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

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CHAPTER III

Assessment Methods for Young Children With Communications Disorders - Continued

In-Depth Assessment of Children With Communication Disorders

Several standardized tests and alternative assessment methods have been developed to provide a more in-depth assessment of children who have a possible communication disorder. These tests are intended to further evaluate children when a communication disorder is considered possible due to risk factors and clinical clues, parent or professional concerns, and/or positive screening test results.

In-depth assessment can be used in several ways to assess children with possible communication disorders, including to:

  • determine if a communication disorder is present
  • establish a specific diagnosis, and assess the severity and specific attributes of the communication disorder
  • determine if intervention is indicated, and aid in planning intervention strategies and selecting treatment targets
  • establish a baseline for measuring progress and evaluating treatment outcomes

The following recommendations address some of the specific techniques that are available for the in-depth assessment, especially the analysis of spontaneous language samples. Other techniques may be used but are not described in as great detail because no scientific studies were found that met the criteria for evidence.

General Approach for In-Depth Assessment of Communication Disorders

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

Recommendations

Goals of the in-depth speech/language assessment

  1. When screening suggests the child has a possible communication problem, an in-depth assessment by a speech/ language pathologist is recommended in order to determine if a communication disorder is present. [D2]
  1. In assessing a child with a confirmed communication problem, it is recommended that an in-depth assessment be used to:
  • establish a specific diagnosis, and assess the severity and specific attributes of the communication disorder
  • determine if intervention is indicated, and aid in planning intervention strategies and selecting treatment targets
  • establish a baseline for measuring progress and evaluating treatment outcomes [D2]

Aspects of the child's communication to be assessed

  1. It is recommended that an in-depth assessment focus on identifying the child’s strengths as well as delays and intervention needs. [D2]
  1. In planning the in-depth assessment, it is recommended that professionals share information about the assessment process with families. It is important to solicit parent concerns and questions that will assist in the choice of assessment materials and procedures. [D2]
  1. It is recommended that an in-depth speech/language evaluation include an assessment of the child's:
  • hearing ability and hearing history
  • history of speech-language development
  • oral-motor functioning and feeding history
  • expressive and receptive language performance (syntax, semantics, pragmatics, phonology)
  • social development
  • quality/resonance of voice (breath support, nasality of voice)
  • fluency (rate and flow of speech) [D2]

Interpreting and documenting the results of the assessment

  1. In assessing a child who has a possible communication disorder, it is very important that professionals use clinical judgment in addition to all information gathered about the child and not rely solely on test scores. [D2]
  1. It is important that all the methods, approaches, and results of the in-depth assessment be fully documented in the assessment report. [D2]
  1. It is important to document any alteration in the usual testing procedure because of the child's linguistic or cultural variation. [D2]

Communicating assessment results

  1. It is recommended that the results of the in-depth assessment be shared with the parents and other professionals caring for the child. [D2]

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  1. In reporting results of the assessment it is important to consider the impact on the family. [D2]
  1. It is important for parents to explore the possibility of a second or independent evaluation when they continue to have concerns about speech/language development and they disagree with the results of the assessment. [D2]

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When other evaluations are needed

  1. It is recommended that a formal speech/language assessment be completed within the context of a multidisciplinary assessment that evaluates the child across all developmental domains. [D2]

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  1. When assessment results confirm that there is a communication disorder, it is important to try to determine possible causes or contributing factors for the disorder. Following an evaluation by a speech language pathologist, a referral to an appropriate professional may be important because it may reveal:
  • an underlying or associated medical condition that may be treatable
  • genetic factors related to the communication disorder warranting genetic counseling or other interventions
  • environmental factors (such as family or physical factors) that may be addressed to help the child or the family
  • information about the prognosis for the child's development [D2]

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Specific Techniques for an In-Depth Assessment of Speech and Language

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

Recommendations

Need for standardized and alternative assessment approaches

  1. It is recommended that the in-depth assessment of young children with possible speech/language disorders include both standardized tests and alternative assessment approaches.
  • Standardized tests are important because of the objectivity and structure they offer to the assessment process, even though standardized test scores alone are insufficient to make a diagnosis.
  • Alternative approaches, such as an analysis of samples of the child's speech and language, are important because many dimensions of communication are not easily measured using standardized tests (such as pragmatics, discourse, voice, fluency, oral-motor, and feeding). [D1]

Specific components to be included in an in-depth assessment

  1. It is recommended that an in-depth assessment of a child who has a possible speech or language disorder include the following components (which are described in more detail in recommendations below):
  • standardized tests of expressive and receptive language
  • samples of spontaneous speech collected in a natural context
  • observations of communicative interactions
  • dynamic assessments of the child's language abilities [D1]
  1. Standardized tests of expressive and receptive language are recommended as part of the in-depth assessment. It is important that these tests be age appropriate and include both norm-referenced and criterion-referenced measures, as described below:
  • norm-referenced measures compare the child's performance to an appropriate peer group (matched for age, culture, and language)
  • criterion-referenced measures compare the child's performance with a established level or pre-determined standard [D1]
  1. Samples of spontaneous speech collected in natural contexts are recommended as part of in-depth assessment to determine level of language development and obtain a description of language form, content, and use. It is important to obtain and analyze age-appropriate speech samples (such as for infants one might analyze sounds in vocalizations while for older children one might analyze sentence length and structure). [A]
  1. Observations of communicative interactions between the caregiver and child are recommended as part of in-depth assessment since such observations can serve as a measure of the effectiveness of the child's communication. [D1]
  1. Dynamic assessments are recommended as part of in-depth assessment to help determine if a child is at a developmental level appropriate to learning specific new language skills. Such dynamic assessments may involve a brief trial of speech/language therapy to determine if the child is able to benefit from that type of therapy. [D1]

Analyzing spontaneous language samples

  1. Language measures derived from spontaneous language samples may be useful as a quantitative method for assessing speech and language problems in young children. Such measures include mean length of utterance (MLU), as well as measures of syntax (grammar), morphology (word structure), semantics (the meaning of words), and pragmatics (functional use of language).
  • Language measures from spontaneous language samples, such as MLU and percent structural errors, are a critical component of an in-depth assessment.
  • The use of objective measures from spontaneous language samples may provide a less biased, more ecologically valid approach to the measurement of language production in young children than standardized psychometric measures. [A]

Samples of spontaneous speech. This method involves systematically analyzing multiple aspects of spontaneous samples of language often gathered during standardized play sessions or other naturalistic settings. Detailed protocols are then used to analyze the elements and construction of the language sample.

The assessor gathers several samples of the child's actual language. Samples are sometimes obtained from audiotapes or videotapes of such sessions and later analyzed using systematic protocols.

Standardized techniques are used to analyze and score the language sample. Analysis of the speech sample first involves breaking it down to determine the elements of language used and the various elements that are combined to form communication. This includes specific methods for counting or measuring specific elements and constructions of the language sample. In order to provide an overall picture of the child's level of language development, these measurements are sometimes combined in mathematical algorithms or other calculations to arrive at summary measures such as the mean length of utterance (MLU).

Timing and setting of the in-depth assessment process

  1. It is recommended that assessment of the child's communication and language status be done using multiple measures across multiple occasions. This is important because young children have limited attention spans and stamina. In addition, a child's performance may vary depending on their familiarity and comfort with the examiner and the setting. [D1]

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  1. It is important to remember that there may be specific setting requirements for standardized tests and that alternative settings may influence the validity of the results. [D1]
  1. It is recommended that assessment include observation of the child's communication skills in play and language interaction patterns in his/her daily context. [D1]
  1. It is useful to assess the child's communication and language status with multiple communication partners (such as parents, sibling, and peers). At the very least, it is important that the child's communication and language skills be evaluated while the child is interacting with a parent. [D1]

Assessing Other Developmental Domains and Special Evaluations

Hearing, Oral-Motor/Feeding Problems, Augmentative Communication

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

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

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]
  1. 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

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

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  1. 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]
  1. 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