Language Delay in Young Children: Assessment and Intervention Leslie Rescorla Bryn Mawr College [email protected] Philadelphia Early Intervention Staff November, 2006 OVERVIEW Part I • Normal language development • Screening for language delay • Outcomes of children with SLS & late talkers Part II • Assessment and differential diagnosis • Case illustrations • Intervention approaches Normal Language Acquisition Language acquisition is a rapid process • 12 months: a few words • mama, dada, dog • 18 months: many children have 50 words and some are combining words • more juice, allgone car • 24 months: expect 50 words and combinations • mean: 150-200 words on LDS, 2-3 word phrases • telegraphic (this my cup, baby eat cookie) • 30 months: some morphemes • plurals, ing, in/on, possessive Rapid Changes from 2.5 - 4 Years Short sentences by age 3 • using complete sentences (SVO) • can ask questions, use negatives • many morphemes: articles, -ed, -s,’s By age 4, producing complex sentences • • • • using clauses, multi-verb sentences auxiliary and copula forms present can carry on conversations can talk about past, present, and future Language Delay Language delay: a heterogeneous condition • not a unitary disease like chicken pox Is language delay primary vs. secondary? • language problem secondary to other disorder? • rule out hearing impairment, mental retardation, and autism/PDD -- all associated w/ language problems • language delay is primary • toddlers: often called late talkers (LTs) • preschoolers: usually called SLI Subtype • Expressive, receptive, or both? Language Delay: Four Domains Phonological: sound system of language • problem in phoneme perception, categorization • problem discriminating, processing rapidly? • problem in phoneme production • lack reduplicated babbling by 7-10 months • small repertoire, few sounds - especially consonants Lexical/semantic: vocabulary system • vocabulary delay: fewer than 50 words by 2 • most late talkers have <25 words by 24-30 mos. Four Domains, continued Grammar: syntax & morphology • Few/no phrases @ 24 mos • 3-4 word sentences only by 4 years • poor on rec & exp w/ compound, complex sentences • delay in morpheme acquisition • slow to acquire morphemes, especially verbal ones • telegraphic speech - omission in obligatory contexts Pragmatics: communicative use of language • problems comprehending & indicating intent? • gesture, nonverbal, vocalization • problems in dialogue, conversation Language Screening Language delay is a public health problem • concerns about language delay prompt most referrals of young children • language delay associated with many other problems (MR, PDD, hearing impairment) • early language is a major risk factor for later learning and psychiatric problems • early identification & intervention desirable Language Development Survey (LDS) • screening tool for language delay in toddlers • co-normed with Child Behavior Checklist Language Development Survey Language Development Survey (LDS) • checklist completed by parents of children 18-35 months • 310 vocabulary words arranged by semantic category • Vocabulary score : sum of words used spontaneously • Does child combine words into phrases? • If yes, parent writes gives five longest & best phrases • mean number of words calculated for the five phrases LDS norms • Vocabulary score norms - separately by gender – 18-23, 24-29, and 30-35 months age groups • Mean Phrase Length – 24-29 & 30-35 months age groups with genders combined Psychometric Properties of LDS Reliability • Test-retest reliability: .97-.99 • Cronbach’s alpha: .99 Validity • Correlations with expressive language tests: .66-.87 • Sensitivity generally >80%, specificity > 85% • Predictive validity from age 2 (Rescorla, 2002) (N=59) • age 7 vocabulary = .63 • age 8 grammar = .41 • age 6 phonological awareness =.44 • age 8 listening comprehension = .43 • age 8 & age 9 reading = .39 & .34 Language Delay Categorical vs. dimensional views • Categorical: SLI is discrete illness • at extreme: genetically based defect prevents mastery of syntax and morphology systems • Dimensional: language spectrum • delay, disorder are at tail of normal distribution • less severe - outgrow it earlier, fewer areas • more severe – persist longer, more areas affected Late talkers vs. kids with SLI • categorical: LTs not SLI (most outgrow it) • dimensional: less severe on same spectrum Language Endowment Spectrum NLI SLI LTs severe LI chronic LI Average language skills >average language skills superior, language skills Outcomes of Children with SLI Tomblin kindergarten LI study to 2nd grade • 581 children identified in school-based study • 231 LI & 373 controls followed to 2nd grade – did not require NV>V discrepancy (not SLI) • >1.5 SD difference in language and reading • 52% of SLIs vs. 9% of controls had RD Bishop age 4 SLI follow-up study • 44% of sample had “good outcome” • average in language & reading by 5-6 and at age 8 • BUT: worse at 15 than controls on many language & reading measures • 56% “poor outcome” worse at all ages Our Late Talker Research Late Talkers • Bayley MDI > 85 • Reynell Receptive Language score within 3 months of CA • Reynell Expressive Language score at least 6 months below CA • < 50 words or no word combinations on LDS Comparison Children • Bayley MDI > 85 • Reynell Receptive Language score within 3 months of CA • Reynell Expressive Language score within 3 months of CA • > 50 words and word combinations on LDS Age 17 Follow-Up Groups INTAKE MEASURES Late Talkers Typical Developers (N=26) (N=23) Age in months 26.62 25.83 Hollingshead SES 53.69 55.74 Bayley Nonverbal 14.15 15.17 Reynell Receptive z .15 1.03 *** Reynell Expressive z -1.62 .36 *** LDS Total Vocabulary 24.54 235.17 *** *** No significant differences on intake measures within LT and TD groups between those seen and not seen at age 17 = no selective attrition Language Outcomes Ages 5-8 1 0.8 0.6 0.4 0.2 0 -0.2 -0.4 -0.6 Age 5 Age 6 LT Age 7 TD Age 8 Mean Standard Score Language Outcomes by Group at 6,7,& 8 14 12 10 8 6 4 2 0 Vocab 6 Grammar 6 Sent. Imit 6 Vocab 7 Grammar 7 Language Measure LT TD Vocab 8 Grammar List Comp 8 8 Phonological Outcomes Ages 5-7 0.4 0.3 0.2 0.1 0 -0.1 -0.2 -0.3 Age 5 Age 6 LT TD Age 7 Reading Outcomes Ages 6-9 0.3 0.2 0.1 0 LT TD -0.1 -0.2 -0.3 Age 6 Age 7 Age 8 Age 9 Reading Outcomes by Group at 6, 7, 8, & 9 Mean Standard Score 115 110 105 100 95 90 85 Reading 6 Reading 7 Reading 8 Reading Measure LT TD Reading 9 Age 13 Outcomes By Group 14 12 Score 10 8 6 4 2 0 Vocab 13 Grammar 13 Verb Mem 13 Age 13 Measure LT TD Reading 13 Reading Comp 13 Age 17 Outcomes Measure LT TD d Vocabulary Grammar Verbal Memory Reading 13.5 105.1 10.0 105.4 15.5** 113.4** 11.8** 109.2 .80 .86 .90 .39 Correlations Among Age 17 Measures Grammar Verbal Memory Rdg/Writing Vocabulary Grammar Verbal Memory .65* .39** .63** .70** .57** .38** Preschool Predictors of Age 17 Outcomes 0.6 Correlation 0.5 0.4 0.3 0.2 0.1 0 Vocab 17 Grammar 17 Verb Mem 17 Reading 17 Age 13 Measure LDS 2 Grammar 3 Grammar 4 Grammar 5 Our Outcome Conclusions • Most LTs have normal language skills by 5 • LTs are consistently inferior to comparison children in vocabulary, grammar, and verbal memory skills through age 17. • Late talkers weaker in decoding at 8 and 9 • LTs worse in comprehension at 13 • Age 17 vocabulary, grammar, verbal memory, and reading significantly intercorrelate • LDS at 2 predicts outcome quite well Assessment of Language Skills Communicative intent (PDD? S-P LD?) • assess use of gestures, facial expression, grunts to communicate, range of intents expressed Play & Imitation (PDD?, MR? ) • assess spontaneous pretend play, ability to imitate modeled play schemes, representational skills Receptive language (R, E, or both delayed?) • ability to comprehend phrases, words, gestures Expressive language • use of phrases, words, vocalizations, babbling • phonetic repertoire, oral-motor skills Assessment of Cognitive & Social/Emotional Development Nonverbal ability (MR, develop. delay?) • puzzles, blocks, visual-motor skills, problemsolving, object permanence skills) Social relatedness (PDD? S-P LD?) • eye contact, joint attention, reciprocity, sociability Attention, Self-regulation (ADD?) • concentration, attention, impulse control, frustration tolerance, & temper management Assessment of Behavioral & Emotional Problems Assess adjustment broadly • best to collect data from different informants • tap broad range of emotional/behavioral problems • use standardized, normed measures CBCL/1.5 - 5 & C-TRF • Normed in general population sample • 99 problem items (0,1,2 scale) (not true, somewhat or sometimes true, very true or often true • write in concerns & best things about the child • norms for empirically based syndromes & DSM scales Relations Between Language Problems & Behavior Problems Children > age 5 • Many studies show a link between language and behavior problems Children at age 3 • language problems & behavior problems link found in two general population samples, but reduced when children w/ low IQ excluded Children < age 3 • results mixed: association varies with size, diversity, yield, and referral status of sample Case Example: Kenny Randall • Background information reported – Kenny Randall - age 30 months – nursery school teacher concerned because he did not interact much with other children and often talked to himself • Assessment process – parents completed the CBCL/1.5-5 – two teachers completed the C-TRF – ASEBA software scored the forms and produced the profiles Cross-Informant Comparison • Informants have different views of the child • Informants who see the child in different contexts have different perspectives on the • ASEBA software provides systematic comparisons between informants • informants are compared on items, syndromes, DSM-oriented scales, Internalizing, Externalizing, and Total Problems scores • level of agreement between informants = correlations, which can be compared to those for similar pairs of raters in the normative sample Case Example: Sam Harkin Background information reported • • • • Age 2-3, youngest of four children Walked early, good language comprehension Communicative with gestures and noises Requests labels of objects and pictures Assessment process • 2 hour office visit • play activities with psychologist and SLP • LDS and CBCL completed by parents Assessment Session Findings Clinical observations • • • • • • • • • Social, interactive, responsive, playful child Comprehension of many requests, labels Attentive, cooperative, persistent Enthusiastic, appropriate, reciprocal play Good problem-solving skills with toys Learned new skills with manipulative toys Easily engaged in pretend play No intelligible words, some jargon/grunts Joint attention, spontaneous sharing interests with parents and with examiners LDS/CBCL Findings LDS findings • No words reported - possibly says “dada” • Below 15th percentile for vocabulary • 39 words for boys, 83 words for girl • Below 20th percentile for phrase length • <2.35 for boys and girls 24-29 months CBCL results • In normal range on all CBCL syndromes & DSM-oriented scales • Only concern noted is expressive language delay Case Example: Melissa Kane Background information reported • • • • Age 2-10, oldest of two children Walked early, few phrases by 24 months Reported as active and difficult since infancy Reported to be irritable and overreactive Assessment process • 1 hour observation at daycare • 2 hour office visit • play and testing by early childhood team • CBCL/LDS completed by parents, C-TRFs completed by teachers Assessment Findings Daycare observations • Short attention span, active, fast-moving, intrusive • Noncompliant, controlling, demanding Office observations • Good cognitive and play skills • Impulsive, oppositional, active, demanding LDS/CBCL/TRF findings • LDS: 40% percentile for Vocabulary, 20th percentile for Mean Phrase Length – slight expressive delay • Elevated scores from most informants on: • Emotionally Reactive, Attention Problems, and Aggressive Behavior syndromes • DSM-oriented Attention Deficit Hyperactivity Problems and Oppositional Defiant Problems scales When To Provide Intervention? Link intervention decisions to diagnosis • hearing impairment --intervene immediately to improve hearing and to foster language • MR/DD - intervene immediately and broadly to foster development in all areas • PDD - intervene immediately to foster social relatedness, language, play, & flexibility (Kenny) • SLI combined type - intervene early to foster receptive language • SLI expressive only - consult and watch till 2, intervene by 2-6 if still not talking (Sam) Intervention: Behavioral Behavioral techniques • • • • • highly structured, data-based, decontextualized target sounds, words, phrases: drill to mastery set up discriminative stimuli for responding use shaping & prompt fading, build generalization use primary and secondary reinforcers • widely used with PDD & kids with severe behavioral impairments • may need if spontaneous communication, normal imitation, joint attention, & reciprocity are weak • can be effective in shaping communicative behaviors & increasing responses - but “unnatural” Intervention: Play-Based Intervention principles • model & promote language in natural interaction • build capacity for joint attention and communication through play with adult partner • stimulate words, phrases linked to child’s play activities and focus of attention • foster social connection, use mutual enjoyment to build imitative skills and reinforce communication • works best when kids have some appropriate play skills, social relatedness, & imitation skills • works best when receptive language skills and communicative intent are better • leads to more spontaneous use, when it works Linking Assessment to Intervention • if MR: gear therapy to MA-appropriate skills • if PDD: focus on eye contact, receptive language, imitation, communicative intent, basic words • if ADD: use methods to foster & sustain attention, reduce impulsivity while shaping language skills • if socially withdrawn & anxious: use play-based, social communication methods to foster relaxed interaction, encouragement of intent • if receptive skills delayed: focus on reliable responding to nouns, verbs, adjectives & preps Conclusions Early identification & treatment • although many children with early language delay show spontaneous remission, many don’t • best to screen at 2, monitor till 30 months, and intervene by 3 if not making good progress Use differential diagnosis framework • determine child’s profile of skills and deficits • determine if MR, PDD, R & E delay • assess general behavioral/emotional functioning Link intervention to assessment results • choose degree of structure, intensity to fit the case • use more “natural” methods IF they will work
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