Assessment of Speech and Language Development in the Young Child

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Assessment

of Speech

and

Language

Development

in the

Young

Child

Martin Bax, Hilary Hart, and Sue Jenkins

From the Thomas Coram Research Unit and St Mary’s Hospital Medical School, London

ABSTRACT. A clinical method of assessing speech and language development in preschool children is described. Sixty-two 3-year-old children were assessed by a pedia-trician, a speech therapist, and a psychologist. In 55 children there was agreement between all three exam-iners. Three children with articulation problems were rated as having normal comprehensive and expressive language by the psychologist. Three children were rated as having normal speech and language development by the pediatrician and speech therapist but delayed by the psychologist; all three had behavior problems. One fur-ther child rated as having a speech and language problem by the pediatrician was rated as normal by the speech therapist and psychologist. It is concluded that pediatri-cians can make reliable assessments of speech and lan-guage development. Pediatrics 66:350-354, 1980; devel-opmental assessment, speech and language testing.

Speech and language disorders are the

common-est development problems affecting preschool

chil-dren. We have found a prevalence of speech

prob-lems in 14% of 3-year-old children and 5.5% of

4/2-year-old children in an area of central London.’

Other studies have reported rather different rates2;

the National Child Development study found 1.4%

of children aged 7 years with largely unintelligible speech and a larger group with some speech

disor-der.3 Delayed and disordered speech development has been found to precede later reading and writing difficulties4 and children with reading difficulties are known to go on to have difficulties throughout their school career and possibly later.5’6 In view of

the seriousness therefore of the condition, and in

order for further diagnostic appraisal to be made of

these young children, the diagnosis should be made

as

early as possible. This can be done as part of the routine developmental screening process by a

doc-Received for publication Aug 15, 1979: accepted Jan 18, 1980. Reprint requests to (MB.) Research Community Paediatricians, Thomas Coram Research Unit, 41 Brunswick Sq, London WCIN LAZ, England.

tor or health aide but it is important that it should

be done reliably and validly. The purpose of the present communication is to report our experience

of developmental assessment of the child in

rela-tionship to speech and language and the reliability

of such assessments. Frankenberg et al7 report on the overall validity of the Denver Developmental

Screening Test and report correlations between

that test and a variety of more formal psychological

tests. They report good correlation not only with

the whole Denver scale but with the subsection of

the test concerned with language development.

Our own approach to development of the young

child is less formal than that proposed in the Denver

scale and islargely based on the sorts of techniques outlined in the volume on developmental screening by Egan et al.8 We have reasons for preferring this less formal approach in that it allows us to assess

the child more rapidly, an important consideration

if an adequate health service is to be applied to a

whole population. Moreover, the young child is

often resistant to formal testing; if asked to build a

tower of bricks he may prefer to put them in a line;

he may refuse to look at some pictures offered by

the examiner but talk readily to his mother about

something else. We like to take advantage of the

young child’s behavior and allow him partly to

direct our examination as we find this the most

speedy and efficient way of assessing young

chil-dren. Furthermore, our aim as physicians is not to

get a developmental quotient (which we think is

unreliable at this age) but to decide which children

are abnormal and require help. Nevertheless, it is

important to see that such an approach reliably

identifies those children who have a speech and

language problem. In this paper we are reporting

the results of one such study.

PEDIATRIC ASSESSMENT OF SPEECH AND

LANGUAGE

When the child enters the room for this pediatric

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deliber-ately start by talking to the mother and taking the history from her and allow the child to stand by her

or, if he wants to, move immediately to the low

table placed close by her on which there are usually some toys. We do not, therefore, initiate

conversa-tions straight away but if the child starts talking of

course we respond. We also observe and listen to

any mother/child interactions. Soon, we can start

play at the low table and we will usually carry out

assessment of nonverbal items and fine motor func-tions first before asking the child to name pictures or toys.

The materials used must be familiar to the child

and relevant to the environment from which he

comes. London children aged 3 years may

call a

sheep or acow a dog but readily distinguish between

a red bus and a lorry, although children who have

recently emigrated to this country and who have

not been out very much may be better off with

domestic objects from the home. Children who have

little experience of looking at books may perform badly with pictures but do better with solid objects. We use, therefore, the testing material in the

STY-CAR (available from the National Foundation for

Educational Research, Darville House, 2 Oxford

Road East, Windsor, Berks FL4 1DR) sets and have

various additional equipment of our own. We all

carry the Michael Reed hearing test cards

(avail-able from National Institute for the Deaf, Gower

Street, London WC1) which can be used to test

vocabulary and various series of pictures such as those on the Renfew test.

Children in our longitudinal studies are routinely

seen at 6 weeks, 6 months, 1 year, 18 months, 2, 3,

and 4#{189}years of age. At 18 months we score the

number of words we actually hear the child use (1

to 5, 6 to 10, 10 or more); but at this age we may

hear little speech at the clinic and we accept

paren-tal report. By the time we see the child at the age of 2years, we expect him to be displaying vocabu-lary to us of far more than ten words though again

we do not precisely count the number he uses. We

expect to hear him combining two or three words

to make sentences and this is also scored, but again

we then make our own estimate of the child’s

per-formance. By age 3 years, we are a little more

formal, asking him to point to his eyes, nose, and

mouth, and with picture cards to elicit some words

we try to get him to talk about something to us;

usually, domestic issues are the easiest ones. For the examination at age 4#{189}-years, we expect to hear

many of the words either from the Reed card or the

STYCAR and we listen specifically to certain words

to check consonantal development. We expect the

child now to produce reasonably complex sentences

and to carry on a conversation with us. We get the

child to repeat a sentence. We emphasize that we

try to make an assessment of whether the child’s

speech and language is normal, possibly abnormal,

or abnormal and do not attempt to make any rating

of the normal child’s level of development.

The norms for speech and language development

in children are reported in many standard texts of

normal child development (eg, Griffiths, 1970)

al-though the clinical evidence on which they are

based is quite slight. A 3-year-old child is expected

to have a vocabulary of more than 300 words and

to make simple sentences whereas a 4#{189}-year-old child will have a vocabulary approaching 500 words and should be able to construct sentences with a

more complicated syntax and of more than seven

words. At age 3 years, therefore, a child who was barely using sentences and had a very restricted

vocabulary would be described as abnormal and at

age 4#{189}years, a child who made only one or two

word sentences and again whose vocabulary was

poor, that is to say he failed to identify the many

common pictures and toys we have around in the

clinic, would be rated as abnormal. In terms of

articulation we specifically score the consonantal

souncIs as these are

consonantal sounds which are either acquired late or commonly substituted (see Ingram’#{176}).

To get a reliable assessment of the child’s speech

and language, the doctor or health aide must be

able to develop a good social relationship with the child. The geography of the room is important in this connection. The doctor should not sit across

a desk from the child and should be informally

dressed and accustomed to crouching down so that

he is at the child’s eye level and not bending down

over him. The child will often point to objects

before he will speak and will speak to his mother before he will talk to a stranger. If he is shy he will be very conscious of adults and their physical prox-imity and a fierce eye regard wifi inhibit the child’s

functioning. The parents should be present during

the examination; the siblings should be present if

they are a help and not a hindrance.

The last thing a shy young child wifi do is speak to a stranger. It is less demanding for him to handle

objects-bricks, toy cars, and so on-and slowly

participate in playing with them. Next he may point to or pick up an object if casually asked, “Where is the car?” and only finally will he start whispering words. Pausing and waiting too long is never a good idea; keep actively playing and talking yourself and the child will join in. If formally asked to do things,

he may refuse but when he does something that

elicits a positive comment he is more likely to move onto another activity.

All the children, of course, have a full

develop-mental assessment and physical examination

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studies on these children have been reported pre-viously.’ In addition, we also take a medical and

developmental history from the mother and make a behavioral assessment of the child, based largely

on the mother’s report and also on observation of

the child at the time of the examination. With the

3- and 4#{189}-year-old children we almost always see

the children in the health room of their nursery

school where the child, of course, is in a familiar

atmosphere and indeed if we have any difficulties

assessing the child in the medical room we would

go down and listen to him in the nursery class and

playground situation. The present report is

con-cerned only with the 3-year-old children.

METHODS

Sixty-two children representing a majority of the

3-year-old children in a geographically defined area

in London who were attending the Coram

Chil-dren’s Centre had such an assessment. All of the

children were seen by the pediatricians with one or

both of their parents, usually the mother, and the assessment reported here was always based on our findings and not on the history derived from the

parent (we have reported our work on the

devel-opmental history taking elsewhere”).

In addition, all children were seen independently

by two psychologists from the Thomas Coram

Re-search Unit who carried out a Reynell

Develop-mental Language Scale (RDLS) on the children

and these assessments are made without prior

knowledge of the clinician’s findings. The RDLS is a standardized assessment consisting of a compre-hensive and an expressive scale.’2 In the

compre-hension section the child is required to identify and

carry out instructions of graded lengths and

com-plexity using familiar household items and minia-ture toys. The expressive scale is divided into three

parts: (1) a structure section which provides an

assessment of the child’s grammatical development

from his spontaneous conversations during the

as-sessment session; (2) vocabulary-the child is

re-quired to name household items and pictures; and

(3) contents section which assesses the child’s abil-ities to use language descriptively using action pic-tures. The RDLS does not assess articulation. The

children were also independently assessed by a

speech therapist (pathologist) who had recently joined the research staff. She had had experience working with one member of the staff previously

and they had discussed methods of assessment

to-gether, but she had not been involved in the

elab-oration of the clinical assessment the doctors

car-ried out and no discussion took place about the

methods of assessment she used in this study.

We do not intend to go into the details of the

types of assessment the speech therapist used, but

initially the therapist observed the children in their

classroom, recording in writing examples of

inter-action with staff or other children, noting responses

indicating comprehension, observing the use of ges-ture, and transcribing utterances. She also observed

each child on his own in her own room during a

play session in which she participated using dolls, teacups, dolls furniture, and some simple children’s books. In some incidences she recorded this session for a later analysis. She matched the data collected

from these observations with the norms collated by

Sheridan,’3 Grifflths,9 and Crystal’4-the choice of

further assessments was directed by her initial find-ings.

RESULTS

Out of the 62 children there were 47 who both

the doctor and speech therapist agreed were normal

and all these children scored better than -1.5 SD

on expression on the RDLS. Eight children, seven

boys and one girl, were assessed as definitely

ab-normal by both the doctor and the speech therapist and all eight scored lower than -1.5 SD on expres-sion in the RDLS (Table). A further three children, all boys, were thought to be abnormal by the doctor

and speech therapist but scored above -1.5 SD on

the RDLS. All three of these children had

articu-lation problems and in fact two of them had been

drawn to the attention of the doctors by teachers

because their speech was uninteffigible. (A.E. and

L.R.).

A further three children, all girls, scored below

-1.5 SD on the RDLS but were scored by both the

doctor and speech therapist as having normal

speech and language development. On the other

hand, all three children had been scored as having

a definite behavior problem and indeed, the

psy-chologist noted difficulty in cooperation with them

during the RDLS testing. Two of these children

(K.C. and K.C.) were sisters and were well known

to the medical team because of their difficult family

background with a depressed mother and a strict

father who regularly beat the children. They were

withdrawn and frightened children and it is not

surprising that they performed poorly in the stan-dardized test situation. The third child (S.M.) also

comes from a nonoptimal background with a single

depressed mother and she was highly active and

had a poor attention span. Observation of her

lan-guage during a play situation convinced both doctor

and speech therapist that her level of language

comprehension was essentially normal. It is perhaps

worth remarking here that we have been able to

demonstrate in our studies an association between

disturbed development and speech and language

delay.’5

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TABLE. Results of Speech and Language Assessment by Doctor, Speech Therapist, and Reynell Developmental Language Scale (RDLS)

Speech and Language Assessment Score of <-1.5 SD on RDLS Score of >-1.5 SD on RDLS (n = 61)*

No. % No. %

Rated normal by doctor and 47 77 3t 5

speech therapist

Rated abnormal by doctor 3 5 8 13

* One additional child was assessed as abnormal by the doctor, normal by

the speech therapist, and scored >-1.5 SD on RDLS. He also had a behavior disorder.

t These three children had definite behavior disorders. :1:These three children had articulation problems.

having definitely abnormal speech and language by

the doctor at age 3 years but regarded as normal by

the speech therapist when she saw him

(unfortu-nately, a couple of months later). This child scored

-0.8 SD on comprehension and 0.1 on expression

on the RDLS and so the speech and language were

clearly within normal limits. Again, the child was in

the definitely abnormal behavior pattern group

being aggressive, difficult to control, and having

frequent temper tantrums. In summary, there is

agreement between doctor, speech therapist and

the psychologist’s assessment on the RDLS on 55

of the 62 (47 normal and eight definitely abnomal).

Three children rated normal on the RDLS had

articulation problems and three rated abnormal on

the RDLS but normal by the doctor and speech

therapist had behavior problems. One further child

with a behavior problem was rated abnormal by the

doctor but not by the speech therapist or the

psy-chologist on testing. No cases of speech disorder

were missed by the medical team and

over-report-ing

occurred in one case only.

IMPLICATIONS

After the study the speech therapists and doctors discussed their findings although at this time they did not have the results of the psychologist’s Rey-nell test. Repeat hearing assessment was requested

for any child with erratic response to sound or who

seemed to have a low level of comprehension-one

child was found to have intermittent bouts of

con-ductive hearing loss and eventually had a

myrin-gotomy. Discussions with the teachers followed and

together the speech therapist and teachers

deter-mined whether the delayed language development

was in line with general development or whether

there was evidence of overall intellectual retarda-tion. In none of the children in the study was there believed to be significant retardation. Following this, delayed syntactical development was initially

assessed informally and the speech therapist made

transcripts of the child’s language in the classroom. The child then received periods of unstructured

one-to-one language stimulation from the therapist

in conjunction with the chosen member of staff.

Where syntactical delay was found to be severe and

intransigent, syntax was analyzed by the method

outlined by Crystal et al’4 and treatment was

initi-ated in time with the normal acquisition of syntax. We have reported one ofthese children elsewhere.’6

For other children the staff was encouraged to

stimulate language development by individual

con-tact with the child.

DISCUSSION

These findings indicate that it is entirely possible for a trained doctor to identify reliably children who have language delay at the age of 3 years. In carry-ing out a routine clinical assessment of a child at tb.is age, we would anticipate doing a full medical

and development assessment in approximately 20

minutes and it is worth emphasizing that the RDLS

assessment alone takes approximately #{189}hour and

carrying out a formal developmental screening test

takes about the same time. We think our approach, therefore, to testing is both practical and efficient.

Once the child of 3 to 3#{189}years of age has been reliably identified as having a speech and language delay, clearly the issue arises as to what form

treat-ment should take. We have carried out one

con-trolled trial of a home-based speech therapy

pro-gram in a different area and we were not able to

demonstrate a statistically significant result com-paring children who did not participate in the pro-gram and children who did; on the other hand the act of diagnosis often affected the parent so that he or she might decide, for example, to stop work or to

put the child into a playgroup and this should affect

the outcome. We also know that among the children

in the 3-year-old group are probably some who are

late “normal” in development but there are some

children whose speech and language is abnormal

and it is probably these for whom treatment is most

necessary. We have given an account of one such

child.’6

The causes of speech and language delay are

complex representing a close interaction between

the biological status of the child and the

environ-ment. Children with speech and language delay are

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among all social groups and their outlook is not

necessarily very good. It is important to understand

with a developmental disorder that the manifests-tion at one age may differ from another age, so that

the child of age 3 years who does not talk may go

on to be a child of 13, 14, or 15 years old in social

difficulty.’7 It is for this reason that we believe that

simple methods of identifying these children are of

extreme importance: the benefits of helping them

might be great.

ACKNOWLEDGMENTS

We thank our colleagues at the Thomas Coram

Re-search Unit for their help, in particular the late Professor Jack Tizard, Ian Plewis, Gill Pinkerton, and Martin Hughes. We also thank Pam Stevenson, speech therapist, who assessed all the children in this study.

REFERENCES

1. Bax M, Hart H: Health needs of preschool children. Arch Dis Child 5184S, 1976

2. Stevenson J, Richman N: The prevalence of language delay in a population of three year old children and it association with general retardation. Dev Med Child Neurol 18:431, 1976 3. Peckham CS: Speech defect in a national sample of children

aged seven years. Br J Disord Commun 82: 1973

4. Ingram TTS: Early Experience and Visual Information in Perceptual and Reading Disorders. Washington, DC, Na-tional Academy of Sciences, 1970

5. Rutter MS, Tizard J, Whitmore K: Education, Health and Behaviour. London, Longman, 1970

6. Critchley M: Development Dyslexia. London, Heinemann, 1978

7. Frankenburg WK, Camp BW, Van Natta PA, et al: Relia-biity and stability of the Denver Developmental Screening Test. ChildDev42:1315, 1971

8. Egan D, Illingworth RS, MacKeith RC: Developmental screening 0-5 years. Clinics in DevelopmentalMedicine, No. 30. London, Heinemann, 1969

9. Griffiths R: The Abilities of Young Children. London, Child Development Research Centre, 1970

10. Ingram TTS: Developmental disorders of speech, in Vinken PJ, Bruyn GW (eds): Handbook of Clinical Neurology, ed 4. Amsterdam, North Holland Publishing Co, 1969, p 407 11. Hart H, Bax, M, Jenkins 5: The value of a developmental

history. Dev Med Child Neurol 20:442, 1978

12. Reynell J: Reynell Developmental Language Scales. Man-ual Experimental Edition. Windsor, NFER, 1969

13. Sheridan MD: The Developmental Progress oflnfants and Young Children. London, Her Majesty’s Stationary Office, 1968

14. Crystal D, Fletcher P, Garmen M: The Grammatical

Anal-ysis of Languqge Disability: A Procedure for Assessment and Remediation. London, Edward Arnold, 1976 15. Jenkins S, Bax M, Hart H: Behaviour problems in preschool

children. J Child Psychol Psychiatry 21:5, 1980

16. Bax MCO, Stevenson P: Analysis of a developmental lan-guage delay. Proc R Soc Med 70:727, 1977

17. Bax MCO: Developmental assessment is a necessity. Proc R Soc Med 69:387, 1976

SOME DETERMINANTS OF MOTHER-INFANT INTERACTION IN THE PREMATURE NURSERY

This study examines the relative contribution to early maternal behavior of

the psychosocial history of the mother, perinatal events, and infant behavior.

The interaction of 32 mothers and their very low birth weight infants was

observed both during maternal visits to the premature nursery and during

feedings in the infants’ first three months at home. It was found that mothers showed a consistent level of activity vis-a-vis their infants; that this activity level was related to their responsivity to behavioral cues from the infants; and

that it was predictive of caretaking patterns at home. Only psychological

variables within the mothers’ background were found to be significantly related to these maternal activity patterns.

R.H.R.

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1980;66;350

Pediatrics

Martin Bax, Hilary Hart and Sue Jenkins