Screening for Universal Abilities and Trajectories with Children

Screening serves to identify people who need further assessment, not to describe any person’s abilities in detail. And, again, a group screening situation provides an excellent example of a genuinely multi-cultural situation. We use our knowledge of continua, dimensions, and human universals to do the best we can for as many people as we can, thinking differently than we might think if we knew which specific person we would be working with. In multi-cultural screening situations, in other words, we focus on the features of human speech, language, cognition, communication, swallowing, and development that are known to be true for all people.

In pediatric multi-cultural screening situations, to begin with, we do not start from the specific phonemes, morphemes, or semantic items that would be our focus if we were building a specific bridge to a specific child. Instead, we use our knowledge of linguistic and communicative universals, and we focus on the known trajectories in typical development for all infants and children.

Spend some time with Box 17.3, which lists many universal, or almost universal, abilities and trajectories in children’s communicative and swallowing development that can serve as the basis for your multi-cultural screening procedures.

Do you see the influence and the importance of thinking about children’s language development by seeking universals, not by starting with a specific? Children’s first words, to take an obvious example, reflect the words they have heard. As we think multi-culturally or screen 12-month-old children, therefore, we do not start with a list that includes mama, dog, and juice. These words are very specific examples, not universal human needs, and the issues are much broader than merely translating from language to language or allowing for a family’s synonyms. In a multi-cultural or multi-lingual screening situation, you would need all the translations, a non-solution that would achieve little more than burying you under piles of word lists. Translation to another language also does not solve the larger issue that some children have not enountered mothers, dogs, or juice. The universal is that all children, by about age 12 months, should be starting to use expressively some approximations of the words that they are exposed to in their daily lives — so we start there.

Remember, also, that bi-/multilingualism is normal and that people of all ages use and combine their languages and their dialects in many ways, all of which are normal (Module 6). As we screen children’s communication abilities, therefore, we screen in and using and allowing for their combined or overall abilities in their language(s) and in the ways that they use their language(s) (i.e., we assume translanguaging, García et al., 2017). Most people hear or use more than one language, dialect, or mixture of languages or dialects, some more than others along many continua; this is normal and a human universal, not a problem that requires us to learn or use a special strategy (Seltzer & de los Ríos, 2021). At the screening level, there is no need to ask everything twice, much less to try to nail down a specific “percentage” of the time a child “uses” any particular language. You might need an interpreter, as a cross-linguistic adaptation, if the child or the family uses or prefers only languages you do not know, but the content of your questions, and the way you think about the answers and about the child’s abilities, should be designed from the universal view that bi-/multilingualism is normal and that the mix of one or more languages that children use is normal. (See Module 20 for more detail about interpreting the abilities of some bi-/multi-lingual children, but the overall message is that children learn and use the language(s) and the combinations of languages they are exposed to. Most of the points in Box 17.3 are even true for children who use well-supported AAC systems from a young age, but such a child probably will not appear at a general pre-intervention screening.)

Finally, before we move on, let’s also take a moment to highlight the last point in Box 17.3., one of the most well-established principles from research about all children’s language and social communication: Parental reports predict and correlate highly with the identification of disorders (for a range of different examples, see Ebert, 2017; Mahendra, 2012; Restrepo, 2008). The over-identification problems we have addressed elsewhere stem from professionals’ decisions, not from parents’ concerns or descriptions. When parents are concerned, they are usually correct. When parents have complaints about the processes by which their toddlers or young children were evaluated, the complaint is usually that professionals dismissed their concerns about their children in ways that delayed accurate diagnosis or necessary assistance (e.g., Mahendra, 2012).

Building on the universals from Box 17.3, therefore, including building on our trust of parents, our actions in multi-cultural screening for expressive and receptive language development, often in the form of speech development and the development of skills with spoken and then written language, might include any of the options summarized in Box 17.4.

One way to approach screening for a few age-appropriate universals (from the top of Box 17.4) might be to look for such universals as those provided in Box 17.3, or in materials such as ASHA’s “How Does Your Child Hear and Talk?” (ASHA specifies that its “How Does” materials are not intended as screening instruments, and the distinction is important. We do not use them as instruments or as checklists; we use them as sources of research-supported summary information to be applied and interpreted in thoughtful ways.) The universal need is to look for the few key speech, language, hearing, swallowing, and social communication behaviors that typically developing children of this age would have developed, or to look for the appropriate equivalent of those behaviors if variations such as using ASL characterize the child’s environment.

At the same time, we screen not only for behaviors but for development itself. Typically developing children are dynamic language learners who show noticeable improvement every few months. We can therefore screen for problems by seeking information from the child’s caregivers not only about the child’s current abilities but also about the trajectory of their abilities. We can also ask caregivers to describe the child’s overall communication behaviors, using general questions that might start as broadly as “Tell me about a recent conversation you had with your child” or “Tell me about what it would be like if your child was telling you about something that happened to her earlier in the day.” We can then use “Yes and” to ask follow-up questions that acknowledge the caregiver’s statements and seek the further information we need, in a positive or neutral frame: “Thanks, and how long would her stories about what happened at school usually be?” The distinction between description and interpretation is important, here: the caregiver is the expert on what their child does, and you are the expert on what that behavior might mean.

We do also ask, of course, about the questions or concerns that a caregiver might have about the child’s speech, expressive language, receptive language, and social communication abilities, using general terms such as “What would you like some help with, about your child’s talking?”, “What questions do you have about how your child understands language?”, or “What have you noticed about the way your child communicates or plays with other people?” Some families will not interpret or report many speech or language issues as “problems” or as “disorders,” so we avoid those words. (And we ask “What questions do you have” rather than “Do you have any questions” to invite questions and signal our willingness to answer them; “Do you have any questions” is often interpreted as the professional’s way of ending a conversation, with the patient expected to respond that no, they do not have any questions.)

Notice, again, that in multi-cultural screening situations we do not depend on specific words, morphemes, or syntactic structures from any particular language or dialect, and we do not depend on any forms or instruments that were developed with one set of cultural or linguistic expectations in mind, even if those forms have been translated. If you have access to a child’s caregivers, ask universally phrased questions that will allow you to gather information about the child’s overall abilities in expressive and receptive morphology, syntax, semantics, pragmatics, social communication, and pre- or early literacy regardless of, across, and combining all the languages or dialects the child uses.

Are you starting to wish for a protocol or an easy list of questions to follow? And, of course, do you immediately recognize why there is no such thing, if we are genuinely seeking to be ready for any child from any background? I am not aware of any commercially available screening instrument that was truly designed to seek universally applicable information about all children’s expressive and receptive translanguaging abilities and speech-production abilities. Many studies have demonstrated that scores from most screening instruments, even those we might consider well established and widely used screeners, tend to be problematically affected by the children’s race, ethnicity, dialect, or even family income level (see Eisenberg et al. (2019); Moland and Oetting, 2021).

For children aged 2 years or older, however, as noted in Box 17.4, there are two instruments that you might want to consider or that appear to represent reasonable options for most children.

First, for children aged 2;0 or older, consider the Intelligibility in Context Scale (ICS, McLeod et al., 2012) in the caregiver’s best language (from the Intelligibility in Context Scale webpage at Charles Sturt University; http://www.csu.edu.au/research/multilingual-speech/ics ). The ICS addresses articulation, phonology, and overall speech production (not language) by asking universal questions about whether familiar adults understand the child. It therefore neatly side-steps any language- or dialect-centric assumptions about which phonemes children should learn when, while freeing us as clinicians from the impossible task of having to learn or look up the phonemic structure of all languages. The ICS is freely available in more than 60 languages or dialects and asks universal questions (e.g., Does the person completing the form understand the child?) using a simple 5-point scale. Substantial cross linguistic research supports general rules that children aged 2-3 years should be intelligible at least “sometimes” (rated at 3 on the ICS) for most listeners and that children aged 4 years or older should be intelligible “usually” (ratings of 4) to most listeners (McLeod & Crowe, 2018).

Second, for children aged 4;0 to 9;11, consider the Diagnostic Evaluation of Language Variation - Screening Test (DELV-ST; Seymour et al., 2018). The DELV-ST was specifically developed to focus on language structures that are “noncontrastive” across the general, mainstream, or northern White American Englishes and the African American Englishes; as such, a low score on the DELV-ST Part II can reasonably be interpreted as suggesting that the child is at risk, or is not at risk, for a language disorder (rather than merely demonstrating that a child has or has not been exposed to certain features of a monolingal White northern dialect, as we addressed in Module 14). The DELV-ST Part I provides a score intended to describe “how far” from “mainstream” American English the child’s speech might be; I find that part of the instrument unnecessary at best and genuinely problematic at worst. The Part II score, however, seems to provide precisely what I want a screening instrument to provide: some reasonable sense of whether the child is at risk for a disorder (and therefore needs to be further assessed) or not.

Given that these two instruments are two of the very few exceptions, most multi-cultural pediatric language screening will consist of your expert adaptation and modification of a range of universally phrased questions, rather than your use of a specific checklist, protocol, or instrument. Consider, among many others, some some of the example questions provided in Box 17.5., all of which were designed to determine how children are functioning and developing in their own environments, not designed to compare children to any narrow, predetermined, or culturally or linguistically irrelevant standard.

We can also screen by interacting with the child (or with the child and their caregiver together) for a few minutes in relatively unstructured play or conversation. One fairly universal approach might be to provide several toys, books, or materials; offer the child the opportunity to choose from among them; and then talk to the child about what they chose (if they chose), what they are doing, or what matters to them. Use what you see, hear, and learn from and about the child in child-directed play or conversations as the basis for marking any checklist you might be using, rather than using a pre-arranged checklist to direct your interactions with the child. Interpret the quality rather than the quantity of the child’s speech to you, and use information from the caregivers if the child’s conversations with you seem limited; you are a stranger to the child, and many children know better than to talk to strangers.

For school-aged children, our interactions can also be structured around information they have been addressing in their classrooms. Ask children what they have been doing with their teacher, what books they have been reading, or what last week’s lessons were about. Listen for words that would have been the specific vocabulary associated with that lesson; listen for the complexity of the child’s language as they explain. Curriculum-based screening is essentially a posttest-only dynamic assessment; if you have time to incorporate true dynamic assessment, building from curriculum-based knowledge again helps to provide appropriate expectations for all children (see Laurie & Pesco, 2023).

Finally, as you work with a child or with a family and begin to draw your interpretations, be sure also to listen to the child’s caregivers, and if siblings are in attendance listen to them as well. Children who sound like the other speakers in their lives are probably developing speech and language in ways that are typical for their culture or community. Notice, here, again, that children who have been exposed to more than one language or more than one dialect routinely switch between their languages/dialects and combine their languages/dialects in many ways and for many reasons. With bi-/multilingual or bi-/multi-dialectal children and families in particular, again, we phrase all our questions in ways that include all the child’s abilities (i.e., assuming and validating translanguaging, or seeking to understand all the child’s abilities with language and languages; García et al., 2017). Using or mixing more than one language or more than one dialect is normal, typical, and almost unremarkable for many people. Bilingualism and multilingualism are normal, as is knowing different things to different degrees. Using more than one language does not cause or contribute to speech or language disorders, and clients who use more than one language or more than one dialect are not a “problem” that requires us to learn or to use any special strategies in screening (Seltzer & de los Ríos, 2021; and see our Section Four). Ask your universal questions, and recognize and respect the answers each child and each family give you; don’t start your relationship with this family by trying to limit the child’s abilities to any one of their many dialects or languages or by trying to divide between languages that the family treats as fluidly and creatively combined.

Overall, in multi-cultural pediatric screening situations, we presume competence, or assume that most children are probably developing typically. At the same time, we design our screenings such that they can identify potential concerns or problems in ways that will be as universally applicable as posible. Thus, we seek information about the child’s abilities and about their developmental trajectory; we assume that the child’s communication behaviors are appropriate for their background unless the child is not meeting applicable universal developmental markers or is not demonstrating continued growth; and we seek and believe any concerns raised by the adults who know the child.

If screening in this way does identify any cause for concern, we then move to cross-cultural assessment procedures designed specifically for that child. If screening in this way does not identify any cause for concern, we check that conclusion with the family (“From what I can tell, her speech and language seem to be developing just fine. How does that conclusion fit with what you see at home?”) and probably decide that the child is developing typically in ways that fit their community, culture, language, background, and experiences — regardless of how similar or dissimilar our own might be.