Identifying children at risk for language impairment: screening of communication at 18 months

Sir, Ever since the early 1980s, Child Health Centres (CHC) all over Sweden have been recommended by the Swedish National Board of Health and Welfare (1) to assess language development in 18-mo-old children. The requirement for passing this assessment, predocumented in the national health record, is set at “a use of eight to ten words and understanding of more”. However, these demands—never empirically based— have long been questioned by speech and language therapists (SLT), partly because of the cut-off set at eight words, partly because many more dimensions other than production and reception are involved in language communication—especially in young children. Bruce et al., in their study “Identifying children at risk for language impairment: screening of communication at 18 months”, have made a laudable attempt to construct and evaluate a language screening which is based on both direct observations and a parent questionnaire covering expressive and receptive skills as well as interaction and play behaviour (2). From their results they conclude “that it is important to focus on receptive skills and play behaviour at the expense of expressive skills” and recommend “that professionals should carry out the screening in close collaboration with parents”. This—the collaboration with parents—is not however substantiated by their results showing: “No significant correlation was found between the questionnaire for parents at 18 mo and the language assessment at 54 mo”. The superiority of direct observations compared toparents’ opinion has earlier been documented in Swedish studies, where the latter are less reliable in identifying language delay in 3and 21⁄2-yold children, when compared to a clinical examination close in time (3, 4). On the other hand, and as Bruce et al. claim, “parents often become concerned about their children’s language development between 1 and 2 y of age and this motivates screening, optimally by means of a parental report. ” Furthermore, to work in active collaboration with parents was one of the agreements from the state-of-the-art conference concerning child health care—held in 1999 (5). Thus, a close collaboration with parents seems well motivated. Contrary to the results of Bruce et al., both Swedish and international studies have shown that parents’ assessments of their children’s word production are reliable provided they use checklists, on which they can recognise the words their children say (6–8). In the light of this and of the statement by Bruce et al. that “[e]arly language comprehension problems might be difficult to identify at 18 mo. ” and that “language comprehension is dependent on the screening procedure and may be difficult to distinguish from comprehension of context and is sometimes difficult to separate from lack of motivation, shyness and so on”, their exclusion of expressive skills in favour of an assessment of receptive skills is surprising. The strong correlation for professionals (in the article by Bruce et al. =SLT students) conducting a communication screening at 18 mo, when validated with results of language tests, has already been mentioned, as has the superiority of professional judgements (here = CHC nurses) in earlier studies (2, 3). The possibility of having SLTs or SLT students, i.e. specialists, involved as a matter of routine at CHC screenings is, however, far from realistic, at least as long as the need of SLTs still exceeds the access. In spite of my seemingly critical opinion I regard the new approach to a language and communication screening of 18-mo-old children as promising, and I am looking forward to seeing whether it will be possible to revise the screening for use by CHC nurses, i.e. professionals but non-specialists, with instructions on how to administrate it and with clear referral criteria. I am also waiting for a report showing that an extended language screening at 18 mo of age has satisfactory sensitivity, specificity and predictive value in a population-based study.