These are the New York State Department of Health Clinical Guidelines for Early Intervention providers as they relate to Communication Disorders and Predictors of Continued Language Delay.

Appendix E - Clinical Clues Adapted From the NYS EIP Clinical Practice Guidelines

Clinical Clues for Communication Disorders⁸¹

Normal Language Milestones and Clinical Clues for Possible Language Disorders

During the First 3 Months

Normal Language Milestones

• looks at caregivers/others
• becomes quiet in response to sound (especially to speech)
• cries differently when tired, hungry or in pain
• smiles or coos in response to another person's smile or voice

Clinical Clues / Cause for Concern at 3 months

• lack of responsiveness
• lack of awareness of sound
• lack of awareness of environment
• cry is no different if tired, hungry, or in pain

From 3-6 Months

Normal Language Milestones

• fixes gaze on face
• responds to name by looking for voice
• regularly localizes sound source/speaker
• cooing, gurgling, chuckling, laughing

Clinical Clues / Cause for Concern at 6 Months

• cannot focus, easily over-stimulated
• lack of awareness of sound, no localizing toward the source of a sound/speaker

From 6-9 Months

Normal Language Milestones

• imitates vocalizing to another
• enjoys reciprocal social games structured by adult (peek-a-boo, pat-a-cake)
• has different vocalizations for different states
• recognizes familiar people
• imitates familiar sounds and actions
• reduplicative babbling ("bababa," "mamamama"), vocal play with intonational patterns, lots of sounds that take on the sound of words
• cries when parent leaves room (9 mos.)
• responds consistently to soft speech and environmental sounds

Clinical Clues / Cause for Concern at 9 Months

• does not appear to understand or enjoy the social rewards of interaction
• lack of connection with adult (lack of eye contact, reciprocal eye gaze, vocal turn-taking, reciprocal social games)
• no babbling, or babbling with few or no consonants

From 9-12 Months

Normal Language Milestones

• attracts attention (such as vocalizing, coughing)
• shakes head "no," pushes undesired objects away
• waves "bye"
• indicates requests clearly; directs others' behavior (shows objects; gives objects to adults; pats, pulls, tugs on adult; points to object of desire)
• coordinates actions between objects and adults (looks back and forth between adult and object of desire)
• imitates new sounds/actions

Clinical Clues / Cause for Concern at 12 Months

• is easily upset by sounds that would not be upsetting to others
• does not clearly indicate request for object while focusing on object
• does not coordinate action between objects and adults
• lack of consistent patterns of reduplicative babbling
• lack of responses indicating comprehension of words or communicative gestures

From 12-18 Months

Normal Language Milestones

• single-word productions begin
• requests objects: points, vocalizes, may use word approximations
• gets attention: vocally, physically, maybe by using word (such as "mommy")
• understands "agency": knows that an adult can do things for him/her (such as activate a wind-up toy)
• uses ritual words ("bye," "hi," "thank you," "please")
• protests: says "no," shakes head, moves away, pushes objects away
• comments: points to object, vocalizes, or uses word approximation

Clinical Clues / Cause for Concern at 18 Months

• lack of communicative gestures
• does not attempt to imitate or spontaneously produce single words to convey meaning
• child does not persist in communication (for example, may hand object to adult for help, but then gives up if adult does not respond immediately)
• limited comprehension vocabulary (understands <50 words or phrases without gesture or context clues)
• limited production vocabulary (speaks <10 words)

From 18-24 Months

Normal Language Milestones

• uses mostly words to communicate
• begins to use two-word combinations: first combinations are usually memorized forms and used in one or two contexts
• later combinations (by 24 months) with relational meanings (such as "more cookie," "daddy shoe"), more flexible in use

Clinical Clues / Cause for Concern at 24 Months

• reliance on gestures without verbalization
• limited production vocabulary (speaks <50 words)
• does not use any two-word combinations
• limited consonant production
• largely unintelligible speech
• compulsive labeling of objects in place of commenting or requesting
• regression in language development, stops talking, or begins echoing phrases he/she hears, often inappropriately

From 24-36 Months

Normal Language Milestones

• engages in short dialogues
• expresses emotion
• begins using language in imaginative ways
• begins providing descriptive details to facilitate listener's comprehension
• uses attention getting devices (such as "hey")
• preparative development characterized by collections of unrelated ideas and story elements linked by perceptual bonds

Clinical Clues / Cause for Concern at 36 Months

• words limited to single syllables with no final consonants
• few or no multi-word utterances
• does not demand a response from listeners
• asks no questions
• poor speech intelligibility
• frequent tantrums when not understood
• echoing or "parroting of speech" without communicative intent

Appendix F - Predictors of Continued Language Delay

Table III-7: Predictors Of Continued Language Delay In Children With Language Delays At 18-36 Months

(from New York State Department of Health Early Intervention Program – Clinical Practice Guideline on the Assessment and Intervention with Young Children with Communication Disorders)

This table lists factors that predict which children found to have language delay at 18-36 months will continue to have language delay in the future. The more of these predictors a child exhibits, the more serious the concern that the child will continue to have language problems and the greater the need for speech language therapy. Some of the specific predictors may not apply to children 18-24 months if typically developing children would not be expected to exhibit the communicative behaviors.

Speech

Language Production

• Particularly small vocabulary for age
• Less diverse vocabulary particularly in regard to verbs
• Preponderance of general all-purpose verbs (such as "do," "make," "want," "go")
• More transitive and fewer intransitive verbs (such as "give ball")

Language Comprehension

• Presence of 6-month comprehension delay
• Large comprehension-production gap with comprehension deficit

Phonology

• Few prelinguistic vocalizations
• Limited number of consonants
• Limited variety in babbling structure
• Fewer than 50% consonants correct (substitution of glottal consonants and back sounds for front)
• Restricted syllable structure
• Vowel errors

Imitation

• Few spontaneous imitations
• Reliance on direct model and prompting in imitation tasks of emerging language forms

Non-Speech

Play

• Primarily manipulating and grouping
• Little combinatorial and/or symbolic play

Gestures

• Few communicative gestures, symbolic sequences, or supplementary gestures

Social Skills

• Behavioral problems
• Few conversational initiations; interactions with adults more than peers
• Difficulty gaining access to activities

Health and Family History

• Recurrent otitis media
• Family history of persistent problems in language learning