Our Evaluation Model
A child's level of communication development may be the best indicator of a developmental delay. Delays or disorders in communication development are the most prevalent symptom in children with disabilities (Wetherby & Prizant, 1996). When serious health or physical impairments are not present, a delay in language development may be the first evident symptom that a child is not developing normally. A language delay may be the primary problem or reflect delays in other domains (i.e., socioemotional, cognitive, motor, or sensory).
Most children develop their first words between 12 and 15 months, and it is common practice to wait until a child is 18 to 24 months and still not talking to refer the child for an evaluation. The challenge for service providers determining whether to make a referral for a developmental evaluation is two-fold. First, many children who are late in talking catch up on their own and need to be distinguished from children who will have persisting language problems. Second, children with delayed language skills need to be identified even earlier before language develops. Research over the past two decades has identified a collection of language predictors that are indicators of later language development and promise earlier and more accurate identification (McCathren, Warren, & Yoder, 1996; Wetherby & Prizant, 1993; 1996). The following 7 language predictors have been identified:
- Emotion and Use of Eye Gaze,
- Use of Communication,
- Use of Gestures,
- Use of Sounds,
- Use of Words,
- Understanding of Words, and
- Use of Objects.
These studies have demonstrated that children delayed only in the use of words are very likely to catch up on their own while children who are delayed also in several or many of the other predictors are likely to have persisting problems. Instead of waiting for children to start using words, evaluating these language predictors is a promising solution to improve early identification.
Wetherby and Prizant (2001) have developed an evaluation tool, the Communication and Symbolic Behavior Scales- Developmental Profile (CSBS-DP), that measures these 7 areas in young children. The purpose of the CSBS-DP is twofold: first, for early identification of children who have or are at-risk for developing a communication impairment; and second, to monitor changes in a child's communication, expressive speech, and symbolic behavior over time. Three components make up the CSBS-DP, each designed to measure the 7 language predictors listed above:
- a one-page Infant/Toddler Checklist completed by a parent in a doctor's office or child care facility;
- a four-page follow-up Caregiver Questionnaire (CQ); and
- a Behavior Sample (BS), taken while the child interacts with a parent present.
The Checklist and CQ provide important information about the child's abilities based on caregiver report. The BS uses a standard but flexible format for sampling and evaluating behavior from young children. Preliminary national norms are available on children between the ages of 6 and 24 months (Wetherby & Prizant, 2001). The CSBS-DP is available from Paul H. Brookes Publishing Co. at www.brookespublishing.com
FIRST WORDS Project Evaluation Model
The approach to early identification used by FIRST WORDS is a new referral and evaluation system that uses the CSBS-DP (Wetherby & Prizant, 2001) to identify children 6 to 24 months of age at risk for developmental disabilities. Our system is a two-step process designed to maximize the role of the family and minimize the time required by healthcare or childcare providers, thereby enhancing effectiveness and cost-efficiency.
Step One:
The first step is to screen communication using the CSBS-DP Infant/Toddler Checklist, a brief one-page parent report form. The Checklist is a quick way to decide if a developmental evaluation is needed. When the Checklist is received and scored at FIRST WORDS, we send families a report indicating either that their child is performing as expected for his/her age or that more information is needed.
Step Two:
For children performing as expected for their age on the Checklist, families
are sent another Checklist again 3 months later to monitor communication
development.
For children performing below what is expected for their age on the Checklist,
families are invited for a developmental evaluation. We use two sources
of information to evaluate young children- parent report and a direct evaluation
of the child. The use of multiple sources of information is recommended
for young children because of the variability in their behavior.
- We use two parent report tools that are more in-depth than the Checklist and are mailed or given to families - the CSBS-DP Caregiver Questionnaire (CQ) and the Ages and Stages Questionnaires (ASQ). The CQ is similar to the Checklist but is a 4-page form that solicits more detailed information and asks parents to indicate specific gestures, sounds, words and play skills their child uses and to describe strengths and concerns about their child. The ASQ (Squires, Potter, and Bricker, 1995) is a 30-item questionnaire with 6 items across the following 5 domains: communication, gross motor, fine motor, problem solving, and personal social. These two questionnaires are complimentary, with the CQ providing indepth information on communication and the ASQ providing brief information across domains.
- We invite families for a direct evaluation of the child. A clinician contacts the family by telephone to arrange this evaluation at a time that is convenient for the family. The clinician explains that the parent(s) will be in the room with their child during the entire evaluation. We use the CSBS-DP Behavior Sample (BS) to measure the child's emotion and eye gaze, communication, gestures, sounds, use of words, understanding of words, and use of objects, as well as other standardized measures of language and cognitive development. The BS is structured using child-friendly techniques to encourage children to communicate at their best. The clinician gives the parents feedback about their child's strength and any areas of concern during the evaluation and also provides the parent with a written report.
Families are sent a detailed report summarizing how their child is communicating, any areas of concern, and what to expect over the next few months based on the information gathered from the parent report tools and the direct child evaluation. For children performing below what is expected for their age on the evaluation measures, we make referrals for further evaluation and/or to services available in the community. Through our project we offer services to children who are not yet eligible for services through Part C of IDEA.