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

CHAPTER III

Assessment Methods for Young Children With Communications Disorders - Continued

The early identification of children with communication disorders, as with other developmental disorders, can occur in a variety of ways. In some cases, certain behaviors or lack of progress in the child's development may cause parents or other caregivers to become concerned that the child may have a communication problem. In other instances, a professional seeing the child for routine health care may become concerned about a possible communication disorder based on information from the parents or direct observation of the child.

Defining risk factors and clinical clues

A number of risk factors and clinical clues that heighten the concern of a possible communication disorder may be noted by parents, professionals, or others interacting with the child. The concepts of risk factors and clinical clues, as these terms will be used in this guideline, are described below:

• Risk factors are defined in this guideline as current or historical observable behaviors or findings that suggest that a child is at increased risk for either having or developing a communication disorder. For example, a history of chronic ear infections and hearing loss is a risk factor for communication disorders.

• Clinical clues are defined in this guideline as specific behaviors or physical findings that heighten concern that a child may currently have a communication disorder. For example, if a parent notices that a child has no spoken words at 18 months, this would be a clinical clue of a possible communication disorder, including hearing loss. Clinical clues may be noticed by the parents, others familiar with the child, or by a professional who is evaluating or caring for the child.

Using risk factors and clinical clues to identify possible communication disorders

Understanding and recognizing risk factors and clinical clues for communication disorders is an important way to identify children under the age of 3 with possible communication disorders. Some of these risk factors and clinical clues can be identified at a very early age; others are not as apparent and may not be recognized until caregivers or professionals notice that the child's use of language is delayed. In general, risk factors for communication disorders that can be identified early in infancy are those that are closely related to certain biological and social-environmental factors.

The presence of a particular risk factor or clinical clue is not sufficient to establish that a communication disorder exists. Risk factors and clinical clues for communication disorders are sometimes seen in children who are typically developing and do not have a communication disorder. Therefore, recognition of a risk factor or clinical clue is just the first step in the process of identifying children with communication disorders and merely indicates that further assessment is needed.

The role of developmental surveillance

Developmental surveillance is the term that most accurately describes the approach currently practiced by many health care providers and other professionals for the early detection of a variety of developmental problems. Developmental surveillance is a flexible, continuous process in which knowledgeable professionals monitor a child's developmental status during the provision of health care or early childhood services.

The process of developmental surveillance includes the following components:

• eliciting and attending to parents' concerns
• obtaining a relevant developmental history
• observing children accurately
• sharing opinions and concerns with other relevant professionals and with parents

There are various methods that can be employed in carrying out general developmental surveillance. One important method of developmental surveillance is for professionals to monitor the child's development in relation to critical age-specific "developmental milestones."

Developmental surveillance may involve the use of parent questionnaires and formal screening tests. Questionnaires may be given to parents to involve them in monitoring their children's development. Formal screening tests of general development can also be conducted. Appendix D summarizes the characteristics of some of the common standardized tests of general development that are used for children from birth to 3 years of age.

One part of the general developmental surveillance is to look specifically at the child's communication development. Several studies have evaluated patterns and timing of typical speech and language development in young children. These are known as "normal language milestones" and can be used as a reference to monitor the child's speech and language development as part of the ongoing developmental surveillance process.

Various ways that communication disorders are first identified

In summary, there are multiple ways that a concern about a child's communication may first be identified. Sometimes parents are the first to notice something that raises a concern about their child's communication. In other cases, concerns about a child's communication may first be noted as a result of developmental surveillance during health care visits or while the child is in the care of other early childhood professionals. These initial concerns are usually based on information about risk factors, current behaviors, or the results of routine screening tests of the child's general development.

Typically developing children vary somewhat in the timing of their communication development. Therefore, it is sometimes difficult to determine whether a child who shows signs of an early communication difficulty or delay will go on to achieve more typical language performance or will have ongoing language problems.

Recommendations

Importance of early identification and follow-up

1. It is important for parents and professionals working with young children to be able to identify potential communication disorders as early as possible. [D2]

2. In assessing the communication development of children from birth to 3 years old, it is important to recognize:

• communication is not limited to spoken language

• communication can be assessed before the onset of spoken words [D2]

3. Once a heightened concern of a communication disorder has been identified, it is important for professionals to perform or arrange for appropriate screening and in-depth assessment of the child's communication. [D2]

Challenges in early identification of communication disorders

4. It is important to recognize that early identification and accurate diagnosis of communication disorders can be challenging in children under 3 years of age (especially in young children who are otherwise developing typically). [D2]

5. It is important to recognize that when a communication disorder is identified at a very young age, predicting the future course may be difficult. [D2]

6. It is important to recognize that the reliability of the diagnosis for speech/language problems usually improves as the child gets older. [D2]

Recommendations

Importance of recognizing risk factors and clinical clues

1. It is important to be aware of the risk factors and clinical clues which can alert parents, other caregivers, and health professionals that further evaluation may be needed to identify the possibility of a communication disorder. [A]

2. It is recommended that identification of risk factors or clinical clues for communication disorders trigger appropriate on-going developmental surveillance. [D1]

Using risk factors to identify possible communication disorders

3. The presence of risk factors for communication disorders may be useful in identifying children under the age of 3 who have a possible communication disorder. (See Tables III-1 through III-4.) [B]

4. It is important to remember that not all children with identifiable risk factors will have a communication disorder and that children who have a communication disorder may have no known risk factors. [B]

Using clinical clues to identify possible communication disorders

5. It is important to recognize that communication disorders occur frequently in the presence of other developmental disorders. Specific risk factors include:

• hearing loss
• oral-motor or feeding problems
• cognitive delay
• motor problems
• autism
• other neurological problems
• social-emotional behavior issues [B]

6. If a child is found to have a developmental disorder other than communication, it is important to assess communication. [B]

7. If a child is found to have a communication disorder, it is important to assess other areas of development. [B]

8. The presence of certain clinical clues for communication disorders may be useful in identifying children under the age of 3 who have possible speech/language or hearing problems. (Clinical clues for communication disorders are listed in Table III-5 .) [D1]

9. Clinical clues, when observed in a young child, may signal a need for further assessment of a possible communication disorder, hearing loss, or other developmental problem. [B]

Addressing concerns of parents and early childhood professionals

10. If parents have concerns that their child may have a communication disorder, (because of the identification of risk factors or clinical clues), it is recommended that they discuss these concerns with a health care provider or other professional experienced in evaluating young children with developmental problems. [D1]

11. If an early childhood professional suspects that a child has a developmental problem (including a possible speech/ language or hearing problem) it is important that these concerns be discussed with the parents and that appropriate evaluation by a health care provider or other professional be recommended. [D1]

Table III-1:

Risk Factors for Speech / Language Problems In Young Children

• Family history of hearing or speech/language problems
• Parents with hearing impairment or cognitive limitation
• Children in foster care
• Family history of child maltreatment (physical abuse or child neglect)

* The more premature the birth and the more complicated the perinatal course, the greater the risk is for communication disorders and other developmental problems.

Table III-2:

Risk Factors for Hearing Problems in Young Children

Genetic or Congenital Factors

• Family history of hereditary childhood sensorineural hearing loss
• Congenital infections known to be associated with hearing loss
• Craniofacial anomalies
• Birth weight less than 1,500 grams
• A genetic syndrome known to include hearing loss

Exposures or problems occurring after birth

• Low Apgar Scores (0-4 at one minute or 0-6 at five minutes)
• Hyperbilirubinemia requiring exchange transfusion
• Ototoxic medications
• Bacterial meningitis
• Mechanical ventilation for five days or longer
• Recurrent or chronic otitis media with effusion

From: Joint Committee on Infant Hearing, 1994

Table III-3:

Risk Factors And Clinical Clues For Oral-motor/Feeding Problems in Young Children

Risk factors

• Craniofacial disorders or syndromes (of the head and neck)
• Cleft lip/cleft palate
• Tracheotomy
• Cerebral palsy

Table III-4

Clinical Clues of Possible Autism in Young Children

The clinical clues listed below represent delayed or atypical behaviors that are seen in children with autism (although some of these findings may also be seen in children who have a developmental delay or disorder other than autism).

If any of these clinical clues are present, further assessment may be needed to evaluate the possibility of autism or other developmental disorder.

• Delay or absence of spoken language
• Looks through people; not aware of others
• Not responsive to other peoples facial expressions/feelings
• Lack of pretend play; little or no imagination
• Does not show typical interest in, or play near peers purposefully
• Lack of turn taking
• Unable to share pleasure
• Qualitative impairment in nonverbal communication
• Does not point at an object to direct another person to look at it
• Lack of gaze monitoring
• Lack of initiation of activity or social play
• Unusual or repetitive hand and finger mannerisms
• Unusual reactions, or lack of reaction, to sensory stimuli

From: Clinical Practice Guideline for Autism/Pervasive Developmental Disorder, New York State Department of Health, 1999.

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