Assessing for other developmental problems

Many young children who are initially identified as having a possible speech/language problem will eventually be shown to have other developmental problems in addition to the communication disorder (Guralnick, 1998). Many of these children, however, retain a primary diagnosis of communication disorder for a long time and primary intervention often continues to be speech/language therapy either because their other problems go undiagnosed or because other areas of development are less delayed than communication. As such, consideration of other possible developmental problems is an important component of evaluating children with possible communication problems.

Possible associated developmental problems include, but are not limited to: cognitive or other neurological impairments, motor problems, behavioral or emotional disorders, hearing problems, oral-motor deficits, feeding disorders, or health problems. Behaviors that may signal problems in addition to communication disorders include: an unexplained lack of progress in therapy, problems with social awareness and relationships, lack of age appropriate concepts, and poor motor coordination.

Assessing for hearing problems

For children with suspected speech or language disorders, evaluation of hearing status is an especially important part of the screening and assessment process. This part of the guideline provides general recommendations about an appropriate assessment of hearing for children with risk factors for hearing problems or for children whose hearing screening results are abnormal.

Hearing loss is a reduction in threshold sensitivity experienced by the child reducing some or all of the child's ability to hear speech and other sounds within the environment. Hearing loss may be due to one or more conditions that impede the normal reception of sound energy by the sense organ (inner ear or cochlea) of hearing. Hearing loss in children can result in speech and language delay, difficulties in parent-child and peer-child interactions, academic achievement, and low self-esteem. Evidence exists that the earlier a hearing loss is detected and addressed, the better the outcome (Carney and Moeller, 1998).

Hearing loss can be permanent or temporary. Hearing disorders can affect the inner ear or cochlea (sensory loss), the auditory nerve (neural loss), or the middle ear and/or outer ear (conductive loss). Conductive hearing loss can co-occur with sensory hearing loss; this is termed a 'mixed' hearing loss. The amount or degree of hearing loss may range from mild (25-40 decibels or dB), moderate (45-65 dB), severe (70-90 dB) to profound (greater than 90 dB) impairment. Configuration or shape of the hearing loss may be flat (affecting all pitches or frequencies of the speech range equally), sloping (affecting high frequencies more than low frequencies), or rising (low frequencies having poorer thresholds than high frequencies).

Permanent Congenital Hearing Loss

Permanent congenital hearing loss (PCHL) in infants and young children may be either the result of familial (genetic) factors or the result of a prenatal condition. PCHL is usually sensory; however, PCHL may also be conductive (as in cases for partial or complete closure of the outer ear canal or deformities of the middle ear); more rarely it is neural in type. Hearing loss may also be acquired at or shortly after birth. Hearing loss can occur in one or both ears.

The prevalence of bilateral severe to profound sensory hearing loss in childhood is estimated to be about 1/1000. Prevalence estimates are variable (< 1/1000 to 6/1000) depending upon definition (criterion decibel level of hearing loss and whether both bilateral and unilateral hearing losses are included). Prevalence of hearing loss is significantly higher in infants cared for in the neonatal intensive care unit (NICU), estimated at 2-3/100 (JCIH, 1994; NIH, 1993).

When hearing loss occurs at birth or within the first few months of life (prelingual onset) the impact on communication development is usually significant because it occurs during the time considered critical for language learning. Even a mild hearing loss can delay speech and language development in the young child.

Children with developmental delays are at greater risk for hearing loss than children who are developing typically. The majority of children with PCHL have multiple problems. Therefore, the existence of developmental delays (autism, cognitive delays, and general developmental problems) is a risk indicator (red flag) for hearing loss.

Otitis media with effusion

Otitis media with effusion (OME) is a common condition of early childhood, particularly prevalent during the first three years of life (AHCPR, 1994). OME usually occurs after an episode of acute otitis media (an ear infection) has resolved. OME is characterized by the presence of fluid within the middle ear that results in some degree (mild to moderate) of temporary, conductive hearing loss. Usually no other signs or symptoms accompany the disorder. Children with sensory hearing loss may also have OME resulting in a mixed hearing impairment. OME is treated medically and surgically in some cases (AHCPR, 1994). Persistent bilateral OME with accompanying hearing loss for a period of three months is considered a 'red flag' for communication development (JCIH, 1994).

Assessing for oral-motor and feeding problems

Although developing recommendations for children with oral-motor and feeding problems is outside the primary scope of this guideline, some general recommendations are included in this section because children who have these problems often also have or are at risk to develop a speech or language problem. These recommendations present a general approach for identifying and assessing oral-motor and feeding problems.

Assessing the need for augmentative communication

Effective communication is essential for a child's social and cognitive development. Children who are unable to communicate effectively with parents and peers may experience high levels of frustration that can influence the child's behavior, self-esteem, and the ability to learn. Augmentative communication involves using various methods and/or equipment to assist in the child's communication.

Augmentative communication systems may include sign language, picture boards, electronic voice output devices, and computers. An augmentative communication system may be a composite of communication strategies that may include communication devices, manual signs, and other communication techniques such as gestures, facial expressions, and non-speech vocalization.

General Developmental Assessment

Recommendations

Important elements of the general developmental assessment

1. When evaluating young children for possible communication disorders, it is strongly recommended that measures of general cognitive and social functioning and emotional interaction be integral components of the assessment. [D2]

2. It is important to be aware that the three general conditions most likely to present themselves as a speech/language problem are:

• hearing impairment
• autism spectrum disorders
• general cognitive impairment (developmental delay/ mental retardation) [D2]

Evaluating cognitive function

3. It is very important to assess cognition in young children with suspected communication disorders. [D2]

4. It is important to recognize that cognition can be adequately evaluated in children under 3 years of age and often requires a variety of approaches. [D2]

5. It is important that assessment of cognition in young children include some type of performance-based (language free) measure, such as:

• the Bayley Scales of Infant Development (an assessment tool that allows language items to be separated from items related to cognition)

• play-based assessments [D2]

Assessing Young Children with Communication Disorders and Other Developmental Problems

Recommendations

Evaluating children with cognitive impairments

1. When evaluating young children for general cognitive impairment (general developmental delay), it is strongly recommended that communicative skills be a special and separate focus of the assessment. [D2]

2. It is important to recognize that:

• communication disorders are more common in young children who have other developmental problems or disorders.

• an infant or young child with both a communication disorder and another developmental disorder will present greater challenges for assessment and intervention planning. [D2]

3. It is important that a child's level of cognitive abilities be considered when assessing whether the child has a communication disorder. [D2]

Children with hearing, vision, or motor problems

4. It is recommended that the child's sensory capacities and modes of response be considered when selecting assessment materials and procedures:

• if a young child has significant limitations in hearing, vision, or motor abilities, adaptations of materials, setting, or testing/response procedures may be necessary if the assessment results are to accurately reflect the child's communication abilities.

• the input of parents and others who know the child well can be extremely important in determining the most appropriate materials, procedures, and adaptations to be used.

• it is important that adaptations of materials and procedures be based on the child's individual strengths and needs. [D2]

Assessing Hearing Problems in Young Children

Recommendations

Components of a comprehensive hearing assessment

1. When hearing loss is suspected in a young child, it is recommended that the type, degree, and configuration of a child's hearing loss be determined as soon as possible, as this influences intervention strategies. [D2]

2. It is recommended that a comprehensive assessment of hearing for infants and young children (from birth to 3 years old) include the following as components of an audiometric test battery (see Table III-6):

• hearing history
• behavioral audiometry testing (using an age/developmentally appropriate response procedure)
• electrophysiologic procedures [D2]

3. Physiologic tests that may require sedation (such as the auditory brainstem response: ABR) are recommended for children whose hearing assessment results are unreliable or inconsistent and their auditory status remains unknown. ABR is an appropriate test for children suspected of hearing loss who are too young (<5 months) for behavioral testing procedures. [D2]

Inappropriate methods for assessment of suspected hearing problems

4. Behavioral observation audiometry (an unconditioned response procedure) is not recommended for the assessment of hearing in infants and children. It is unreliable and has too many false positive thresholds and false negative findings. Examples include clapping hands or ringing a bell. [D2]

5. Determining a speech threshold alone is not a sufficient test of hearing. Sloping or rising configurations of hearing loss may be missed if only this measurement technique is used. [D2]

6. Parent report alone is an insufficient method of determining whether or not a hearing loss exists. Parent report is neither sensitive or specific for many types and degrees of hearing loss. [D2]

Table III-6

Components of a Comprehensive Hearing Assessment

• History of otitis media (ear infections and fluid within the middle ear)
• Auditory behaviors (reacting to and recognizing sounds)
• Parents' general concern about hearing and communication
• Risk factors for hearing loss (JCIH, 1994)

Behavioral audiometry testing

• Observation of general awareness of sound (for example, mother's voice, environmental sounds, music) used to determine a general level of auditory responsiveness or function. This is an unconditioned behavioral response procedure.

• Visual Reinforcement Audiometry (VRA) and Conditioned Orienting Response (COR) Audiometry. Used to determine threshold sensitivity in infants beginning at about 6 months of age (developmental age). A head turn response upon presentation of an audiometric test stimulus is rewarded by the illumination and activation of an attractive animated toy.

• Conditioned Play Audiometry (CPA). Used to determine threshold sensitivity in young children beginning at about 2 years of age (developmental age). A play response (block drop, ring stack) in response to the presentation of an audiometric test stimulus is rewarded by social praise.

Electrophysiologic procedures

Acoustic admittance measurements including:

• Tympanometry - assesses the mobility of the eardrum. A probe attached to a soft, plastic ear tip is placed at the ear canal opening and air pressure is varied in the ear canal.

• Acoustic reflexes - an involuntary middle ear muscle reflex to sounds is recorded, usually elicited by moderately loud tones or noises.

• Evoked otoacoustic emissions (EOAE) - assesses the function of the outer hair cells of the cochlea by recording a cochlear echo. A probe attached to a soft ear tip is placed at the ear canal opening. A microphone delivers clicks or tones. Another sensitive microphone within the ear tip records the cochlear echo. EOAEs are not recorded in ears with hearing loss greater than about 30 dB (mild hearing loss).

• Auditory Brainstem Response (ABR) or Brainstem Auditory Evoked Response (BAER) - used to estimate hearing threshold sensitivity using clicks or tones. These tests are also used to determine the integrity of the auditory pathway from the cochlea to the level of the brainstem. Small disc electrodes are pasted on the scalp and auditory potentials (electrical activity generated by the auditory nerve and brainstem) evoked by repetitive stimuli delivered by an earphone are recorded by a computer.

Assessing Oral-Motor and Feeding Problems In Young Children

Recommendations

1. It is useful to have a team of pediatric professionals involved in ongoing assessment of children for whom there are concerns about oral-motor function or feeding. Team members might include:

• speech language pathologist
• primary health care provider
• developmental pediatrician
• gastroenterologist
• otolaryngologist
• occupational therapist
• nutritionist
• psychologist [D2]

2. It is recommended that the professionals involved in the assessment of children with oral-motor and feeding concerns have knowledge of normal oral-motor and feeding development as well as experience and expertise in assessing children with such problems. [D2]

3. Commercially available clinical assessment tests may sometimes be useful in assessing oral-motor and feeding problems in infants and young children. Examples of such tests are:

• The Neonatal Oral-Motor Feeding Scale
• The Pre-speech Assessment Scale [D2]

4. It is recommended that the components of an initial oral-motor and feeding assessment include:

• physical examination and comprehensive history
• observation of interaction patterns
• body posture and positioning effects and needs
• oral-motor exam, including:

• presence/absence of oral reflexes
• structure and praxis of lips, tongue, palate
• oral sensation
• laryngeal function
• control of oral secretions
• respiratory control
• swallowing for nutrition
• oral postural control and voice
• observation of trial feeding
• indications for specialized studies (such as videofluoroscopy) [D2]

Assessing the Need for Augmentative Communication In Young Children

Recommendations

1. It is important to assess the need for an augmentative communication, especially when speech is not an effective mode of communication for the child. This may be particularly useful for:

• severe dysarthria/apraxia and oral-motor dysfunction
• neuromotor disorders such as in cerebral palsy
• autism
• severe neurodegenerative disorders
• children dependent on ventilators [D2]

2. It is recommended that parents be counseled that the use of an augmentative communication system does not preclude the development of spoken language and may even facilitate the development of speech. [D2]

3. It is important to consider that for some children, an augmentative communication system (including sign language) may be transitional or temporary. [D2]

4. It is important that in determining the specific type of augmentative communication systems, the professional assess and consider the child's:

• positioning needs
• fine motor/gross motor capabilities
• vision and hearing status
• level of cognitive skills/receptive language [D2]

5. In recommending the use of a specific augmentative communication system it is important that professionals consider:

• multicultural and multilingual issues related to the use of the system by the family and the child
• settings where the augmentative communication system will be used (such as, the home, child care settings, etc.)
• access method (pointing, switch use, etc)
• options for a trial session with various systems [D2]

6. It is recommended that an evaluation for an augmentative communication system be conducted by a multidisciplinary team that may include:

• speech language pathologist
• physical therapist
• occupational therapist
• audiologist [D2]

Using Results of the Assessment in Deciding Whether to Initiate Speech/Language Therapy

This section of the guideline describes a decision-making framework for deciding whether or not to initiate speech/ language therapy for children age 18-36 months depending on the nature of the speech/language problem and the developmental level of the child. In this process, professionals use information from both the in-depth speech/language assessment and the developmental assessment, including any special assessments for hearing or oral-motor problems.

In determining whether or not to initiate speech/language therapy, separate recommendations are given for children who have speech/language problems accompanied by other developmental problems (such as general developmental delay, hearing problems, or oral-motor problems) and for children with a speech/language problem alone.

General Approach for Considering the Initiation of Speech/Language Therapy

Recommendations

1. In making decisions about whether or not to initiate speech/language therapy, it is important that parents and professionals have all current information, including:

• in-depth speech/language assessment
• a developmental assessment that includes appropriate assessment of the child's cognitive status
• assessment of hearing
• assessment of oral-motor functioning, if problems are present
• assessment of general health status [D2]

2. After the findings of the in-depth speech/language assessment, developmental assessment, and any special assessments are available, it is important to use this information to make a preliminary decision regarding the need for speech/language therapy, based on:

• the degree of the child's speech/language delay
• the type of the child's speech/language disorder
• the child's cognitive status
• the presence of hearing, oral-motor, or any other significant problems that may affect the child's communication [D2]

Considering Speech/Language Therapy for Children Who Have Speech/Language Problems Associated with Other Developmental Problems

Recommendations

Children with speech/language problems and general developmental delays

1. For children with general developmental (cognitive) delays, who are found on in-depth assessment to have speech/language delays, it is important to initiate formal speech/language therapy when:

• the overall level of language delay significantly exceeds (is more severe than) the overall level of developmental delay

• there is a discrepancy between a child's language comprehension level and the expressive language level (even if the overall language level is commensurate with the child's overall developmental level)

• the child has a specific language impairment in either language comprehension, expressive language, or both [D2]

2. It may be beneficial to initiate speech/language therapy for children with developmental disorders associated with specific conditions in which speech and language problems are usually a major component (such as Down syndrome or autism). [D2]

3. It may not be necessary to initiate formal speech/language therapy for children with general developmental (cognitive) delays if the following three conditions are met:

• the child's comprehension and expressive language are both commensurate with the child's developmental level, and

• the child has no other specific speech/language impairments, and

• the cognitive delay is not associated with a specific condition in which language and communication problems are usually a major component (such as Down syndrome or autism) [D2]

4. For children who have language delays commensurate with their level of developmental delay and have no other specific speech/language disorders, it is recommended that:

• professionals and parents initiate activities to stimulate language development, including appropriate social interactions

• active developmental surveillance be ongoing, both for the child's communication problems and all other developmental problems [D2]

5. In deciding whether speech language therapy may benefit children who have language delays commensurate with their level of developmental delay and have no other specific speech/language disorders, it is important to consider the following questions:

• What is the level of confidence that the measured levels of cognitive and language ability are accurate (realizing that cognitive tests that rely on language ability may sometimes underestimate a child's cognitive level)?

• What activities and interventions might be the most effective ways for stimulating the child's general development?

6. It is important to recognize that the indications for speech/ language therapy in a child with general developmental delay may change over time as the child develops. [D2]

Children with speech/language problems associated with hearing loss

7. If a child is found to have a hearing problem, it is important that the child receive an appropriate audiological and/or medical intervention before considering speech/ language therapy. [D2]

8. It is recommended that speech/language therapy be initiated for children with speech/language problems determined to be the result of a temporary conductive hearing loss associated with otitis media with effusion. [D2]

[Note: The guideline panel chose not to make recommendations specific to children with permanent sensorineural hearing loss. While this is considered an important topic, it is outside the scope of this guideline.]

Children with speech/language problems associated with oral-motor problems

9. When a child's speech intelligibility is significantly reduced as a result of oral-motor deficits, it is recommended that speech/language therapy be initiated to address this concern. [D1]

Considering Speech/Language Therapy for Children with Speech/Language Problems and No Other Developmental Problems

Recommendations

1. When in-depth speech/language assessment finds that a child has a speech/language problem, but the developmental assessment indicates no general developmental delay or other developmental problems, then it may be useful to consider if the child has the following:

• a delay in expressive language but normal language comprehension, and no other specific language impairments

• a specific language impairment [D1]

Children with severe speech/language delays

2. For children at age 18-36 months who have had an in-depth assessment that indicates a severe delay and who have no other apparent developmental problems, it is recommended that formal speech/language therapy be initiated. A severe delay may be indicated by:

• at 18 months, no single words
• at 24 months, a vocabulary of fewer than 30 words
• at 36 months, no two-word combinations [B]

3. It is also recommended that children with a severe speech/language delay receive a comprehensive health assessment to look for medical conditions that might be causing or contributing to the delays. [D2]

Children with milder expressive delays only

4. When deciding to initiate speech/language therapy for children age 18 to 36 months who have a delay in expressive language only and no other apparent developmental problems (normal language comprehension, no hearing loss, and typically developing in all other ways), it is important to:

• assess if the child has a higher or lower likelihood of continuing to exhibit a language delay
• recognize that predicting whether a child has a higher or lower likelihood of continuing to have a language delay requires experienced clinical judgment [D1]

5. In assessing the likelihood that a child with a current mild delay in expressive language will continue to have ongoing language problems or will catch up with typically developing peers, it may be useful for the speech language pathologist to consider the extent to which the child exhibits the factors predicting continued language delay as shown in Table III-7 . [D1]

6. For children with a current delay who exhibit more of the prognostic factors in Table III-7, it is recommended that:

• formal speech/language therapy be tried

• ongoing monitoring of the child's progress and activities to promote language development (described in the part on Enhanced Developmental Surveillance) be continued

• children receive periodic in-depth assessment of their communication level and progress (whether or not speech/language therapy is initiated) [D1]

7. For children with current delay who exhibit fewer of the prognostic factors listed in Table III-7, it is recommended that:

• formal speech/language therapy not be initiated at this time

• activities to promote language development be continued, along with the parents' ongoing monitoring of the child's progress

• the child be reevaluated by the speech language pathologist in no more than 3 months to assess progress in communication development

• the child's need for speech/language therapy be reconsidered at the time of re-evaluation depending on the child's progress [D1]

Research needs

8. It is important for research to be done to further validate the specific indicators that differentiate those children who will "outgrow" expressive language delays from those children who will continue to experience delays. [D2]

Predictors of Continued Language Delay in Children with Language Delays at 18-36 Months

Table III-7 lists factors that predict which children found to have language delay at 18-36 months will continue to have language delay in the future. The more of these predictors that a child exhibits, the more serious the concern that the child will continue to have language problems and the greater the need for speech/ language therapy.

Some of the predictors may not apply to children 18-24 months if typically developing children would not be expected to exhibit the communicative behaviors. For more information, see Table III-5, Normal Language Milestones and Clinical Clues for Possible Communication Problems in Children from Birth to 3 Years Old.

Table III-7

Predictors of Continued Language Delay in Children with Language Delays at 18-36 Months

Speech

• Particularly small vocabulary for age
• Less diverse vocabulary particularly in regard to verbs
• Preponderance of general all-purpose verbs (such as "do," "make," "want," "go")
• More transitive and fewer intransitive verbs (such as "give ball")

Language Comprehension

• Presence of 6 month comprehension delay
• Large comprehension-production gap with comprehension deficit

Phonology

• Few prelinguistic vocalizations
• Limited number of consonants
• Limited variety in babbling structure
• Fewer than 50% consonants correct (substitution of glottal consonants and back sounds for front)
• Restricted syllable structure
• Vowel errors

Imitation

• Few spontaneous imitations
• Reliance on direct model and prompting in imitation tasks of emerging language forms

Adapted from: Olswang L, et al., (1998).

Non-speech

• Primarily manipulating and grouping
• Little combinatorial and/or symbolic play

Gestures

• Few communicative gestures, symbolic gestural sequences, or supplementary gestures

Social Skills

• Behavior problems
• Few conversational initiations; interactions with adults more than peers
• Difficulty gaining access to activities

Health and Family History

• Recurrent Otitis Media
• Family history of persistent problems in language learning

Issues for Consideration

One area of current discussion among experts in the field is the extent to which formal speech/language therapy is necessary for young children age 18 to 36 months who have a language delay but no other developmental problems.

An important consideration is that there is a certain degree of variation in the timing of language development in typically developing children in this age range. Some experts maintain that children with milder language delays may catch up with typically developing peers by 48 months of age, especially if efforts are made to facilitate language development, such as increasing social interactions and involvement in play groups. However, experts also suggest that beginning speech language therapy by 24 months is important for those children who have more severe delays and those who appear at increased risk for continued delays.

The recommendations above provide a practical approach to this issue. These recommendations are based on evidence in the scientific literature on the natural history of language development for children under 3 years old and on panel consensus opinion.

Several studies suggest that many children who have an expressive language delay at 24 months (but have some words and no other apparent developmental problems) will gradually catch up to a functional language level that is more typical of their peers. (Fischel, et al., 1989; Paul, 1991; Paul and Alforde, 1993; Rescorla and Schwarz, 1990; Thal, et al., 1994)

In a recent review of the scientific research literature on young children with language delays, Olswang, et al. (1998) identified several factors noted in these studies that appeared to predict which children with language delays at 18 to 24 months would still have delays at 36 to 48 months old. These predictors of future language delay are listed in Table III-7.

Based on this evidence, Olswang (1998) has suggested using these predictors to determine which language-delayed 24 month olds are likely to attain normal language development on their own, and which children are likely to have ongoing language problems and would benefit from speech/ language intervention. It is the opinion of the guideline panel that these predictors for continued delay would probably also apply to most children from 18-36 months and adapted Table III-7 to apply to this age group.

The panel made some additional specific recommendations for children with more severe language delay, based on evidence from several studies. One of these studies (Rescorla and Schwartz, 1990) found that children at 24 months who had a vocabulary of fewer than 30 words continued to have problems in the future. In contrast, in the group of children with milder delays (such as a 30-50 word vocabulary, or over 30 words but no word combinations), some continued to have problems, but a large percentage also caught up with typically developing peers at 4 to 5 years of age.

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