Early Language Milestone Scale and Language

Screening of Young Children

Dewey Walker, MD, Susan Gugenheim, MS, Marion P. Downs, DHS,

and Jerry L. Northern, PhD

From the Department of Otolaryngology, University of Colorado Health Sciences Center,

Denver

ABSTRACT. The purpose of this project was to evaluate early age. Until recently, standardized language
the use of the Early Language Milestone Scale (ELM) in screening tests for children younger than 3 years of
screening language skills in young children. In this study,
age were not available.
657 children from birth to 36 months of age were evalu-
ated with the ELM. The overall failure rate was 8%. Physicians who treat children are in a key posi-
Children who failed the ELM screening were evaluated tion to identify language delay at the earliest pos-
with the Sequenced Inventory of Communication Devel- sible age. Routine use of developmental screening
opment (SICD) that was used as the “gold standard” for tests by pediatricians occurs infrequently.2 Screen-
diagnosing language disorders. In the 12-month age and
younger group, there was poor agreement between the ing tests are customarily used when pediatricians
ELM Scale and the SICD. For infants 13 to 24 months already suspect a problem. Thus, the screening test
of age, there was moderately good agreement between the is not being used for its intended purpose of sepa-
SICD and a second ELM that was administered 1 to 2 rating from the larger population those children
weeks after the initial screening. In the 25- to 36-month
who are at increased risk for the disorder. Instead,
age group, there was excellent agreement
between the
SICD and a rescreen ELM. The agreement
between the the screen is being used as a post hoc confirmation
two instruments indicated that the rescreen ELM cor- of a problem. The test most frequently used for
rectly classified 79% of the 13- to 24-month-old infants screening language is the Denver Developmental
and 89% of the 25- to 36-month-old toddlers. Pediatrics Screening Test (DDST).2’3 A recent study compared
1989;83:284-288; Early Language Milestone Scala, Ian- results of performances on the language sector of
guage, screening.
the DDST with results of speech and language
evaluations. With the DDST 47% of children with
delayed expressive language were not identified,
thereby rendering it an insensitive screen for lan-
ABBREVIATIONS. ELM, Early Language Milestone Scale;
SICD, Sequenced Inventory of Communication Development; guage disorders.4
DDST, Denver Developmental Screening Test. A majority of pediatricians judge a child’s devel-
opmental level by parental recall of milestones or
through observations during the routine physical
examination. In two studies, it has been shown that
Screening for language delay is the most effective pediatricians’ informal appraisals of children’s
method of identifying language disorders. Because mental abilities are inaccurate, with overestimation
the foundations of language are fully established in of abilities occurring most often.5’6 Furthermore, no
normal children between 38 and 40 months of age,’ significant correlation exists between the pediatri-
sufficient language milestones should be accessible cians’ confidence in making appraisals and the ac-
prior to 36 months of age to permit screening at an curacy of their appraisals. The extent of their pe-
diatric experience likewise does not increase their
accuracy.
Received for publication Aug 11, 1987; accepted March 2, 1988. The problem of pediatricians’ overestimating
Reprint requests to (D.W.) Department of Otolaryngology, Uni-
children’s mental abilities through informal ap-
versity of Colorado Health Sciences Center, 4200 E Ninth Aye,
praisals suggests that fewer children are referred
Box B210, Denver, CO 80262.
PEDIATRICS (ISSN 0031 4005). Copyright © 1989 by the for diagnostic testing than are actually develop-
American Academy of Pediatrics. mentally delayed. A survey of Colorado pediatri-

284 PEDIATRICS Vol. 83 No. from

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cians and family practitioners who provide general setting. Each child’s profile is scored as “pass” or
medical care to children younger than 3 years of “fail.” Administration time is one to four minutes.
age was conducted by the present authors. Of phy- From November 1984 to August 1986, children
sicians who responded to the survey, 429 refer from birth to 36 months of age were screened with
children in this age range to speech/language pa- the ELM as a part of a training program for medical
thologists at rates varying from 0.33% to 0.6%. personnel. The study group of 657 children (352
These figures are strikingly small when compared boys, 305 girls) provided a representative sample
with prevalence estimates. The American Speech- from 24 Denver area sites chosen for their wide
Language-Hearing Association reported that 2% to cross-section of ethnic background and socioeco-
3% of 3-year-old children are language impaired.7 nomic status. These sites included ten private pe-
This figure does not include language delay due to diatric offices, three HMOs, two family practice
causes such as mental retardation, cerebral palsy, residency training centers, seven neighborhood
or deafness. Silva8 reported a prevalence of 8.4% in health clinics, and two family practice offices. The
his study of937 3-year-old children in New Zealand. testing procedures were performed at these sites by
Routine screening of young children is para- two speech/language pathologists certified by the
mount if language problems are to be identified American Speech-Language-Hearing Association.
early, accurately, and consistently. The purpose of At each site, during six half-days in a 2-week period,
the present study was to evaluate the effectiveness every child from birth to 36 months of age who
of the Early Language Milestone Scale (ELM)9 as entered the clinic for either a sick or well visit was
a screen for language delay in young children. screened. Sick children were included in the study
because some children receive health care only
MATERIALS AND METHODS when ill. In the few cases in which a sick child
failed the screening, the attending physician was
The ELM is a standardized language screening notified and encouraged to rescreen that child at a
instrument designed to provide physicians and later visit.
other health care professionals with a rapid means Children who failed the initial ELM screening
of screening the language development of children plus randomly selected children who passed the
less than 3 years of age. The ELM was originally screening were subsequently evaluated with the
validated by Coplan et al’#{176}
with a population of 119 Sequenced Inventory of Communication Develop-
children considered to be at increased risk for de- ment (SICD),” a widely accepted diagnostic lan-
velopmental disability. A sensitivity of 97% and a guage test in which a combination of parent report
specificity of 93% were reported with that popula- and direct testing are used. The SICD was selected
tion. The test is focused on expressive, receptive, as the criterion test because it is the only language
and visual language, primarily through parent re- test of the appropriate age range standardized with
port with occasional direct testing of the child. The children in the United States. The SICD was orig-
ELM format is similar to the DDST and is shown, inally validated against the Peabody Picture Vocab-
in part, in Fig 1. The familiar format allows for ulary Test, mean length of response, and structural
ease of administration within a general pediatric complexity score; it was found to correlate signifi-
cantly at the .001 level with these measures. Test-
retest reliability averaged 92.8%.
MONTHS 1 2 3 4 5 6 7 8 9
I I I I 1 4 4 4 The SICD testing and a second ELM, ie a re-
Coo ..
screen, were administered 1 to 2 weeks after the
2 Reciprocal Vocalization original ELM screening by the same two speech/
[ 3 Laugh language pathologists. The screening and diagnos-
LU tic results were given to the physician in charge of
>->
E 4 Raspb#{128}
‘-‘Cl) 5 Mono. Babble t
each child and referral recommendations were
1.Cl)
made.
6 Polysyllabic Babble [
7 Mama/Dada: any CLII
8 Mama/Dada: correct L I RESULTS
9 First Word (Not Mama/Dada)
Of the 657 children, 53 (8%) failed the ELM
10 46 Single W
I I I I I I I t 4 Scale; 13 of these 53 were lost to follow-up, whereas
40 underwent testing with the SICD. Of the initial
Fig 1. Portion of Early Language Milestone score sheet
657 children, 604 passed the ELM screening; 37 of
showing items in auditory expressive area for children
birth to 9 months of age (reprinted with permission from these children also underwent testing with the
Modern Education Corporation). SICD (Fig 2). The ELM failure rate at various age

ARTICLES 285
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 657 Subjects screened
with ELM

53 failed 604 passed

Fig 2.
13 lost
follow-up

Outcome
/ to

for subject groups

N
(0 to
77 subjects
with
rescreen

36 months
SICD
evaluated

ELM
and

of age). ELM, Early Language

Milestone Scale; SICD, Sequenced Inventory of Communication Development.

intervals ranged from 4% to 14% (Table 1). No TABLE 1. Early Language Milestone Scale Failure
Rate by Age
significant difference was found between the male
failure rate of 9.4% and the female rate of 6.5% (x2 Age (mo) No. (%) of Children No. (%) of Children
Who Failed
= 1.749,P= .186).
The sensitivity and specificity of the initial ELM s12 234 9 (4)
13-18 153 14 (9)
screen and the ELM rescreen for children of all
19-24 109 9 (8)
ages tested are shown in Table 2, in which the 25-30 97 12 (12)
SICD was used as the standardized test for diag- 31-36 64 9 (14)
nosing language disorders. Sensitivity is the ratio
of children correctly rated as abnormal by the
screening test to the total number of children rated TABLE 2. Early Language Milestone (ELM) Sensitiv-
as abnormal by the criterion test. Specificity is the ity and Specificity for Children From Birth to 36 Months
ofAge (N = 77)*
ratio of children correctly rated as normal by the
screening test to the total number of children rated ELM Sequenced Inventory of
Communication Development
as normal by the criterion test. The sensitivity and
Initial ELM Rescreen ELM
specificity of the initial ELM were 87% and 70%,
respectively, and the rescreen ELM sensitivity and Failed Passed Failed Passed

specificity were 77% and 85%, respectively (Table Failed 26 14 23 7

2). Sensitivities and specificities for the age groups Passed 4 33 7 40
0 to 12 months, 13 to 24 months, and 25 to 36 * Results are numbers of children. Sensitivity of the
months are shown in Table 3. For the 11 children initial ELM screen was 87%, specificity 70%; sensitivity
tested in the 12 months and younger age group, the of the rescreen ELM was 77%; specificity 85%.
sensitivity of both the initial and rescreen ELM
was 0% , indicating a lack of agreement between the
DISCUSSION
SICD and the ELM. In the 13- to 24-month-old age
group, sensitivity and specificity of the initial ELM There is general agreement among physicians
were 100% and 60%, respectively, sensitivity and that screening for language problems is an integral
specificity of the rescreen ELM were 78% and 80%, part of the primary medical care of children. There
respectively. The overall correct classification rate is little agreement concerning the implementation
in this group was 72% with the initial ELM and of the screening process, however. Two major ob-
79% with the rescreen ELM. For the 25- to 36- stacles that preclude uniform practices in screening
month-old age group, sensitivity and specificity of are physicians’ varying levels of awareness of ap-
the initial ELM were 100% and 75%, respectively, propriate application of screening measures and the
and that of the rescreen ELM were 94% and 85%, unavailability of a valid language screening tool.
respectively. The overall correct classification rate The critical issue in validating a screening tool is
for this latter age group was 86% with the initial determining the level of agreement with the stand-
ELM and 89% with the rescreen ELM. ardized diagnostic test. The ideal agreement be-

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286 LANGUAGE SCREENING
TABLE 3. Early Language Milestone (ELM) Sensitiv- ficity of both of the ELM screenings are reasonable
ity and Specificity by Age Group* (Table 3). For the initial ELM screening in this age
Sequenced Inventory of group, the sensitivity and specificity were 100% and
Communication Development
75%, respectively, indicating no underreferrals and
Initial ELM Rescreen ELM a 25% overreferral rate. With the rescreen ELM,
Failed Passed Failed Passed the sensitivity and specificity were 94% and 85%
ELM at 0-12 mo of respectively, bringing the underreferral rate to 6%
age (n = 11) and the overreferral rate to a more acceptable 15%.
Failed 0 1 0 0 Again, the physician can make the decision to refer
Passed 4 6 4 7 a child based on the results of either the initial or
ELM at 13-24 mo
the rescreen ELM.
ofage (n = 29)
Failed 9 8 7 4 In the 12 months and younger age group, the
Passed 0 12 2 16 sensitivities of the initial and the rescreen ELM
ELM at 25-36 mo were 0%, indicating a lack of agreement between
ofage (n = 37) the ELM and the SICD. This finding is unexpected
Failed 17 5 16 3
in view of the satisfactory agreement in the older
Passed 0 15 1 17
age ranges. Some reasons for this discrepancy
* Results are numbers of children. For 0 to 12 month age
emerged from an analysis of the two tests. First, a
group, initial ELM screen sensitivity was 0%, specificity
86%; repeat ELM screen sensitivity was 0%, specificity
comparison of the number of items in each test for
100%. For 13 to 24 month of age group, initial ELM the three different age groups was made. For the
screen sensitivity was 100%, specificity 60%; repeat ELM children 13 to 36 months of age, the comparison
screen sensitivity was 78%, specificity 80%. For 25 to 36 showed two and one-half to three times more items
month of age group, initial ELM screen sensitivity was
on the SICD than on the ELM, a finding that one
100%, specificity 75%; repeat ELM screen sensitivity was
94%, specificity 85%.
would expect when comparing a diagnostic test with
a screening test. However, in the 12 months and
younger age group, the SICD contains four fewer
tween the two measures is 100% sensitivity and items than the ELM. This difference raises ques-
100% specificity, but screening tests, by nature, are tions concerning the adequacy of the SICD as a
not so accurate. Usually, a compromise must be criterion test and suggests that the ELM may be
made between the sensitivity and specificity to the better test for this age range.
minimize the underreferrals and overreferrals. Un- A second factor that was found to influence the
derreferrals are defined as those children who ac- agreement between the ELM and the SICD in the
tually have a problem but who are not correctly 12 months and younger age group is the SICD’s
identified as such by the screening (false-negative design of scoring and reporting the language age in
results). Overreferrals are defined as those children 4-month intervals (eg, 4 months, 8 months, 12
who are referred for a problem but whom diagnostic months). In our opinion this design results in a
testing shows to have no problem (false-positive greater number of children 12 months and younger
results). failing the SICD. For example, the only options
For all children 13 to 36 months of age, the level available for a 6-month-old infant are a score of 4
of agreement between the SICD and ELM ranged months and a score of 8 months. A language age of
from moderately acceptable to highly acceptable. 4 months is too far below than this infant’s expected
Focusing on the 13 to 24 months of age range, an performance to be within normal limits. On the
initial ELM screening resulted in a sensitivity of other hand, a language age of 8 months would
100% and a specificity of 60% (Table 3). The sen- probably be unattainable by most 6 month-old ba-
sitivity and specificity of a second, or rescreen, bies.
ELM were 78% and 80%, respectively. The initial The third area of discrepancy was discovered in
ELM overreferral rate of 40% is high. When a an analysis of the validation studies of the SICD in
rescreen ELM is used, the overreferral rate de- the 12 months and younger age group.’1 One of the
creases to 20% but the underreferral rate increases criterion tests against which the SICD was vali-
to 22%. The inevitable trade off between overrefer- dated, the Peabody Picture Vocabulary Test, has a
rals and underreferrals is brought into question. basal age of 24 months, rendering it ineffective for
The individual physician, aided by clinical acumen use at younger ages. Similarly, the other criterion
and the probability of follow-up in various settings, tests, the Mean Length Response and the Struc-
can best decide whether to refer a child for further tural Complexity Score, are both tests for measur-
evaluation after the initial ELM or a rescreen ELM. ing the language abilities of children older than 18
For children 25 to 36 months of age, the figures months of age. Thus none of the criterion tests used
pose less of a dilemma. The sensitivity and speci- to validate the SICD in children birth through 12

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ARTICLES 287
months is appropriate for that age range. These children from 13 to 36 months of age. The best age
three findings point out the weaknesses of the SICD range for the ELM is 25 to 36 months of age. A
in the 12 months and younger age group, and ac- child may be referred for diagnostic evaluation after
count for the lack of agreement between the SICD an initial ELM screening has been failed or after
and the ELM in this age range. the results of a second ELM screening are evaluated
Because the ELM is largely based on parental 1 to 2 weeks later. Inherent in these recommenda-
report, the screening results are only as good as the tions is the expectation that all children referred
parents are informed, observant reporters. Prob- for diagnostic testing will have their hearing eval-
lems with parental reporting accounted for some of uated as the first step in the assessment process.
the differences between the initial and rescreen For children 12 months of age and younger the
ELM results. Some parents who were uncertain findings of this study are inconclusive.
about language milestones at the time of the initial Finally, screening without follow-up is of no ben-
screening became more aware of their child’s mile- efit to the child. The providers of health care are
stones during the period between the two screen- responsible for arranging definitive diagnostic eval-
ings. The rescreen ELM was therefore a truer re- uations of suspect cases and providing for remedia-
flection of the child’s actual abilities. With diag- tion when appropriate and possible.’2
nostic testing, however, a small number of children
who failed the initial ELM and passed the rescreen
ELM were found to have language deficits. In this ACKNOWLEDGMENTS
latter group, the rescreening was a less accurate
This project was conducted through a grant from the
reflection of the child’s abilities.
Robert Wood Johnson Foundation.
The results in this study may have been affected We thank Dennis Lezotte, PhD, and James Murphy,
by the expertise of our screeners, who were speech/ PhD, for providing their statistical expertise.
language pathologists. Although they administered
the screenings in the prescribed, standardized man-
ner, they were more attuned to language deficits REFERENCES
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288 LANGUAGE SCREENING

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 Early Language Milestone Scale and Language Screening of Young Children
Dewey Walker, Susan Gugenheim, Marion P. Downs and Jerry L. Northern
Pediatrics 1989;83;284

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 Early Language Milestone Scale and Language Screening of Young Children
Dewey Walker, Susan Gugenheim, Marion P. Downs and Jerry L. Northern
Pediatrics 1989;83;284

The online version of this article, along with updated information and services, is located on
the World Wide Web at:
http://pediatrics.aappublications.org/content/83/2/284

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