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