Appendix E - Clinical Clues Adapted From the NYS EIP Clinical Practice Guidelines

Clinical Clues for Communication Disorders⁸¹

Normal Language Milestones and Clinical Clues for Possible Language Disorders

During the First 3 Months

Normal Language Milestones

• looks at caregivers/others
• becomes quiet in response to sound (especially to speech)
• cries differently when tired, hungry or in pain
• smiles or coos in response to another person's smile or voice

Clinical Clues / Cause for Concern

• lack of responsiveness
• lack of awareness of sound
• lack of awareness of environment
• cry is no different if tired, hungry, or in pain

From 3-6 Months

Normal Language Milestones

• fixes gaze on face
• responds to name by looking for voice
• regularly localizes sound source/speaker
• cooing, gurgling, chuckling, laughing

Clinical Clues / Cause for Concern at 6 Months

• cannot focus, easily over-stimulated
• lack of awareness of sound, no localizing toward the source of a sound/speaker

From 6-9 Months

Normal Language Milestones

• imitates vocalizing to another
• enjoys reciprocal social games structured by adult (peek-a-boo, pat-a-cake)
• has different vocalizations for different states
• recognizes familiar people
• imitates familiar sounds and actions
• reduplicative babbling ("bababa," "mamamama"), vocal play with intonational patterns, lots of sounds that take on the sound of words
• cries when parent leaves room (9 mos.)
• responds consistently to soft speech and environmental sounds

Clinical Clues / Cause for Concern at 9 Months

• does not appear to understand or enjoy the social rewards of interaction
• lack of connection with adult (lack of eye contact, reciprocal eye gaze, vocal turn-taking, reciprocal social games)
• no babbling, or babbling with few or no consonants

From 9-12 Months

Normal Language Milestones

• attracts attention (such as vocalizing, coughing)
• shakes head "no," pushes undesired objects away
• waves "bye"
• indicates requests clearly; directs others' behavior (shows objects; gives objects to adults; pats, pulls, tugs on adult; points to object of desire)
• coordinates actions between objects and adults (looks back and forth between adult and object of desire)
• imitates new sounds/actions

Clinical Clues / Cause for Concern at 12 Months

• is easily upset by sounds that would not be upsetting to others
• does not clearly indicate request for object while focusing on object
• does not coordinate action between objects and adults
• lack of consistent patterns of reduplicative babbling
• lack of responses indicating comprehension of words or communicative gestures

From 12-18 Months

Normal Language Milestones

• single-word productions begin
• requests objects: points, vocalizes, may use word approximations
• gets attention: vocally, physically, maybe by using word (such as "mommy")
• understands "agency": knows that an adult can do things for him/her (such as activate a wind-up toy)
• uses ritual words ("bye," "hi," "thank you," "please")
• protests: says "no," shakes head, moves away, pushes objects away
• comments: points to object, vocalizes, or uses word approximation

Clinical Clues / Cause for Concern at 18 Months

• lack of communicative gestures
• does not attempt to imitate or spontaneously produce single words to convey meaning
• child does not persist in communication (for example, may hand object to adult for help, but then gives up if adult does not respond immediately)
• limited comprehension vocabulary (understands <50 words or phrases without gesture or context clues)
• limited production vocabulary (speaks <10 words)

From 18-24 Months

Normal Language Milestones

• uses mostly words to communicate
• begins to use two-word combinations: first combinations are usually memorized forms and used in one or two contexts
• later combinations (by 24 months) with relational meanings (such as "more cookie," "daddy shoe"), more flexible in use

Clinical Clues / Cause for Concern at 24 Months

• reliance on gestures without verbalization
• limited production vocabulary (speaks <50 words)
• does not use any two-word combinations
• limited consonant production
• largely unintelligible speech
• compulsive labeling of objects in place of commenting or requesting
• regression in language development, stops talking, or begins echoing phrases he/she hears, often inappropriately

From 24-36 Months

Normal Language Milestones

• engages in short dialogues
• expresses emotion
• begins using language in imaginative ways
• begins providing descriptive details to facilitate listener's comprehension
• uses attention getting devices (such as "hey")
• preparative development characterized by collections of unrelated ideas and story elements linked by perceptual bonds

Clinical Clues / Cause for Concern at 36 Months

• words limited to single syllables with no final consonants
• few or no multi-word utterances
• does not demand a response from listeners
• asks no questions
• poor speech intelligibility
• frequent tantrums when not understood
• echoing or "parroting of speech" without communicative intent

Clinical Clues for Motor Disorders⁸²

Clinical Clues for a Possible Motor Disorder

Abnormalities of Muscle Tone

• Asymmetric (not equal on both sides) tone or movement patterns
• Greater passive flexor tone in arms when compared to legs at any age
• Popliteal angles (bend of knee joint) of 90° or more after 6 months post term
• An imbalance of extensor and flexor tone of the neck and trunk
• Extensor posturing of the trunk or excessive shoulder retraction at rest or when pulled to sit
• Hypotonia (floppiness) of the trunk:
  • The baby slips through the hands when held under the arms in a vertical position
  • There is excessive draping over the hand when held in prone (face down) suspension
• Plantar flexed feet
• Hands held habitually in a fisted position

Non-Sequential Motor Development

• Early rolling
• Brings head and chest up on forearms in prone position prior to developing good head control
• Preference for early standing prior to sitting
• Walking with support before crawling

Qualitative Differences in Motor Development Commonly Reported by Parents and Caregivers

• Startles easily; jittery
• Does not like to cuddle; seems "stiff"
• Arches back frequently
• Baby seems "floppy"
• Infrequent or limited variety of movement
• Favors one side of body more than other
• Feeding problems, particularly after 6 months
• Falls backward when in a sitting position
• Crawls in a "bunny hop" fashion
• Walks on tiptoes
• "Scissors" legs while standing
• Sits with legs in "w" position (reversed tailor position)

Observations of Movement and Posture

• Rolling as a unit (log rolling) after the age of 6 months
• Hyperextension of head and neck when prone in conjunction with significant head lag when pulled to sit
• When prone, readily lifts head and neck, but arms are kept extended along trunk
• When pulled to sit from lying down position, comes to standing instead of sitting position
• One or more of the following occurs in the sitting position:
  • Child sits on lower lumbar sacral region
  • Hips and knees are flexed and hips are adducted
  • Legs are positioned in a reverse tailor or "w" posture
  • A tendency to thrust trunk backward while sitting
• One or more of the following is observed during crawling:
  • Legs are moved as a unit resulting in "bunny hop" movements
  • Hips are excessively adducted, reciprocal movements of legs are done very slowly, and movements are "jerky" in appearance
• Legs are kept extended and adducted while child creeps (pulls body forward with arms)
• In a supported standing posture, legs are excessively extended and adducted and child stands on toes
• While walking, one or more of the following are observed:
  • Crouched gait (hips are flexed and adducted, knees are flexed and feet are pronated)
  • Intermittent tiptoe gait and overextension of the knees

Clinical Clues for Possible Autism⁸³

• Looks through people; not aware of others
• Not responsive to other people's facial expressions/feelings
• Lack of pretend play; little or no imagination
• Does not show typical interest in, or play near peers purposefully
• Lack of turn taking
• Unable to share pleasure
• Qualitative impairment in nonverbal communication
• Not pointing at an object to direct another person to look at it
• Lack of gaze monitoring
• Lack of initiation of activity or social play
• Unusual or repetitive hand and finger mannerisms
• Unusual reactions, or lack of reaction, to sensory stimuli
• Delay or absence of spoken language
• Looks through people; not aware of others

Clinical Clues for Down syndrome⁸⁴

Common Characteristics of Children With Down Syndrome

Physical Characteristics

• Short stature
• Low muscle tone
• Joint laxity
• Flat facial profile
• Upward slanting eyes
• Abnormal shape of the ears
• Little finger with only one joint
• A deep crease across the palm
• Obesity

Developmental Characteristics

Developmental delay

• cognitive
• motor
• communication
• social skills
• adaptive/self-help

Hall's Ten Signs of Down Syndrome in Newborns

Neonatal sign	% Frequency (percent of newborns affected)
Poor Moro reflex	85
Hypotonia	80
Flat facial profile	90
Upward-slanting palpebral fissures (eyelid openings)	80
Morphologically simple, small round ears	60
Redundant loose neck skin	80
Single palmar crease	45
Hyperextensible large joints	80
Pelvis radiograph morphologically abnormal	70
Hypoplasia of fifth finger middle phalanx	60
Adapted from: Tolmie 1998

Clinical Clues for Vision Impairment⁸⁵

Clinical Clues of Possible Vision Impairment: Physical Exam Findings

• Abnormal head posture
• Abnormal craniofacial features (such as microcephaly, ptosis)
• Abnormal pupil response
  • Abnormal red reflex
  • Asymmetrical Bruckner test
  • Afferent pupil response (APD)
• Absence or abnormality of optokinetic nystagmus (OKN) after age 6 months
• Coloboma
• Corneal opacification or congenital cataracts
• Asymmetrical corneal light reflex
• Direct observation of an eye turn
• Delayed, absent, or abnormal visual fixation/following
  • Absence of any fixation at birth
  • Has not developed good fixation (saccade) by 6-9 weeks
  • Has not developed good following (pursuit) by 2-3 months
• Iris abnormalities
  • Albinism (findings of albinism such as transillumination)
  • Aniridia (absence of the iris)
• Nystagmus (other than reflex nystagmus such as OKN)
• Strabismus
• Abnormal head posture
• Abnormal craniofacial features (such as microcephaly, ptosis)
• Abnormal pupil response

Clinical Clues of Possible Vision Impairment: Visual Behaviors⁸⁶

Information about visual behaviors that may indicate a possible vision problem can be obtained from observation of the child, from expression of parental concern about the child's vision, or from information provided by the parent(s) in response to specific questions. Examples of clinical clues of a possible vision problem include:

Visual Behaviors

• Photophobia (avoidance of bright light/squints in bright light/preference for dim light)
• Stares at bright lights
• Closes one eye
• Non-directed or "roving" eye movements
• Does not seem to respond to parent's face
• Does not seem to imitate parent's facial expression
• Does not seem to follow movement of objects or people
• Does not reach for bottle when presented quietly
• Does not seem to show interest in toys/objects within reach
• Does not seem to show visual interest in television
• Does not seem to show interest in books
• Seems to have limited interest in different kinds of toys
• Does not seem to recognize colors or shapes
• Bumps into objects
• Visual self-stimulatory behaviors (e.g., eye rubbing, pressing, or poking)

Clinical Clues of Possible Vision Impairment: Visual Developmental Milestones⁸⁷

The age ranges for the visual developmental milestones are approximate and will vary somewhat for each child. Because many of the visual milestones are dependent on other areas of development (such as development of cognitive and motor skills), a delay or failure to achieve a visual developmental milestone may be an indication of a vision problem, or it may be an indication of some other developmental delay.

Failure to achieve the following milestones may be an indication of a vision problem.

Visual Developmental Milestones

By 6 weeks:

• Stares at surroundings when awake
• Momentarily holds gaze on bright light or bright object
• Blinks at camera flash
• Eyes and head move together

By 24 weeks:

• Eyes begin to move more widely with less head movement
• Eyes begin to follow moving objects or people (8-12 weeks)
• Watches parent's face when being talked to (10-12 weeks)
• Begins to watch own hands (12-16 weeks)
• Eyes move in active inspection of surroundings (18-20 weeks)
• While sitting, looks at hands, food, bottle (18-24 weeks)
• Begins to look for and watch more distant objects (20-28 weeks)

By 48 weeks:

• May turn eyes inward while inspecting hands or toy (28-32 weeks)
• Eyes more mobile and move with little head movement (30-36 weeks)
• Watches activities in the environment for longer periods of time (30-36 weeks)
• Visually attends to dropped toys (32-38 weeks)
• Visually inspects toys while holding (38-40 weeks)
• Creeps after favorite toy when seen (40-44 weeks)
• Sweeps eyes around room to see what's happening (44-48 weeks)
• More and more visual inspection of objects and persons (46-52 weeks)

By 18 months:

• Uses both hands and visually steers hand activity (12-14 months)
• Visually interested in simple pictures (14-16 months)
• Often holds objects very close to eyes to inspect (14-18 months)
• Points to objects or people using words "look" or "see" (14-18 months)
• Looks for and identifies pictures in books (16-18 months)

By 36 months:

• Smiles, facial brightening when views favorite objects and people (20-24 months)
• Likes to watch movement of wheels, egg beater, etc. (24-28 months)
• Watches own hand while scribbling (26-30 months)
• Visually explores and steers own walking and climbing (30-36 months)
• Watches and imitates other children (30-36 months)
• Begins to keep coloring on the paper (34-38 months)
• "Reads" pictures in books (34-38 months)

Clinical Clues for Hearing Impairment⁸⁸

Any one clue at any age may be a clinical clue of hearing loss.

Clinical Clues of Possible Hearing Loss

At 3 Months

• Lack of responsiveness to voice
• Lack of awareness of environmental sound
• Does not visually track to voice

At 6 Months

• Lack of awareness of sound, no localizing toward the source of a sound/speaker
• Vocalizes with little variety

At 9 Months

• Lack of connection with adult (vocal turn-taking, reciprocal social games)
• Does not associate a sound with its source (such as not responding to sound toys)
• No babbling, or babbling with few or no consonants

At 12 Months

• Lack of consistent patterns of reduplicative (canonical) babbling (such as "babababa")
• Lack of responses indicating comprehension of words
• Exclusive reliance on context for language understanding
• Lacks vocalizations that sound like first words (such as "ma-ma" or "da-da")

At 18 Months

• Does not attempt to imitate words
• Does not spontaneously produce single words to convey meaning
• Limited comprehension vocabulary (understands <50 words or phrases without gesture or context clues)
• Limited production vocabulary (speaks <10 words)
• Speech largely unintelligible
• Lack of progress in vocabulary development from 12 to 18 months (plateau or lack of progress at any age)
• Limited consonant production

At 24 Months

• Reliance on gestures without verbalization
• Speech largely unintelligible
• Limited production vocabulary (speaks <50 words)
• Does not use two-word combinations

At 36 Months

• Social interactions with peers are primarily gestural
• Words limited to single syllables with no final consonants
• Few or no multi-word utterances
• Does not demand a response from listeners
• Asks no questions
• Poor speech intelligibility
• Frequent tantrums when not understood

⁸¹ Reproduced from Table III-5, Assessment Chapter, New York State Clinical Practice Guideline on Communication Disorders
⁸² Reproduced from Table 3, Assessment Chapter, New York State Early Intervention Program Clinical Practice Guideline on Motor Disorders
⁸³ Reproduced From Table III-4, Assessment Chapter, New York State Early Intervention Program Clinical Practice Guideline on Autism
⁸⁴ Tables 1 and 3, Assessment Chapter, New York State Early Intervention Program Clinical Practice Guideline on Down Syndrome
⁸⁵ Reproduced from Table 7(a), New York State Early Intervention Program Clinical Practice Guideline on Vision Impairment
⁸⁶ Reproduced from Table 7(b), New York State Early Intervention Program Clinical Practice Guideline on Vision Impairment
⁸⁷ Reproduced from Table 7(c), New York State Early Intervention Program Clinical Practice Guideline on Vision Impairment
⁸⁸ Reproduced from the Assessment Chapter, Table 5, New York State Early Intervention Program Clinical Practice Guideline on Hearing Loss

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