Developmental Language Disorders SPH 801A

Assessment of pre-linguistic and emerging language

Jenny Brown, Macquarie University,August 2015

I the use of some of Dr Liora Ballin’s slides from the 2013 Beijing SP Summer School lectures, which assisted in the revision of this presentation.

Texts:Paul, R & Norbury, C.F (2012). Language disorders: From infancy through adolescence (4th ed). St. Louis, MI: Mosby.Owens, R. E. (2011). Language development: An introduction (8th ed.). Boston, MA: Pearson Education.

Why do we need to assess?• To establish a child’s level of functioning• To screen• To diagnose• To decide on intervention• To set goals

Assessment (Haynes & Pindzola, p3)

Principles of assessment

• Developmental research on the sequence and processes of typical language and communication development should provide the framework for assessing a child’s language and communicative abilities

Principles of assessment

• Assessment involves gathering information about a child’s communicative behavior across situational contexts over time; Assessment is an ongoing process, not a one-time episodic event

Principles of assessment

• Assessing and responding to the needs of the family will contribute to the child’s ultimate progress

Principles of assessment

• Assessing the interactions between the child and the child’s communicative partners to determine which behaviours help or hinder the development of language and communication skills

• The purpose of assessing partner style is to help partners develop an awareness of strategies that facilitate successful and positive interactions

Principles of assessment

• To ascertain a child’s communicative strengths and needs, therapists should use a variety of strategies, including direct assessment, naturalistic observation, and interviewing significant others

Principles of assessment

• A variety of instruments or tools may be used in assessment, and should be selected based upon a child’s developmental level, the purpose of the assessment, and the assessment strategies used

Considerations in designing and implementing Ax (Kelly & Rice, 1986 in Owens, 2004)

• Child’s chronological and functional age• Child’s sensory systems• Caregiver concerns• Status of child’s psychological functioning• Child’s interests and materials available• Child’s activity level• Child’s attention span

Use knowledge of Typical Development

• We need to know our norms• Have them ‘handy’• Use them in preparing an assessment• Use them in talking to parents after an

assessment or in a report

Process of assessment (Owens, 2004)

Referral, Questionnaire and Interview

Observation

Formal TestingConversationa

l Langua

ge Sampli

ng

Process of assessment

• Interview and/or questionnaire• Observation– in a naturalistic environment

• Standardised tests• Criterion based measures • Language sampling• Play assessment

• Hearing screening

Assessment of toddlers…

What questions do we want to be able to answer by the end of the assessment

process?

Interview and/or questionnaire

• Involves caregivers – (e.g., parents, teachers, grandparents…)

• Source of information on child’s functioning• Provides opportunity to document factors that

may affect language development• Purpose to gather information

Ask questions about:• Prenatal, perinatal, and postnatal medical history• Medical history that could affect speech and language

development (e.g., hospitalisation, ear infections, feeding problems)

• Family history of language or literacy difficulties• Any known conditions?• Developmental history

– Speech and language development – (e.g., age of babbling, first words, word combinations, longer sentences)

– Motor development – (e.g., sitting, walking, toilet training)– Eating and drinking development - any feeding difficulties?

• Child's educational history

Ask questions about:

• The child’s current communication:– Routine language use - Elicit examples of the child’s

communicative attempts • (e.g., Tell me about what happens when…)

– What motivates the child to communicate?– How does the child communicate?– With whom does the child communicate?– What does the child do when communication fails?

• Impact of language difficulties?

Ask questions about:

• How does the child communicate?– Does the child use vocalisations, gestures, eye contact, or other

means of communication?– Who understands the child’s communication efforts?

• Does the child play alone or with others?• Does the child demonstrate any turn-taking behaviours?• Does the child ever initiate communication? How? In which

situations?• Which situations seem to be high-communication contexts?• Which caregivers seem to engage in the most interaction with

the child?

Ask questions about:

• Does the child– Make wants known?– Request help?– Point to objects or actions, name, or both?– Request information?– Seek attention?– Demonstrate emotion?– Protest?

• How and when?• Get examples

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Family-Centred Practice – Basic Principles

• Support, trust & respect parents• Use strengths-based approach• Understand & accept parents’ perceptions &

experiences• Don’t overwhelm them with professional language!• See Paul (2012, Appendix 6.1) for further suggestions

What do you want to know

Eg A parent has said that their 2;7 year old boy doesn’t talk enough for his age. He seems to understand ‘everything’. He’s mainly using words and is slower than his sister was. He attends day care 5 days a week and spends a fair amount of time watching ‘Into the Night Garden’. What do you want to know more about? That is, what do you want to ask more questions about or clarify?(Think about how you ask these questions)

Early stages of communication

• Pre-intentional - 0-8 mths• Pre-linguistic - 9-18 mths• Emerging - 18mths – 3yrs

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Areas for Assessment of Pre-intentional children

• Feeding & Oral-Motor Development• Vocal Development• Intentional communication• Hearing• General Development• Parent-Child Communication

Areas for Assessment of Pre-linguistic children

• Prelinguistic behaviours – joint attention, turn-taking, imitation (motor and sound), vocalisations

• Communicative intentions or functions • Gestures• Play• Parent-child interactions

For toddlers with little language…

“By examining the child’s prelinguistic skills, we can identify the child’s unique profile of communication strengths & challenges. This profile can then be used to facilitate decision making in both assessment and intervention” Crais, Watson & Baranek, 2009, p. 96

Toddlers communicating

What do you notice in this recording…

What communication skills do you notice?Is she typically developing?

Http://www.youtube.com/watch?v=GARBeOrfhFo

http://www.youtube.com/watch?v=fsDqd5TxNTw&feature=related

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Development of Joint Reference (Owens, 2011)

Phase 1• 8 wks: Visual tracking of caregiver’s movements• 12 wks: Infant attends to utterances addressed to

him/her• 4 mths: Infant follows caregiver’s line of regard• 6 mths: infant responds to object name

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Development of Joint Reference (Owens, 2011)

Phase II• 7 mths: Infant established joint reference by pointing• 8 mths: infant points or reaches & shifts gaze

between object & caregiverPhase III• 8 – 12 mths: Reaching, requesting, pointing &

showing; gesture alone & gesture + vocalisation

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Assessing Joint Attention

• Observe child and parent with different toys/objects/books

• Mundy et al (2003). Manual for the abridged Early Social Communication Scales (ESCS) http://www.ucdmc.ucdavis.edu/mindinstitute/ourteam/faculty_staff/ESCS.pdf– Initiating & responding to joint attention– Initiating & responding to behavioural requests– Initiating & responding to social interaction

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Assessment of Vocalisation

• Developmental vocal assessment (See Paul, 2012 p.195)

• Suggestion of +- 50 – 70 “comfort state” vocalisations; can be collected in 20 minutes; may need more than 1 session if infant is fractious

• Vocalisation = vowel- or consonant-like elements produced on exhalation

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Assessment of Vocalisation

• Failure of canonical babbling by 10 months predicts delays in the acquisition of words & word combinations in 2nd year of life (Oller at al, 1998)

• Rate of vocalisation (# of vocalisations ÷ # of minutes) should increase steadily (no norms available)

• If no change in vocalisation rate for +- 6 mths check hearing

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Assessment of Vocalisation

• Does child produce multisyllabic babbling?• 16 months: more consonants than vowels

expected• Babble by 12 months have sentence-like

intonation & prosody• If there is evidence of gesture use, the infant

might not be pre-intentional

Three aspects of communicative intentions to assess

1. Range of communicative functions2. The frequency of communication 3. Forms of communication– The means by which the child attempts to

communicate a message

Range of communicative functions• Proto-imperatives: To get an adult to do or not do

something– Requests for objects– Requests for action– Rejections or protests

• Proto-declaratives: To get an adult to focus on an object or event by showing off or showing or pointing out objects for the purpose of establishing social interaction or joint attention– Comments

Communicative Intentions (Owens, 2010)

Before 24mths:responding to Qs; continuance; declaring; making choices; labelling/naming; protesting/denying; repeating; 24–36mths:greeting/calling; predicting; replying (without prompt); requesting assistance/ clarification/ information/ objects; 36mths+:expressing feelings, giving reasons, hypothesizing;

The frequency of intentional communication

• Changes over the age range– 18 months: 2 instances of intentional communication per minute– 24 months: 5 instances of intentional communication per minute

• (Chapman, 2000)

• Children with mild to moderate ID in the pre-linguistic period who produced less than 1 proto-imperative every 5 minutes unlikely to develop functional speech one year later (Yoder, et al. 1998)

Therapy to focus on increasing the frequency of nonverbal communication, particularly proto-imperative

Forms of intentional communication

• Children increase the sophistication of the forms of communication they use as they progress through emerging language periods

• Note the forms of communication – Gesture, pointing, reaching– Eye gaze– Vocalisation

Development of communicative intent – nonpurposeful

Stage Behaviour Example

Pre-intentional Reflexive behaviour that expresses inner state and serves as signal for adult who interprets it. Not directed at others; no anticipation of others.

Cry, posture change, facial expressionReach for object

Unintentional-intentional

Behaviour is goal oriented (reaching for object) but is not intended to be communicative. Not directed at others; no anticipation of others.

Reach for object, look at or regard object

Development of communicative intent - purposeful

Stage Behaviour ExampleNonconventional

Nonconventional gestures, usually physical contact, used with intent of affecting adult. Demonstrates intention to communicate by eliciting behaviour, checking adult attending, and anticipating outcomes. Persistence or frustration if goal unmet.

Tug, push away, pull

Conventional Standard gestures and vocalisation used with intention of affecting adult’s behaviour.

Alternating gaze, hand object, point, wave, shake head

Concrete Limited use of iconic symbols to represent the environment. Range of intentions.

Point, reach, offer, request assistance and information

Development of communicative intent - symbolic

Stage Behaviour ExampleAbstract Limited use of arbitrary symbols,

used individually, to represent the environment. Limited to the “here and now”. Still heavy reliance on gestures and vocalisation.

Symbols

Formal Rule-bound symbol combinations; referent need not be present. Language is primary means of communicating.

Combination of symbols

Owens, R. E. (2011). Language development: An introduction (8th ed.). Boston, MA: Pearson Education.

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Assessment of Communicative Intention: How

• Observation of play/interaction with items in the Ax context

• Observing child around eating times/with food

• Parental report• Elicited play (if intentional behaviours not

observed or reported)• Communication temptations

Communicative Intentions

https://www.youtube.com/watch?v=nQxDG4LD1Eo

How can we elicit them if we haven’t seen them?

Communication temptations

Think of 3 possible activities to tempt a child to demonstrate different communicative functions or intentions that might work in an Ax setting

COMMUNICATION INTENTIONS OBSERVATIONS Student: ________________________ Date: ________________________ Age: ________________________

Record behaviours observed in appropriate column, depending on form of communication used:

EARLY INTENTIONS FORM: GESTURE VOCALISATION WORD FUNCTION EXPRESSED Request action

Request object

Protest

Comment

LATER INTENTIONS FORM: GESTURE VOCALISATION WORD FUNCTION EXPRESSED Request information

Answer

Acknowledge

Other:

COMMENTS: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

AREAS NOT YET OBSERVED: ______________________________________________________________________________________________________________________________________________________________________

POSSIBLE COMMUNICATION INTENTIONS TO BE TARGETED: ______________________________________________________________________________________________________________________________________________________________________

OBSERVATIONS COMPLETED BY: _____________________

J.Brown (2013), Macq. Uni, Sp & H Clinic, based on: Paul, R., & Norbury, C. F. (2012). Language Disorders: from Infancy through Adolescence. Listening, Speaking, Reading, Writing, and Communicating (4th edition). St Louis, MI: Mosby.

Gestures in the Prelinguistic & Emerging Language Stages (Capone & McGregor, 2004)

• Deictic – showing, giving, pointing• Symbolic play schemes - actions depicting

object functions• Representational – a form is used to

‘stand for’ a referent

Gesture & Language

• 8 -12 mths: gesture predominates• 12- 18 mths: gesture + word like

vocalisations • 18 – 24 mths: conventional words &

combinations; increased range of functions

Observation - Development of gestural behaviour

Gestural Factor Consequence

Frequency Toddlers with disability use fewer gestures

Type Onset of pointing predicts language development

Communicative function

Limited variety of gestures (especially for joint attention and social interaction) in 18-24 month olds is associated with later diagnosis of autism and developmental disabilities

Coordination of gesture with gaze and vocalisation

By 15 months, typically developing toddlers combine gesture with gaze and/or vocalisations; Lack of this coordination is associated with language delay and/or autism

Transition from contact to distal gestures

Failure to acquire gestures to indicate objects at a distance is associated with developmental disorders; it is frequently seen in autism

Transition to words

Children who predominate in using gestures to label objects after 20 months may have language delay

Gesture observation

Therefore, what are we looking for?• Frequency• Type• What is the function or purpose• Is it with gaze or vocalisation• Contact or distal• With or instead of wordsNeed context to answer these

Play observation

• Why is this important?– Natural context for language

– Encourages language production– May elicit specific linguistic structures• E.g., more likely to produce spatial terms in play with

objects than in conversation

Play observation: Milestones

• 6-12 months– Handles objects with simple motor schemes• (e.g. banging, mouthing)

– Drops objects– Bangs two objects together– Acquires objects on own– Gives object to another– Pushes a ball

Play observation: Milestones

• By 12 months– Uses some toys appropriately without mouthing

or banging– Explores moving parts of toys– Finds a hidden toy– Is aware objects exist when not seen

Play observation: Milestones

• By 18 months– Dumps objects out of containers– Places objects into containers– Hands toy to adult for assistance– Attends to operating components of toys (e.g.,

buttons)– Discovers how to use toys through exploration– Uses toys appropriately (e.g., pushes car)– Engages in symbolic play with self (e.g., eats pretend

food)

Play observation: Milestones

• By 24 months– Engages in symbolic play with toys (e.g., brushes

doll’s hair)– Combines two toys in sequenced actions (e.g.,

pours from pot to cup)– Imitates familiar routines (e.g., sweeps)– Refers to toys not present– Uses books and other literacy props in play (e.g.,

pretends to write)

Play observation: Milestones

• By 30 months– Represents personally experienced events,

including those that occur infrequently (e.g., going to doctor)

– Re-creates sequences during play (e.g., takes baby’s clothes off, puts baby in bath, dries baby, dresses baby)

– Uses lots of language during play

Play observation: Milestones

• By 36 months– Engages in role play with toys and other children– Uses toys to act out scenarios or plays– Acts out scenarios in which child was not directly

involved (e.g., fire fighter fighting a fire)– Engages in highly imaginative play (e.g., exploring

planets on a spaceship)

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Assessment of Play

• Symbolic Play Test (Lowe & Costello, 1979)

• Communication and Symbolic Behaviour Scales (CSBS) (Wetherby & Prizant, 2003)

• Play Scale (Carpenter 1987)

• Symbolic Play Scale Checklist (Westby 1980)

Speech Pathology and Play Assessment

• What is our role in assessing play?• Why do we need to consider play?• Need to consider – symbolic play

development and also social play development

• Spontaneous and elicited play

For children with ASD (Prelock, 2006)

• In what ways does the child use objects?• In what ways does the child explore objects?• How does language affect the child’s play?• How does the social context affect the child’s play?• How does the chld’s independent play look cf peer

play?• Does the play look different in structured vs

unstructured situations, prompted/elicited vs spontaneous?

Materials

• Need to consider the toys used in a play assessment – 2 years – blocks, pull and wind up toys, dolls– 3 years – books, clothes, puppets, barn with

animals– 5 years + toys with many pieces, action figures– Older children

PLAY AND GESTURE OBSERVATION SHEET Student: ________________________ Date/Age: ________________________

Observations by: ________________________ PLAY

TOYS/EQUIPMENT USED BEHAVIOURS OBSERVED - HOW THE CHILD INTERACTED WITH TOYS

GESTURES OBSERVED IN CONVERSATION OR PLAY: ______________________________________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________

SUMMARY OF MAIN TYPES OF GESTURE AND PLAY OBSERVED: TYPE OF GESTURE/PLAY

10-15mth level 15-18 mth level 18-21 mth level 21-24 mth level

DEICTIC Show

Deictic gesture + word

Give

Point

Ritualised request

SYMBOLIC Recognitory gesture Self-directed play Other-directed play Planned multi-scheme play

Play scheme without object

Sequence of play schemes

REPRESENTATIONAL Representational gestures

Representational gestures accompany speech

Gesture + word combinations used to express two-word meanings

NEXT TYPES OF PLAY/GESTURES TO BE DEVELOPED: ______________________________________________________________________________________________________________________________________________________________________

J.Brown (2013), Macq. Uni, Sp & H Clinic, based on: Paul, R., & Norbury, C. F. (2012). Language Disorders: from Infancy through Adolescence. Listening, Speaking, Reading, Writing, and Communicating (4th edition). St Louis, MI: Mosby.

Parent-Child Interactions

Formal or informal analysisCharacteristics of typical mother infant communication: (Rossetti 2001)

• Short utterance length with simple syntax• Small core vocabulary• Topics limited to here and now• Heightened facial expression and gesture• Meaningful responses – turntaking and prolonging• Frequent verbal rituals

What should we look for in parent-child interactions? (Paul & Norbury 2012)

• Pleasure and positive affect• Responsiveness to child’s cues of readiness to interact• Acceptance of baby’s overall style and temperament• Reciprocity and mutuality• Appropriateness of choice of objects and activities for

interactions • Lang stimulation and responsiveness • Encouragement of joint attention and scaffolding the

child’s participation

Areas to assess in children with Emerging Language (approx 18mth-3yrs)

Areas to assess in toddlers:• Communicative intentions/pragmatics• Gesture• Play• Comprehension• Expression (lexical, semantic-syntactic)• Phonology/speech

Language sampling

• Spontaneous or elicited sample of child’s, speech, language, and communication– Where: Home, classroom/preschool, clinic– With whom: Parent, sibling, therapist– Activity: Conversation, play, or recall of event• Materials?

• Quantitative and qualitative information

Advantages

• Language in a naturalistic context – unique opportunity to survey vocabulary,

grammar, and pragmatic skills in more naturalistic contexts

• Useful way to document change

What can it sample?

• Pre-linguistic skills• Vocabulary• Grammatical complexity• Syntactic structures and sentence length• Pragmatic functions

Consider conversational partners

• Use familiar conversation partners with young children

• Instruct caregivers to be nondirective, interested, and responsive– E.g., talk about what they and the child are doing

What to use to get the best sample

• Low structure interactions (follow child’s lead)• Toys that allow multiple episodes with symbolic

play – toys that lend themselves to ‘pretending’• Mix of familiar and non-familiar toys• Interesting toys• BooksMore on the ‘how’ of language sampling next week

Ax task

• Look at DVD of Jack 2;1 years• What pre-linguistic, play, gesture and

communicative intentional observations can you make?

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Assessment Tools for Emerging Language

• MacArthur-Bates Communicative Development Inventories (Fenson et al, 1989)

• Preschool Language Scale-4 and 5 (Zimmerman et al, 2004, 2011)

• Reynell Developmental Language Scales III (Edwards et al, 1999)

• Expressive One Word Picture Vocabulary Test (EOWPVT)& Receptive One Word Picture Vocabulary test (Brownell, 2000)

• Rossetti Infant-Toddler Scale (Rossetti, 2006)• Receptive-Expressive Emergent Language Scale – 3rd ed

(REEL-3)(Bzoch, League & Brown, 2003)

• Communication and Symbolic Behaviour Scales (CSBS) Normed Edition (Wetherby & Prizant, 2003)

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Assessing ComprehensionStandardised tests• comprehension and expression subtests, eg PLS-5, Reynell III• single-word vocabulary, e.g. Peabody Picture Vocabulary, CSBS

Probe (criterion referenced tasks)• Does the child understand any words without the support of non-linguistic

cues?• Can the child understand sentences?• Can the child respond to different questions?• Does s/he understand semantic relations?

• Parent report on language checklists – elicit specific examples• Observe responses in conversation - don’t rely on this alone

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Strategies for Assessment of Comprehension (Miller & Paul, 1995)

• Comprehension of single words without non-linguistic cues [12 – 18 mth level of functioning]

– Nouns – 6 to 8 objects (Instruction: “Give me X”, “Show me X”)

– Verbs – kiss, pat, throw, push,etc. (Instruction: “Do X”)• Comprehension of two-word semntic relations, e.g.

action-object (“Kiss the doll”) [18 – 24 mth level of functioning]:

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Strategies for Assessment of Comprehension (Miller & Paul, 1995)

• Comprehension of three-word semantic relations, e.g. agent-action-object (“Let the doll sit on the chair”) [24 – 36 mth level of functioning]

• If successful at last level, use a standardised test

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Assessment of Receptive Language

• Common comprehension testing pattern at this stage:– Simple Nouns (with gesture if required)– Simple verbs (with gesture if required)– Action – object semantic relations (unusual

associations first e.g. hug the shoe)– Agent - action – object (known vocab items then

more difficult but age appropriate items)– Think about ‘information carrying units’ or ‘key

words’• After this use a standardised test

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Assessment of Expressive Vocabulary

• Some info from standardised assessments – PLS 4/5

• Identify vocabulary from recorded language sample

• Parent report – MacArthur CDI; Vineland Adaptive Behavior Scales – Communication Domain; informal;

What do we do when the parent’s report is quite different from what we see in a session in terms of number and types of words?

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Assessing Syntax-Semantics

• Frequency of word combinations– Frequency of single vs. 2 word combinations (>50% of

utterances should be 2-word combinations by 24 months)

– TTR– Parental diary

• Semantic relations expressed– Brown (1973)– Developmental Sentence Analysis (Lee, 1973)– Lahey (1988) – content/form assessment

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Assessing Syntax-Semantics

• MLU will be either 0 – 1at this stage and is very easy to compute

• Probably won’t use complex grammatical analysis (particularly under 50 words – usually there are few 2 word combinations under 50 wrds)

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Diagnosis informed by considering..

• Child’s performance compared to standardized normative data

• Child’s performance on criterion-referenced tasks

• Conversational partners’ perspective• Communicative expectations• Functional language skills

Homework Task

Plan an assessment of 2;4 year old:What communicative intentions, gestures, play, receptive language, expressive language, sounds/phonology would you be looking for?

Ideas for eliciting or probing for those areas in terms of what equipment or strategy you might use. How will you try to elicit behaviours if you don’t see them?

References• Crais, E., Watson, L., & Baranek, G. (2009). Use of gesture development in profiling children’s prelinguistic

communication skills. American Journal of Speech-Language Pathology, 18 (1), 95-108.• Haynes, W. O., Pindzola, R. H. (2008). Diagnosis and evaluation in Speech Pathology (7th edition). Boston:

Allyn and Bacon. • Miller, J. & Paul, R. (1995). The clinical assessment of language comprehension. Baltimore, MD: Paul H.

Brookes.• Owens, R. E. (2011). Language development: An introduction (8th ed.). Boston, MA: Pearson Education.• Owens, R. E. (2004). Language disorders: a functional approach to assessment and intervention (4th

edition). Boston: Allyn and Bacon. • Paul, R., & Norbury, C. F. (2011). Language disorders from infancy through adolescence: Listening,

speaking, reading, writing, and communicating (4th ed.). St. Louis: Mosby Elsevier.• Prelock, Patricia A (2006). Autism spectrum disorders : issues in assessment and intervention. Pro-Ed,

Austin, Tex• Yoder, P., Warren, S., & McCathren, R. (1998). Determining spoken language prognosis in children with

developmental disabilities. American Journal of Speech Language Pathology, 7, 77-87.

Early Intervention Training Institute Newsletter (1998). Downloaded August 2013. http://www.einstein.yu.edu/uploadedfiles/Centers/childrens-evaluation-rehabilitation/EITI%2005%201997%201998%20Winter.pdf