Level of language development
Ability
Percentile 50 (milestones) (references)
Percentile 90 (cornerstones) (references)
Suggested question for parents and caregivers
Vocalization
Reduplicating babbling
6 months (Gerken 1994; Largo et al. 1986; Oller et al. 1999; Papoušek and Papoušek 1989; Penner 2000)
At what age did your child use doubled syllables such as ‘baba’?
Phonetic and phonological level
Correct articulation of all speech sounds except sibilants
4 years and 6 months (Fox 2006; Fox and Dodd 1999; Schäfer and Fox 2006)
At what age did your child speak vowels and consonants correctly (except sibilants)?
Semantic and receptive lexical level
First language comprehension
9 months (Bates et al. 1994)
At what age did your child first understand words such as ‘no’ or names?
Expressive lexical level
Speaking first words
13 months (Bates et al. 1994, 1995; Kauschke 1999; Menyuk et al. 1995)
18–20 months (Largo et al. 1986)
At what age did your child speak its first word(s)?
Speaks ‘mama’ (‘mom’, ‘mum’, ‘mummy’) or ‘papa’ (‘pop’, ‘dad’, ‘daddy’)
10–15 months (Zollinger 2004)
18–20 months (Largo et al. 1986)
At what age did your child first call you ‘mama’ (‘mom’, ‘mum’, ‘mummy’) or ‘papa’ (‘pop’, ‘dad’, ‘daddy’)?
Speaks roughly 50 words
24 months (Szagun and Steinbrink 2004)
At what age did your child speak 50 words? Did you make a list of the words?
Hierarchical organizing of words
At what age did your child know ‘apple’ as a fruit or ‘carrot’ as a vegetable?
Morphological and syntactic level (grammar)
Uses two-word sentences
18–24 months (Clahsen 1986; Tomasello 2000; Weissenborn 2000)
At what age did your child first combine two words?
Uses three-word sentences
24–30 months (Clahsen 1986; Kauschke 1999; Szagun and Steinbrink 2004)
No data
At what age did your child first combine up to three words to a sentence?
Uses questions
30–36 months (Clahsen 1986; Penner and Kölliker-Funk 1998; Rothweiler 2002; Weissenborn 2000)
No data
At what age did your child first use a sentence as a question?
Uses subordinate clauses
No data
At what age did your child first use a subordinate clause?
Pragmatic level
Respects turn-taking in conversations
2 years (Karmiloff and Karmiloff-Smith 2001)
At what age did your child respect turn-taking in a conversation?
Organizes themes in conversations
3 years (Karmiloff and Karmiloff-Smith 2001)
At what age was your child able to tell you something that happened?
Fluency
Speaks without word repetitions, prolongations, blocks and remarkable coping strategies
Does your child speak fluently most of the time? (Note that word repetitions at age around 3 are ‘normal’)
Exemplary questions are: At what age did the child utter words such as ‘Mom’, ‘Pa’, names of siblings or ‘No’? At what age did the first two-word sentence come? How many words does the child speak at present? Did the parents count the number of words, or—much better—did they make a list of words their child uses or has used at certain developmental milestones such as the second birthday?
It is also important to know whether parents apply any strategies to improve the communicative abilities of the child. It might be helpful to demonstrate a typical example of corrective feedback (improved repetition of an utterance) or parallel talk (parent parallels the child’s actions verbally and repeats utterances of the child correctly and unobtrusively without requiring answers to questions): Is one of these methods known by the parents?
A developmental speech-language disorder can be suspected if answers at one or more subscales of the developmental language scale have been found to be below the normative developmental age of the child. The respective answers in a diagnostic interview also help to choose appropriate tests to confirm the diagnosis of a speech-language disorder.
Medical history in children with a suspected speech-language disorder
Topic | Diagnoses | Related question | Treatments and therapeutic interventions | Related questions |
|---|---|---|---|---|
Birth | Preterm birth, low birth weight, hypoxia, hyperbilirubinemia, risk factors for DDLS | At what gestational age was the child born? Was the birth ‘normal’ or ‘complicated’? What exactly happened? What was the result of the neonatal hearing screening test? | Stay at neonatal intensive care unit (NICU), blood transfusion, oxygen, extracorporeal membrane oxygenation (ECMO), aminoglycosides | After birth, was your child in hospital for a long period? What kind of treatment did your child receive? |
Hearing | Congenital hearing loss, periods of serous or mucous otitis media with effusion, acute otitis media, mastoiditis, auditory deprivation, meningitis, encephalitis, cerebral insult, head trauma | Does your child suffer from a permanent hearing loss or ear infection? When was it diagnosed? | Ear surgery, hearing aids, cochlear implants, bone conduction implants, middle ear implants, educational programme for hard-of-hearing children | Does your child wear hearing aids or an implant? Did your child undergo ear surgery? |
Malformations | Craniofacial abnormalities such as cleft lip, cleft palate, preauricular or neck fistulas, malformations of the auricula, preauricular lobes, stenosis or atresia of the outer ear canal, facial dysmorphia such as hypertelorism or epicantus; other malformations concerning, for example, the brain, heart, kidneys, liver or limbs | Does your child suffer from a malformation? | Surgical treatment | Has your child received a surgical treatment? How long did he or she stay in hospital? |
Speech-language development | Developmental language delay (late talker); developmental disorder of speech and language (DDSL), subclassified in specific (or primary) DDSL and DDSL with language-relevant comorbidities (DDSLC or unspecific or secondary DDSL); speech fluency disorder | See Table 11.1, column ‘Suggested questions for parents and caregivers’ | Counselling on linguistic enrichment and corrective feedback, training interventions, educational programmes | Have you already been counselled on how to facilitate the speech-language abilities of your child? Has your child already received a speech-language therapy? Does your child attend an educational programme? Or is your attitude ‘wait and see’? |
Psychomotor, oromotor and cognitive development | Developmental disorder or delay, cerebral palsy (CP), seizure disorders, dyspraxia, ataxia | Does your child suffer from any developmental delay or disorder? | Training, educational programmes | What kind of training therapies or services does your child receive, e.g. physiotherapy? Does your child attend an educational programme? Or is your attitude ‘wait and see’? |
Other diseases | For example, hypothyreosis | Did neonatal screening or follow-up examinations reveal any other diseases? | Medical treatment | Does your child need medication? Which ones and what dosages? |
The interview continues with questions on recent treatments and otherwise interventions (Schönweiler 1993; Tomasello 2000). For instance, a child may have undergone surgery for otitis media with effusion, cleft lip or palate and cardiac defects. In cases of severe illness or complications, a child may have been hospitalized for a long time. In particular, a phoniatrician should ask whether ear surgery has been performed and whether the adenoid glands or the tonsils have been removed or if such a surgery is planned.
Questions should also focus on recent diagnostic examinations, counselling, trainings and other remediation services including their quality and quantity. Have the parents already been counselled on linguistic enrichment principles such as narrative reading and corrective feedback? If a training or therapy is ongoing, it should be asked for the kind of professionals involved, the methods used and the total amount and frequency of sessions administered so far. If no treatment is running, the physician should ask whether the child is in a ‘wait-and-see’ phase at current. Parents should be also asked whether a child is under medication and if so to provide details such as generic names and dosages. Furthermore, information is needed about diagnostic and therapeutic steps that have already been planned by other professionals.
Interview on family history of speech, language and hearing disorders, developmental delay and intellectual retardation
Topic | Relevant diagnoses | Related questions |
|---|---|---|
Speech and language | Developmental language delay (late talker); developmental disorder of speech and language (DDSL), either specific (or primary) DDSL or DDSL with language-relevant comorbidities (DDSLC or unspecific or secondary DDSL); speech fluency disorder | Do members of the family suffer from a speech-language disorder, dyslexia or fluency disorder? |
Hearing | Congenital hearing loss (conductive or sensorineural), ear malformation (e.g. preauricular fistulas or lobes, ear canal atresia) | Do members of the family suffer from hearing loss? Did or do members of the family wear hearing aids or a hearing implant? Did members of the family receive a surgical correction of an inborn ear abnormality? |
Psychomotor, oromotor and cognitive skills | Developmental disorder or delay, cerebral palsy (CP), seizure disorders, dyspraxia, ataxia | Did or do members of the family suffer from neurological or psychiatric diseases? Did or do family members receive a special education because of a disability? |
Questions should also address the child’s emotional and social development and environmental situation (Schönweiler 1993; Tomasello 2000). It should be asked whether a child lives at home, together with the family, or if she or he grows up with a single parent or in a home where one parent is often absent or where grandparents or other caregivers overtake the care. Information should be gained also on the presence and number of siblings, their age and the position of the child in the sequence of siblings. Furthermore, it should be asked about the daily care for the child, for example, whether she or he attends a kindergarten.
Questions of the diagnostic interview should be carefully formulated in order to avoid embarrassing the parents. For example, medically important questions on consanguinity, professional qualifications and educational background of the parents might sometimes be perceived to be personal or intrusive and might cause discomfort. Sometimes parents are not prepared to answer certain questions immediately. It might be appropriate then to return to relevant questions later after the clinician had gained more trust from the parents.
11.2 Questionnaires on Child Development
11.2.1 Definition
Questionnaires are instruments for targeted assessment of one or more developmental domains of a child. In the context of early childhood development, they are often used for the detection of developmental risks in terms of secondary prevention. They are considered an effective and reasonable method for the screening for developmental peculiarities.
11.2.2 Construction Principles
For parent questionnaires, which assess the developmental status of children, various question-answer formats are used: in partially standardized questionnaires, the questions usually are uniform, and the answers of the interviewees are open (open-ended questions). This format is used in questions on a child’s history such as pregnancy, delivery or medication.
In standardized questionnaires, the questions are expressed uniformly too, but the answers are predetermined (closed-ended questions). Possible predetermined types of answer for closed-ended questions are dichotomous (two possible answers, e.g. for yes/no questions) or polytomous answers (more than two predetermined answers). The scaling (measure) of answers to questions, based on the level of measurement (Trochim 2006), can be nominal (e.g. gender), ordinal (e.g. highest educational level) or by interval (e.g. age).
11.2.3 Quality Criteria
Validity for psychometric tests according to the American Educational Research Association, American Psychological Association and National Council on Measurement in Education (2014)
…the degree to which evidence and theory support the interpretations of test scores.
Reliability according to Trochim (2006) the consistency and repeatability of measures, which are interdependent (Fig. 11.1)
Objectivity, the independence of a test result from general conditions and confounding factors such as environmental conditions or examiners
Relationship between validity and reliability of psychometric tests (From Trochim and Donnelly (2007). The Research Methods Knowledge Base, 3E. © 2007 Custom Solutions, a part of Cengage, Inc. Reproduced by permission. www.cengage.com/permissions)
If they rely on normative data, the representativeness of the validation sample (e.g. examined population) is fundamental. Relevant secondary quality criteria are the acceptance by respondents (e.g. comprehensibility, reasonability), economics (e.g. costs, investigation time, analysis time) and usefulness (e.g. consequences such as early intervention for a child who has been classified as being impaired).
11.2.4 Limitations
Partially standardized questionnaires with open-ended questions offer the respondent more freedom to answer questions according to the individual situation and therefore to describe the reality as closely as possible. They have the downside, however, that a standardized evaluation is not possible unless a post hoc assignment of answers to standard formats is done, in order to enable generalization. On the contrary, standardized questionnaires are sometimes criticized because their predetermined answers may appear schematic and misleading or miss the individually appropriate answer, so that the specific situation of the respondent cannot be fully described. Nevertheless, on the whole they reveal the more reliable and trustworthy results and are the main tools of psychometric tests, for example, in psychology. Sources of potential error can hamper data evaluation, such as skipping questions because they are not clear, doubtful answers due to unclear questions or unintended response bias (e.g. extreme responding, social desirability bias, acquiescence bias).
11.2.5 Implications
Questionnaires on child development either refer to various developmental domains such as motor, cognitive, socio-emotional and language (e.g. Ages and Stages Questionnaires (ASQ-3), Squires et al. 2009; Parents’ Evaluation of Developmental Status (PEDS), Glascoe 1999; Parents’ Evaluation of Developmental Status—Developmental Milestones, Brothers et al. 2008) or to one domain (e.g. MacArthur-Bates communicative development inventories, Fenson et al. 2007; Language Development Survey, Rescorla 1989; Parent Language Checklist, Burden et al. 1996; Structured Screening Test, Laing et al. 2002). They are often used as screening instruments for assessment of developmental risks. For-parent questionnaires especially have proven of value, as these can be filled in at home or in the waiting room of a doctor’s office. Mostly, only little time is required from the medical staff to analyse the results. If they are atypical, elaborate diagnostics should follow.
11.3 Assessment of the Developmental Speech and Language Status of Children
11.3.1 Normal Language Development: The Concept of Milestones and Border Stones
Time course of the normal German language acquisition (modified according to de Langen-Müller et al. 2012, with kind permission from Peter Lang GmbH, Internationaler Verlag der Wissenschaften)
Domain | Stage of development | Milestone (average age) | Borderline stone (age at 90th percentile) |
|---|---|---|---|
Early language perception | Interest in human language (‘eavesdropping’) | Prenatally, first weeks of life | |
Perception of rhythmic and prosodic features of mother tongue | Prenatally, first weeks of life | ||
Development of vocalization | Crying | Birth | |
Cooing | Sixth to eighth week | ||
Marginal babbling (testing of sound production) | Fourth month | ||
Canonic babbling (syllables of consonants and vowels, e.g. ba) | Sixth month | Eighth to tenth month | |
Reduplicated babbling (doubling of syllables, e.g. baba) | Eighth to tenth month | 11th to 15th month | |
Varying babbling (e.g. bada) | Eighth to tenth month | ||
Acquisition of the phonological system | Elementary sound inventory Simple syllable structures (mostly open syllables) | 12th month | |
Starting organization of the phonological system (use of sounds of the target language) | 18th month | ||
Starting to overcome phonological processes (systematic developmental changes of pronunciation of the target language) | 2.5–4.5 year of life | ||
Development of phonological awareness: detect syllables; ‘clap’ syllables; detect rhymes; detect initial sounds | About third year of life | ||
Development of phonological awareness: detect and localize phonemes (smallest contrasting unit regarding meaning in the sound system), segmentation, analysis and synthesis of sounds into words | About fifth year of life | ||
Acquisition of vocabulary | Starting to understand words | Ninth month | |
Understanding approximately 50 words | 16th month | ||
Pre-forms of naming (situation-dependent proto-words) | Tenth month | ||
Purposeful usage of mama and papa | Tenth to 15th month | 18th to 20th month | |
Production of the first words (one-word utterances) | 13th to 20th month at latest | 18th to 20th month | |
Production of at least 50 words | 18th to 24th month at latest | 24th month | |
Vocabulary spurt | 18th to 21th month | ||
Stage 1: personal/social words (yes, hello), relational words (there, on), onomatopoeia, proper names, some nouns | 12th to 18th month | ||
Stage 2: noun growth, start of verb acquisition | 19th to 30th month | ||
Stage 3: verb growth, function words (because), pronouns | 30th to 36th month | ||
Overextensions and underextensions (e.g. dog/bow-wow for naming all animals) | Second year of life | ||
Acquisition of the hierarchical organization of the mental lexicon; understanding semantic relations | Third year of life till school age | ||
Acquisition of word formation: compounding (composition, e.g. front door) + derivation (e.g. heat → heater; sun → sunny) | Second to fifth year of life | ||
Acquisition of grammar | Production of word combinations (two- or more-word utterances) | 18th to 24th month at latest | 25th to 26th month |
Increase of utterance length: at the age of 3 years, approximately 3 words per utterance on average | Third year of life | ||
Production of simple syntactic structures | Third year of life | ||
Decrease of omissions of obligatory constituents (e.g. subject) | Third year of life | ||
Decrease of omissions of function words | Third to fourth year of life | ||
Verbs in second position (Lisa cake eat → Lisa eats cake or What eats Lisa?) | 30th to 36th month | ||
Use of variable sentence types: declarative sentence, interrogative sentence, exclamatory sentence | 30th to 36th month | ||
Occurrence of subordinate clauses | 36th month | ||
Use of the definite article (the) | 30th to 36th month | ||
Correct subject-verb congruency (I eat—she eats) | Second to third year of life | ||
Acquisition of the German case system, accusative at first, dative later | 36th month to school entry age | ||
Acquisition of the plural system | Second to sixth year of life | ||
Acquisition of tempus markers Temporary grammatical overextensions (I runned away.) | Third year of life Third to fourth year of life | ||
Development of conversational and narrative abilities | Eye contact with primary attachment figure | Third month | |
Early expression of communicative intentions via looking, gestures and vocalizations | First year of life | ||
Triangular eye contact Establishing shared focus of attention | Ninth month | ||
Adherence to turn-taking rules | Second year of life | ||
Child relates to conversation partner in dialogue | 18th month | ||
Organization of topics in dialogue | Third year of life | ||
Development of narrative competence; increasing coherence (content-related) and cohesion (formal connection of text elements) in narration | 36th month to early school age | ||
Understanding irony and metaphors | Sixth year of life | ||
Literary language acquisition | Logographic stage (recognition of frequent words) | Preschool age, early elementary school age | |
Alphabetic stage (linkage between sounds and letters) | Early elementary school age | ||
Orthographic stage (learning of orthographic rules) | Elementary school age |
11.3.2 Diagnostics of Developmental Disorders of Speech and Language
For the diagnosis of developmental disorders of speech and language (DDSL), the separation of specific developmental disorders of speech and language (SDDSL) and DDSL with comorbidities has to be taken into consideration. Hence the first step of the diagnostic process is to seek comorbidities, because SDDSL is an exclusion diagnosis. Furthermore, DDSL have to be distinguished from socioculturally caused environmental language abnormalities, which do not need treatment but language input and training (see Sect. 9.8).
11.3.2.1 Analysis of Spontaneous Speech
The analysis of spontaneous speech is an important tool in the diagnostics of developmental language deficits, and it complements language tests. It is based on the observation of the child during a guided game or a dialogue, mostly with adults (parents or examiner). It is important to create situations that stimulate the child to communicate. Speech and language-related behaviour and utterances of the child have to be documented. Video recordings may be helpful for language and interaction analyses and may also provide information on the parental communicative behaviour and style. From such informal observations, important information about phonetic-phonological, semantic-lexical, morphologic-syntactical and pragmatic-communicative abilities of a child can be gained. Furthermore, prosody, speech fluency and motivation to speak and to communicate as well as joyfulness of speaking may be analysed. For the evaluation of the spoken utterances, speech competence (the mastery of the speech-language systems) has to be distinguished from performance (the demonstration of the competence while communicating). Speech-language diagnostics aims to elicit as much as possible competence via performance within a short time (Neumann et al. 2009).
For a more thorough analysis of spontaneous speech, a detailed transcription, coding and analysis of language samples can be gained from audio or video recordings. Computer programs may be useful here, such as the Systematic Analysis of Language Transcripts (SALT) (Miller et al. 2011; SALT Software 2014) and the Computerized Language Analysis (CLAN) Program (MacWhinney 1995), which is a part of the Child Language Data Exchange System (CHILDES 2014), a database of speech audio files and text transcriptions in more than 20 languages serving as a central repository for first-language acquisition data (CHILDES 2014). Transcripts are necessary to calculate, for example, the mean length of utterances (MLU). This is a measure of linguistic productivity and language proficiency in children. It is the average number of morphemes per utterance contained in a sample of 100 utterances. The MLU is a benchmark of language acquisition, a good marker of DDSL, and may predict the further reading abilities of children (Bishop and Adams 1990; Rice et al. 2010). However, because the usefulness of MLU is questioned, it should not be used as the only diagnostic measure of language proficiency in children.
11.3.2.2 Examination of the Developmental Speech and Language Status with Informal and Nonstandardized Procedures
For a rough, informal evaluation of the phonetic-phonological, semantic-lexical and pragmatic competence of a child, simple test tools such as picture cards are suitable. Grammatical abilities might also be judged by using pictures that stimulate the production of specific grammatical structures, such as ‘Brush your teeth!’ to elicit the imperative or ‘This is one apple, and these are two…?’ for eliciting information on plural production (Neumann et al. 2011). The informal judgement of the types of language-related competence of a child requires the knowledge from professionals on the age-appropriate developmental targets (milestones) for each tested linguistic level (see Table 11.4).
11.3.2.3 Language Tests
The assessment of language skills should be performed with valid and normed tests, in order to get, as far as possible, examiner-independent, reproducible and reliable results. The use of only such tests enables the comparison of an individual test result with normal values, its interpretation and a differentiated evaluation of a child’s language developmental status compared with the age norm. Comprehensive language tests that examine all or at least some linguistic levels have to be distinguished from tests that analyse only one type of competence, for example, vocabulary. The scores of single subtests of comprehensive tests ought not to be interpreted separately for different linguistic domains (grammar, vocabulary, etc.); otherwise such tests would reveal more children suspected of a DDSL than its prevalence (Neumann et al. 2011). In other words, if many subtests are performed, the probability is high by chance alone that at least one of them would indicate a deficit, which may lead to overdiagnosis. Therefore, a weighting system is required that evaluates test results according to the severity and prognosis of the specific deficiency.
Principles of the Interpretation of Test Values
Example: A child has performed a speech perception test and has solved 6 of 10 items correctly. At first glance this suggests a quite good test result, which, however, may be oversimplified and wrong, because from the reference values it is clear that in the normative sample all children are able to solve five items correctly, and the majority of subjects even at least six items. A transformation of the raw value ‘6’ into a standardized value, for example into the 10th percentile (to be interpreted roughly as: 90% of the subjects of the normative sample have solved more items) or a value that is even more related to the distribution of the normative values, such as the intelligence quotient, indicate a rather ‘below average’ result in this example (Petermann and Macha 2005).
Principles of generation of standard values and frequently used standard scales for the assessment of DDSL/SDDSL. Percentile, z-, T-, C– and intelligence (IQ) scales: selected standard values in a normal distribution (Gaussian curve) and convention of their interpretation (modified according to Petermann and Macha (2005) with kind permission from the authors)
The standardized values shown in Fig. 11.2 follow this sequence: (a) The average value of a distribution is identified. (b) A numerical value according to the chosen scale is attributed to the average. The percentile scale attributes the percentage of 50 to the average of the scale; the IQ scale, the IQ value 100; the z scale, the z value 0; the T scale, the T value 50; and the C scale, the value 5. (c) In order to interpret a test score, the spread of the distribution is of interest, in particular the distance between the average and the standard deviation (SD), because the test values on a specific scale are related to the SD. For example, the IQ scale subdivides the distance between the average and one standard deviation into 15 scale units (an IQ value of 85 represents an intelligence that deviates 1 SD from the average downwards; an IQ of 70 indicates a deviation of 2 SD from the average downwards). The T scale attributes 10 points to the distance of the SD from the average. In this way each of the scales enables the quantification of direction and extent of a deviation from the average by a scale value.
The percentages given on the Gaussian bell curve of a normal distribution are useful for orientation. They indicate the proportion of subjects of a sample (e.g. the norming sample) which is in the respective performance range. Between −1 and +1 SD lie about 68.2% of all subjects, i.e. more than two thirds. Below −1 SD are located the worst 15.8% of the subjects of the normative sample related to the values of a specific test; below −2 SD, the worst 2.2%; and below −3 SD, the worst 0.1%.
Related to those reference values, the performance in a certain test can be interpreted. The region between −1 and +1 SD from the average is regarded as the average or normal region (~68.2% of all subjects), i.e. a T value of 43 or an IQ of 91 is ‘average’. The deviation of a test value of more than one but not more than two SD from the average may be interpreted as ‘below average’ or ‘above average’ (13.6% of subjects are located on each side of the average distribution). The ‘below average’ region is often considered as a region of risk. Thus, a T value of 35 or the 12th percentile is ‘below average’ and an IQ value of 125 ‘above average’. Deviations of more than ±2 SD from the average may be named ‘far below/above average’ (2.2% on each side). A T value of 26 or the second percentile is thus ‘far below average’ and an IQ < 70 as well (regarded an intellectual disability), and an IQ > 130 is ‘far above average’ (intellectual giftedness) (Petermann and Macha 2005).
Diagnostic Criteria for Specific Developmental Disorders of Speech and Language
Perceptive and expressive language skills, as assessed from standardized and normed tests, are 1.5–2 SD below the age-dependent normative values at one or more than one language/communicative level.
The expressive and receptive language skills, as assessed by structured behavioural and linguistic analyses, are considerably below the average abilities of the age norm.
The use and understanding of nonverbal communication are within the age norm.
The assumption of normality is justified.
Additionally, the ICD-10 defines a double discrepancy criterion between cognitive and language competence: for an SDDSL diagnosis, language perception or language production of a child is below the level appropriate for his or her age. Additionally, the receptive/expressive language competence is 1–1.5 SD below the nonverbal IQ that is at least average (IQ ≥ 85) (see criteria 1 and 4). This criterion is, however, under debate.
Diagnostic algorithm for developmental disorders of speech and language (modified according to de Langen-Müller et al. 2012, with kind permission from Peter Lang GmbH, Internationaler Verlag der Wissenschaften)
11.3.2.4 Screening Tests for the Developmental Speech and Language Status
Parent questionnaires have been shown to be a useful screening for the language development status of young children (Dale 1991). Universal or regional screening tests at kindergarten or preschool ages, i.e. short and easy to perform and to analyze language tests, have been implemented in some European regions. They aim at the detection and support of children with language abnormalities by either language therapy or training, in order to ensure sufficient language competence at school entry. In most cases such screening can distinguish between children who have language abnormalities and those who do not. Only a few screening tests, such as the German Kindersprachscreening (KiSS.2), trichotomize between (a) normally developed children, (b) children who have sociogenically caused language abnormalities and who require language training and (c) those who are suspect for having a DDSL and need therapy (Neumann and Euler 2013).
Agreement between the results of language screening and diagnostic language assessment with language tests
Diagnostic tests | ||||
|---|---|---|---|---|
DDSL (D+) | No DDSL (D−) | Total | ||
Screening | REFER (S+) | cp | fp | cp+fp |
PASS (S−) | fn | rn | fn+cn | |
Total | cp+fn | fp+rn | cp+fp+cn+fn | |
Hypothetical ROC curve of a screening procedure. Because for ROC analyses the original proportions of false positives have been used, which are 1-specificity, the x-axis values descend from 100. The figure demonstrates an ROC curve (circles), a trend curve assuming a normal distribution of the data (blue curve), the upper and lower 95% confidence limits (dashed red lines) and the diagonal (grey line). The predictive power of a screening starts above the diagonal. The larger the AUC, the higher the validity of the screening. An increase in specificity in the decision algorithm of the screening results in a decrease of the sensitivity. An ideal curve would run rectangularly along the y-axis and the upper borderline of the diagram. Image adapted from Keller (2014) with kind permission of Dr. Thomas Keller
For a PASS/REFER decision, a cut-off criterion has to be defined. Cut-off values may be derived from the prevalence of a disease. If the prevalence of SDDSL is given as 4–7% and that of DDSL with comorbidity estimates at least 3%, then diagnostic testing for DDSL should not reveal much more than 10% of children in a normal population who fail it, which is between −1 and −2 SD (see ‘Diagnostic Criteria’ in Sect. 11.3.2.3). For screening the borderlines have to be extended, because a certain number of false positives (children who do not pass the test but have no DDSL) have to be accepted in order to minimize the number of false negatives (children who pass the test despite a DDSL). The cut-off value of a screening depends on a trade-off between the proportion of false negatives that is acceptable and that of false positives, which would increase the number of children who have to undergo follow-up diagnostics. It seems reasonable that screening should reveal about 15% of children who do not pass it in order to get the (at maximum) 10% of children who really have a DDSL from subsequent diagnostics.
The real language status of a child and the screening result for a given cut-off point can be compared in a contingency table (Table 11.5). In ROC curves the value pairs of specificity and sensitivity of a screening are drawn for all possible cut-off values. The area under the curve (AUC) indicates the validity of a screening. The more it approaches 1, the higher the validity.
Language screening programs are crucial because (a) children without language abnormalities are easier to detect than those with abnormalities (Law et al. 2000), (b) the language development for each specific linguistic competence has large variance and (c) there is often only poor evidence for a sufficient validity of a reference tests. Therefore, sensitivities and specificities of language screening that do not lie below 80% are assumed by convention to be acceptable (Petermann and Macha 2005; Plante and Vance 1994).
11.3.2.5 Examples of Language Screening, General and Specific Speech-Language Tests and Developmental Tests that Include Language Subtests
Screenings, general developmental language tests and (The spelling x;y years in the table means x years and y months of age.) language-covering general developmental tests for German- and English-speaking Europe for the evaluation of a risk for a DDSL and other developmental disorders or delays
Method | Aim | Age-related test (year;month) | |||||
|---|---|---|---|---|---|---|---|
≤12 months | 12–24 months | 25–36 months | 3–5 years | 6–10 years | ≥11 years | ||
Screenings Parent questionnaires | Evaluation of a risk | ELFRA 1 (1;0) PLS-5 ST (0–7;11) MBCDI (0;8–3;1) | ELFRA 2 (2;0) ELAN (1; 4–2;2) FRAKIS (1;6–2;5) SBE-2-KT (1;9–2;0)a,b CDI (1;3–5;11) PLS-5 ST (0–7;11) LDS (1;6–2;11) MBCDI (0;8–3;1) | ELAN (1;4–2;2) SBE-3-KT (2;8–3;4) CDI (1;3–5;11) PLS-5 ST (0–7;11) LDS (1;6–2;11) MBCDI (0;8–3;1) | KiSS.2 (4;0–4;5)b SSV (3;0–5;0) LSV (4;0–6;5) BISC (preschool age) HASE (4;0–6;11) ETS 4–8 (4;0–8;11) CDI (1;3–5;11) PLS-5 ST (0;0–7;11) NSST S (3;0–7;11) LiSe-DaZ (3;0–6;11)b | ETS 4–8 (4;0–8;11) NSST S (3;0–7;11) LiSe-DaZ (3;0–6;11)b | |
General developmental language tests and language-covering general developmental tests | Evaluation of a deviation from the age norm | PLS-5 (0;0–7;11) BISD III (0;1–3;6) | BISD III (0;1–3;6) | SETK-2 (2;0–2;11) PDSS (2;0–6;11) TELD, −2, −3 (2;0–7;11) NRDLS (2;0–7;5) WJ-III (2;0–90;0) BISD III (0;1–3;6) Vineland-II (0;0–90;0) | SETK 3–5 (3;0–5;11) PDSS (2;0–6;11) P-ITPA (4;0–11;0) BUEVA (4;0–5;11) HSET (3;0–9;0) TELD, −2, −3 (2;0–7;11) TOLD (4;0–17;11) NRDLS (2;0–7;5) CELF (5;0–21;0) CELF-P (3;0–6;11) WJ-III (2;0–90;0) BISD III (0;1–3;6) ITPA-3 (5;0–12;11) LiSe-DaZ (3;0–6;11)b TOLD-P:4 (4;0–8;11) Vineland-II (0;0–90;0) WRAT-4 (5;0–94;0) | PDSS (2;0–6;11) P-ITPA (4;0–11;0) BUEVA (4;0–5;11) SET 5–10 (5;0–10;11) HSET (3;0–9;0) TELD, −2, −3 (2;0–7;11) TOLD (4;0–17;11) NRDLS (2;0–7;5) CELF (5;0–21;0) CELF-P (3;0–6;11) WJ-III (2;0–90;0) ITPA-3 (5;0–12;11) LiSe-DaZ (3;0–6;11)b TOLD-P:4 (4;0–8;11) TOLD-I:4 (8;0–17;11) Vineland-II (0;0–90;0) WRAT-4 (5;0–94;0) | LTB-J (grade 9–10) TOLD (4;0–17;11) CELF (5;0–21;0) WJ-III (2;0–90;0) ITPA-3 (5;0–12;11) TOLD-I:4 (8;0–17;11) Vineland-II (0;0–90;0) WRAT-4 (5;0–94;0) |
Examples of specific language tests examining distinct linguistic skills for German- and English-speaking Europe
Diagnostic fields | Competence | Age-related test (year;month) | |||||
|---|---|---|---|---|---|---|---|
≤12 months | 12–24 months | 25–36 months | 3–5 years | 6–10 years | ≥11 years | ||
Basal or precursor functions | |||||||
Verbal/phonological working memory | HASE (4;0–6;11) BISC (preschool age) Mottier (4;0–16;0) KiSS.2 (4;0–4;5) ETS 4–8 (4;0–8;11) AWMA (4;0–22;0) SSV (3;0–5;11) | HASE (4;0–6;11) BISC (preschool age) Mottier (4;0–16;0) AWMA (4;0–22;0) ETS 4–8 (4;0–8;11) MÜSC (first 5 school weeks) | AWMA (4;0–22;0) Mottier (4;0–16;0) | ||||
Oral-motor skills | Check lists (e.g. Garliner; Giel & Tillmanns-Karus; Kittel) | Check lists (e.g. Garliner; Giel & Tillmanns-Karus; Kittel) | Check lists (e.g. Garliner; Giel & Tillmanns-Karus; Kittel) | ||||
Phonological awareness | TPB (4 to about 7 years) BISC (preschool age) ETS 4–8 (4;0–8;11 | TPB (4 to about 7 years) MÜSC (first 5 school weeks) ETS 4–8 (4;0–8;11) | |||||
Language competence | |||||||
Phonetics/phonology | Articulation | PLAKKS-II (1;6–5;11) | PLAKKS-II (1;6–5;11) PDSS (2;0–6;11) GFTA-2 (2;0–21;11) | AVAK (children) PLAKKS-II (1;6–5;11) PDSS (2;0–6;11) KiSS.2 (4;0–4;5) TDA (3;0–8;0) GFTA-2 (2;0–21;11) PAT (3;0–8;11) | PDSS (2;0–6;11) TDA (3;0–8;0) GFTA-2 (2;0–21;11) PAT (3;0–8;11) | GFTA-2 (2;0–21;11) | |
Phoneme discrimination | PDSS (2;0–6;11) | PDSS (2;0–6;11) KiSS.2 (4;0–4;5) Mottier (4;0–16;0) | PDSS (2;0–6;11) Mottier (4;0–16;0) BLDT (end of second grade) | ||||
Grammar | Morphology Perception | PDSS (2;0–6;11) | SETK 3–5 (3;0–5;11) PDSS (2;0–6;11) TROG-D (3;0–10;11) KiSS.2 (4;0–4;5) NSST (3; 0–7; 11 years) NRDLS (2; 0–7; 5) TTFC-2 (3;0–12;11) TOLD-P:4 (4;0–8;11) | PDSS (2;0–6;11) NSST (3;0–7;11) TROG-D (3;0–10;11) TTFC-2 (3;0–12;11) TOLD-I:4 (8;0–17;11) TOLD-P:4 (4;0–8;11) | TTFC-2 (3;0–12;11) TOLD-I:4 (8;0–17;11) | ||
Production | FRAKIS (1;6–2;5) | PDSS (2;0–6;11) | SETK 3–5 (3;0–5;11) ESGRAF-R (4–16 years) PDSS (2;0–6;11) KiSS.2 (4;0–4;5) NSST (3;0–7;11) TOLD-P:4 (4;0–8;11) | ESGRAF-R (4–16 years) PDSS (2;0–6;11) NSST (3;0–7;11) TOLD-I:4 (8;0–17;11) TOLD-P:4 (4;0–8;11) | ESGRAF-R (4;0–16;0) TOLD-I:4 (8;0–17;11) | ||
Syntax Perception | TSVK (2–8 years) PDSS (2;0–6;11) NRDLS (2;0–7;5) | TSVK (2;0–8;0) TROG-D (3;0–10;11) MSVK (5 year-end of first grade) SETK 3–5 (3;0–5;11) PDSS (2;0–6;11) KiSS.2 (4;0–4;5) NSST (3;0–7;11) NRDLS (2;0–7;5) TTFC-2 (3;0–12;11) TOLD-P:4 (4;0–8;11) | TSVK (2;0–8;0) TROG-D (3;0–10;11) MSVK (5 year-end of first grade) PDSS (2;0–6;11) NSST (3;0–7;11) NRDLS (2;0–7;5) TTFC-2 (3;0–12;11) TOLD-I:4 (8;0–17;11) TOLD-P:4 (4;0–8;11) | TTFC-2 (3;0–12;11) TOLD-I:4 (8;0–17;11) | |||
Production | ELFRA 2 (2;0) FRAKIS (1;6–2;5) | PDSS (2;0–6;11) NRDLS (2;0–7;5) | SETK 3–5 (3;0–5;11) PDSS (2;0–6;11) KiSS.2 (4;0–4;5) NSST (3;0–7;11) NRDLS (2;0–7;5) TOLD-P:4 (4;0–8;11) | PDSS (2;0–6;11) NSST (3;0–7;11) NRDLS (2;0–7;5) TOLD-I:4 (8;0–17;11) TOLD-P:4 (4;0–8;11) | TOLD-I:4 (8;0–17;11) | ||
Semantics and vocabulary | Semantics | ELFRA 1 (1;0) | PDSS (2;0–6;11) NRDLS (2;0–7;5) PPVT III (2;6–90;0) | Teddy-Test (3;0–8;6) MSVK (5 year-end of first grade) PDSS (2;0–6;11) KiSS.2 (4;0–4;5) NRDLS (2;0–7;5) PPVT III (2;6–90;0) | Teddy-Test (3;0–8;6) MSVK (5 year-end of first grade) NRDLS (2;0–7;5) PPVT III (2;6–90;0) TOLD-I:4 (8;0–17;11) | PPVT III (2;6–90;0) TOLD-I:4 (8;0–17;11) | |
Vocabulary Perception (passive) | ELFRA 1 (1;0) | PDSS (2;0–6;11) PPVT III (2;6–90 years) NRDLS (2;0–7;5) | PDSS (2;0–6;11) KiSS.2 (4;0–4;5) TTFC-2 (3;0–12;11) CREFT-3 (5;0–89;11) PPVT III (2;6–90;0) NRDLS (2;0–7;5) | PDSS (2;0–6;11) CREFT-3 (5;0–89;11) TTFC-2 (3;0–12;11) TOLD-I:4 (8;0–17;11) NRDLS (2;0–7;5) | PPVT (14;0–60;0) CREFT-3 (5;0–89;11) TOLD-I:4 (8;0–17;11) TTFC-2 (3;0=12;11) PPVT III (2;6=90;0) PPVT German version (13;0–90;0) | ||
Production (active) | ELFRA 1 (1;0) | ELFRA 2 (2:0) ELAN (1;4–2;2) FRAKIS (1;6–2;5) | PDSS (2;0–6;11) NRDLS (2;0–7;5) | AWST-R (3;0–5;6) PDSS (2;0–6;11) KiSS.2 (4;0–4;5) CREFT-3 (5;0–89;11) NRDLS (2;0–7;5) | WWT 6–10 (6;0–10;0) PDSS (2;0–6;11) CREFT-3 (5;0–89;11) NRDLS (2;0–7;5) TOLD-I:4 (8;0–17;11) | CREFT-3 (5;0–89;11) TOLD-I:4 (8;0–17;11) | |
Pragmatics/communication | Vineland-II (0;0–90;0) Das pragmatische Profil (0;0–10;0) | Vineland-II (0;0–90;0) Das pragmatische Profil (0;0–10;0) | MSVK (5 year-end of first grade) KiSS.2 (4;0–4;5) Vineland-II (0;0–90;0) Das pragmatische Profil (0;0–10;0) | MSVK (5 year-end of first grade) Vineland-II (0;0–90;0) Das pragmatische Profil (0;0–10;0) | Vineland-II (0;0–90;0) | ||
Register of examples of language screening tests, general and specific language tests and language-covering developmental tests for German- and English-speaking Europe
Test | Language | References |
|---|---|---|
AVAK | German | Hacker D, Wilgermein H (2001) AVAK-Test mit CD-ROM Analyseverfahren zu Aussprachestörungen bei Kindern, 2nd. edn CD-ROM 2006) Reinhardt, München |
AWMA | English | Alloway TP (2007) Automated working memory assessment (AWMA). Pearson, Oxford. Available via www.psychcorp.co.uk/product.aspx?n=1343&s=1492&cat=1356&skey=3909. Accessed 7 June 2014 |
AWST-R | German | Kiese-Himmel C (2005) Aktiver Wortschatztest für 3-bis 5-jährige Kinder – Revision. Beltz, Göttingen |
BISC | German | Jansen H, Mannhaupt G, Marx H et al (2002) Bielefelder Screening zur Früherkennung von Lese-Rechtschreibschwierigkeiten. 2nd revised edn. Hogrefe, Göttingen |
BISD III | English | Bayley N (2006) Bayley scales of infant and toddler development, 3rd edn. Harcourt Assessment Inc., San Antonio |
BLDT | German | Niemeyer W (1976) Bremer Lautdiskriminationstest 2. Klasse BLDT, Herbig, Bremen |
BUEVA | German | Esser G, Wyschkon A (2002) BUEVA – Basisdiagnostik umschriebener Entwicklungsstörungen im Vorschulalter. Hogrefe, Göttingen |
CDI | English | Ireton H (1992) Child Development Inventory. Behavior Science Systems, Inc., Minneapolis Ireton H, Glascoe FP (1995) Assessing children’s development using parents’ reports: the Child Development Inventory. Clin Pediatr (Phila) 34(5):248–255 |
CELF | English | Semel E, Wiig E, Secord W (1995) Clinical evaluation of language fundamentals, 3rd edn. The psychological corporation, Harcourt Brace & Company, San Antonio |
CELF-P | English | Wiig EH, Secord W, Semel E (1998) Clinical evaluation of language fundamentals – preschool (CELF-preschool). The psychological corporation, Harcourt Brace Jovanovich, San Antonio |
CREFT-3 | English | Wallace G, Hammill DD (1994) Comprehensive receptive and expressive vocabulary test, 3rd edn (CREFT-3). Pro-Ed, Austin |
Das Pragma-tische Profil | German | Dohmen A, Dewart H, Summers S (2009) Das Pragmatische Profil – Analyse kommunikativer Fähigkeiten von Kindern. Elsevier, München |
ELAN | German | Bockmann AK, Kiese-Himmel C (2006) ELAN—Eltern Antworten. Beltz, Göttingen |
ELFRA | German | Grimm H, Doil H (2006) ELFRA – Elternfragebögen für die Früherkennung von Risikokindern, 2nd revised edn. Hogrefe, Göttingen |
EOWPVT-R | English | Gardner MF (2000) Expressive one-word picture vocabulary test – revised (EOWPVT). Academic Therapy, Novato |
ESGRAF-R | German | Motsch HJ (2018) ESGRAF-R Testmanual: Evozierte Sprachdiagnose grammatischer Fähigkeiten, 2nd revised edn. Reinhardt, München |
ETS 4-8 | German | Angermaier M (2007) Entwicklungstest Sprache 4 bis 8 Jahre (ETS 4-8). Pearson Assessment, Frankfurt |
FRAKIS | German | Szagun G, Stumper B, Schramm SA (2007) Fragebogen zur frühkindlichen Sprachentwicklung und FRAKIS-K (Kurzform). Pearson, Frankfurt |
GFTA-2 | English | Goldman R, Fristoe M (2000) Goldman-Fristoe Test of Articulation-2 (GFTA-2). American Guidance Service, Circle Pines |
HASE | German | Schöler H, Brunner M (2008) HASE – Heidelberger Auditives Screening in der Einschulungsdiagnostik, 2nd revised edn. Westra, Wertingen |
HSET | German | Grimm H, Schöler H (1991) Heidelberger Sprachentwicklungstest (HSET), 2nd revised edn. Hogrefe, Göttingen |
ITPA-3 | English | Hammill DD, Mather N, Roberts R (2001) Illinois test of psycholinguistic abilities, 3rd edn (ITPA-3). Pro-Ed, Austin |
KISS.2 | German | Euler HA, Holler-Zittlau I, van Minnen S et al (2010) Psychometrische Gütekriterien eines Kurztests zur Erfassung des Sprachstandes vierjähriger Kinder. HNO 58(11):1116–1123 Neumann K, Holler-Zittlau I, Euler HA (2011) Kinder-Sprach-Screening “KiSS”. Available via https://soziales.hessen.de/gesundheit/kinder-sprachscreening-kiss. Accessed 7 June 2014 |
LDS | English | Rescorla L (1989) The language development survey: a screening tool for delayed language in toddlers. J Speech Hear Disord 54:(4)587–599 |
LiSe-DaZ | German | Schulz P, Tracy R (2012) LiSe-DaZ. Linguistische Sprachstandserhebung – Deutsch als Zweitsprache. Hogrefe, Göttingen |
LSV | German | Götte R (1976) Landauer Sprachentwicklungstest für Vorschulkinder LSV. Beltz, Weinheim |
LTB-J | German | Barwitzki K, Hofbauer C, Huber M et al (2008) LTB-J – Leipziger Testbatterie zur Messung des formal-sprachlichen Entwicklungsstandes bei Jugendlichen. BBW, Leipzig |
MBCDI | English | Fenson L, Marchman VA, Thal DJ et al (2007) MacArthur-Bates communicative development inventories: user’s guide and technical manual, 2nd edn. Paul H. Brookes Publishing, Baltimore |
Mottier | German | Kiese-Himmel C, Risse T (2009) Normen für den Mottier-Test bei 4- bis 6-jährigen Kindern. HNO 57(9):943–948 Risse T, Kiese-Himmel C (2009) Der Mottier-Test. Teststatistische Überprüfung an 4- bis 6-jährigen Kindern. HNO 57(5):523–528 |
MSVK | German | Elben CE, Lohaus A (2000) Marburger Sprachverständnistest für Kinder MSVK. Hogrefe, Göttingen |
MÜSC | German | Mannhaupt G (2006) Das Münsteraner Screening zur Früherkennung von Lese- und Rechtschreibschwierigkeiten (MÜSC). Cornelsen, Berlin |
NRDLS | English | Edwards S, Letts C, Sinka I (2011) The New Reynell Developmental Language Scales (NRDLS). GL Assessment, London |
NSST | English | Lee, Lee LL (1969) Northwestern syntax screening test. Northwestern University Press, Evanston |
NSST S | English | Ratusnik DL, Klee TM, Ratusnik CM (1980) Northwestern syntax screening test: a short form. J Speech Hear Disord 45(2):200–208 |
PDSS | German | Kauschke C, Siegmüller J (2009) Patholinguistische Diagnostik bei Sprachentwicklungsstörungen, 2nd edn. Elsevier, Heidelberg |
PAT | English | Pendergast K, Dickey SE, Selmar JW et al (1984) Photo articulation test. Stoelting, Chicago |
PPVT III | English | Dunn LM, Dunn LM (1997) Examiner’s manual for the Peabody Picture Vocabulary Test-third edition (PPVT-III). American Guidance Service, Circle Pines |
German | Bulheller S, Dunn LM, Dunn LM et al (German edition) (2003) Peabody Picture Vocabulary Test: (PPVT); Manual. Swets Test Services, Frankfurt | |
P-ITPA | German | Ballaschk K, Hänsch S, Esser G (2010) P-ITPA. Potsdam-Illinois Test für Psycholinguistische Fähigkeiten. Hogrefe, Göttingen |
PLAKSS-II | German | Fox A (2014) PLAKSS-II Psycholinguistische Analyse kindlicher Sprechstörungen-II, 1st edn. Pearson, Frankfurt |
PLS-5 | English | Zimmerman IL, Steiner VG, Pond RE (2011) PLS-5 Preschool Language Scales, 5th edn. Pearson, San Antonio |
PLS-5 ST | English | Zimmerman, IL, Steiner VG, Pond RE (2011) Preschool Language Scale-5 Screening Test, 5th edn. (PLS-5 Screening Test). Pearson, San Antonio |
Prüfbögen zur Mundmotorik | German | Garliner D (1989) Myofunktionelle Therapie in der Praxis – Gestörtes Schluckverhalten, gestörte Gesichtsmuskulatur und die Folgen – Diagnose, Planung und Durchführung der Behandlung. Hütig, Heidelberg Giel B, Tillmanns-Karus M (2004) Kölner Diagnostikbogen für Myofunktionelle Störungen. modernes lernen, Dortmund Kittel AM (2009) Myofunktionelle Therapie, 9th revised edn. Schulz-Kirchner, Idstein |
SBE-2-KT | German | Suchodoletz Wv, Sachse S (2009) Sprachbeurteilung durch Eltern, Kurztest für die U7 (SBE-2-KT). Available via http://www.kjp.med.uni-muenchen.de/download/SBE-2-KT.pdf. Accessed 7 June 2014 |
Suchodoletz Wv, Sachse S (2009) Sprachbeurteilung durch Eltern, Kurztest für die U7 (SBE-2-KT), non-normalized translation in 33 languages. Available via https://www.kjp.med.uni-muenchen.de/download/SBE-2-KT.pdf. Accessed 13 April 2018 | ||
SBE-3-KT | German | Suchodoletz Wv, Kademann S, Tippelt S (2009) Sprachbeurteilung durch Eltern, Kurztest für die U7a (SBE-3-KT). Available via http://www.kjp.med.uni-muenchen.de/download/SBE-3-KT.pdf. Accessed 7 June 2014 |
SET 5-10 | German | Petermann F, Metz D, Fröhlich LP (2010) SES 5-10. Sprachstandserhebungstest für Kinder im Alter zwischen 5 und 10 Jahren. Hogrefe, Göttingen |
SETK-2 | German | Grimm H, Aktas M, Frevert S (2000) Sprachentwicklungstest für zweijährige Kinder SETK-2. Hogrefe, Göttingen |
German | Grimm H, Aktas M, Frevert S (2010) Sprachentwicklungstest für drei- bis fünfjährige Kinder SETK 3-5, 2nd revised edn. Hogrefe, Göttingen | |
SSV | German | Grimm H, Aktas M, Kießig U (2003) Sprachscreening für das Vorschulalter SSV. Kurzform des SETK 3-5. Hogrefe, Göttingen |
Teddy-Test | German | Friedrich G (1998) Teddy-Test. Hogrefe, Göttingen |
TDA | English | Templin MC, Darley FL (1969) The Templin-Darley tests of articulation; a manual and discussion of articulation testing, 2nd edn. Bureau of Educational Research and Service, Division of Extension and University Services, University of Iowa, Iowa City |
TELD, TELD-2, TELD-3 | English | Hresko WP, Reid DK, Hammill DD (1981) Test of early language development. Pro-Ed, Austin, TX |
TTFC-2 | English | McGhee RL, Ehrler DJ, DiSimoni F (2007) Token test for children-second edition (TTFC-2). Pro-Ed, Austin, TX |
TOLD-P:4 | English | Newcomer PL, Hammill DD (2008) Test of Language Development-Primary, 4th edn (TOLD-P:4). Pro-Ed, Austin |
TOLD-I:4 | English | Hammill DD, Newcomer PL (2008) Test of Language Development-Intermediate, 4th edn (TOLD-I:4). Pro-Ed, Austin |
TPB | German | Fricke S, Schäfer B (2011) Test phonologischer Bewusstheitsfähigkeiten, 2nd edn. Schulz-Kirchner, Idstein |
TROG-D | German | Fox AV (2008) TROG-D – Test zur Überprüfung des Grammatik-Verständnisses, 3rd edn. Schulz-Kirchner, Idstein |
TSVK | German | Siegmüller J, Kauschke C, van Minnen S et al (2010) Test des Satzverständnisses bei Kindern. Eine profilorientierte Diagnostik der Syntax. Elsevier, Heidelberg |
Vineland-II | English | Sparrow SS, Balla DA Cicchetti DV (2005) Vineland Adaptive Behaviors Scales, 2nd edn (Vineland-II). American Guidance Service, Circle Pines |
WJ-III | English | Woodcock RW, McGrew KS, Mather N (2001) Woodcock-Johnson-III Tests of achievement. Riverside Publishing, Itasca |
WRAT-4 | English | Wilkinson GS, Robertson GJ (2006) Wide Range Achievement Test – fourth edition (WRAT-4) professional manual. Psychological Assessment Resources, Lutz |
WWT 6-10 | German | Glück CW (2007) WWT 6-10. Wortschatz- und Wortfindungstest für 6- bis 10-Jährige. Urban & Schwarzenberg, München |
11.4 Oral-Motor Examination Protocol
11.4.1 Introduction
The orofacial system consists of bony, nervous and muscular components. As in all mammals, the primary functions of this orofacial system are food intake (sucking, eating, drinking, biting, swallowing) and breathing. Furthermore, its potential for mimicry is an important communication means. In humans it additionally serves a secondary function: speech sound production. For children, the structural and functional adequacy of the oral-motor system provides the basis for the development of all the named functions.
An oral-motor examination, as part of the phoniatric assessment in cases of developmental speech, language and swallowing abnormalities, helps to verify normal patterns as well as organic or functional deficits underlying phonetic (mechanical and acoustical forming of speech sounds) speech sound disorders and swallowing problems in childhood. This examination together with an assessment of the status of speech sound development as described in Sect. 11.5 should be used systematically in order to enable a distinction between phonetic and phonological (linguistic) components of speech sound abnormality or disorder.
After a parental interview on the clinical history of their child, focusing on the development of the primary functions and oral perception, oral-motor examination includes the exploration of the following orofacial components and their interplay, in order to
and swallowing: lips, jaws, teeth, tongue, hard palate, soft palate and pharynx. It should comprise the following aspects:
determine their structural and functional adequacy for speech
Nicolosi et al. (2003)
Inspection of the structure and muscle tone at rest, assessing size, symmetry, shape and possible presence of scars, clefts or other anomalies of the specific orofacial components
Examination of oral functions during the performance of specific oral movements, observing muscle tone, coordination and extent of mobility
The results of the above-named examinations provide relevant information about the possible causes of speech sound disorders and swallowing problems of the children examined. With respect to differential diagnoses, this examination also serves as a decision-making (‘pass/fail’) procedure (American Speech-Language-Hearing Association (ASHA) 2004) to initiate further comprehensive assessments if cardinal symptoms of specific disorders are found, such as dysglossia, central speech motor processing disorders (dyspraxia, dysarthria) or peripheral or central swallowing disorders (ASHA 2004). In the following key aspects of an oral-motor examination, potential methods and possible observations are listed.
Clinical history
Test instruments and materials
Inspection of the orofacial structures and evaluation of muscle tone at rest
Examination of oral function in motion
Interpretation
11.4.2 Clinical History
Pregnancy and birth: foetal distress, natural or assisted childbirth, prematurity, damaging or deleterious factors.
Age of acquisition of developmental skills (walking, early speech, micturition/faecal control). If these functions are delayed, a potential developmental retardation has to be taken into consideration.
Feeding, diet and food intake: natural, artificial (e.g. tube feeding), type of bottle nipple, difficulties in sucking, mastication, age of weaning, coughing or choking while or after eating/drinking, aspiration of food or liquid into the lungs (chronic respiratory failure, pneumonia).
Development of oral perception: intensity of oral exploration in the first year of life; tolerance/acceptance of varying food consistencies and food tastes/flavours.
Diseases of ear, nose and throat.
Parafunctions: dummy/pacifier (type, frequency, age of weaning), digit or object sucking, labial or lingual sucking, nail biting, bruxism, snoring, dribbling.
11.4.3 Test Instruments and Materials
In order to carry out the examination, a source of frontal light and basic examination materials are needed: gloves, tongue depressors, small mirror for mirror-fogging test and nasal speculum or nasal fibrescope. For the evaluation of swallowing and chewing, solid, semisolid and liquid aliments are used.
11.4.4 Inspection of the Orofacial Structure and Muscle Tone at Rest
Assess the size, symmetry, shape and possible presence of scars, clefts or other anomalies of each orofacial structure as below.
11.4.4.1 External Orofacial Examination
Facies:
Facial malformations or other anomalies, e.g. hypo-/hypertelorism, epicanthus
Lips:
Structure: size, symmetry, lingual frenulum, scars, clefts
Function:
Resting position: lips open or closed, hypo- or hypertonus
Closure: complete, incomplete
Nose/Nostrils:
Examination using the nasal speculum or nasal fibrescope and a small mirror for:
Structure: size, form variants, malformations, deviation of nose or nose septum, hyper- or hypoplasia of nasal conchae, width of nostrils, nasal entrance and ducts
Function: nasal airway obstruction, mucus, mucosal swallowing
Temporomandibular Joint:
Structure: symmetry of the mandibular branches, protrusion or retraction/hypoplasia of mandibula
Function: degrees of freedom and extent of movement
11.4.4.2 Intraoral Examination
Tongue:
Structure: form and size such as macroglossia, microglossia, scars, symmetry
Function: muscular tone, position at rest (protrusion, support on the palate, support on incisors interdental), motility, fasciculation, deviation
Cavum Oris and Pharynx:
Structure: dental status, status of palate and pharyngeal tonsils (hypertrophy, status after adeno-/tonsillectomy or tonsillotomy, scars), status of mucosa (mucus, swelling, infections), salivary cysts
Function: closure of mouth, muscular tone, hypersalivation, velopharyngeal insufficiency
Hard Palate:
Structure: malformations or abnormalities such as clefts or fissures, scars, fistulae, form deviations (flat or ‘Gothic’)
Function: closure between the mouth and nose, mouth closure
Soft Palate:
Structure: malformations or abnormalities such as clefts, bifid uvula, short, long or deviating uvula
Function: velopharyngeal insufficiency, hypernasal speech, nasal regurgitation during swallowing
Teeth and Occlusion:
Structure: dental status (decayed, missing or filled teeth, dental diastema, malposition) for the primary dentition (deciduous teeth) and for the permanent dentition.
Function: occlusion. The child is requested to bite and to show her or his teeth.
Anteroposterior match: Class I (normocclusion), Class II (distocclusion), Class III (mesiocclusion)
Vertical match: normal bite, open bite (anterior, lateral), overbite
Transversal match: crossbite (uni- or bilateral), lateral deviation
11.4.5 Examination of Functionality
Lips:
In order to examine mobility, the child is requested to make the following movements: lifting, stretching, lateralization, vibration (lip flapping) and kissing. The child’s ability to perform these movements and the muscular tone and strength with which they are performed are assessed for:
Tone and strength: hypotonus, hypertonus
Mobility: normal, difficult/restricted in a certain direction, very limited, impossible
Closing: complete, incomplete, impossible
Tongue:
For examining mobility the child is requested to stretch his or her tongue out; to raise, lower and lateralize it; and to press it against the cheeks from inside the mouth. The tone is examined by using a tongue depressor, asking the child to press against it. In babies and young children, the examination is completed by tactile stimulation of the mouth mucosa and the tongue:
Mobility: stretching out, upwards (touching nose), downwards, right, left, rotation
Tone and strength: hypotonus, hypertonus
Lingual frenulum: normal, shortened (ankyloglossia)
Temporomandibular Joint:
For examining mobility the child is requested to open and close his or her mouth and to complete lateral motions. Muscle tone is evaluated by palpating the joints bimanually:
Mobility: opening (normal, difficult/restricted in certain directions, very limited, impossible), symmetry of closure
Dysfunctions: cracking, bruxism, clicks, blockage
Soft Palate:
In order to evaluate sufficient velopharyngeal closure of the soft palate, the child is requested to vocalize a word with the plosive /c/ (e.g. cuckoo, Coca-Cola). Breath noise (rhinophonia aperta) indicates lacking or incomplete velopharyngeal closure. Furthermore, vowel sounds are examined, for example, of /u:/ or /a:/. A nasal component (airy noise) indicates a functional rhinophonia aperta.
Chewing and Swallowing:
The child’s myofunctional maturity is evaluated according to her or his age. Food intake (chewing and drinking), oral preparation and swallowing should be observed. Possible findings are:
Chewing with open mouth
Gathering of saliva at the corners of the mouth or on the lips
Food remaining in the mouth after swallowing
Drooling, dribbling of saliva or food
Movement forward of the tongue while speaking, chewing and swallowing (tongue thrust), tongue pressure on teeth, lateral tongue pressure, lingual interposition between teeth
Head movements, effort in perioral muscles
For babies: adaptation to the bottle nipple
For infants and young children: licking a spoon
11.4.6 Interpretation
By interpreting the results of the examination for an individual child, the causes for developmental speech sound and swallowing disorder as named in the following can be differentiated. Other disorders, which should either be excluded or considered as potential diagnoses that need further assessment, are listed below:
11.4.6.1 Phonological Speech Sound Disorder
In the case of a speech sound disorder or abnormality, a phonological cause or at least a component has to be assumed, if the organic and myofunctional adequacy of the orofacial system is given and other potential comorbidities (including hearing loss) are excluded. In this case, the phonological developmental status must be examined closely as described in Sect. 11.5.
11.4.6.2 Phonetic Speech Sound Disorder
Orofunctional causes: immaturity or imbalance of orofacial functions and oral senses without organic abnormalities (including normal hearing); functional inadequacy such as hypotonus of orofacial muscles, poor coordination of oral-motor sequences, often associated with abnormal development of food intake or oral perception (e.g. limited acceptance of a sufficient variety of food flavours or consistencies)
Mechanical causes: for example, a missing tooth, diastema, velopharyngeal insufficiency
In cases of insufficient velopharyngeal closure and excessive nasal component of speech sounds (rhinophonia aperta), careful differential diagnosis is essential because several underlying causes are possible (e.g. neurological; organic; functional) (Grunwell 1993); see also Part I, Speech Disorders (Dysglossia/Nasality/Velopharyngeal Insufficiency), Volume 2.
Speech sound disorders due to hearing impairment (see Part IV, Disorders of Hearing Development).
Dysglossia: a speech sound disorder due to an organic affection of articulation organs (lips, tongue, palate, teeth, jaw, vocal folds) caused by oro- or craniofacial malformations, paralyses, injuries, tumours, muscle disorders or surgery (e.g. cleft lip or palate, macroglossia, scars); see Part I, Speech Disorders (Dysglossia/Nasality/Velopharyngeal Insufficiency), Volume 2.
There is evidence that a shortened lingual frenulum (ankylogossia) may affect breastfeeding and can be treated by surgical procedures. However, there is insufficient evidence that it affects speech sound development or that surgery improves articulatory development of a child. Therefore, frenulotomy or frenuloplasty is not recommended for improvement of speech sound disorders in cases of ankyloglossia (Francis et al. 2015).
Speech-language-relevant syndromes: oro- or craniofacial malformations or abnormalities are often symptoms of a syndrome and should be diagnosed comprehensively (see Sect. 9.10).
Functional (peripheral) swallowing disorders: orofacial dysfunctions/myofunctional disorders with orofacial muscle imbalance and difficulties in motor coordination and sequencing lead to insufficient oral preparation of swallowing, tongue thrust, malocclusion, mouth breathing, retardation in the development of oral perception and oral hyper-/hypo-sensibility; see Part I, Speech Disorders (Dysglossia/Nasality/Velopharyngeal Insufficiency), Volume 2.
Central swallowing disorders: coughing or choking during or after eating/drinking; penetration or aspiration of food or liquid into the lungs; recurrent episodes of pneumonia; raised temperature (as early sign of subclinical pneumonia); substantial/rapid weight loss with no clear cause (Nicolosi et al. 2003); see Part VI, Swallowing Disorders including Rehabilitation of Tumour Patients, Volume 2.
Oral dyspraxia: inability to plan and perform an oral-motor task on purpose; symptoms:
groping, trial-and-error behaviour; purposeful programming of muscular movement while involuntary movements remain intact.
Nicolosi et al. (2003)
Dysarthria: a
motor speech disorder due to impairment originating in the central or peripheral nervous system…
Usually part of a more generalised neurological impairment…
(e.g. cerebral palsy)
Respiration, articulation, phonation, resonation and/or prosody may be affected; volitional and automatic actions, such as chewing and swallowing and movements of the jaw and tongue may also be deviant.
Nicolosi et al. (2003)
See Part IV, Acquired Motor Speech Disorders (Dysarthria, Dyspraxia), Volume 2.
11.5 Assessment of Speech Sound Development
11.5.1 Speech Sound Disorders (SSDs) in Children
The assessment of speech sound development is obligatory for comprehensive speech and language evaluation of a child with communication concerns or whenever an SSD is suspected (ASHA 2016).
Speech sound disorders (SSD) is an umbrella term…
(introduced by the ASHA in 2004)…
referring to any combination of difficulties with perception, motor production and/or the phonological representation of speech sounds and speech segments…that impact speech intelligibility.
ASHA (2016)
SSDs constitute the largest group of communication difficulties amongst young children. In English-speaking countries, the prevalence of SSDs in childhood (3–11 years) varies from 3 to 15% (for an overview see McLeod et al. 2013). SSDs in children can be of known (e.g. organic) or unknown aetiology (McLeod et al. 2013); those of unclear origin represent the largest portion (Fox-Boyer et al. 2016). Organic causes of an SSD are hearing impairment, orofacial dysfunction (myofunctional disorder), craniofacial anomalies such as cleft palate or other dysglossia, genetic or non-genetic syndromes and neurological impairment or diseases (e.g. cerebral palsy leading to dysarthria or apraxia) (ASHA 2016). Genetically based SSDs identified by familial clustering of SSDs are also included. For SSDs with unknown causes, several risk factors are discussed (e.g. repeated otitis media, deficits in phonological working memory, delayed phonological development) (Fox-Boyer et al. 2016). Childhood apraxia of speech (CAS) depicts an outlier in the field of SSD (for details see Sect. 10.2). Neurological causes are hypothesized without the evidence of neurological findings associated with the disorder (Fox-Boyer et al. 2016).
Classification of speech sound disorders (SSD) in children based on etiology and psycholinguistics developed by Reichmuth and Vauth. (1) The five subgroups from the classification of speech sound disorders of unclear origins are from Dodd (2005), Fox-Boyer et al. (2016). (2) Excluding functional dysphonia and speech fluency disorders. (3) For diagnostic and treatment reasons, Reichmuth (2018) underlines the necessity to classify speech sound disorders in hearing-impaired children as a both phonetic and phonological disorder. (4) Several aetiological factors are known to foster the emergence of orofacial dysfunction and sensory deficits: e.g. preterm birth, organic reasons for persisting mouth breathing, oral habits and tongue thrust (Bigenzahn 2003); see also Part I, Speech Disorders (Dysglossia/Nasality/Velopharyngeal Insufficiency), Volume 2. The organic origin does not always become obvious. So orofacial dysfunction and sensory deficits can be subsequent or co-occurring symptom as long as the origin is not known
Characteristics of SSD subtypes (Overview developed by Reichmuth and Vauth)
Subgroup | Definition |
|---|---|
Phonetic disorder | General inability to perform correctly the articulatory movements required to produce a certain phone (isolated or in word); maintained ability to realize phonological information correctly if a hearing impairment is excluded |
Of unknown origin | |
– (without evident organic reason) | • Substitutions or distortions of the same sounds in isolation and in all phonetic contexts during imitation, elicitation and spontaneous speech tasks (e.g. lateral lisp) (Dodd 2014); affects around 12% of all children with SSDs of unknown origin (Dodd 2014) |
Of known origin | |
– Orofacial dysfunction | • Oral sensory deficits; orofacial dysbalance; orofacial hypotonus: for example, tongue thrust, an oral myofunctional phenomenon that can affect production of some sounds, e.g. /s/, /z/, /sh/, /ch/ and /j/ (ASHA 2016), and may cause multiple interdentality of other alveolar sounds (e.g. t, l, n) (see Part I, Speech Disorders (Dysglossia/Nasality/Velopharyngeal Insufficiency), Volume 2) |
– Dysglossia | • Structural causes: e.g. craniofacial malformations such as cleft palate or macroglossia influence the ability to perform correct articulatory movements; both articulation and resonance (e.g. nasal component, hypernasality) may be affected; maintained ability to realize phonological information correctly if a hearing impairment is excluded (see Part I, Speech Disorders (Dysglossia/Nasality/Velopharyngeal Insufficiency), Volume 2) |
– Hearing impairment | • Peripheral hearing loss; sensory-input-caused limitations in speech sound development, which can be reduced by early identification (e.g. by newborn hearing screening) and treatment (hearing devices) of the hearing loss (see also ‘phonetic-phonological disorder in hearing-impaired children’ in this table) |
– Genetic (e.g. syndromes) | • Genetic causes lead to diverse aspects of organic origins of SSDs (e.g. dysglossia, hearing loss, orofunctional deficits); syndrome-specific SSD expression, e.g. in Down syndrome, Pierre Robin syndrome, Franceschetti syndrome |
Phonological disorder | Defined as failure of the correct use of the linguistic component of a speech sound (phoneme); inability to process or deficiency in processing phonological information correctly and to use a phoneme linguistically correctly in words, even though the isolated performance of the phone is possible |
Of unknown origin | |
– Phonological delay | • Prolonged use (at least 6 months) of at least one (formerly) physiological phonological process of normal speech sound development (see Table 11.10) (Fox-Boyer et al. 2016; Dodd 2014); isolated performance of the phone is (often) possible |
– Consistent phonological disorder | • Consequent use of at least one pathological phonological process (Fox-Boyer et al. 2016; see also Dodd 2014); isolated performance of the phone is (often) possible |
– Inconsistent phonological disorder | • Inability to pronounce repeatedly a specific word identically; a high rate of inconsistency >40% (in a given wordlist of 25–30 words) (see also Dodd 2005, 2014; Fox-Boyer 2014); isolated performance of the phone is (often) possible |
Of known origin | |
– Genetic | Family history of SSD |
– Phonetic-phonological disorder in hearing-impaired children | • Overall influence of the hearing loss on the phonological acquisition often leads to specific, mostly consistent, phonological processes (even when hearing devices are fitted): structural simplification such as deletion of (weak) syllables and final consonants, nasalization of vowels and vowel shift; structural simplification such as deletion of speech sounds or weak syllables and assimilation as well as systemic simplifications such as stopping of fricatives (see Table 11.10) |
Neurological motor-speech disorders | |
Of unknown origin | |
– Childhood apraxia of speech (CAS; synonym: verbal developmental dyspraxia) | • Failure of central oral or verbal motor planning functions are assumed (see Sect. 10.2 for details) without obvious neurological impairment; inadequate intonation (e.g. word stress and prosody); speech characterized by inconsistency, oromotor symptoms (e.g. difficulty in sequencing of articulatory movements), slow speech rate, disturbed prosody, short length of utterance, poorer performance in imitation than in spontaneous speech production (Dodd 2014); predominant use of vowels; reduced use of consonants; adiadochokinesis (inability to execute repetitions of rapidly changing articulatory movements) |
Of known origin | |
– Dysarthria | • Motor-speech disorder due to impairment of the central or peripheral nervous system; respiration, articulation, phonation, resonation or prosody may be affected; volitional and automatized motor actions such as jaw and tongue movements in chewing and swallowing may also be deviant; usually part of a neurological impairment, e.g. cerebral palsy (Nicolosi et al. 2003); see Part IV Acquired Motor Speech Disorders (Dysarthria, Dyspraxia), Volume 2 |
– Dyspraxia | • Impaired capacity to programme the position of speech musculature and the sequencing of muscle movements (respiratory, laryngeal and oral) for the volitional production of phones as part of a neurological impairment, e.g. cerebral palsy; involuntary production of the same phone or movement is possible, e.g. cerebral palsy (Nicolosi et al. 2003; see Part II) |
Children with speech sound disorders can have difficulties with perception, articulation/motor production, phonological representation of speech segments (consonants and vowels), phonotactics (syllable and word shapes) and prosody (lexical and grammatical tones, rhythm, stress, and intonation) that may affect speech intelligibility and acceptability.
International Expert Panel on Multilingual Children’s Speech (2012)
Differential diagnosis is needed but often difficult to provide, owing to the large heterogeneity of speech sound disorders. Mixed profiles (phonetic and phonological abnormalities) are also common (Strand and McCauley 2008; Navasivayam et al. 2013). Mandatorily, organic causes should initially be detected or excluded (including hearing tests and oral-motor examination). Especially in cases of excessive nasal components of speech (hypernasality), differential diagnosis is essential because several underlying serious causes are possible for insufficient velopharyngeal closure (e.g. neurological, organic, functional, sensory). In case of uncertainty, a referral to a neuro-pediatrician for excluding a neurological cause is obligatory.
11.5.2 About Speech Sounds: Linguistic Fundamentals for Assessment
Every language has its specific inventory of speech sounds (for details on 57 languages, see Speech Accent Archive, Weinberger 2015). The way children develop the proper articulation of speech sounds (phonetics) and their correct linguistic use in language (phonology) follows physiological processes.
The phonetic component emphasizes the specific physical and articulatory characteristics of each speech sound.
In this sense speech sounds are called phones. The regular development of a child’s phonetic inventory depends on normally developed speech organs, as well as normal hearing and oral-motor control. In this context the acquisition of the correct use of phones is an aspect of speech development. Speech sounds are usually subclassified into two broad groups: consonants and vowels. See Fig. 11.6 for an example of the phonetic inventory of consonants in English from the Speech Accent Archive (Weinberger 2015). See Fig. 11.7a, b for vowel charts of Jones (1972, adapted) and the International Phonetic Association (IPA 1999).
The phonological component emphasizes the linguistic aspect speech sounds have in language as phonemes. A phoneme is the
shortest arbitrary unit of sound in a given language.
Nicolosi et al. (2003)
It distinguishes the meaning of one word from another in the particular language: e.g. the use of the phonemes /t/ or /p/ distinguishes between the word cut and cup. So the acquisition of the correct linguistic use of phonemes is an aspect of language development.
Native phonetic inventory—English: the consonants found in most native English dialects are demonstrated. Source: Speech Accent Archive, Weinberger (2015) Speech Accent Archive, for English, adapted from Ladefoged (2006). Matrix of consonants: consonants are determined by three parameters according to the manner of formation—(a) place of articulation (x-axis), (b) mode of articulation (y-axis) and (c) use of voice (voiced/voiceless), e.g. [t] vs. [d] (definition adapted from Nicolosi et al. 2003). The worldwide convention is to transcribe phones according to the International Phonetic Alphabet (IPA). Republished with permission of South-Western College Publishing, a division of Cengage Learning, from A Course in Phonetics. Ladefoged P. 5th edition. Thomson Wadsworth, Boston © 2006
(a) Cardinal tongue position regarding tongue height (vertical dimension) and tongue backness (horizontal dimension) for different vowels (i, e, ε, a; see Fig. 11.7b). Adapted by Ishwar and LadyofHats, based on Jones (1972). Image URL: https://de.wikipedia.org/wiki/Datei:Cardinal_vowel_tongue_position-back(png).svg. Covered by Creative Commons Attribution-ShareAlike 3.0 licence. (b) Schematic vowel diagram from the International Phonetic Alphabet representing the three main features to describe vowels: (1) In the vertical dimension vowels are arranged according to the degree of aperture of the mouth and jaw (from open to closed vowels) and the tongue height relative to the roof of the mouth. (2) In the horizontal dimension, vowels are arranged according to the position of the tongue in the mouth during the articulation (tongue backness: front, central, back). (3) The rounding of the lips during articulation determinates rounded from unrounded vowels (roundedness). The worldwide convention is to transcribe vowels according to the International Phonetic Alphabet (IPA) (definition adapted from IPA 1999; 2015; Nicolosi et al. 2003; Ladefoged 2006)
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