive accurate information about typical language development and communication disorders (see Table III-5), including:

• typical language development in infants and young children

• ways to recognize possible communication disorders as early as possible

• risk factors and clinical clues for communication and hearing disorders

• steps to take if a communication disorder is suspected [D2]

2. It is important that parents and other primary caregivers of children who have a possible communication disorder receive accurate information about typical language development and communication disorders to allow them to:

• function as active partners with health care providers in monitoring the overall development and health of the child

• become informed advocates for their children

• develop informed and reasonable expectations about typical language development, the nature and outcome of communication disorders, and appropriate assessment and intervention methods if a delay or disorder is suspected [D2]

EIP 7

Recommendations

1. It is important that all primary health care providers and early childhood professionals who deal with children from birth to 3 years old be knowledgeable about identifying communication disorders (see Table III-5), including:

• typical language development in young children

• risk factors and clinical clues for early identification of communication disorders and hearing loss

• appropriate methods to screen for communication disorders and hearing loss in young children

• clinical clues and risk factors for other developmental problems associated with communication disorders

• appropriate actions for referrals when a communication disorder or other developmental problem is suspected [D2]

2. It is important that speech and language pathologists involved in assessing and treating communication disorders in young children be knowledgeable about:

• typical language development in young children

• risk factors and clinical clues for early identification of communication disorders and hearing loss

• appropriate methods for screening and for in-depth assessment of young children

• clinical clues and risk factors for other developmental problems associated with communication disorders [D2]

• appropriate actions for referrals to other professionals if other conditions associated with communication disorders are suspected [D2]

Why professionals need to know this information

3. It is important that early childhood professionals (teachers, administrators, and paraprofessionals working in day care, nursery school, and similar early childhood settings) receive information about communication disorders in order to:

• facilitate the early recognition of children with possible communication disorders, including hearing loss (such as by making appropriate observations)

• give accurate information to parents and families

• assist in making appropriate referrals

• provide appropriate information to facilitate screening, assessment, and monitoring of possible communication disorders

• recognize the possible impact of a communication disorder on other areas of development [D2]

4. It is important for health care professionals (physicians, nurses, nurse practitioners, physician assistants, and other health care professionals) to understand typical language development and communication disorders so that they can:

• facilitate the early recognition of children with possible communication disorders, including hearing loss (such as by asking appropriate questions)

• raise the level of concern and facilitate recognition/ diagnosis of other medical and developmental conditions that may need treatment

• facilitate the use of appropriate surveillance methods

• give accurate information to parents and families

• assist in making appropriate referrals

• provide medical information and act as a liaison between the family and other service providers related to the child's health care needs [D2]

Training professionals

5. It is recommended that all professionals who will be working with children from birth to 3 years old receive training on the general development of young children, including information about the development of language and communication. [D2]

6. It is recommended that training for all professionals who will be working with children from birth to 3 years old include information about cultural and ethnic variations of language. [D2]

7. It is recommended that training related to communication development in young children be available through continuing professional education. [D2]

Recommendations

Respecting the culture of the family

1. It is important to consider and respect the family's culture, including linguistic variations, when assessing children for possible communication disorders. [D2]

Normal variation versus communication disorder

2. It is important to understand that a regional, social, or cultural/ethnic variation of a language system is not considered a disorder of speech or language. [D2]

3. It is important to remember that children who are bilingual or multilingual cannot have a communication disorder in one language alone. The effects of a communication disorder will be present across all of the child's languages. [D2]

The multilingual/multicultural assessment process

4. It is recommended that assessment materials and strategies be appropriate to the culture and language of the child and family. [D2]

5. It is particularly important to consider the following cultural factors:

• the role and expectations of the family
• child rearing practices
• cultural beliefs about health and education [D2]

6. In cases where a child is acquiring more than one language or dialect, it is recommended that the assessment process take into account the child's abilities in each language being acquired and consider the influence of one language upon the other. [D2]

7. Clinical judgment and natural language samples involving a parent or other family member interacting with the child are particularly important ways to evaluate a child's language development while taking into account the child's cultural and linguistic background. [D2]

8. It is recommended that, whenever possible, the evaluator use tests that have been normed on the child's cultural-linguistic group. [D2]

Using an interpreter and/or a cultural informant

9. It is strongly recommended that professionals screening and evaluating a child's communication status be fluent in the child's primary language and be familiar with the child's cultural background. [D2]

10. Documenting a speech and language disorder in a bilingual child is a complex process and is best accomplished by a bilingual professional familiar with both of the child's languages and the cultural environment of the child. [D2]

11. It is important that professionals assessing a child with a possible communication disorder be knowledgeable about the social-cultural influence of the family's values, beliefs, communication style, and linguistic output on the child's communication development. [D2]

12. When there are no evaluators available who are fluent in a child's primary language, it is strongly recommended that a trained interpreter participate in the evaluation process. [D2]

13. When the evaluator lacks knowledge about the social-cultural influence of the family's values, it is important to have a cultural informant involved in the assessment process. A cultural informant is a person who can serve as a link between the family's culture and the evaluator's culture. [D2]

	Send questions or comments to: bei@health.state.ny.us
	Revised: June 2002