Measuring the earliest forms of communication

As you may have realized (with frustration!) by now, we have limited options for evaluating the expressive communication skills of children who are minimally verbal. Enter: the Communication Complexity Scale (CCS), designed to measure just that. Prior papers have described the development of the CCS and determined its validity and reliability, but in this study, we get to see it in action with a peer-mediated intervention.

First, a little bit about the tool. It’s a coding scale—not a standardized assessment—that can be used during observations. Because prelinguistic communication skills often take time to develop with this population, this tool helps us think about all the incremental steps along the way and accounts for the variety of communicative modes the children might use. It’s a 12-point scale following this pattern:


The researchers found that the CCS could measure improvement in overall communication complexity and behavior regulation for preschoolers with autism after a peer-mediated intervention (the same one we reviewed here!).

So far in the research, the CCS has only been used during structured tasks meant to elicit communicative responses (see the supplemental material), such as holding a clear bag with toys where the child can see it, but can’t access it independently. We know it's crucial to observe our students in natural communication opportunities, though, so we'd have to be a little flexible in using the CCS during unstructured observations. The scale could definitely be useful when describing communication behaviors during evaluations or when monitoring progress. Wouldn’t it be much more helpful to say “The child consistently stopped moving (i.e. changed her behavior) in response to the wind-up toy stopping” instead of “The child was not observed to demonstrate joint attention”? Using the CCS, we have new ways of describing those “small” behaviors that really aren’t small at all!

NOTE: This study crosses over our Early Intervention vs. Preschool cut-offs, with kids from 2 to 5 years old. So is published in our School-Age section, too!

Find links to the scale and score sheets, here.

Thiemann-Bourque, K. S., Brady, N., & Hoffman, L. (2018). Application of the communication complexity scale in peer and adult assessment contexts for preschoolers with autism spectrum disorders. American Journal of Speech-Language Pathology. doi:10.1044/2018_AJSLP-18-0054

Why a Spanish word list won’t necessarily work for all Spanish speakers


Gonzalez & Nelson remind us of the need to consider the cultural background of Spanish–English bilingual infants when administering the MacArthur Inventario del Desarrollo de Habilidades Comunicativas: Primeras Palabras y Gestos (IDHC), also known as the Spanish form CDI. The IDHC was originally created and normed using a monolingual Mexican sample from Southern California and Mexico. But Spanish isn’t exactly the same across all Spanish-speaking countries. As result, many of the words on the IDHC reflect Mexican Spanish and may be unknown or uncommon to children from other Latinx communities. While there are adaptations of the IDHC for use with Cuban, Chilean, and Columbian children, this still doesn’t represent the cultural–linguistic diversity we’ll see, especially when many Latinx children come from mixed-nationality homes.

The authors of this study administered the Mexican-normed IDHC to 27 Spanish–English bilingual infants of mixed Latinx backgrounds. The Spanish vocabulary scores for the infants of mixed Latinx backgrounds were significantly lower than the scores of the Mexican norming sample. Further analysis revealed that the parents of mixed Latinx backgrounds reported significantly lower comprehension for a subset of 16 words on the IDHC. It turns out these words were often described by parents as words they themselves didn’t know or words they didn’t commonly use at home. This highlights a potential issue with roughly 4% of the 428 words on the IDHC. When these words were removed, the bilingual mixed Lantinx group continued to have lower scores than the monolingual Mexican group, but the difference in scores was no longer significant. You can check out a complete list of the unknown/uncommon IDHC words in Appendix A.

Unfortunately, we don’t have updated and more inclusive norms for the IDHC to account for these unfamiliar words yet. BUT there is a silver lining here. Using a total vocabulary score (i.e., Spanish IDHC + English CDI) closed the gap between the mixed Latinx and Mexican groups. *Does happy dance* Even with the potentially problematic words on the IDHC, the impact appears to be minimized when both Spanish and English results are combined. This finding reiterates the importance of assessing bilingual children in both languages to get a more complete picture of overall language development.


Gonzalez, S.L., & Nelson, E.L. (2018). Measuring Spanish comprehension in infants from mixed hispanic communities using the IDHC: A preliminary study on 16-month-olds. Behavioral Sciences. Advance online publication. doi: 10.3390/bs8120117

Imitation: a simple and powerful strategy for parents of toddlers at-risk for ASD

While we all know that involving parents in early intervention for toddlers with ASD is important, knowing where to start can be another matter altogether. What if there was one simple and effective strategy that we could teach parents right off the bat--one they could master easily with a big impact? Imitation might fit that bill.

Imitation is a strategy you already have in your toolbox: it’s as simple as copying what a child says or does. It’s been researched in different forms for decades, and it belongs to a family of strategies called “responsive” language strategies. Other responsive strategies include following the child’s interests, avoiding questions and directions, and responding to his communication attempts.

The great thing about imitation as a strategy is that it naturally incorporates many components of other responsive strategies. If a parent is imitating his child, then he is probably following his child’s interests, reducing the number of questions he asks, and paying more attention to how his child is communicating. If we teach parents to imitate, maybe we won’t need to explicitly teach the other responsive strategies!

These researchers did a small study in which they taught three parents of toddlers with ASD* to imitate their children’s actions, gestures, and words (the format of the sessions is fully described in the article!) Generally speaking, the sessions had these components:

  1. The therapist reviewed the parent’s questions or concerns that had come up since the previous session.

  2. The therapist explicitly taught the parent about why imitation is important and how to use it.

  3. The therapist played with the child and pointed out when she imitated the child.

  4. The parent played with the child while the therapist provided the parent with constructive coaching and feedback.

  5. The therapist summarized the session and answered the parent’s questions.


The results showed that all three of the parents were able to master the imitation strategy, and all three children made improvements in their social eye gaze. An extra cool bonus? As parents started imitating their children, the number of questions and directions they gave naturally decreased without the therapist explicitly instructing them to do so. Talk about getting some great bang for your buck! Imitation shows promise of being a simple and efficient “first strategy” to teach parents. 

*or suspected ASD


Killmeyer, S., Kaczmarek, L., Kostewicz, D., & Yelich, A. (2018). Contingent Imitation and Young Children At-Risk for Autism Spectrum Disorder. Journal of Early Intervention. doi:10.1177/1053815118819230.

Is early regression in autism a thing?

Short answer:


Long answer:  

Note: What we’re talking about here = loss of language and other skills between 15 and 30 months of age in children with ASD (Barger et al., 2013).

First, it’s important to understand where data to answer this question comes from. Historically, it’s been from retrospective studies (parent report, home video). More recently, we’ve combined this with prospective studies (e.g. tracking infants at high familial risk of autism from birth, so you can measure as they grow!) The combination of the two is powerful, and has illuminated things not previously captured (e.g. declining visual attention in the first year for kids with ASD (Elsabbagh et al., 2013).

Second, what we’re measuring matters: skills slowly diverging from the typical path is different than a skill plateau, which is different than actual regression—and we have to keep this straight across studies. Also, how you measure it matters—for example, a decline in standard scores on tests over time could represent any of the previously-mentioned phenomena. Further, it’s likely that all three of these things exist in autism—it’s not a homogenous group! 

Finally, don’t forget that there are other conditions that are characterized by regression (e.g. Rett syndrome, Heller’s syndrome), and sometimes autism combined with something else (e.g. epilepsy) will show marked regression. So be aware that regression is associated with many childhood disorders.

But, yes, lots of studies point toward there being a notable group of children with autism who show true regression from infancy to toddlerhood. (Do any of you remember how there for a while we thought regression in autism wasn’t a thing, and the parents were wrong? Yeah… The parents weren’t wrong.)

Longer (and obviously the most thorough) answer:

Pearson, N. , Charman, T. , Happé, F. , Bolton, P. F. and McEwen, F. S. (2018). Regression in autism spectrum disorder: Reconciling findings from retrospective and prospective research. Autism Research, 11, 160–1620.

A bit more. We were chatting with Dr. McEwen about this article, and she had a helpful comment we wanted to share:

“…regression seems to occur gradually in some children, and a very slow loss of skills is likely to be harder to pick up than a sudden, dramatic loss of skills. The former might involve a gradual loss of social engagement, whereas the latter could be a child who suddenly loses language. So it's important for speech and language professionals to be aware that it's not just dramatic loss of language that they should be alert to.”

How gesture and word development intertwine in toddlers

We know that children with ASD have difficulty with gestures. If a child comes to us who doesn’t point to share attention, we have red flags waving in our heads. Children with ASD are delayed in their use of gestures, use them less frequently, and have a smaller repertoire. We also know that in typically developing children, gestures come before speech and predict later language abilities. Little research, however, has actually delved into what gesture development looks like in toddlers with ASD and how it relates to their overall language development. Does their gesture development follow a predictable sequence, and does that sequence match that of their TD peers? How are gestures and verbal language linked for toddlers with ASD?

These researchers examined the gesture development of 42 toddlers with ASD and found:

  • Toddlers with ASD’s gesture and language development followed a predictable path that mirrors typically developing peers. This path differed in one interesting and important way, though: typically developing children use pointing as a pre-verbal means of communication, but for many toddlers with ASD, pointing emerged after they began to use words.

  • For toddlers with ASD, as well as their TD peers, combining gestures with single words precedes and predicts when they will begin to use word combinations.

So what does this mean for us?


First, a point of caution: this study looked at the development of gesture use in toddlers with ASD, but this study design can’t tell us what causes what. Simply because combining words and gestures comes before phrase speech does not necessarily mean that teaching a child to combine words and gestures will result in a child using phrase speech. In order to make that claim, we will need a randomized controlled trial of an intervention that attempts to teach toddlers with ASD phrase speech through targeting gesture and word combinations.

Nonetheless, these findings lend some support to intervention approaches that follow typical development. If a child is not yet using words, targeting early gesture use may support intentional communication and first words. If a child is speaking but not combining his words and gestures together, targeting combining words and gestures may support the development of phrase speech. 


Talbott, M. R., Young, G. S., Munson, J., Estes, A., Vismara, L. A., & Rogers, S. J. (2018). The Developmental Sequence and Relations Between Gesture and Spoken Language in Toddlers With Autism Spectrum Disorder. Child Development. Advance online publication. doi: 10.1111/cdev.13203.

Parent-delivered communication intervention for infants and toddlers who are DHH

If you’re an early intervention SLP, you’ve probably had a child who is deaf or hard of hearing (DHH) on your caseload at one time or another. Why? Well, advances in hearing aid and cochlear implant technology have certainly improved the speech and language outcomes of children who are DHH, but aided hearing isn’t the same as typical hearing. And even with early amplification, these children often still miss out on language stimulation pre-amplification, which can lead to delays.

In this study, they taught the parents of nine 6 to 24-month-olds with hearing loss to use four different strategies to promote and reinforce their communicative attempts. This included visual strategies such as moving toys in the child’s line of sight, and interactive strategies such as following the child’s lead and modeling target language to their actions. Parents were also taught responsive strategies like balancing the number of conversational turns that they took when communicating with their child, and linguistically stimulating strategies like expanding on their child’s spontaneous utterances.

The parents who participated in the training and delivered the intervention used more strategies that support communication compared to the parents in the control group. And, by the end of the study, the infants and toddlers who received the intervention demonstrated more prelinguistic communication skills compared to the children in the control group.  

The beauty of this study is twofold: 

First, the strategies that were included in the intervention are all things that we as EI providers are already well-versed in. {That’s because we’re all pretty darn familiar with enhanced milieu teaching (Hemmeter & Kaiser, 1993), prelinguistic milieu teaching (Yoder & Warren, 2002), and The Hanen Program (Girolametto, Pearce, & Weitzman, 1996)}. Second, if you’re an EI therapist, a big part of your job already involves parent training and coaching. This article provides a very simple, clear description of the key strategies that you can teach parents of infants and toddlers on your caseload who are DHH. Definitely the kind of article that you can read and then immediately apply to your practice, which is the best kind of article, am I right?!


Roberts, M. (2018). Parent-Implemented Communication Treatment for Infants and Toddlers With Hearing Loss: A Randomized Pilot Trial. Journal of Speech, Language, and Hearing Research. Advance online publication. doi: 10.1044/2018_JSLHR-L-18-0079

Social disadvantage and language development—what matters, and how much?


This is one of the largest studies we’ve seen in a while on factors than impact infant and toddler language—over 1000 babies were followed to see what matters most for language development in the first two years of life.

First, one of the really beautiful things about this study is that they measure social disadvantage, but actually differentiate things parents can control (that is, what they do with their child) from things they can’t (e.g. family income, maternal education). So bravo for that! Then, note that this study is dense. We’re only skimming the surface, here, with the biggest takeaways for SLPs, which are:

 What parents do with their child matters:

  • e.g. “…reading to their child, telling stories, singing and taking the child on errands to public places… having toys… books available in the home… having a safe and supportive home environment.”

  • (In fact, here’s another recent study showing that responsive verbal behaviors in play interactions with a parent at 12 months are predictive of language outcomes at 36 months in a cohort of families experiencing adversity.)

Language at 15 months is highly predictive of language at 2 years.

  • Implication: Are we catching kids early enough?

Now, I think most SLPs pretty much already knew that. But what you may not have a good feel for is how much these things matter. To put it in perspective—the single strongest measured predictor of language was biological sex. Also, most of what predicts language development was not something the researchers were able to measure. Instead, it’s some other thing(s), likely, “… other developmental or genetic mechanisms.” So, basically, what parents do with their children is important not because it matters the most, but because we have control over it (well… we can try to).


Law, J., Clegg, J., Rush, R., Roulstone, S., Peters, T.J. (2018) Association of proximal elements of social disadvantage with children's language development at 2 years: an analysis of data from the Children in Focus (CiF) sample from the ALSPAC birth cohort. International Journal of Language and Communication Disorders. Advance online publication. doi: 10.1111/1460-6984.12442.

Preterm birth + social disadvantage = extra at-risk

*Another study on social disadvantage; this time, over 100 infants studied.

We know that babies born pre-term are at a higher risk for developmental delays, including language. We also know that children born into socially disadvantaged environments are at risk for language delay. So what happens when a baby from a socially disadvantaged* background is born early? The most SLP-relevant findings include:

  • full-term infants with fewer social risk factors had the best language scores at age 5

  • but low social risk isn’t enough to make up for prematurity (< 30 week gestation)— that is, preterm infants with low social risk did not experience as much language growth from 2- to 5-years as the full-term children (thus, addressing social risk for preterm kids is good, but may not be enough to close the language gap by 5 years)

  • high social risk was associated with decreasing language scores as developmental demands increased with age (and the authors found this trajectory was associated with maternal affect and maternal intellectual ability, so parent interventions addressing affect and responsiveness may be helpful for these children)

The big picture? Just because everything looks “ok” for a child at 2 years doesn’t mean things will look that way at 5 years when cognitive, linguistic, and motor development gets more demanding. Also, very preterm infants and toddlers, at a social disadvantage or not, need our support. We can start by training parent responsivity, but it looks like some preterm children could need more intensive interventions to close the developmental gap between themselves and their full term peers.

*Their definition of social risk included factors like teen parents, single parents, no high school diploma. Refer back to the previous study, though, that shows how a healthy home environment can reduce the impact of these factors.


Lean, R. E., Paul, R. A., Smyser, T. A., Smyser, C. D., & Rogers, C. E. (2019). Social adversity and cognitive, language, and motor development of very preterm children from 2 to 5 years of age. The Journal of Pediatrics. Advance online publication. doi:10.1016/j.jpeds.2018.07.110.

Language delay and behavior problems: How can we help?

It’s not much of a surprise to EI SLPs that language problems and behavior problems can be pretty intertwined (e.g., here), and parenting style can be associated with both behavior and language outcomes. We also know that well-designed parent-implemented interventions can be wonderfully effective (they had better be if entire states are re-vamping their early intervention programs to promote the coaching model). So—can we support these things simultaneously?


Garcia et al. implemented the Infant Behavior Program (IBP) with a group of mother–child pairs. The Infant Behavior Program was adapted from the Child-Directed Interaction (CDI) component of Parent-Child Interaction Therapy (PCIT). Programs like PCIT and Triple P- Positive Parenting Program have been shown to help children reduce negative behaviors, but no one has really studied what how (or if) those parent implemented behavior interventions affect language development. While PCIT training and certification is geared toward mental health professionals, the components of CDI and IBP will sound familiar to EI SLPs. The intervention guides parents to interact with their children using positive parenting skills, avoiding negative parenting skills, and ignoring unwanted behavior, and consisted of 5–7 weekly visits of 60–90 minutes. Parents were then asked to continue using the taught parenting skills in 5-minute increments throughout the day.

“Do” (Positive parenting skills)

  • Imitating

  • Describing

  • Reflecting

“Don’t” (Negative parenting skills)

  • Negative talk

  • Questions

  • Commands

Researchers found that change in parenting style was associated with an increase in the children’s total number of utterances. (Note: this effect was seen at six months after the intervention ended; the kids didn’t show a difference in total number of utterances at three months, or number of different utterances at either time they were tested). But the authors cautioned that presence of negative parenting skills did not change the toddlers’ number of utterances for better or for worse, so definitely don’t interpret this to mean we should throw out questions and commands.

So if an EI SLP is called in on a case where both language and behavior are concerns, but parent priority is behavior, maybe we start with those “positive” responsive techniques (labeling, imitating, and reflecting) before we jump in with questions and commands, because it looks like these positive behavior strategies can also help with language development!


Garcia, D., Hungerford, G. M., Hills, R. M., Barroso, N. E., & Bagner, D. M. (2019). Infant language production and parenting skills: A randomized controlled trial. Behavior Therapy. Advance online publication. doi:10.1016/j.beth.2018.09.003

And more...

  • Dai et al. found that bilingual caregivers of children with ASD and DD can communicate with their children in both languages without adverse effect on their children’s language functioning. (Feel like you already knew that? Well here’s a citation for ya!)

  • Fusaroli et al. found that parents’ language complexity predicted the complexity of their toddler with ASD’s language four months down the road. This finding suggests that modeling grammatically rich and complex language for toddlers with ASD may benefit their language development (as opposed to over-simplified telegraphic speech). While we need an intervention study to tell us if that is truly the case, research has already demonstrated this for toddlers with language delays (which you can read about in a previous review here).

  • To get a better feel for how underserved and under-identified families access health information about development, Gallagher et al. conducted focus groups of parents of typically developing and children with disabilities who lived in an urban area and experienced low income and low literacy skills. The authors found that while these parents knew about a variety of sources of information, they experienced and reported barriers to health literacy resources (e.g., printed materials were too dense, or not literal enough). The parents in the focus groups offered suggestions for making developmental health information accessible to a more diverse audience. This is a good read if you are ever in a position to develop marketing or awareness materials.

  • EI SLPs sometimes encounter (and experience!) mom-guilt when serving families whose mothers work. This study was exploratory but offers us a bit of information we can share when the need arises. Laing and Bergelson found that 17-month-olds’ vocabulary measures of noun type and token did not differ significantly between toddlers of full-time working and stay-at-home mothers. Interestingly, toddlers who experienced mixed care (so their moms worked part time, or stayed home early and went back to work as their children got older), did have more noun types and tokens than kids who experienced one type of care.

  • McLeod et al. examined teacher–child interactions during Enhanced Milieu Teaching (EMT) sessions. All children in the study had DLD and attended Head Start. Two teacher inputs were linked to greater usage of target vocabulary words by children during EMT sessions: (1) following the child’s attentional or communicative lead and (2) providing vocabulary supports to teach or clarify the meanings of target words. We’ve written about parent-implemented EMT for children with DLD before. For more descriptive info about teacher input and child vocabulary go check out the article.

  • Can you screen “everybody” (e.g. via routine pediatricians’ checkups) and reliably catch autism early, between 14–36 months, without over-identification? Yes, probably! This meta-analysis by Sanchez-Garcia provides quantitative data in support of universal toddler screenings for ASD.


Dai, Y.G., Burke, J.D., Naigles, L., Eigsti, I.M., & Fein, D.A. (2018). Language abilities in monolingual- and bilingual- exposed children with autism or other developmental disorders. Research in Autism Spectrum Disorders. Advanced online publication. doi: 10.1016/j.rasd.2018.08.001.

Fusaroli, R., Weed, E., Fein, D., & Naigles, L. (2019). Hearing me hearing you: Reciprocal effects between child and parent language in autism and typical development. Cognition183, 1–18.

Gallagher, P. A., Greenberg, D., Campbell, J. M., Stoneman, Z., & Feinberg, I. Z. (2018). Early identification and connection to services among urban parents who have low income and low-literacy skills. Focus on Autism and Other Developmental Disabilities. Advance online publication. doi: 10.1177/1088357618794913.

Laing, C. & Bergelson, E. (2019). Mothers’ work status and 17-month olds’ productive vocabulary. Infancy, 24(1), 101–109.

McLeod, R.H., Kaiser, A.P., & Hardy, J.K. (2018). The relation between teacher vocabulary use in play and child vocabulary outcomes. Topics in Early Childhood Special Education. Advance online publication. doi: 10.1177/0271121418812675

Sánchez-García, A.B., Galindo-Villardón, P., Nieto-Librero, A.B. et al. (2019). Toddler Screening for Autism Spectrum Disorder: A Meta-Analysis of Diagnostic Accuracy. Journal of Autism and Developmental Disorders. Advance online publication. doi: 10.1007/s10803-018-03865-2.