Decision Making in Assessment and Early Intervention Planning

Language, Speech, and Hearing Services in Schools, Volume 22, 19-30, April 1991

Decision Making in Assessment and Early InterventionPlanning

Elizabeth R. CraisJoanne E. Roberts

University of North Carolina-Chapel Hill

This article presents a series of decision trees to help inplanning assessment and intervention with handicapped chil-dren between 3 months and 5 years of age. The decision treesconsist of a series of assessment questions leading to suggestionsfor intervention. Steps in using the decision trees are describedand a case example presented.

KEY WORDS: screening, decision-making, communication as-sessment, preschool assessment, preschool intervention

For many speech-language pathologists (SLPs) work-ing in the schools, the recent mandates of P.L. 99-457(1986) will expand the populations of children who willreceive speech and language services. The new legisla-tion proposes services for handicapped and at-risk 3- to5-year-old children and provides incentives for states tobegin providing services for handicapped and at-riskbirth to 3-year-olds and their families. The purpose of thisarticle is to present a series of decision trees to help inassessment and intervention planning with young hand-icapped children. First, a rationale for use of the decisiontrees is presented, followed by the decision trees them-selves and their description. Finally, a case example ispresented to illustrate the use of the decision trees inassessment and intervention planning.

Rationale

When speech-language pathologists (SLP) assessyoung children, three issues are immediately encoun-tered. First, a limited number of standardized instru-ments for the birth to 5-year-old population are available,with even fewer measures available for the birth to3-year-old range. Second, the instruments that do existare narrow in scope and often omit important assessmentareas. In a survey by Crais and Leonard (1990) of graduatetraining programs, of the tests used "routinely" to assessthe birth to three population, few include items that deal

with early social routines or communicative intentions. Athird issue facing SLPs is the difficulty in relating theresults of standardized testing to specific interventiongoals. For example, a receptive or expressive age scoremay provide an estimate of the child's developmentallevel, but may have limited utility in selecting specificgoals for intervention. Indeed, a number of clinicians andresearchers (Leonard, Prutting, Perozzi, & Berkley, 1978;Miller, 1981; Muma, 1978) argue against the sole use ofstandardized testing and encourage a combined use ofstandardized and nonstandardized (i.e., informal observa-tion) assessment measures.

As an alternative or addition to standardized testing,this article proposes a set of decision trees developed forplanning assessment and intervention with very youngchildren. Decision trees by design include a sequencedset of questions followed by available response choices.The decision trees presented here can be used to orga-nize the types of questions to be asked and to help theSLP make decisions about the need for further assess-ment. The decision trees focus on handicapped andat-risk children functioning developmentally betweenthe ages of 3 months and 3 years, recognizing that many ofthe children seen for early intervention are chronologi-cally older yet developmentally within this range.Clearly, for some children, particularly those with severeor multiple handicapping conditions or those who aremedically fragile, the assessment and intervention activ-ities may need to be modified. The SLP, in conjunctionwith other care providers, can determine each child'scapabilities and limitations, and can carefully apply thatknowledge to the use of the decision trees. Furthermore,use of the decision trees presumes some background andfamiliarity with such areas as prespeech and language,play, social routines, gestures, intentions, and parent-child interaction. For the SLP needing additional infor-mation in these areas, the following sources can be useful(Carlson & Bricker, 1982; Chapman, 1981; Dunst, 1981;Dunst & Wortman-Lowe, 1986; Golinkoff, 1983; Roth &Spekman, 1984; Seibert & Hogan, 1982).

© 1991, American Speech-Language-Hearing Association 19 0161-1461/91/2202-0019$01.00/0

20 Language, Speech, and Hearing Services in Schools

THE DECISION TREES

Decision trees are provided for children functioning atthe prelinguistic (Figure 1), one word (Figure 2), andmultiword (Figure 3) stages. The trees include sets ofquestions to assess a child's current level of communica-tion functioning and activities to guide intervention plan-ning. Each decision tree is divided into three majordomains: Social Interaction, Comprehension, and Pro-duction. Production has been further divided into twosubdomains: (a) Spontaneous and (b) Imitative Produc-tion. Although each domain is presented as discrete, anyone behavior within a domain typically incorporatesaspects of the other domains.

The questions in the decision trees were drawn fromseveral published sources (Brown, 1973; Miller, 1981;Retherford, Schwartz, & Chapman, 1981; Seibert &Hogan, 1982; Snyder-McLean, Sack, & Solomonson,1985) as well as our own clinical experiences. The indi-vidual assessment questions and intervention activitiesare listed in a developmental sequence from early devel-oping to later developing. Because some behaviors de-velop simultaneously, however, the sequence should notbe viewed as invariant. The assessment questions serveas a basic framework and are not presented as an absoluteprogression of each child's communication skills. Asnoted by Yoder and Kent (1988), decision trees should beused as "guidelines" and "prompts" for assessment andmanagement rather than as definite programs for clinicalintervention.

Most of the behaviors addressed in the decision treequestions can be elicited through interaction with thechild and from parent or caregiver interviews. For prelin-guistic children, the focus is on early developing socialand interactive aspects of communication. If a child usesonly gestural and vocal behaviors, we believe the focus inassessment should primarily be on determining whetherthese behaviors represent functional communication. Forverbal children, the focus remains on the functional andinteractive aspects of communication; thus, assessment ofsemantics and pragmatics rather than phonology or syntaxare highlighted.

Steps in Using the Decision Trees

Selecting the stage to begin. Initially, the clinician canuse information from a completed case history form,parent interview, and other referral information to estab-lish which of the decision trees appears most suitable.The SLP should then become familiar with items fromeach domain on the decision tree, perhaps highlighting indifferent colors items to be looked at with a particularchild.

Preparing for the assessment. The SLP could then setup an interactive play setting with the child to observeand elicit a range of communicative behaviors (e.g., typesof initiations, modes of communication, intentions dis-played). By structuring situations to elicit the communi-

cative behaviors addressed in the assessment questions,the SLP can record the behaviors that are readily used bythe child and look for those that are emerging. The parentor teacher may also be asked to describe: (a) whatcommunicative behaviors the child uses, does not use, oris learning to express (i.e., requests for objects or atten-tion); (b) how those behaviors are typically expressed:nonverbally (i.e., gesture, body movement, and facialexpression), vocally (i.e., speech sounds or nonspeechsounds), or verbally (i.e., speech or signing); and (c) inwhat situations they are usually exhibited.

Recording the information. The clinician can use aplus (+) for questions with positive responses, a minus(-) for those failed, and a plus/minus (+/-) for questionswhich result in inconsistent or questionable responses.Throughout the interactions, the clinician can place thesemarks directly on the decision trees next to each itemadministered or observed. In addition, the SLP can addexamples of behaviors and other brief notes about thechild's communicative efforts.

In using the decision trees, it is also important toremember that opportunity plays a part in the skills thatare exhibited by a child, both in terms of the opportuni-ties previously provided and those available in the imme-diate environment. For example, the type as well as thefrequency of interactions that are initiated, responded to,and encouraged by parents or teachers often shape thekinds of behaviors the child displays. Talking with theparent(s) or teacher(s) and also observing them interact-ing with the child will help clarify the communicativeinteraction opportunities routinely available to the child.In addition, if a child did not exhibit a target behaviorduring the assessment, this does not mean that the childcannot perform the behavior. Providing the context forthe child to act does not always mean the child will act.Therefore, both previously and currently provided oppor-tunities must be considered.

Moving through the assessment. The next step in usingthe trees is for the SLP to select one domain and movevertically through the list of questions, stopping wherethe child either does not demonstrate a few consecutivebehaviors or does so only in a limited or inconsistentmanner. Once the child's current level of functioning isestablished within one domain on the decision tree, theSLP should then move through the other two domains.Although the three decision trees are presented sepa-rately, within any one domain, the SLP may need to moveback and forth among the trees to explore a child's fullrange of communication skills.

Seeking additional information. At any point in theprocess, the items within a domain that were failed or thatwere inconsistent or questionable (+/-) can be readmin-istered. Further analysis in any of the domains can also beinitiated by using developmental scales or informal pro-cedures to identify additional behaviors between theachieved and unachieved questions. Some useful instru-ments are: Communicative Intention Inventory (Coggins& Carpenter, 1981), Hawaii Early Learning Profile (Fu-runo, O'Reilly, Hosaka, Inatsuka, Allman, & Zeisloft,1979), Parsons Preschool Curriculum (Snyder-McLean,

22 19-30 April 1991

CRAIS & ROBERTS: Decision Making 21

Sack, & Solomonson, 1985) and Communication andSymbolic Behavior Scales (Wetherby & Prizant 1990). Inaddition, information about the developmental levels ofother domains (e.g., motor play, cognition) is important.The SLP can turn to standardized instruments or devel-opmental scales such as the Batelle Developmental In-ventory, (Newborg, Stock, Wnek, Guidubaldi, & Svinicki,1984) to assess motor skills; the Symbolic Play Scale(Westby, 1980) and Assessing Prelinguistic and EarlyLinguistic Behaviors (Olswang, Stoel-Gammon, Coggins,& Carpenter, 1987) to assess play and cognitive skills; andMiller, Chapman, Branston, & Reichle's (1980) article toassess sensorimotor cognitive skills.

Selecting goals and activities for intervention. As thefirst step in planning intervention for a child, the cliniciancan examine the questions on the decision trees for thebehaviors that were and were not displayed. Using thesuggested activities in Figures 1-3 as guidelines, specificgoals for the child can then be developed. In planning anintervention program, the SLP can begin by focusing onthe highest level question in each domain that the childdid achieve in order to expand upon the child's availableskills and to build in an upward and outward fashion fromwhere the child currently functions.

When developing individual goals from the decisiontrees, the clinician should ask the following questions: (a)Is this goal important to the child's development?, (b)Will it improve communication in a substantial manner?,and finally, (c) Why should this particular goal be selectedfor intervention? As long as the three answers representactivities performed or needed in the child's daily life,then those activities should be implemented for a partic-ular goal. However, when the answers to the questionsinclude a "no" or an "I'm not sure," then the clinicianmust rethink the need for, and ultimate selection of, thosegoals.

Case Example for Using the Decision Trees

To illustrate the use of the decision trees for assessmentand intervention, a case study of an 18-month-old child,Ellen, will be described. On the case history form, El-len's parents noted that she makes "lots of sounds" butdoes not use "real" words yet and that she clearly ex-presses some desires (e.g., not wanting to go to bed).Through use of the prelinguistic decision tree (Figure 1),Ellen's communicative behaviors were observed andelicited during two activities, playing with toys andeating a snack. Initially, Ellen and the clinician played onthe floor with a ring stacking toy, blocks, baby doll,blanket, baby bottle, stacking cups, windup toy, andteddy bear. The clinician later brought out juice, cups,and graham crackers, served herself juice, and watchedfor Ellen to request juice or crackers and to gain theclinician's attention. The following is an overview of theresults of the interactions. For each of the assessmentquestions on the prelinguistic decision tree, Ellen's score(+, -, or +/-) and examples of her behavior during theactivities are provided in Table 1.

Social Interaction. Ellen was successful in eliciting in-teractions and responding to an adult in play routines. Sheexpressed herself nonverbally using grabbing and pointingto request juice, exhibited a frown when her mother tookaway her doll, and showed and gave objects. She did not,however, express any intentions using verbal means.

Comprehension. Ellen looked at objects mentionedand responded appropriately to one common routinewhen contextual cues were present (i.e., she lay down fordiaper changing when her mother felt her diaper andsaid, "let's change your diaper"). However, when hermother did not give her the physical cue of touching herdiaper, she did not react to the phrase "let's change yourdiaper."

Spontaneous production. Ellen's vocalizations con-sisted of consonants and syllable repetitions, however;her use of vocalizations was limited (i.e., no repetition ofvaried syllables, rising intonation, or jargon).

Imitative production. Although Ellen imitated somemotor and oral-motor actions and nonspeech sounds, shedid not imitate any speech sounds or word approximations.

Planning Goals and Objectives

To demonstrate the use of the decision trees in plan-ning an intervention program, Table 2 lists several goalsand objectives for Ellen. For each domain, one to twogoals are described below.

Social interaction. Because Ellen was able to bothinitiate and respond during play interactions, the firstgoal consisted of expanding Ellen's existing interactionswhile shaping and developing new routines. Startingwith actions that are already within Ellen's repertoire(e.g., she requests toys by holding out her hand), theclinician can add new components from other routines(e.g., prompting Ellen to reach out for the peek-a-booblanket), and then move to new actions (e.g., taking andgiving back the blanket). The purpose of these activitiesis to further Ellen's ability to participate in longer andmore varied routines. The second goal, to increase thevocal expressions of communicative intentions, may beachieved within many of the same activities described forthe first goal. See Dunst (1981), Fey (1986), and Hart andRisley (1978) for other suggestions on developing infants'and young children's early social routines.

Comprehension. Because the assessment questions in-dicated that Ellen could recognize labels of several ob-jects, Ellen's comprehension vocabulary should be ex-panded while developing her ability to indicaterecognition consistently through choosing a named objector acting on it in a specified way. The clinician can playhiding and finding games with common objects whilelabeling them (i.e., "Where's the X?"). It is helpful to usehighly motivating activities such as water play where thechild chooses a toy while the clinician labels it. Later, theactivity can include the clinician requesting specific toysand the child responding to her request. Because Ellen'scomprehension skills are at a slightly higher level thanher production, the second goal focuses on increasing


TABLE 1. Summary of assessment results using the prelinguistic decision tree to assess play andsnack interactions with Ellen.

Prelinguistic Decision TreeAssessment

Domain Number Score Example Behaviors Observed

Social Interaction

Comprehension

SpontaneousProduction

ImitativeProduction

#1 + Elicited attention by vocalizing to request bottle.#2 + Responded by vocalizing "ah ah" when clinician

held out bottle.#3 + Elicited attention by vocalizing & waving block

while handing block to clinician.#4 + Held up block to show Mom.#5 + Gave block to clinician.#6 + Participated in play routine by gesturing to

clinician to put block in box.#7 + Continued play activity by holding up shirt in

"tickle" game.#8 + Displayed variety of nonverbal intentions: grabbed

and pointed at juice indicating request, frowned toprotest Mom taking doll.

#9 - Did not exhibit verbally any intentions.#1 + Reacted to voice by turning head.#2 + Looked at blocks pointed to by clinician.#3 + Acted on block by picking it up when pointed to

by clinician.#4 + Acted on bottle by picking it up when Mom said

"bottle."#5 + Layed down when Mom touched diaper and said,

"Let's change your diaper".#6 + Hugged doll when clinician said, "hug dolly."#7 - Did not look for absent doll when clinician said,

"Where's dolly?".#8 - Did not respond when Mom said from a distance,

"Let's change your diaper."#1 + Vocalizes frequently.

#2#3#4#5#6#7#8

#9#10#1

#2

#3

#4#5#6#7

+ Produced /m/, /b/, /g/.+ Produced "bababa."

No alternating syllables heard.+ Refused graham crackers by saing "unh unh."- Did not use vocalization with rising intonation.- Did not use jargon vocalizations.+ Did use same vocalization "ag" repeatedly to

indicate juice.+ Pointed when vocalizing "ah."- Did not use word approximations.+ Imitated clinician's motor actions by holding up

blanket in "peek-a-boo."+ Imitated clinician's oral motor actions by smaking

lips when eating cracker.+ Imitated nonspeech sounds by coughing after

clinician.- Did not imitate speech sounds.- Did not imitate sounds with motor actions.- Did not imitate word approximations.- Did not imitate any one-syllable words.

comprehension of semantic relations between words(e.g., action + object, "eat cookie," or agent + action,"baby sleep"). The clinician can model for Ellen themotor actions and verbal labels for varied semantic rela-tions, beginning with the same action and different ob-jects (i.e., kiss baby, kiss horse) or the same agent anddiffering actions (i.e., baby eat, baby sleep).

Spontaneous production. Because Ellen only uses lim-ited vocalizations, her vocalizations should be expandedto increase the number of semantic relation categories

expressed. The clinician can begin by using Ellen'sexisting repertoire of vocalizations and model them com-bined with some of Ellen's nonverbally expressed seman-tic relations (e.g., using "ah ah" to indicate recurrence).Later, these vocalizations can be shaped to approximatenames for common objects in which Ellen expressesinterest. At this time, syntax and phonology were seen assecondary goals and only targeted through work on goalsin other domains (e.g., semantics and pragmatics).

Imitative production. Imitating Ellen's motor actions

22 19-30 April 1991


TABLE 2. Goals and objectives for intervention with Ellen.

I. SOCIAL INTERACTION1. Increase number, length, and diversity of social interactions.

a. Increase number of interactive games (e.g., "this little piggie," bounce on knee for "horsie").b. Increase number of games incorporating recurrence (e.g., child bounces for "more"; holds up blanket for more actions).c. Increase use of vocalizations in games, choose same word or syllable to express the game (e.g., "boo" for peek-a-boo).

2. Increase frequency, diversity, and use of vocalizations and word approximations to express communicative intentions.a. Increase number of nonverbal intentions expressed (e.g., commenting by pointing to unusual happenings).b. Expand existing vocalizations to other intentions (e.g., requests to protests).c. Expand requests to new objects and agents (e.g., first within comprehension vocabulary, later to newly introduced items).d. Expand requests to different actions (e.g., go, up, bounce on knee).e. Expand protests to combine vocalization + gesture (e.g., "unh unh" and pulling away, when someone pulls toy).f. Expand vocalizations of intentions to include use of approximations modeled by clinician (e.g., "oh" for "no").

II. COMPREHENSION1. Expand comprehension vocabulary.

a. Increase identification of objects, actions, agents. Play games with objects in a bag or box, take out and label them.b. Increase comprehension of common actions on objects (e.g., eat, drink, go, sleep, with child as agent).

2. Increase comprehension of semantic relations.a. Increase recognition of different action + object combinations (e.g., eat cookie, eat apple).b. Increase type of recognition responses (e.g., eye gaze, pick up, imitate action) for familiar agents, objects, and actions, and

their combinations).III. PRODUCTION

1. Spontaneous: Expand vocalizations and word approximations.a. Increase use of word approximations for common objects and agents (e.g., "bo" for boat).b. Increase use of semantic relations by modeling (e.g., rejection, "unh unh mi" for "no milk").

2. Imitation: Increase diversity of imitated actions, sounds, and syllables.a. Expand imitation of motor acts (e.g., begin with imitation of acts already in child's repertoire, try to incorporate into social

games (e.g., wave "bye bye" as part of peek-a-boo).b. Increase use of motor acts within child's repertoire combined with vocalizations in repertoire (e.g., wave "bye bye"

producing "i-i").c. Increase use of new sounds and syllables during sound games.d. Increase use of new sounds with familiar motor acts during bathtime, feeding, and playtime.

while producing some of her vocalizations can be usefulin building Ellen's interest and ability to produce andimitate varied vocalizations and approximations. The cli-nician can also introduce "sound games" by vocalizing asound within the child's repertoire while acting on a toy(i.e., putting rings on a ring toy, throwing blocks into ortaking them out of a bucket). As the child begins toproduce the vocalization combined with the motor action,the clinician gradually shapes the routine by incorporat-ing more vocalizations and sounds.

Cross-domain goals. Although examples of individualactivities are presented for each goal within a domain,activities may meet several goals across domains. Forexample, the "sound games" activity under ImitativeProduction, encourages social and motor routines whilebuilding imitation and spontaneous production skills. Inthis way, multiple goals are achieved through one activity.

CONCLUSION

In this article, three decision trees were presented toassess communication and plan intervention for veryyoung children. The decision trees provide a nonstand-ardized assessment method for collecting and organizinginformation and include ideas for use in interventionplanning. With the current focus on serving youngerchildren, the decision trees may be a useful tool for SLPsin assessment and program planning.

ACKNOWLEDGMENTS

Preparation of this manuscript was supported in part by Spe-cial Education Programs, Special Education and RehabilitativeServices, U.S. Department of Education, Grant #G008401614,and the North Carolina Council on Developmental Disabilities.We thank Lesley Olswang, Carla Brooks, and Lou Rossetti fortheir kind remarks on an earlier draft of this paper.

REFERENCES

BROWN, R. (1973). A first language. Cambridge, MA: HarvardUniversity Press.

CARLSON, L., & BRICKER, D. (1982). Dyadic and contingentaspects of early communicative intervention. In D. Bricker(Ed.), Intervention with at-risk and handicapped infants:From research to application, (pp. 291-309). Austin, TX:Pro-Ed.

CHAPMAN, R. (1981). Exploring children's communicative in-tents. In J. F. Miller (Ed.), Assessing language production inchildren, (pp. 111-136). Baltimore, MD: University ParkPress.

COGGINS, T., & CARPENTER, R. (1981). The communicativeintention inventory: A system for observing and coding chil-dren's early intentional communication. Applied Psycholin-guistics, 2, 235-251.

CRAIS, E., & LEONARD, R. (1990). P.L. 99-457: Are speech-language pathologists prepared for the challenge? Asha, 32(4),57-61.

DUNST, C. (1981) Infant learning. Hingham, MA: TeachingResources.

DUNST, C., & WORTMAN-LOWE, L. (1986). From reflex to sym-bol: Describing, explaining, and fostering communicative


competence. Augmentative and Alternative Communication,2, 11-16.

FEY, M. (1986). Language intervention with young children. SanDiego, CA: College-Hill Press.

FURUNO, S., O'REILLY, K., HOSAKA, C., INATSUKA, T., ALLMAN,T., & ZEISLOFT, B. (1979). The Hawaii Early Learning Profile.Palo Alto, CA: Vort.

GOLINKOFF, R. (1983). The transition from prelinguistic tolinguistic communication. Hillsdale, NJ: Erlbaum.

HART, B., & RISLEY, T. (1978). Promoting productive languagethrough incidental teaching. Educational Urban Society, 10,407-432.

LEONARD, L., PRUTTING, C., PEROZZI, J., & BERKELY, R. (1978).Nonstandardized approaches to the assessment of languagebehaviors. American Speech and Hearing Association, 20(5),371-379.

MILLER, J. (1981). Assessing language production in children:Experimental procedures. Baltimore, MD: University ParkPress.

MILLER, J. F., CHAPMAN, R. S., BRANSTON, M., & REICHLE, J.(1980). Comprehension development in sensorimotor stages 5and 6. Journal of Speech and Hearing Research, 23, 284-311.

MUMA, J. (1978). Language handbook: Concepts, assessment,intervention. Englewood Cliffs, NJ: Prentice-Hall.

NEWBORG, J., STOCK, J., WNEK, L., GUIDUBALDI, J., & SVINICKI,J. (1984). Batelle Developmental Inventory. Allen, TX: DLM.

OLSWANG, L., STOEL-GAMMON, C., COGGINS, T., & CARPENTER,R. (1987). Assessing prelinguistic and early linguistic behav-iors in developmentally young children. Seattle, WA: Univer-sity of Washington Press.

P.L. 99-457. (1986). Education of the Handicapped Act Amend-ments of 1986, Title I, Handicapped Infants and Toddlers,Washington, DC, House Congressional Records.

RETHERFORD, K., SCHWARTZ, B., & CHAPMAN, R. (1981). Se-mantic roles and residual grammatical categories in mother

and child speech: Who tunes into whom? Journal of ChildLanguage, 8, 583-608.

ROBERTS, J., & CRAIS, E. (1989). Assessing communicationskills. In D. Bailey & M. Wolery (Eds.), Assessing infants andpreschoolers with handicaps (pp. 339-389). Columbus, OH:Charles E. Merrill.

ROTH, F., & SPEKMAN, N. (1984). Assessing the pragmaticabilities of children: Part I. Organizational framework andassessment parameters. Journal of Speech and Hearing Disor-ders, 49, 2-11.

SEIBERT, J., & HOGAN, A. (1982). A model for assessing socialand object skills and planning intervention. In D. McClowry,A. Guildford, & S. Richardson (Eds.), Infant communication,development, assessment, and intervention, (pp. 21-53). NewYork: Grune & Stratton.

SNYDER-MCLEAN, L., SACK, S., & SOLOMONSON, B. (1985).Genetic Skills Inventory, Parsons Preschool Curriculum. Par-sons, KS: University of Kansas, Bureau of Child Research.

WESTBY, C. (1980). Assessment of cognitive and language abil-ities through play. Language, Speech, and Hearing Services inSchools, 11, 154-168.

WETHERBY, A. M., & PRIZANT, B. (1990). Communication andSymbolic Behavior Scales, Research Edition. San Antonio,TX: Special Press.

YODER, D., & KENT, R. (1988). Decision making in speech-language pathology. Philadelphia, PA: B.C. Decker Inc.

Received January 3, 1989Accepted March 12, 1990

Requests for reprints may be sent to: Elizabeth Crais, Divisionof Speech & Hearing Sciences, CB 7190 Wing D Medical School,University of North Carolina, Chapel Hill, NC 27599.

22 19-30 April 1991


SOCIAL INTERACTION

Assessment Questions Intervention Activities

COMPREHENSION


Does child attempt to elicitadult's attention to getphysical needs met (e.g.,hunger, sleep)?

NO

YES

2 ___Does child respond to adultby vocalizing or gesturing(e.g., reaches for adult'sextended hands, vocalizeswhen adult begins or stopsan interaction)?

YES

Does child attempt to elicitadult's attention with sounds NOand/or gestures to engage ininteractions?

YES

Does child hold up/showobjects to others? NO

YYES

5Does child spontaneouslypoint to objects/persons or NOgive objects to others?

YESYES

6Does child participate in anyplay routines or interactions NOby vocalizing, using gestures,and/or facial expressions?

YES I

Does child appear to want tocontinue a play activity by NOrepeating a facial expression,body movement, and/orvocalization?

YES

Does child nonverbally NO(through gesture orvocalizing) exhibit any earlierdeveloping intentions (i.e.,attention-seeking, requests,protests) with familiarpeople?

YES

Does child verbally exhibit Oany earlier developingintentions with familiarpeople?

YESGo to Figure 2 Social Interaction

'Figures 1-3 were adapted from Roberts & Crais (1989).

Model pointing to a desiredobject (e.g., point to car)while vocalizing and labelingobject ("car").

Develop simple routines.Choose random behaviorsthat child exhibits,incorporate them into socialgame (e.g., child lifts blanket,start peek-a-boo).

Does child react to voice? NO-

YES

2

3

Does child look at objects(e.g., bottle) or people (e.g.,Mama) that an adult points toor looks at?

YES

Does child act on objectpointed to or looked at byadult (e.g., pick up the ballindicated)?

YES

Does child look at, point to,or act on objects or peoplementioned by adult?

NO

- NO

NO NO

YESI

5

6

7

8

FDoes child respond tocommon routines whencontextual cues are present(e.g., caretaker waves, saying"Let's go bye-bye")?

YES

Does child respond tocommon routines whencontextual cues are notpresent (e.g., "Let's gobye-bye" before coats aretaken out or anyone goes tothe door)?

NO

NO

NO

NO

Select one or two simpleroutines (e.g., bye-bye,pat-a-cake) and repeatedlyuse behaviors and words.

YESGo to Figure 2 Comprehension

Attempt to shape existingvocalizations to expressverbally existing intentions("oh" to "no").

FIGURE 1. Decision tree for child at the prelinguistic stage.

Encourage interactions whenchild is likely to express aphysical need (e.g., duringfeeding, give child smallamount of food, withhold it,wait for any movement,gesture, or vocalization andgive more food).

Associate any reaction tosound, movement ortemperature with talking(e.g., child moves arm inresponse to touch, says "ah").

Make sounds or vocalizationsin response to child's actionsand pause for child'sresponse.

Establish joint attention toobjects or people. Hold upobject in front of child, shakeand say, "look." Repeat bymoving object to a differentposition but still in view.

Respond to any vocalizationsthe infant makes (e.g., whenchild moves or vocalizes,caretaker turns to focusbriefly on child, then turnsaway again).

Begin by looking at, thengiving child object. Later,just use eye gaze toencourage any actions onobject.

Model showing behavior.Hold up object, get child'seye contact, smile and/orvocalize, then take out ofsight Repeat.

Hold and shake object andlabel it: take it away, bring itback and label it. Labelobject frequently.

YES

Does child respond bylooking at, pointing to ordoing action when hearingaction word (e.g., throwball")?

YES

Imitate any action of child(e.g., throwing ball). Pausefor child to repeat action, andlabel it.

Does child look for orrespond to absent objects orpersons when named (e.g.,"ball" when in other room)?

After child participates in aplay activity, pause and lookat child, and if anymovement, gesture, orvocalization occurs, continueactivity with animation.

Play hiding games with anobject or person (e.g., hidepart of a truck and ask,"Where's the truck?"gradually hide more of thetruck).

Set up environment to elicit adesired intention and model(e.g., give child somethingnot liked, model pushingaway object and say"unh-unh").

Repeat familiar routine(bye-bye) using same settingand words and graduallyeliminate contextual cues(e.g., don't get coats out first).

Ii

r

L

4

e

I

*

I 1

r

-

26 Language, Speech, and Hearing Services in Schools 22 19-30 April 1991

SPONTANEOUS

Assessment Questions lntervention Activities

Does child produce anyvocalizations (e.g., "ah","eh")?

YES

2 Does child produce anyconsonant sounds (e.g., "da","ga")?

r Does child vocalize whenrefusing or commenting onan object/person/food?

NO -

NO-

NO-

NO

NO-

YES

Does child vocalize using a - NOrising intonation to signal aquestion?

YES

Pt I IDoes child use jargon orspeech-like strings ofvocalizations?

NO-

YES

Does child use same NO-vocalization in repeatedinstances to indicate sameobject or event?

YES

I

PRODUCTION*IMITATION


1 I a. .,... .. I _Does child Imitate motoractions (e.g., reaching,clapping)?

YES

2 Does child imitate oral motor NO-actions (e.g., lip smack,raspberry)?

YES

3 Does child imitate anynonspeech sounds (e.g.,cough, squeal?)

NO

YES

4Does child imitate speechsounds or syllables (e.g.,vowel ("a"), consonant ("b")or consonant + vowelcombinations ("ba")?

5

6 r

7 _YES

Does child imitate anyone-syllable words?

NO

NO

NO-

NO

body-part naming. I

YES

Go to Figure 2 Imitation*For children with severe motor, cognitive, and/or sensory impairments, alternative communi-cation modes may be necessary

Does child use gestures NO Select gesture andcombined with vocalizations? vocalization child uses and

model the combination (e.g.,if to protest, child shakeshead ir sys "ah," model

YES both together)lI

Does child use word NO- Play gaes with child yapproximations? identifying objects by word

approximations (e.g., "oh" or"boat," "a" or "hot").

YESGo to Figure 2 Spontaneous Production

Attend to any sounds madeby the child and reinforcewith smiles, touches, andvocalizations.

YES

Listen for and reinforce anysounds which areconsonant-like (e.g., gurgles,lip sacking).

Does child use the samesounds/syllables in soundstrings (e.g., "a-a-a" or"bababa")?

Imitate natural actions inchild's repertoire (e.g.,reaching for toy) and hIuildsequence of turns imitatingchild.

3

4

5

YES

Listen for any sound orsyllable used frequently andmodel repetition ofsonnd/syllable.

Does child use alternatingvowels or consonants instrings (e.g., "ba-da-ba" or"be-ba-be")?

YES

Imitate playfully any oralmotor action that childperforms (e.g., smacks lipsafter drinking). Wait fisr childto do again and imitate again.

Listen for sounds or syllablesused frequently and modelalternating repetitions?

Imitate playihdly anynonspeech sounds in child'srepertoire. Wait for child todo again and imitate.

Model refusal behavior, usingboth gesture and vocalizationduring play activity orinteraction (e.g., give foodchild doesn't desire, model"unh-unh" and shake head).

YES

Imitate nonspeech soundsfirst and encourage child tomake soind again. Addspeech sounds to sequences(e.g., child squeals, caretakersqueals and adds "ee"'').

Does child imitateapproximations of solndcombined with motor acts(e.g., "m-mn" for motor soundwhile pushing car)?

Model rising intonation tofind out the label for object(e.g., ulse "da?" to indicate"what's that?" while pointingto new object)

Use sounds in child'srepertoire and try to combinewith motor actions withinchild's repertoire (e.g., say"no" or "oh" as shakes headwhen cookie is taken away).

YES

Does child imitateapproximations of words(eg., "ow" for "out" whentaking blocks soit of bucket)?

Play sound games and repeatnonsense syllables, especiallyto protest or comment onsomething (e.g., "os, na, isa,na" to protest).

Play motor imitation gamesand alternately add words orword approximations (e.g.,hands up, "up" or "h".

iluitate 'oclizaltions madeby child using same onerepeatedly to indicate sameolhject or action (e.g., if childsays "g" when sees a car, say

g, es, car").

Play naming ganes whereclinician pulls objects isit ofbag and labels them or use

10

FIGURE 1. (cont.).

i

i-

F_ NO-_ I

_


SOCIAL INTERACTION'


1 I -..... I I .- .Does child verbally exhibitany earlier developingintentions (i.e.,attention-seeking, requests,protests) with familiarpeople?

YES

Does child nonverballyexhibit any intentions withunfamiliar people?

NO-

YES

3Does child verbally exhibit i NO-any intentions with anunfamiliar person?

YES

Does child verbally express a NO-variety of communicativeintentions?

YES

IDoes child initiate a familiarplay routine related to thecontext and then take oneturn in the interaction?

IYES

IDoes child maintain attentionto a play activity orinteraction for a continuousminute, when playing with a"focused" adult?-

YES

Does child take turns in aninteraction by exchangingsocial roles during game(e.g., adult tickles child, thenchild becomes the "tickler").

YES

Does child participate in playroutines associated with dailyactivities (e.g., rubber duckjumps into bath and quacksat start of each bath time)?

- NO-

-NO-

-NO---

- NO-

Interaction:_ NO----I Return to Figure I Social I

COMPREHENSION

Assessment Questions

Does child respond tocommon routines whencontextual cues are notpresent (e.g., "Let's gobye-bye")

YEs

Does child respond to anytwo-word sequences (e.g.,kiss baby, eat cookie)?

YES

I3

4

5YES

Intervention Activities

NO Return to Figure Comprehension.

NO

-NO

]_ NO4

Does child respond to one N O -action + one object requests(e.g., kiss baby).

YES

lDoes child respond to 2two-part sequences, forexample, 1 action + 2 objects(e.g., "push the ball andblock"), or 2 actions + Iobject (e.g., "kiss the dollyand hug dolly")? (See Table14.3).

YESI

Does child respondapproximately to simple whquestions (e.g., what, where,who)?

-NO

-NO-

YES

Go to Figure 3 Comprehension

Choose object familiar tochild and select one commonaction (e.g., eat, drink). Playgames acting on and labelingthe object and action.)

Ask Wh questions in socialgames (e.g., "Where is yournose, ears?" and modelresponse, "Here's my nose.")Repeat question andresponse. Start with "what,"then "who," and "where."

YS

Does child take three turnsin an interaction or in a playactivity initiated by an adult?

NO - Initiate a play activity orinteraction (e.g., pat-a-cake,peek-a-boo), pause for child's_-rp .. ...... ith hn.s

ready to clap), take anotherturn quickly (e.g., clap) and

YES pause again.

Go to Figure 3 Social Interaction'As the child's communicative skills improve, these turn-taking behaviors should first be seenvocally and later verbally.

FIGURE 2. Decision tree for child at the one-word utterance stage.

X I Attempt to elicit attention bybringing out novel or actiontoys (e.g., windup toy). Afterdemonstrating toy, allow it tostop, and reinforce any signalfrom child indicating interest.

Use "reported" verballyexpressed intentions (e.g.,"no") and play a game whereat each turn child canrespond "no" (e.g., offerwrong puzzle pieces). Beginby modeling and then waitfor child's response.

Does child respond to avariety of semantic relationsin two-word utterances usingfamiliar words (e.g., agent +action, possessor + object, oraction + object: e.g., "horseeat", "dog bite")?

Select words in child'sone-word comprehensionvocabulary, label, and act outdifferent combinations (e.g.,"boy eat," "baby's shoe,""throw toy").

YESI

During daily activities orplay routines create a needfor communication andmodel utterances to express achild's intention, (e.g., builda block tower and say "moreblock" when need anotherand "block fall" when towerfalls).

Can child respond to avariety of semantic relationsin two-word utterances withless familiar combinations(e.g., "horse sit," "dog kiss")?

Play games using andlabeling different objectswith same action, anddifferent actions with sameobject.

Set up environment toencourage a familiar routine(e.g., position yourself fortickle routine) and pause forchild's turn. If no response,model approximate initiation(e.g., "tickde").

4 [

5

6

7

Y L

Start with familiar actions onobjects (e.g., eat cookie,throw ball) then move to lessfamiliar actions (e.g., patball).

Select activity or game (e.g.,pat-a-cake, horsie) the childenjoys and plays for anincreasingly longer period oftime, maintaining child'sattention.

l l~~~~~~~~~~~~~~

Select agent and action wordsin child's comprehensionvocabulary. Target initiallyagent + action "baby eat"and action + object "eatcookie" sequences. Act outand label (e.g., "kiss baby"and then "hug baby" whileplaying with doll).

Play familiar game andmodel the initiator's role forthe child (e.g., take child'shands and tickle yourself).

Begin repeating the sameaction or action/soundsequence at the same timeduring a daily activity.

ll

I

_I

R

A

·- -- 1 C \ __ ___ I1U

I


SPONTANEOUS

Assessment Questions Intervention Acticities

22 19-30 April 1991

PRODUCTIONI MI TATION

Assessment Questions lulteraention Activities

Return to Figure 1Spontaneols Production.

Does child imitate anyone-syllable words?

YES

NO Return to Figure I Imitation.

Does child use same wordapproximation in repeatedinstances to indicate sameobject or event?

NO-

YES

Does child imitate anytwo-syllable words?

YES

Does child use wordapproximations to expressany intentions?

NO-

YIS

Does child use consistentlyany recognizable words?

YES

Does child use rcognizablewords to express anycommunicative intentions(e.g., requesting, protesting,or attention seeking)?

YES

66 Does child sise one-word

utterances to express thesemantic roles (e.g., agent,action, rejection, recurrence,possession)?

YES

7 _Does child say more than 20words?

_NO-

-NO

NO-

YES

Does child imitate orapproximate any two-wordcombinations?

NO

YES

Does child imitate or [ NO-approximate a variety oftwo-word combinations (e.g.,kiss baby, kiss Mama)?

YES

Go to Figure 3 Imitation Production

Does child use rising NO-intonation in one-wordutterances (e.g., "car?")?

YES

Does child use words in the NO-vocabulary categories:people, animals, commonobjects, actions?

YES

Does child chain single NO Use words in single wordwords together with pause vocabulary. Model two-wordbetween or use any two-word combination as doing actioncombinations? (e.g., "mr throw," "car,

truck", "more juice?"). Cancombine with motor actions(e.g., tapping) or visual

YES stimuli (e.g., pictures).

Go to Figure 3 Spontaneous Production

Does child use wordapproximations?

NO• Choose an approximationused frequently and/or onethat is close to a particulardesired production (e.g., "oh"for "boat"). Model thevocalization when pointing tothe object or event.

NO-

Set up environment to elicitintention and model wordand word approximation (e.g.,"oos" and "juice").

Target one-syllable wordschild can make and pausebetween syllables (tum-my)as combine with motor action(e.g., say "tummy," whilepatting tummy).

Target vocalizations withinrepertoire during functionalactions. Model, acceptinggradually any consistentvocalizations (e.g., child says"m," model "ma" whenevermother comes into room).

Target functional two-worlcombinations withinrepertoire and blend wordscloser and closer together.Combine with motor actions(e.g., tapping) or pictures.Target "want juice," whenchild desires juice or"Mommy, no," when doesn'twant something.

Set up environment toencourage communicationintentions (eg., placing afavorite toy out of reach butwithin view, pause tor childto take trn, ard if noresponse, model "'ear").

Choose any two-wordsequence and play gamesalternating each word withothers (e.g., kiss baby, kissdoggie, hug baby, doingaction).

Label objects and actions indaily activities. Set upenvironment to elicit a wordand model, encourage wordapproximations (e.g., give alittle joice and ask "Morejuice?". Hide part of truckand ask, "Where truck?")

Label objects and actions indaily activities (e.g., "light,""light on," as turn light on).Imitate any vocalization bychild and shape towardwords (e.g., "i" for "light").

S

9

10

Play pointing andquestioning games. Hold uptwo objects, point to one, ask"ball?" with risingintonation, and then labelobject "yes, ball."

Label objects and actions indaily activities and vary theobject (e.g., "bonny p,doggie uip, bunny down,doggie down." Can also losestory books)

FIGURE 2. (cont.).

i ' /7z

L

4

}

_-

II

-


SOCIAL INTERACTION


COMPREHENSION


Does child take three turnsin an interaction or in a playactivity initiated by anadult??

NO- Return to Figure 2 SocialInteraction.

Does child respondappropriately to simple "Whquestions" (e.g., what, where,who)?

N O Return to Figure 2Comprehension.

2

3

4

I

YES

Does child communicate torequest information andanswer questions?

YES

6 Does child repeat his ownutterances that vere notunderstood by adult?

NO

NO

NO

_NO-

NO-

YES

Does child maintain topic for NO--at least 3 trns by expandingand elaborating the topic?

YES

IDoes child provide listenerwith information on a topicfrom past experiences thatare not tied to the immediatecontext?

Play social games withdifferent roles (e.g., hide andseek, telephone, "get ya").Use gestures and then modelspeech demonstrating bothroles.

Play games taking turnsadding information (couldinitially use pictures asstimuli); give reinforcementfor new words added (e.g.,"that boy," "boy sad," "icecream fell.").

NO Do an activity (e.g., makepeanut butter sandwichesand eat them). Later modeltelling the parent whathappened (e.g., "We made apeanut butter sandwich, weate the sandwich, we cleanedup.")

2 _

YESDoes child respond to simpleyes/no questions (e.g., "Isthat you nose?")?

L

6

7

s

For higher level skills, see individual assessment instruments.

Ys

Does child understand theprepositions inlon/lnder?

YES

IDoes child respond to moreadvanced Wh questions (e.g.,"Which one do you eatwith?", "Why did he cry?")?

YES

Does the child respond totwo actions + two objectrequests (e.g., "Give me theball and pick up the car")?

IYESI

Does child follow a two-partsequence of directions notclearly tied to the context(e.g., "Get your coat and goto the door" for anunexpected walk outside)?

NO

NO

NO-

-NO-

-NO----

YES

Does child exchange socialroles during games (e.g.,adult says "I'm gonna get ya'and tickles the child. Thenchild says "Get ya" andtickles the adult).

YES

YES

Does child verbally initiate atopic closely related to thecontext and continue for atleast one turn?

Does child understandvariety of semantic relationsexpressed in multiwordutterances (e.g., agent +action + object, action +object + location)?

YESI

Wait for child's initiation,encourage use of verbalmeans, take an exaggeratedturn, and indicate it is child'sturn.

Select words in child'scomprehension vocabulary,label, and act out differentcombinations (e.g., "babydrinks juice," "baby eatscookie," "put ball there").

Does child produceutterances during pausesbetween an adult's utterancesin a conversation?

YESI

Pause purposely for a periodof time between speakerturns and look expectantly atthe child.

Ask yes/no questions in socialgames ("Is that your nose?""Yes."). Be exaggerated andmodel correct response.

Does child respond to oneaction + two objects (e.g.,"Give me the ball and car")or two actions + one object(e.g., "Get the car and give itto me") requests?

4

Set up situations or playgames (e.g., hide and seek)where child needs to requestinfonnation, or answer aquestion to complete theactivity.

Use the same action withrepeated single objects (e.g.,"Give + car dog, horse"),then add a second object(e.g., "Give me the car anddog").

Play games of notunderstanding child and thenmodel closer approximationof utterances.

Hide objects and model (e.g.,"Is ball in the box?" "No.""Ball is on box.").

Ask Wh questions in a gameusing initially commonobjects (e.g., "What do youdo with a spoon, cup?") andmodel (e.g., "You eat with aspoon."). Then use 2 choicesand ask "Which one do youeat with?". Focus on onequestion type at a time.

r

Select words incomprehension vocabularyand act out and label actionsand objects. Use requests thatare pragmatically appropriate.

Use one-step directions childcan follow and then chainthem together. Use familiarwords and actions. Begin bygiving gestural cues.

IYES

For higher level skills, see individual assessment instruments.

FIGURE 3. Decision tree for child at the two-word utterance stage and above.

I I

J

_

_ ,

I


SPONTANEOUS


PRODUCTION

22 19-30 April 1991

IMITATION'


i .I.. 1i ._ . ... Does child chain singlewords together with pausebetween or use any two-wordcombinations?

YES

YES

Does child use somemorphological markers (e.g.,plural "s" or presentprogressive "ing")?

IYES

NO_

NO-

NO

Does child use more than 50 NO-words?

YESYES

Does child use any simplesentences

letne NO-

YES

6 [ Does child use prepositions NO(e.g., "in" and "on")?

YES

'7 tDoes child use the modifiers NO-(e.g., big, hot)?

I

Return to Figure 2Spontaneous Production.

Does child imitate orNOapproximate a variety oftwo-word combinations (e... NO

2

kiss baby, kiss Mama)??Doscidimtt n

Does child imitate anythree-word combinations?

IYES

Does child imitate anymorphological markers (e.g.,"baby's bottle," "big cats")? J

- NO-

-NO

YES

Does child imitate any NOsimple complete sentences?

YES

YES

Does child use a risingintonation in two-wordutterances indicating aquestion (e.g., "Mommyeat?")?

YES

Does child use past tense NO -(e.g., walked), possessive(e.g., Daddy's hat) andirregular past tense (e.g.,fell)?

YESI

NO- Play with Fisher-Price houseand people. Model one- andtwo-word questions andencourage imitation (e.g.,"car?," "Mommy go?").

Play games with toys orclothing, targeting one format a time (e.g., accidentallyknock a ball off a table andask "Where's the ball?" "Itfell down?").

]- NO Play hide and seek gamewith objects and alternateturns and ask "Where ball?".h I"

2

3

Does child use a variety ofsemantic relations intwo-word utterances (e.g.,agent + action, object +location, possessor +possession)?

Use words in child'svocabulary and modelcombinations while actingout (e.g., "horsie up," falldown," "Mommy foot").

Play object and pictureturn-taking games, targetingearlier developing markers(e.g., child requests "eye" or"eyes," for Mr. Potatohead).

Target words in repertoireusing familiar pictures orobjects as guide. Usefunctional word combinations(e.g., "put in box," "boythrow ball").

Play games with objects andactions/pictures (e.g., hideand seek, I see, or requestgames: "I want the X,""Where's the X?", "I see aX.").

Target words in repertoireand earlier-developingmarkers using visualrepresentations (e.g., blocks)or motor actions (e.g.,tapping) as say words (e.g.,car and cars) and exaggeratemorpheme "s".

Set up turn-taking games toincorporate simple sentencesusing objects or people (e.g.,"I want X," "I see you," "Igot X.").

Target functional wordcombinations (e.g.. " wantspoon," "Mommy throw theball") and include visualrepresentations or motoractions.

For higher levels skills see individual assessment instruments.*imitation can be initially used for response development with prompts and later fading ofimitation for spontaneous productions.

Manipulate real objects or actout in person "in" and "on"Label and take turns (e.g.,child goes in box andclinician asks "Where's X?"and models "I'm in box").

Play games with objects thatvary along one dimension(e.g., have a big and smallball or a large and small hat).Label as you point to object(e.g., "big ball").

YES

Does child use possessivepronouns (e.g., my, mine), orpersonal pronouns (e.g., he,she)?

8

9

10

11

Play games with toys orclothing, targeting one format a time, (e.g., pull toys outof a bag and ask "Whose isthis?" and model "It's myshoe.").

Does child use "what" and"where" questions (e.g.,"What that?", "What boyeating?", "Where car?")?

FIGURE 3. (cont.).

-1I

et.,. to igure Y. 1.11ation

.

1

I

C-_ NO -

Decision Making in Assessment and Early Intervention Planning

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