Elizabeth Crais

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USING THE BEST AVAILABLE EVIDENCE TO IDENTIFY
INFANTS AND TODDLERS WITH (OR AT RISK FOR)
COMMUNICATION DEFICITS
Elizabeth Crais The University of
North Carolina at Chapel Hill TelAbility/WATCH
Project January 11, 2008
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Where We Are Now?

• Clear evidence that early intervention works
• Growing evidence across a variety of disabilities
  supports maxim earlier ID is better
• 10-12 of school-age population receiving special
  education services
• 12-16 of children have developmental or
  behavioral disabilities (Comm. on Child with Dis,
  2001)
• 7-24 of 2-3 year olds have social-emotional or
  behavioral deficits (Briggs-Gowan et al, 2001)
• How early are we identifying these children?

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Percentage of Children Identified For EI By Age
Range

• 1.6 Birth to 2 years
• 4.9 3-5 years
• 11 6-18 years (U.S. Department of Education,
  2005)
• Even among those identified early 0 - 3
• 14 0-1 years
• 32 1-2 years
• 54 2-3 years
• (Part C Update, 2004)
• Most commonly identified early concerns are
  related to motor or language delays

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Are We Using the Best Predictors?

• One of best predictors of childs future language
  is childs current communication performance
  (Brady, Marquis, Fleming, McLean, 2004 Facon,
  Facon-Bollengier, Gruber, 2002).
• Language skills are a strong predictor of
  cognitive skills (Brady et al, 2004).

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Current Evidence Based Predictors

• Vocal Behaviors
• Vocabulary Comprehension
• Prelinguistic communication
• Gesture Use
• Symbolic Play

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Vocal Behaviors Predictive of Later Language

• More vocalizations
• More consonant-vowel syllables
• Rate of vocalization
• Rate of vocalizations with consonants
• Rate of vocalizations in interaction with others
  (). (McCathern, Yoder, Warren, 1999).
• Ability to use sounds is strongest predictor of
  language skills one year later (First Words)

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Prelinguistic Communication

• Rate of prelinguistic communication
• Rate of symbol use (especially gestures)
• Rate of different symbol use
• Significantly correlated with later language
  outcomes 12 months later
• Amount of prelinguistic communication predictive
  of later symbolic communication (Calandrella
  Wilcox, 2000).
• Frequency of nonverbal communication in
  preschoolers with ASD predicts language 1 year
  later (Sigman Ruskin, 1999)

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Motivation for Our Research in Autism

• Diagnosis of children with autism typically
  occurs between 2 - 3 years of age
• Diagnosis is rare before two years of age
• Yet the literature shows enhanced outcomes with
  early identification and intervention
• Thus, our ultimate goal is to identify children
  with autism even earlier
• But what are the barriers to earlier
  identification?

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Barriers To Early ID Include

• Difficulty identifying behaviors that could be
  markers for group differences
• Need to look for both presence of atypical
  behaviors and absence of typical behaviors
• Limited knowledge of developmental course of
  behaviors that may be common in young children
  (e.g., repetitive movements, mouthing)
• Therefore, relatively late identification makes
  it difficult to know the course of early
  development in these children

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Retrospective Video Analysis

• Ecologically valid methodological tool for
  earlier identification of children at very early
  periods in development (prior to diagnosis)
• Several retrospective video studies of autism
  suggested young children with autism can be
  distinguished from typically developing children
  (Adrien et al., 1993 Baranek, 1999 Osterling
  and Dawson, 1994)

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Retrospective Video Analysis

• UNC researchers have used footage that families
  provided of their child under two years of age
  (well before diagnosis).
• Footage representative of a wide range of family
  play situations.
• Videotapes edited for randomly selected
  cross-section of situations and events.
• Studies include typically developing infants,
  infants later diagnosed with autism, and infants
  diagnosed with developmental delays at 9-12 and
  15-18 months of age.
• (Baranek, 1999 Watson, Crais, Baranek, Roy,
  Dykstra, 2004 Lanter, Colgan, McComish, Watson,
  Baranek, Crais, submitted).

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Possible Behaviors of Interest

• Increasing interest and research in early
  prelinguistic behaviors in children developing
  typically and with autism
• Areas of promise targeted today are gesture use,
  play development, and relationship between play
  behaviors and gesture use
• Helpful to first be familiar with typical
  development in these areas

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Development of Gestures Why Are They Important?

• Early means to communicate
• One of the first signs of intentionality
• Can be used in profiling skills
• Can be helpful in identifying delays
• Important to intervention planning

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Gesture Development and Use

• Amount of gesture use can help distinguish
  between late talkers and children with true
  language deficits (Thal Tobias, 1992 1994).
• Early onset of pointing predictive of advanced
  language skills (Butterworth Morisette, 1996).
• Use of distal (e.g., show, give, point) gestures
  predictive of higher rate of communication
  (McLean, McLean, Brady, Etter, 1991).

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What Are Gestures?

• Gestures are actions produced with the intent to
  communicate and are typically expressed using the
  fingers, hands, and arms, but can also include
  facial features (e.g., lip smacking for "eating")
  and body motions (e.g., bouncing for horsie")
• (Iverson Thal, 1998)

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Age Ranges of Emergence of Common Gestures

• Reaching 6-9 months
• Giving 8-11 months
• Showing 8-13 months
• Pointing 9-14 months
• (Bates et al., 1975 Carpenter, Nagell,
  Tomasello, 1998 Crais, Douglas, Campbell,
  2004 Masur, 1983)

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Functions of Gestures

• Social interaction initiating or sustaining a
  social game or routine, providing comfort,
  teasing, showing off
• Behavior regulation regulate behavior of others
  to obtain an object, get them to carry out
  action, or stop someone from doing something
• Joint attention direct others attention in
  order to comment on an object or event, provide
  information on an object or event, or acknowledge
  shared attention to an object or event

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Age of Emergence of Functional Categories

• Protests 6-8 months
• Requests for actions 6-10 months
• Requests for objects 6-10 months
• Comments 8-11 months
• Answering 13-16 months
• (Carpenter, Mastergeorge, Coggins, 1983 Crais
  et al, 2004)

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Array of Gestures Seen in 9-12 Month Old Children
(Crais et al, 2004)

• Behavior Regulation
• Protest (use body, push away object with hand/s)
• Request Objects (reach for object, pull on
  adults hand with object, point to obtain object)
• Request Actions (reach to be picked up, do the
  action)
• Social Interaction
• Seek Attention (body movement, grab hand, bang
  object)
• Social Games (participate by imitating, initiate
  games)
• Representational Gestures (bye bye, imitation
  clapping, show functions of objects)
• Joint Attention
• Comment (show object, give object)

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Array of Additional Gestures Seen in 15-18 Month
Old Children

• Behavior Regulation
• Protests (shake head no)
• Request Objects (reach while opening closing
  hand)
• Request Actions (point, take hand of adult, give
  object)
• Joint Attention
• Comment (point to object, point to object by
  request)
• Social Interaction
• Seek Attention (show off)
• Representational Gestures (hug objects, smack
  lips, clap for excitement/accomplishment),
• (Crais et al, 2004)

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Results Comparing Group Means for Gesture
Functions at Time 1 (9-12 m)

totgest_1
ASDltTYP DD lt TYP
ASD lt TYP
(ASD n24, DD n14, TYP n22)
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Gesture Use In Infants Toddlers

• Results indicate differences in gesture use
  between 9-12 month old infants later diagnosed
  with autism or developmental disabilities and
  children with typical development.
• Total number of gestures (differences between
  children with ASD TYP, DD TYP)
• Group differences on behavior regulation joint
  attention gestures, but not social interaction
  (9-12 15-18 months)

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Gestures Seen in Sample
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Levels of Play Development
Level 0 No object play Exploratory the way
infant examines the environment in order to gain
information from objects or toys (e.g., mouthing,
banging, shaking, poking) Level I
(indiscriminate actions), Level 2 (simple
manipulations of single objects) Relational two
or more objects used in combination with one
another, without regard to attributes or
functions of objects (e.g., objects pushed,
stacked, nested, piled) Level 3 (taking objects
apart), Level 4 (general combinations)
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Levels of Play Development
Functional influenced by social or cultural
properties of objects (e.g., pretend actions,
spoon to dolls mouth) Level 5 (directed toward
object), Level 6 (toward self), Level 7 (toward
doll), Level 8 (toward other person) Symbolic
items, attributes not actually present, or
substitution of objects Level 9 (object
substitution), Level 10 (agent play), Level 11
(imaginary play) (Baranek, Barnett, Adams,
Wolcott, Watson, Crais, 2005 Belsky Most,
1981 Casby, 1991, Knox, 1997 Libby, Powell,
Messer, Jordan, 1998 Lifter, Sulzer-Azaroff,
Anderson, Cowdery, 1993)
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Age Ranges of Play Levels

• Exploratory
• Level 1 (indiscriminate actions) 2 - 10
  months
• Level 2 (simple manipulations) 2 - 10 months
• Relational
• Level 3 (Takes objects apart) 10 - 18 months
• Level 4 (General combinations) 10 - 18 months
• Functional
• Level 5 (object directed) 12 18 months

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Age Ranges of Play Levels

• Functional
• Level 6 (self directed) 12 18 months
• Level 7 (doll directed) 12 - 18 months
• Level 8 (other directed) 12 - 18 months
• Symbolic
• Level 9 (object substitution) 18 30 months
• Level 10 (agent play) 18 30 months
• Level 11 (imaginary play) 18 30 months
  

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Concurrent Language/Play Associations

• 13 - 20 months
• First words appear along with more consistent
  communicative gestures and single play schemes
  (e.g., child feeds self with spoon)
• 20 - 24 months
• Word combinations appear along with single play
  schemes combined (e.g., child feeds self with
  spoon, then drinks from cup).
• (Kennedy, Sheridan, Radlinski, Beeghly, 1991)

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Predictive Language/Play Associations

• Early skill with communicative gestures predicts
  later language levels (Mundy Gomes, 1998 Thal,
  Bates, Goodman, Jahn-Samilo, 1997)
• Early functional object play has been associated
  with later language ability (Lyytinen et al.,
  1999 Ungerer Sigman, 1984)
• Level of symbolic play exhibited is predictive of
  later language skills (Lyytinen, Laakso,
  Poikkeus, Rita, 1999 Lyytinen, Poikkeus, Laakso,
  Eklund, Lyytinen, 2001).

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Longitudinal Relations between Play and Gesture
Behaviors in Infants with Autism (Watson, Crais,
Baranek, Roy, Dykstra, 2004)

• Examined predictive relations within and across
  the domains of play and gesture from 9-12 to
  15-18 months

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Subjects(Watson, Crais, Baranek, Roy, Dykstra,
2004)

• 27 children in three groups
• Autism spectrum disorder (n 15) DSM-IV
  criteria, verified by CARS scores, and for 10 of
  15 by ADI-R
• DD (n 4) nonspecific, mixed diagnoses
• Typical (n 8)

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T1 to T2 Gesture Use (Watson et al. 2004)

• Figure 1 Mean Frequency of Gestures for Total
  Sample (p.08)

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T1 to T2 Gesture Use (Watson et al., 2004)

• Figure 2 Mean Frequency of Gestures for ASD
  Sample

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T1 to T2 Higher Level Play (Relational Play)
(Watson et al., 2004)

• Figure 3 Mean Second in Higher Level Play for
  Total Sample

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T1 to T2 Higher Level Play (Relational Play)
(Watson et al., 2004)

• Figure 4 Mean Seconds in Higher Level Play for
  ASD Sample

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Clinical Implications

• Preliminary guidelines for clinicians seeking
  developmental models for both the range of
  expected ages of emergence of targeted gestures
  and play behaviors and their hierarchy in
  typically developing children.
• Clinicians can assess the depth and breadth of
  gestures and play behaviors used by children
  demonstrating communication delays
• Hierarchy of gesture and play development can be
  used in determining potential developmental
  targets for intervention.

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Red Flags Approach Social Development

• Be concerned if the child is not By
• Responding to familiar adults with a social
  smile 3 months
• Talking back by vocalizing to familiar adults
  who talk to child 8 months
• Attentive to social games played by familiar
  adults (e.g., Peek-a-Boo) 8 months
• Participating in social games (e.g., hands up for
  Pat-a-Cake) 12 months
• Showing and/or giving objects to familiar
  adults 15 months
• Pointing to objects to indicate interest in
  them 18 months
• Seeking adult interaction to play with toys/look
  at books 18 months
• Pointing either spontaneously or by request to
  pictures in books 24 months
•  
• General Social Concerns inattentiveness to
  people, lack of eye contact or shared mutual gaze
  with familiar adults by 12 months preferring to
  play alone at 18 months or older social play is
  limited to chase or tickle games at 24
  months.

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Intentionality

• Be concerned if the child is not By
• Showing any type of intentional behavior (e.g.
  requests, protests) 10 months
• Communicating for a variety of reasons (e.g.,
  protesting, requesting,
• seeking social interaction, commenting) 18
  months
• Using a variety of means (e.g., gestures,
  vocalizations, eye gaze) 18 months
•  
• General Intentionality Concerns children
  who primarily regulate others behavior (e.g.,
  putting someones hand on toy to operate it,
  leading adult to door to open it), but do not
  display more social forms of communicating (e.g.,
  giving book to another to read, pointing to
  objects of interest, drawing attention to self
  for social reasons).

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Play Skills

• Be concerned if the child is not By
• Mouthing, banging, shaking, and/or manipulating
  objects 8 months
• Throwing, dropping toys especially for others to
  get 12 months
• Participating in social games (e.g., looks for
  Mom during Peek-a-Boo). 12 months
• Giving or showing toys to adults 15 months
• Pushing, pulling, turning on, putting in, and
  taking out objects 18 months
• Showing knowledge of how to use toys functionally
  (e.g., push toy car) 18 months
• Stacking cups or rings on a toy stand (not
  necessarily correct) 24 months
• Performing some pretend play behaviors (e.g.,
  drinking from empty cup) 24 months
• Combining play acts (e.g., rocks baby and puts
  down for nap) 30 months
• Playing with familiar children some of the time
  when in close proximity 36 months
• Taking turns in constructive or pretend play with
  familiar children 48 months
• General Play Concerns children who
  primarily perform play behaviors representative
  of younger children have limited play behaviors
  (e.g., play with only one type of toy, play very
  briefly with toys) seem averse to playing with
  others (including caregivers) play alone for
  longer periods of time than would be expected at
  their developmental age have stereotypic play
  behaviors (e.g., repeatedly open and close
  drawers, line up their toys and become upset if
  others change the order) or display unusual play
  behaviors (e.g., rub plastic stacking rings over
  their hands or face, lick and smell toys).

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Comprehension Skills

• Be concerned if the child is not By
• Looking at objects looked at by others 12
  months
• Acting on objects that are noticed 12 months
• Imitating ongoing actions 12 months
• Responding to own name 15 months
• Attending to an object mentioned 15 months
• Doing what is usually done in a situation (e.g.,
  child puts on coat
• when others do) 18 months
• Using conventional behaviors (e.g., combing hair
  with comb) 18 months
• Acting on objects as the agent (e.g., child
  brushes own teeth
• when asked to Brush the babys teeth) 24
  months
• Responding to many object names 24 months
• Retrieving a familiar object out of sight 24
  months

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Sound Production

• Be concerned if the child is not By
• Producing cooing and gooing sounds 6 months
• Babbling in repeated sequences of sounds (e.g.,
  baba, gaga) 11 months
• Producing 3 different consonant sounds (e.g., b,
  p, m, n, d, k, t, g, w) 18 months
• Imitating any non-speech sounds (e.g., truck
  sound, animal sounds) 18 months
• Using sound sequences that sound like
  talking 24 months
• Producing (VC) syllables (e.g., up), (CVC)
  syllables with a single
• consonant (e.g., cake), and some vocalizations or
  words
• with two or more different consonants (e.g., pat,
  tummy) 24 months
• Producing 6 different consonants 24 months
• Producing initial consonants in most words (says
  at for pat, ot for boat) 36 months
• Producing 10 different consonants 36 months
• Producing any final sounds (bo for boat, e
  for eat) 36 months

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Word Productions and Word Combinations

• Be concerned if the child is not By
• Producing any words or word approximations 18
  months
• Producing 50 words or word approximations 28
  months
• Producing 100 words 30 months
• Combining words 28 months
•  
• E. Crais. (2001). Identifying communication and
  related developmental disabilities in young
  children. In J. Roush (Ed.), Screening for
  hearing loss and otitis media in children. San
  Diego, CA Singular

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Questions?