Information for Providers   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

Assessment Methods for Young Children With Communications Disorders - Continued

Normal Language Milestones and Clinical Clues of a Possible Communication Disorder in Children from Birth to Age 36 Months

Table III-5 describes normal language milestones and clinical clues of a possible communication disorder in children. These concepts are defined as follows.

Table III-5 was compiled from the following references:

Miller J. Assessing language production in children: Experimental procedures. Austin, TX: Pro-Ed, 1981.

Miller J, Chapman R, Branston M, and Reichle J. Language comprehension in sensorimotor stages V and VI. Journal of Speech and Hearing Research, 1980; 23: 284-311.

Olswang L, Stoel-Gammon C, Coggins T, and Carpenter R. Assessing prelinguistic and early linguistic behaviors in developmentally young children. In Assessing Linguistic Behavior (ALB). Seattle, WA: University of Washington Press, 1987.

Table III-5


Normal Language Milestones
Clinical Clues / Cause for Concern

Normal Language Milestones
Clinical Clues / Cause for Concern at 6 Months

Normal Language Milestones
Clinical Clues / Cause for Concern at 9 Months

Normal Language Milestones
Clinical Clues / Cause for Concern at 12 Months

Normal Language Milestones
Clinical Clues / Cause for Concern at 18 Months

Normal Language Milestones
Clinical Clues / Cause for Concern at 24 Months

Normal Language Milestones
Clinical Clues / Cause for Concern at 36 Months

The Parents' Evaluations of Developmental Status (PEDS) is an example of a screening instrument that was designed to elicit parents' concerns about their child's learning and development. One part of this interview asks about articulation and expressive language skills. The interview was developed for use in pediatricians' offices to screen for developmental problems.

Evidence Ratings : [A] =  Strong [B] =  Moderate [C] =  Limited [D1] =  Opinion/Studies do not meet criteria [D2] =  Literature not reviewed

<Recommendations

  1. It is recommended that parents' concerns about their child's communication skills be recognized as important indicators that warrant further assessment for the possibility of a communication disorder including hearing loss. Further assessment might begin with a formal or informal checklist or a direct referral for formal assessment depending on the level of parental concern and presence of other risk factors or clinical clues. [B]
  1. It is recommended that, when asking parents about a child with a possible communication disorder, professionals ask open-ended questions about concerns related to communication skills as well as specific questions about communication milestones. [B]
  1. Following an initial assessment, it is important for parents who continue to be concerned about their child's development to explore the possibility of a second independent evaluation if they are not satisfied with the results of the initial assessment. [D2]

Evidence Ratings : [A] = Strong [B] = Moderate [C] = Limited [D1] = Opinion/Studies do not meet criteria [D2] = Literature not reviewed

<Recommendations

General developmental surveillance for all young children

  1. It is recommended that all young children have periodic developmental surveillance. This might be integrated into routine well-child exams or done at other times when professionals evaluate a child. [D2]
  1. Routine developmental surveillance is important for all young children because it provides ways to:
  • monitor the child's progress in multiple developmental domains
  • actively identify developmental problems as early as possible
  • establish baselines for future possible interventions [D2]

Regular surveillance of communication development

  1. Since communicative behaviors begin at birth, it is recommended that regular developmental surveillance for all young children from birth to 3 years include surveillance of communication development (see Table III-5). [D1]
  1. Because communicative behaviors evolve over time, it is important that developmental surveillance of communication in young children be seen as an ongoing process. [D1]
  1. It is recommended that as a routine part of developmental surveillance a child's communication development be monitored at 6, 9, 12, 18, 24, and 36 months. [D1]

Components of developmental surveillance of communication

  1. It is recommended that developmental surveillance for communication include (see Tables III-1 through III-5):
  • looking for risk factors of communication disorders
  • identifying clinical clues of possible communication disorders (based on normal language milestones)
  • listening to parent concerns about their child's communication development
  • utilizing age-appropriate formal screening tests for communication disorders [D1]

Assessing communication development compared to normal language milestones

  1. It is important for professionals and parents to be aware of the typical stages of language development and normal language milestones (see Table III-5). [D1]
  1. An important part of developmental surveillance for all young children is to assess the child's language development compared with normal language milestones. [D1]
  1. When comparing a child's communication development to normal language milestones, it is important to recognize:
  • there is some variation in the timing at which typically developing children achieve specific language milestones
  • when the child has not achieved a particular milestone by a certain age, this is considered a clinical clue of a possible communication disorder
  • if the child has not achieved all age-appropriate normal language milestones, this is not by itself diagnostic of a communication disorder, but is only an indication that further screening or assessment may be needed [D1]
  1. If a child was born prematurely and is under the age of 24 months, it is important to evaluate the child's development based on child's age corrected for the prematurity.

Screening for communication disorders

  1. It is recommended that formal screening for communication disorders use age-appropriate standardized questionnaires or screening tests that can be quickly and easily administered and interpreted by primary health care providers and other professionals. [D1]

Developmental surveillance for hearing problems

  1. It is strongly recommended that all children receive an objective screening of hearing within the first 3 months of life, preferably in the neonatal period before discharge from the hospital. [D2]
  1. It is recommended that routine developmental surveillance for all young children include surveillance for hearing problems. [D2]
  1. It is recommended that screening for possible hearing problems be done for infants and young children who have:
  • known risk factors for hearing loss (see Table III-2)
  • clinical clues for communication disorders (see Table III-5)
  • parent concerns about a communication disorder or hearing loss
  • abnormal findings on a speech/language screening test [D2]
  1. For children in whom there is an increased level of concern for hearing problems (such as children with frequent ear infections or children whose behavior suggests hearing problems), it is extremely important to do an objective assessment of the child's hearing status. [D2]

<When There Is An Increased Level Of Concern That A Child Has A Communication Disorder

  1. For children in whom there is an increased level of concern about a communication disorder, it is recommended that routine developmental surveillance be intensified to include enhanced developmental surveillance for communication (as defined below). [D2]

This part of the guideline presents recommendations for enhanced developmental surveillance of young children who have no other apparent developmental problems other than a concern about a possible communication disorder.

<Information needed to make informed decisionsProfessionals caring for the child, together with the parents, can make informed decisions about appropriate actions based on the following information:

  1. The child's current level of language development compared to normal language milestones
  1. Progress that has been made in language development since the prior visit
  1. The presence of any risk factors or indications of other developmental problems, including possible hearing problems
<Making decisions for action based on information from surveillance findingsUsing the information above, professionals and parents at each stage in the process can decide to take one or more of the following actions:

  1. Continue to monitor the child's progress and provide for age-appropriate activities and experiences to promote language development
  1. Arrange for an in-depth assessment of possible speech/language problems
  1. Arrange for assessment of hearing and other possible developmental problems

Based on the findings of the in-depth assessment, parents and professionals can make an informed decision about whether or not to initiate additional interventions, such as formal speech/ language therapy.


ENHANCED SURVEILLANCE

Evidence Ratings : [A] = Strong [B] = Moderate [C] = Limited [D1] = Opinion/Studies do not meet criteria [D2] = Literature not reviewed

WHEN A COMMUNICATION PROBLEM IS SUSPECTED

Assessment at the time of the initial visit

  1. When a professional initially suspects a child may have a problem with communication development, it is important to determine if the child also has evidence of:
  • a severe speech/language delay
  • a hearing problem
  • other developmental problems [D2]
  1. It is recommended that a child be considered as having a severe speech/language delay when the child has:
  • at 18 months, no single words
  • at 24 months, a vocabulary of less than 30 words
  • at 36 months, no two-word combinations [B]
  1. If a child has evidence of a severe speech/language delay, it is recommended that the child receive an appropriate in-depth assessment of communication, including an audiological assessment. [D1]
  1. It is recommended that children with a possible severe speech/ language delay receive a comprehensive health examination with a focus on looking for medical conditions that might be causing or contributing to the delay. [D1]

Initiating enhanced surveillance for communication

  1. When there is heightened concern about a child's communication development in a child who does not have a severe speech/language delay or other apparent developmental problems, it is recommended that the professional and parents together undertake a period of enhanced surveillance of the child's communication. [D1]
  1. In implementing an enhanced program of surveillance for communication development, it is recommended that professionals:
  • educate parents about normal language development and language disorders
  • teach parents to use appropriate checklists to monitor communication development
  • teach parents methods to facilitate the child's language development
  • establish an appointment for a follow-up visit [D1]
  1. Once a program of enhanced surveillance has begun, it is recommended that the child be seen for re-evaluation by the professional in 3 months (or sooner, depending on the degree/severity of the disorder and the age of the child). [D1]

Involving the parent in surveillance and language stimulation

  1. It is recommended that parents be provided with information about:
  • expected language milestones and indications for concern (see Table III-5)
  • ways to monitor their child's language development
  • adult behaviors and environments that facilitate language development (such as focused stimulation) [D1]
  1. As part of enhanced surveillance, it is recommended that parents begin systematic monitoring of the child's language through the use of a developmental checklist or questionnaire designed for use by parents, such as:
  • Ages and Stages Questionnaire
  • CDI - Words and Gestures Checklist [D1]
  1. It is important to recognize that some parents may need help in monitoring their child's language and that some may need the information conveyed in a different way. [D1]

General considerations at the time of follow-up

  1. After an appropriate period of enhanced surveillance of the child's communication development, it is recommended that the parents meet with the professional to assess the child's progress. [D1]
  1. At the time of the follow-up visit, it is recommended that decisions about further actions be based on the child's progress in communication development during the surveillance period. Decisions about next steps depend on whether the child's level of communication has: [D1]
  • caught up to the age-appropriate normal language milestones
  • has improved but has not caught up to age-appropriate normal language milestones
  • remains the same as at the initial or previous visit
  • has regressed since the initial or previous visit

Recommended next steps at the time of follow-up

  1. <If the child's level of communication has caught up to age-appropriate normal language milestones:
  1. It is recommended that the child receive no further specific assessment but continue enhanced developmental surveillance for communication and return for re-evaluation in no more than 3 months. [D1]
  1. <If the child's level of communication has improved but not caught up to normal language milestones:
  1. It is appropriate to consider more specific screening or assessment for the possibility of a communication disorder (including hearing loss) if the child has not caught up to language milestones over a 3 to 6 month period of active surveillance, especially if the child has had repeated, consistent exposure to a language-rich environment. [D1]
  1. It may be useful to advise the parents to increase the opportunities for peer interactions. Exposure to children with normal language development might be provided through any of a number of environments, such as library story groups, daycare, or playgroups. [D1]
  1. It is important to recognize that it is often difficult to determine if a communication disorder exists in young children, particularly in children less than 24 months of age. Some children, in the absence of any other developmental concerns, may eventually achieve more typical language performance and thus may outgrow their communication delay. [D1]
  1. If there continues to be no indication of other developmental problems, it is important to continue enhanced surveillance with an emphasis on:
  • encouraging parents to continue monitoring the child's language development
  • intensifying parent education
  • encouraging parents to provide increased exposure to peers with normal language development
  • informing the parents that it is still too early to determine if the child will have language problems in the future, or if the child will eventually catch up to the normal language milestones
  • establishing a hearing history and ruling out hearing loss [D1]
  1. It is recommended that, in the absence of any other developmental concerns, enhanced surveillance be continued and the child return for a follow-up visit in another 3 months. [D1]
  1. <If the child's level of communication remains the same as at the initial visit:
  1. A hearing assessment (comprehensive audiologic evaluation) is very important if it has not yet been done. [D2]
  1. An in-depth evaluation for a possible speech/language problem is recommended for children with no other apparent developmental disorder whose language has not progressed after 3 months of language surveillance and stimulation. [D1]
  1. It is important for the professional to look carefully for risk factors or findings suggesting other developmental problems in addition to the possible speech/language problems. [D2]
  1. Referral to an audiologist, developmental pediatrician, or other specialists may be appropriate. [D2]
  1. <If the child's level of communication has regressed since the initial visit
  1. If a child under 3 years regresses in communication abilities or other developmental skills, it is recommended that the child receive an in-depth medical assessment, which may include evaluation by a developmental pediatrician or pediatric neurologist. [D2]
  1. It is recommended that an in-depth assessment of communication be done by a speech language pathologist. [D2]
  1. A hearing assessment (comprehensive audiologic evaluation) is very important if it has not yet been done. [D2]



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Revised: June 2002