We can’t catch ‘em all; or can we?

Have you ever worked with one of those “quirky” children and thought, “I wonder how he’ll do later?” I mean, sometimes a quirk is just that, but how do we know when a quirk is something more? And why does it matter? Well, we know that early identification (for purposes of securing early intervention) is important for children with autism. But the false-negative rate from screening might be as high as 60% in some cases. That means that some children with autism are not being caught before school age, either because their symptoms aren’t that bad, or the skills they do have are compensating for the deficits. Without a crystal ball, what can we do for those kids who would otherwise fall through the cracks? The authors of this study looked to compare results of the Autism Diagnostic Interview-Revised (ADI-R) in two groups of children with ASD: early diagnosed (before age 5), and late diagnosed (after age 5).


They found no statistically significant difference between groups in Autism Diagnostic Observation Schedule (ADOS) scores or ADI-R scores, although the early diagnosed group had marginally worse communication scores and more often flagged on items such as “used another’s body to communicate”, repetitive use of objects/parts of objects, and pronominal reversal (when children use "he", "she", "you", or their own name instead of “I” or “me”). The later diagnosed group had fewer symptoms and better communication, but again these differences were marginal.

The authors also found some trends between groups in terms of demographics. Children who were Hispanic, of racial minority, had an additional diagnosis such as ADHD, and/or had higher verbal and full-scale IQs were significantly more likely to be diagnosed later.

Now, if you forget the rest of this review, remember this part: in comparing individual items from the ADI-R, there were five symptoms that ALL of the later-diagnosed children displayed. “Deficits in:

  • reciprocal conversation
  • offering to share
  • imaginative play with peers
  • social verbalization/chatting and
  • showing/directing attention.”

What is interesting about these symptoms is that they were all negative. In other words, kids diagnosed later seemed to “not do” stuff they should have, rather than do extra stuff that would raise a concern (like flapping or showing repetitive interests). The authors suggest that “attention to deficits in these behaviors may facilitate earlier identification of ASD without other obvious impairments.” Completing or referring for a more formal assessment when you notice a child has these symptoms could make a difference in outcomes for these children.

*Note: some skills, like being able to have a back-and-forth conversation, aren’t a major concern if toddlers haven’t quite mastered them, but if a child is still demonstrating these deficits by preschool, make that referral!

Goodwin, A., Matthews, N. L., & Smith, C. J. (2018). Parent-reported early symptoms of autism spectrum disorder in children without intellectual disability who were diagnosed at school age. Autism. Advance online publication. doi: 10.1177/1362361318777243

Screening for ASD? There’s an app for that!

Screening for autism in early intervention. From 16–30 months, we have the M-CHAT-R. What do you use beyond 30 months? The SRS-2 is an option now, but there is not a lot of research on how well it works yet. The SCQ starts at 4 years. And all of those are completed through parent report.

What if we had a screener that combined parent report with objective measurement, that could be administered on a parent’s smart phone? Enter Cognoa!


This two-part screener, intended for ages 18–72 months, is contained in a mobile app. Parents answer 15 questions (similar to the M-CHAT-R or SCQ), and then are prompted to record 1- to 2-minute videos of their children in everyday interactions. The questionnaire is scored immediately, and the videos are reviewed by experienced clinicians for a rating score. All of those scores go into algorithms (yay technology) to determine level of risk. Results are then sent to the family, physician, EI team, etc. Kanne, et al. evaluated Cognoa against other screening measures like the M-CHAT-R, SCQ, SRS, and CBCL and found it to be comparatively sensitive and more specific than those screenings. In other words, Cognoa correctly flagged for ASD evaluation as well as the screenings we already use, and it had fewer false positive screenings. Not bad! Unfortunately, there is a downside. Currently, Cognoa is only really available for parents whose employers buy access to the screenings as a health incentive to their employees. In the meantime, we might have to stick with the measures we already know, but keep your eyes and ears peeled in case this app picks up steam!


Kanne, S. M., Carpenter, L. A., & Warren. Z. (2018). Screening in toddlers and preschoolers at risk for autism spectrum disorder: Evaluating a novel mobile-health screening tool. Autism Research. Advance online publication. doi: 10.1002/aur.1959


Hey, wait! This isn’t the only article on autism screening tools found this month! Janvier et al. found that a simple picture-based developmental checklist could successfully differentiate children with and without ASD among low-income, minority families. This screening tool, The Developmental Check In, may be a useful way to screen for autism among underserved children, particularly when parents are not native English speakers.


Janvier, Y.M., Coffield, C.N., Harris, J.F., Mandell, D.S., & Cidav, Z. (2018). The Developmental Check-In: Development and initial testing of an autism screening tool targeting young children from underserved communities. Autism. Advance online publication: doi: 10.1177/1362361318770430

Predicting the path of language development in ASD


This study looked at… well, it looked at a whole bunch of things, so let’s take a step back. You’ve all heard of ASD infant sibling studies, right? Those are where the researchers take a group of high risk infants (because they have siblings with ASD) and compare development to low risk infants (who have siblings who do not have ASD). These studies are popular in longitudinal studies of autism because the researchers have a better chance of observing the developmental trajectories of children with ASD before, during, and after diagnosis.

Now that we’re up to speed on the rationale, let’s get into the specifics. Franchini, et al. assessed 660 infants over a 2.5 year span to measure the trajectory of language development, as well as predictors for development and outcome of language and autism diagnoses.

The authors identified trends in groups of children from 6 to 36 months for a bunch of tests, including the:

If you regularly use any of these tests in your practice, this article may be good to have because it gives a ton of data on what to expect over time in these tests for children with and without autism, and those who are and aren’t high risk.

But what we really want to know as clinicians is—what differentiated those who went on to have an autism diagnosis from those who didn’t?

A big predictor was gesture. Using the MacArthur Communicative Development Inventory, Words and Gestures form (M-CDI), gestures (including aspects of joint attention and pretend play) at 12 months predicted risk category and ASD diagnosis. The authors state, “…a lower rate of gesture use by the first birthday can be associated with a later ASD diagnosis.”

Children who were diagnosed with ASD also tended to follow slower-developing trajectories of both language reception and expression. About 33% later demonstrated language delay (measured by 1.5 standard deviations below the mean on the language portions of the MSEL).

Interestingly, motor skills are playing some sort of role here as well. Gross and fine motor skills were positively associated with gesture development. The authors posit that good motor skills support gesture, which bolsters early language. Though they don’t yet have data to fully support this, they wonder if motor skills may need to be targeted in early intervention programs for the benefit to language, in addition to the benefit they have on movement development, and suggest this as an area for future exploration.


Franchini, M., Duku, E., Armstrong, V., Brian, J., Bryson, S. E., Garon, N., … & Smith, I. M. (2018). Variability in verbal and nonverbal communication in infants at risk for autism spectrum disorder: Predictors and outcomes. Journal of Autism and Developmental Disorders. Advance online publication. doi: 10.1007/s10803-018-3607-9.

Joint engagement predicts language scores, but which kind of joint engagement?

Joint engagement predicts language scores. Got it. But which kind? You lost me. There are different kinds? As it turns out, yes, and this paper offered some pretty good information on them. You have your good old, traditional joint engagement, which is when at least two people actively attend to the same thing at the same time, and each person knows they are attending to the same thing at the same time. But you can break that down even further, into supported and coordinated joint engagement. Supported joint engagement (SJE) is when the child focuses on a shared item, but the parent carries the communicative load, so to speak. The parent supports the rest of the interaction while the child only has to spend cognitive energy on that item. Coordinated joint engagement (CJE), on the other hand, is when the child splits focus between the object at hand and a communication partner. For example, consider a Jack-in-the-Box toy. In SJE, the parent might turn the handle, narrate what is happening, and react to the doll popping out of the box while the child watches, listens, and learns about the weird musical box. In CJE, the child might turn the handle as she otherwise divides her attention between the toy and her parent, commenting and sharing in the suspense and surprise. 

Conway, et al. recorded mothers playing with their two-year olds and administered language assessments at 2, 3, (PLS-4) and 4 years of age (CELF-P2). Mean language scores for the group fell within low average range. The idea was to rate the videos and compare time spent in supported and coordinated joint engagement with maternal responses and language scores. Check out Table 2 in the study for details on the coding and descriptions of joint engagement, and Table 3 for descriptions of maternal responses measured.


It turned out that the more time a mother and child spent in supported joint engagement, the higher the receptive and expressive language scores at 2- and 3-years, but the association was not significant at the 4-year testing. Coordinated joint attention was not associated with language scores, and the authors suggest that coordinated joint attention could be associated with other language skills, like pragmatics. Looking at maternal responses, the authors found that expansion and imitation were associated with language scores when the children spent less time in supported joint attention. The authors suggested that “where SJE is less frequent or of lower quality, expanding or imitating a child’s utterance may be especially important.”

While the authors caution that more studies are needed before generalizing these results, encouraging supported joint engagement and using imitation and expansion in interactions may be a good choice for supporting language development in both typical and late-talking 2-year-olds.


Conway, L. J., Levickis, P. A., Mensah, F., Smith, J. A., Wake, M., & Reilly, S. (2018). The role of joint engagement in the development of language in a community-derived sample of slow-to-talk children. Journal of Child Language. Advance online publication. doi: 10.1017/S030500091800017X

Throwback (2012): Teaching parents to break into their child’s world


Young children with ASD and their parents face a unique set of challenges when it comes to language acquisition. Children with ASD tend to initiate less, have trouble responding to parent gestures like gaze and pointing, may have limited interest in objects, and demonstrate perseverative play.

Venker et al. (2012) trained parents of children with ASD in various types of verbal responsiveness. Parents participated in SLP-led education sessions and several individual and small group parent/child coaching sessions. Parents in the treatment group showed a significant increase in their use of the strategies at the conclusion of the study, compared to parents who were in a delayed treatment group.

So, what actually works for young children with ASD? The strategies below:

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These methods have documented evidence supporting their use with children with ASD. And this study found that parents can easily learn them. Following this study, children showed increases in prompted communication acts and non-verbal communication. For parents new to the world of ASD, these strategies are a great place to start.  


Venker, C.E., McDuffie, A., Weismer, E. S., & Abbeduto, L. (2012). Increasing verbal responsiveness in parents of children with autism: A pilot study. Autism, 16(6), 568–85.

Throwback (2014): English language development of toddlers from bilingual homes: What do older siblings have to do with it?

Those of us who have worked in early intervention with multilingual families know that the level of proficiency that young kids have in each language varies greatly. Although the factors that create this variability are less clear, one thing we do know is that amount of linguistic input has a strong relationship with how quickly young children develop proficiency in each of the languages that are spoken in the home (e.g., David & Wei, 2008; De Houwer, 2009; Gathercole & Hoff, 2007). To extend our understanding of the factors that create linguistic variability from child-to-child, the authors of this study looked at specific sources and contexts of input that might result in more robust language learning.

So, let’s first talk about input for just a minute before I go on to tell you more about this study. Anecdotally, it would be logical to assume that the adult who interacts with an infant or toddler on a daily basis (think: stay-at-home moms, stay-at-home dads, day care providers, nannies) provides the highest level of language input for that child, right? And, it would even be safe to assume that this would be the case for infants and toddlers who are learning English and another language (or, languages), am I right? This is exactly what I assumed before I read this article (And, there is research to back up this assumption, by the way. For example: Hoff-Ginsberg & Krueger, 1991). But, when Bridges and Hoff examined a different factor—influence of input from older siblings—and its relationship to young, multilingual children’s language learning, a different story emerged.

So, to back up for just a minute: why did they decide to specifically focus on older siblings? Well, the authors based their research on case studies of bilingual children (e.g., Caldas, 2006; Wang, 2008; Yip & Matthews, 2007) that suggested that because older siblings use English at school, they “[bring] English into the home” (p. 2). For instance, older, school-age siblings often provide a model of the dominant language (i.e., English) for the younger sibling, and prefer to use that language to interact with their younger brothers and sisters.


The authors carried out two experiments to determine the influence that older siblings might have on 16- to 30-month-old children’s language learning. The first study looked at whether having an older sibling would influence the level of exposure to and development of English in toddlers learning English and another language (such as Spanish, French, and Hebrew). The second study focused on both Spanish and English by looking at potential differences in the amount that both languages were spoken in homes with and without a school-aged sibling, and the impact that an older sibling might have on bilingual toddlers’ development of both languages.

So, what did they find? Well, the results definitely negated any of the assumptions that I had about sources of language input for the infant and toddler population! In general, the authors found that in multilingual families with school-aged children, younger siblings heard more English, their mothers spoke more English, and the toddlers had stronger English vocabulary and grammatical skills. (And, on the flip side, in the second study, the authors also found that toddlers without older siblings heard less English at home and were more proficient in Spanish.)

We spend a lot of time in our field focusing on training and utilizing parents as partners in therapy; particularly, when it comes to work with infants and toddlers in the home. (And, for good reason—it just makes sense, and there’s research to prove its effectiveness! In fact, we’ve reviewed some recent research that focuses on this here and here).

But, the results of this study seem to suggest that older, school-aged siblings may be an underutilized resource for SLPs working with young, bilingual children who are learning English. Given that they have the potential to provide the highest level of English input for infants and toddlers, maybe it’s time that we started thinking about training and utilizing older siblings, as we do with parents, when we work with infants and toddlers from multilingual homes.

*Note: The terms bilingual and multilingual were used interchangeably in this review to describe young children who are learning English and another language.


Bridges, K. & Hoff, E. (2014). Older sibling influences on the language environment and language development of toddlers in bilingual homes. Applied Psycholinguisticss, 35(2), 225–241.

And more

  • Remember the Index of Productive Syntax (IPSyn) from grad school? Altenberg et al. modified the instructions to make them a little clearer and reminded us that IPSyn is great for describing toddlers’ and preschoolers’ grammatical development. See their updated instructions in the article Appendix and consider giving IPSyn another shot. (NOTE: If you’ve never heard of this thing before, it’s a way to measure syntax production in young children.)


  • It seems that we’re always looking for a quicker, easier way to quantify our young clients’ language skills and progress in therapy. This study looked at whether the automated language analysis system, LENA (Language Environment Analysis), a device that’s worn around the child’s neck, could provide a reliable measure of rate of vocalizations during short recording sessions. Results suggested that human transcribers were able to capture more reliable rates of child vocalizations when the recording was 25 minutes or less. So, although the LENA seems to be a useful tool for longer recordings, findings from this study suggest that when transcribing and analyzing short language samples, it’s best to stick to doing it the old-fashioned way—by hand.


  • Sharabi et al. found that mothers of children with ASD tend to be more involved in their child’s care, especially when they felt they had informal support from family and friends. Fathers with higher education levels tended to be more involved with their child’s care, especially single fathers.


Altenberg, E. P., Roberts, J. A., & Scarborough, H. S. (2018). Young children's structure production: A revision of the Index of Productive Syntax. Language, Speech, and Hearing Services in Schools. Advance online publication. doi: 10.1044/2018_LSHSS-17-0092.

Bredin-Oja, H., Fleming, K., & Warren, S. (2018). Clinician vs. machine: Estimating vocalization rates in young children with developmental disorders. American Journal of Speech-Language Pathology, 27, 1066–1072.

Sharabi, A., & Marom-Golan, D. (2018). Social support, education level, and parent’s involvement: A comparison between mothers and fathers of children with autism spectrum disorder. Topics in Early Childhood Special Education. Advance online publication. doi: 10.1177/0271121418762511

Identifying early learning delays in preterm infants

Do you remember a few months back when we learned that preterm infants don’t seem to catch up to their peers’ language skills by school age? Well, this study took a look at how premature and full-term infants learn, and found some interesting differences we can add to our list of things to watch in our preterm cases.

The authors repeated assessments on 23 full term and 30 preterm infants over a period of 18 months to see if there were changes in how the infants performed on means-end tasks, which included a towel or a turntable as the means, and a fun toy as the end. In other words, the authors recorded whether the babies could pull the towel or turn the turntable to get a toy. Success requires a whole bunch of sensory, motor, and cognitive abilities to interact, and typical infants can complete a one-step means-end task like towel pulling by about 8 months (see here for an older study). They also recorded how much time the infants spent exploring, how many different ways the infants interacted with the task, and how many times the infants successfully completed the trials.


The authors found that all infants got better at getting the toy with age, but preterm infants as a group were less likely to succeed in both tasks compared to full-term infants (2.25 times less likely in the towel task and 1.55 times less likely in the turntable task). The authors also found differences in how the babies explored during the tasks. While everyone explored more over time, babies who explored more early in development had more success with the means-end tasks overall. Not only that, but preterm babies showed more variability in their exploration later in development than the full-term babies. As it turns out, we decrease the variability in exploration as we fine-tune our skills. Think about it this way—when we learn a new skill, we try it this way, try it that way, try it another way, and store maps for the most efficient ways to do the skill. We explore less as we get good at it, but pre-term babies continued to explore different behaviors longer than full-term babies in the means-end tasks.

OK, got it. But how can we use it? Diagnostically, we could use these tasks during assessments (the authors suggest the towel task for 5- to 7-month-olds and the turntable task for 11- to 13-month olds). Red flags would include lack of exploration in earlier ages and lots of variability in exploration later in infancy. For intervention, we should remember to encourage infants to explore solutions. Instead of modeling the solution, have fun in the learning process! We can also call attention to the end object so infant can see what happens to the toy when she acts on the towel or the turntable. Help these babies become the little scientists they were born to be!


Cunha, A. B., Babik, I., Ross, S. M., Logan, S. W., Galloway, J. C., Clary, E., & Lobo, M. A. (2018). Prematurity may negatively impact means-end problem solving across the first two years of life. Research in Developmental Disabilities. Advance online publication. doi: 10.1016/j.ridd.2018.03.007

Using fine motor skills to predict language outcomes

Wait... using fine motor skills to predict language outcomes? People who don’t know child development might do a double take on that one. EI SLPs, on the other hand, know that all aspects of early development are connected and there might be some information we can use here!

The authors of this study measured fine motor growth and expressive language over the first three years of life using the Mullen Scales of Early Learning (MSEL), and confirmed or ruled out a diagnosis of autism for at-risk children (kids who had a sibling with a diagnosis of ASD). They wanted to see if there were differences in fine motor development among kids at high risk who ended up with an ASD diagnosis (HRA+), kids at high risk who did not end up with a diagnosis (HRA-), and low risk kids who did not have a sibling with ASD (LRC). They also wanted to know if early fine motor skills predicted expressive language at 3 years.


Well? There was no difference in status of fine motor skills at 6 months. But the HRA+ group showed slower fine motor development between 6 months and 2 years of age compared to the LRC group. The authors state, "Only beginning in the second year of life, did high-risk infants who were later diagnosed with ASD score significantly lower on the MSEL Fine Motor scale than high- and low-risk infants without eventual diagnosis." The authors suggest, “Our finding is consistent with those from prior research indicating that fine motor differences may be a characteristic of infants at high risk for ASD, rather than a core characteristic of the disorder.” One thing we should note is that, even though there were differences between groups in the statistical analysis, all of these fine motor scores fell within average range, so in individual assessments there might not be a flashing red light around that fine motor score.

What is really relevant to EI SLPs is that children who had better fine motor skills in early development had better expressive language scores at 3 years, and this association held for all three groups. The authors cite literature suggesting we might support language development by encouraging fine motor development in infancy (but this remains a hypothesis—they don’t yet have data to show that would work). For those of you who work under a Primary Service Provider model, this might be a good study to share with your teams!


Choi, B., Leech., K. A., Tager-Flusberg, H., & Nelson, C. A. (2018). Development of fine motor skills is associated with expressive language outcomes in infants at high and low risk for autism spectrum disorder. Journal of Neurodevelopmental Disorders, 10(14), 1–11.

Facilitating parent–child playgroups: A how-to guide


Most of us early interventionists work with families one-on-one. But how great would it be to facilitate a parent/child playgroup? Not only could you work with multiple children at once, but you could also connect families going through similar experiences. Green et al. investigated a specific type of playgroup geared toward enhancing parent interaction in communication (referred to as EPIIC) playgroups.

The EPIIC playground was structured like a typical morning preschool session. They did a hello song, a play activity, story time, and snack. They also built in time to address each child’s individual IFSP goals. Each playgroup session had a different theme, such as “what makes me learn to love books” and “what makes me laugh.”

Instead of the teacher or SLP leading the group, the parents worked directly with their children while being coached by the SLP. For instance, the SLP might model a page or two of shared book-reading, and then let the parent take over. The SLP facilitates the session, while parents interact with their child, learn new strategies, and meet other parents in their same boat!

After seven playgroup sessions, all children demonstrated increased communication skills. All of the parents improved their use of communication strategies with their children. Informally, parents reported being very happy with the playgroup, and felt that they learned new strategies and gained knowledge. The EPIIC playgroup model seems like a pretty epic way to deliver evidence-based services to families. Get it?

For a specific breakdown of the playgroup schedule and a full list of the topics used, be sure to check out the original article here.


Green, K. B., Towson, J. A., Head, C., Janowski, B., & Smith, L. (2018). Facilitated playgroups to promote speech and language skills of young children with communication delays: A pilot study. Child Language and Teaching, 34(1) 37–52.