627420

research-article2016
CDQXXX10.1177/1525740115627420Communication Disorders QuarterlyLarson

Article
Communication Disorders Quarterly

Language Screening for Infants and

1­–10
© Hammill Institute on Disabilities 2016
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DOI: 10.1177/1525740115627420

Commercially Available Tools cdq.sagepub.com

Anne L. Larson, MS, CCC-SLP1

Abstract
Children from low-income environments are at increased risk of developing language delays which can negatively affect later
academic and social outcomes. As children age, deficits between children with language delays and their typically developing
peers continue to widen. In order to prevent future disabilities, efficient early language screening tools are needed to
identify infants and toddlers who are at risk of language delay as the first step towards providing early intervention. The
purpose of this review was to identify commercially available language screening tools for use with children under three
years of age. The psychometric properties of each tool are described—including a specific focus on technical adequacy of
the measures for use with diverse families. There are currently four tools available for use with infants and toddlers. The
strengths and limitations of each tool are described, as well as the feasibility of using these tools in diverse populations.

Keywords
birth to 3 years, age, language, assessment, delays/disorders, language/linguistics, vocabulary, literacy, diversity

Early intervention with children who are at risk for delay can
help prevent disabilities (Guralnick, 2005). The importance
of early identification is codified into law in the Individuals
With Disabilities Education Improvement Act (IDEIA,
2004), which requires all states to provide, “a comprehen-
sive child find system . . . that ensures rigorous standards for
appropriately identifying infants and toddlers with disabili-
ties for services . . . that will reduce the need for future ser-
vices . . . ” (20 USC § 1435[a]). Early speech and language
disorders are prevalent disabilities that can cause later diffi-
culty (Law, Boyle, Harris, Harkness, & Nye, 2000; Tomblin,
Zhang, Buckwalter, & Catts, 2000). In a longitudinal inves-
tigation of late-talkers who were identified between 24 and
31 months of age, Rescorla (2009) noted significantly lower
reading and writing ability at 17 years of age.
Compared with their more advantaged peers, children
who are living in poverty are particularly at risk of having
low language skills (see Hoff, 2006, for a review). In one of
the most well-known studies to examine the effects of
socioeconomic status (SES) on language outcomes, Hart
and Risley (1995) estimated that by age 3, children from
upper-income families will have an expressive vocabulary
almost three times larger than their low-income counter-
parts. By kindergarten, children from low SES families
often have significantly lower achievement—a problem
that is then pronounced by low SES students entering lower
quality schools (Lee & Burkam, 2002). The effects of low
SES and vocabulary on child receptive and spoken
language ability and academic achievement persist into
elementary school (Walker, Greenwood, Hart, & Carta,
1994). Children with strong vocabulary skills learn to read
better, read more, and thus learn more.
The negative outcomes associated with insufficient early
language skills predicates the need to identify effective
language screening tools for use with very young children.
Given that 22.5% of children under 5 years are living in pov-
erty (Child Trends Databank, 2014), identification of early
language screening tools that can be used in low-income
populations is also highly relevant. With adequate screening
tools designed for use with low-income populations, young
children who are at risk for language delays will have an
opportunity to be identified for further evaluation and may
receive early intervention services when needed.
Although the gap in expressive language development
for children from low SES families compared with their
peers from higher SES has been identified in laboratory set-
tings at 18 months of age (Fernald, Marchman, & Weisleder,
2013), there is no gold standard early language screening
tool for use in the community. Furthermore, there are no
1
University of Minnesota, Minneapolis, USA
Corresponding Author:
Anne L. Larson, Department of Educational Psychology, University
of Minnesota, 250 Education Sciences Bldg., 56 East River Road,
Minneapolis, MN 55455, USA.
Email: lars4959@umn.edu

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2 Communication Disorders Quarterly 
specific recommendations for screening diverse popula-
tions of very young children. The purpose of this review is
to identify language assessment tools that can be used for
screening language skills in children under 3 years of age.
In addition to examining the technical adequacy of early
language screening tools, this review aims to discuss the
feasibility of using these measures with diverse, low-
income populations who are most at risk of developing lan-
guage delays.
Method
I conducted a systematic review of the literature to identify
language assessments available for use as screening
tools with very young children. The electronic databases
of Education Resource Information Center (ERIC),
PsychINFO, Education Source, and Linguistics and
Language Behavior Abstracts (LLBA) were searched using
the following phrase: “screening AND language AND
(infant OR toddler).” Searches were restricted to peer-
reviewed journals with no limits on publication dates. A
total of 59 articles were identified in these databases, and
an additional 11 unduplicated studies were found using the
same search terms in the American Journal of Speech-
Language Pathology and the Journal of Speech, Language
and Hearing Research. Articles that discussed the develop-
ment, psychometric properties, and/or usability of each
screening tool were included but dissertations and techni-
cal reports were not. Tools were included in the review if
they were (a) narrow-band assessments focused on lan-
guage understanding or use, (b) designed for use with chil-
dren under 3 years of age, (c) brief assessments administered
and scored in under 10 minutes, and (d) commercially
available in English.
Four language screening instruments for children under
36 months of age were identified in the initial search,
including: the Early Language Milestone Scale (ELM
Scale-2; Coplan, 1993), The Capute Scales: Cognitive
Adaptive Test/Clinical Linguistic and Auditory Milestone
Scale (CAT/CLAMS; Accardo & Capute, 2005), the
Language Development Survey (LDS; Rescorla, 1989), and
the MacArthur Communicative Development Inventories
(CDI; Fenson et al., 1994). A secondary search of the afore-
mentioned databases with the full name of each screening
tool and a hand search of all references identified additional
references, and a total of 19 studies were reviewed. The fol-
lowing discussion reports on these findings and includes
information on the psychometric properties, as well as the
feasibility of using each tool.
Literature Synthesis
Initially, researchers developed screening tools specific to
language development to increase pediatrician accuracy
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and quantity of referrals for complete evaluation (Rescorla,
1989). The CAT/CLAMS and ELM Scales were developed
for pediatricians in response to a need to improve on the
Denver Developmental Screening Test, which included only
19 items relevant for the first 3 years of the child’s life
(Coplan, Gleason, Ryan, Burke, & Williams, 1982). The
LDS and CDI were later developed as parent-report tools to
be used in a variety of settings.
Cognitive Adaptive Test/Clinical Linguistic
Auditory Milestone Scale (CAT/CLAMS)
The CAT/CLAMS is a standardized tool developed for use
by pediatricians to measure language and visual-motor
problem-solving development in young children. Several
researchers have examined the concurrent validity of the
CAT/CLAMS with comprehensive developmental assess-
ments and suggest the use of the CAT/CLAMS as a diag-
nostic tool (i.e., Leppert, Shank, Shapiro, & Capute, 1998;
Macias et al., 1998; Rossman et al., 1994); however, Mohay
(2007) suggested the CAT/CLAMS should be used as a
screening tool to identify the need for more comprehensive
formal assessment. When only the language portion, the
CLAMS, is used, administration takes less than 5 min
(Belcher, Gittlesohn, Capute, & Allen, 1997). Three studies
focused on the CLAMS as a screening tool.
The CLAMS includes 43 developmental language
milestones for children from birth to 36 months of age.
Each item is scored (0.25 to 1) based on parent responses
to standardized questions. Rather than asking parents to
recall a specific age at which receptive and expressive lan-
guage skills were acquired, the CLAMS uses a recognition
format (i.e., yes/no questions)—a feature that adds to the
reliability of the measure (Capute, Shapiro, Wachtel,
Gunther, & Palmer, 1986). Although normative data are
available for the CLAMS, most administrators use the
CLAMS Language Quotient (LQ)—the sum of each com-
pleted language task, divided by the child’s chronologic
age, and multiplied by 100 (Belcher et al., 1997). Studies
in this review used a CLAMS LQ of less than 90 (Clark,
Jorgensen, & Blondeau, 1995) and a CLAMS LQ of less
than 80 (Belcher et al., 1997; Capute et al., 1986) as the
cutoff for children who should be referred for comprehen-
sive language evaluation.
Capute et al. (1986) examined the relationship between
the CLAMS and the Bayley Scales of Infant Development
(BSID; Bayley, 1969). The researchers examined the con-
current and predictive validity of the CLAMS in a sample
of young children with mild-to-moderate motor delays
between 12 and 30 months of age. They described parents
as being from all socioeconomic strata with a range of edu-
cation levels. Capute and colleagues (1986) collected data
across three time points and summarized scores using the
CLAMS LQ and a derived Bayley ratio quotient (BRQ).
Larson 3
Authors found strong correlations with the BRQ and mod-
erate sensitivity and specificity in the study sample.
In a later study, Clark et al. (1995) evaluated the concur-
rent validity of the CLAMS with the Sequenced Inventory
of Communication Development (SICD; Hedrick, Prather,
& Tobin, 1984). Again, researchers described the sample as
being from all socioeconomic strata with 99 children
between the ages of 14 and 36 months. Unlike other studies
where the CLAMS was administered in a pediatrician’s
office, testing in this study was completed in the child’s
home or in a quiet room at Houston School for Deaf
Children. Clark et al. (1995) used age quotients to compare
scores on the CLAMS (< 90) with the SICD (< 80), and
concluded that, compared with the SICD, the CLAMS was
most accurate in identifying expressive language delay for
children between 25 to 36 months of age; whereas classifi-
cation accuracy diminished for children who were between
14 and 24 months old.
Belcher et al. (1997) had a slightly different purpose for
their research. They used the CLAMS to evaluate 81 high-
risk preterm infants to determine the need for gestational
age correction at three age intervals. The authors in this
study did not provide information for participants’ charac-
teristics beyond a description of medical exclusion crite-
ria. Belcher et al. (1997) compared CLAMS LQ scores
with one of three comprehensive developmental assess-
ments: The Stanford-Binet Intelligence Scale (53%;
Terman & Merrill, 1976), The BSID (36%), and the
Wechsler Preschool and Primary Scale of Intelligence
(11%; Wechsler, 1976). Developmental quotients less than
71 were considered delayed and a CLAMS LQ of 90 was
used as the cutoff to determine a need for further evalua-
tion. Belcher et al. (1997) noted statistically significant
correlations with comprehensive assessments of 9- to
14-month-olds and 18- to 24-month-olds (r = .34, p < .02
and r = .75, p < .001, respectively), but no statistically
significant relationship for the youngest study participants
between 3- to 5-months-old (r = .27, p > .05). Using
chronological age resulted in the highest correlations
(Belcher et al., 1997).
Researchers in the above-mentioned studies concluded
that the CLAMS is an efficient screening tool with rela-
tively strong, statistically significant relationships with
other measures of child language and cognitive develop-
ment. Across studies, researchers identified stronger rela-
tionships with increases in child age, and determined that
the CLAMS was most effective in identifying expressive
language delay. Despite the relatively positive results from
these studies, however, several issues affect use of the
CLAMS as an early language screening tool.
First, with the exception of Belcher et al. (1997), age
quotients were used as comparisons between the CLAMS
and other more comprehensive measures. Age quotients can
be problematic because they compare children of different
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ages rather than making comparisons between same-age
peers (Mohay, 2007). There are also concerns with using
standard scores on the CLAMS. In a review of The Capute
Scales, Mohay (2007) noted that standard deviations had
large variation depending on child age with an abundance
of young children falling far below the mean, and an over-
represented group of older children exceeding two or three
standard deviations above the mean. In addition to concerns
regarding standardization, the comparison tools used in
these studies are out-of-date ranging from 1969 to 1984.
Assuming that, in general, assessments have improved over
time, the use of outdated assessments makes it difficult for
practitioners to draw conclusions about the accuracy of the
CLAMS with today’s population. Finally, even though two
sets of authors described study participants as being eco-
nomically diverse (Capute et al., 1986; Clark et al., 1995),
neither provided specific breakdowns by number or per-
centage. No authors commented on the racial or ethnic
background of study participants.
ELM Scale and ELM-2
The original ELM Scale included a total of 41 items
arranged chronologically by age of expected develop-
ment—the revised ELM-2 (Coplan, 1993) includes 43
items. Both versions group language development into
three categories: auditory receptive abilities, visual lan-
guage milestones, and auditory expressive function
(Coplan & Gleason, 1990; Costarides & Shulman, 1998).
The tool can be scored using pass-fail criterion (Coplan et
al., 1982) or with a point-scoring technique that allows for
calculation of percentiles, means, and standard deviation
comparisons by age (Coplan & Gleason, 1990). Coplan et
al. (1982) estimated that test administrators can gather
information on child development in 1 to 3 min through
parent report, direct elicitation of skill, and incidental
observation.
The ELM Scale was originally validated by Coplan et al.
(1982) through language evaluation and interviews with 191
children (birth through age 3) and their parents. Study
authors demonstrated high sensitivity (97%) and specificity
(93%) in a cross-sectional sample of children aged 5 to 36
months using a variety of comprehensive standardized
assessments, including: BSID, Stanford-Binet Intelligence
Scale, and Leiter International Performance Scale (Leiter,
1969), and language assessments, including: Receptive-
Expressive Emergent Language Scale (REEL Scale; Bzoch
& League, 1971), Preschool Language Scale (PLS;
Zimmerman, Steiner, & Pond, 1979), and the Peabody
Picture Vocabulary Test (PPVT; Dunn, 1965). Despite using
mostly standardized measures (with the exception of the
REEL Scale), authors did not mention how many children
participated in each type of testing, nor did they provide data
on the sensitivity or specificity for individual assessments
4 Communication Disorders Quarterly 
compared with the ELM. Furthermore, Coplan et al. (1982)
mentioned that, “failing formal assessment was based upon
the presence of significantly delayed language . . .” (p. 679);
however, they did not adequately describe pass-fail criteria
for the standardized assessments.
The original normative sample for the ELM Scale was
primarily middle class and 80% White (Coplan et al.,
1982); however, additional studies using the ELM Scale
have been validated for use with more diverse populations.
Black, Freeland, Nair, Rubin, and Hutcheson (1988) found
high levels of sensitivity (86%) and specificity (100%)
with 48 children with low SES, 60% of whom had mothers
without a high school degree. Other researchers examined
the use of the ELM Scale or ELM-2 with children who
have low birth weight (Byrne, Ellsworth, Bowering, &
Vincer, 1993; Costarides & Shulman, 1998), children who
were born premature and those with physical conditions
that increase the risk for developmental delay (Costarides
& Shulman, 1998), as well as children diagnosed with frag-
ile X syndrome (Mirrett, Bailey, Roberts, & Hatton, 2004).
Costarides and Shulman (1998) found statistically signifi-
cant correlations with the ELM-2 and BSID-II (Bayley,
1993). Mirrett and colleagues (2004) noted moderate to
strong agreement between the ELM-2 and the REEL-2
(Bzoch & League, 1991), but neither study provided data
on the classification accuracy of the ELM-2—making it
difficult to determine the utility of the ELM-2 as a screen-
ing tool.
Like studies that used the CLAMS, authors who exam-
ined the ELM noted lower levels of predictive validity
when screening young children. Despite adequate sensitiv-
ity (87%) and specificity (70%) levels in their sample over-
all, Walker, Gugenheim, Down, and Northern (1989)
demonstrated poor agreement with the SICD at 12 months
(sensitivity 0%, specificity 86%). Variations in sensitivity
of the ELM Scale for young children have been attributed to
low criterion validity on comparison tools (Walker et al.,
1989)—suggesting the ELM Scale may actually be a better
tool for detecting language problems in very young children
(Black et al., 1988).
When comparing the ELM Scale with the BSID, Satish
and colleagues again found lower correlations between the
ELM and BSID for infants under 12 months (Satish et al.,
1988a, 1988b) compared with those 13 months of age and
older (Satish et al., 1988b). In these studies, as well as in a
study by Walker et al. (1989), authors used rescreens for
children who failed the ELM Scale prior to their first birth-
day. Walker et al. (1989) reported increased specificity
(70% to 85%) for the second screening attempt, and sug-
gested gains in specificity due to parents’ increased aware-
ness of developmental milestone attainment following
initial completion of the tool. Increased classification accu-
racy with repeated screening suggests the ELM Scale may
be a useful tool for frequent progress monitoring.
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Researchers have demonstrated the ELM Scale as an
appropriate screening tool across a variety of populations
with good classification accuracy when compared with
comprehensive assessments. Although the ELM Scale was
not as related to comprehensive measures prior to age 12
months, researchers noted improvements with follow-up
screenings. As discussed with the CLAMS, however, the
research on the ELM Scale is out of date and there are no
reports on the classification accuracy of the ELM-2. The
most recent studies addressing the utility of the ELM-2 are
at least 10 years old, and none compare ELM-2 scores with
comprehensive assessments created after 1993.
LDS
The CLAMS and ELM Scale ask if the child uses at least 50
words, but neither requires parents to list their child’s
expressive vocabulary (Rescorla, 1989). In contrast, the
LDS uses parent report on a vocabulary checklist. The LDS
can be completed independently by caregivers in a variety
of settings to identify children at risk for language delay
around age 2. Rescorla (1989) validated the LDS in four
studies with a total of 641 child–caregiver dyads. Families
who participated in the initial studies were both racially and
economically diverse, as is noted in detailed breakdowns
for SES, family type (one- or two-parent), parent employ-
ment status, and parent education (Rescorla, 1989).
The LDS includes 310 vocabulary words arranged
alphabetically in 14 semantic categories: actions, animals,
body parts, clothes, food, household items, modifiers, other,
outdoors, people, personal, places, toys, and vehicles
(Rescorla, Mirak, & Singh, 2000). Parents mark words they
have heard their child use, write down examples of their
child’s longest utterances, and answer questions related to
medical history and family demographics—which can be
completed in about 10 min (Rescorla, 1989). Three criteria
(Delay 1, Delay 2, and Delay 3) can be used to determine a
need for further language assessment after screening with
the LDS (Rescorla, 1989). An additional screening equation
known as Delay 3+ (Klee, Pearce, & Carson, 2000) incor-
porates information about parent concern for their child’s
language development and number of cases of otitis media
up to age 2. Although sensitivity and specificity of the LDS
have been shown to increase when using Delay 3+ (Klee
et al., 2000), the equation has not been used in other pub-
lished research. Across all other studies, the Delay 3 criteria
(child has fewer than 50 words or no word combinations), had
the strongest correlations with other similar measures. Data
calculated with Delay 3 criteria are presented in Table 1.
Original LDS studies reported strong inter-rater reliabil-
ity (r = .99), sensitivity ranging from 61% to 100%, and
specificity between 67% to 96% when compared with other
measures of vocabulary, language, and cognitive skills
(Rescorla, 1989). In many studies, a child’s ability to name
Larson 5

Table 1.  Classification Accuracy From Studies of Early Language Screening Tools.
Study n Age in months Comparison measure(s) R SNS % SPC % PPV % NPV %

CLAMS
  Capute, Shapiro, Wachtel, 44 12–30 BSID .73*** 66 79 80 65
Gunther, and Palmer (1986)
  Clark, Jorgensen, and Blondeau 99 14–36 SICD (receptive) .66*** 78 90 44 98
(1995)  SICD (expressive) .65*** 67 95 75 93
  Belcher, Gittlesohn, Capute, and 81 3–6 BSID, WPPSI, or SB .27* 79 30  
Allen (1997)   9–14 .34*  
18–24 .75***  
ELM
  Coplan, Gleason, Ryan, Burke, and 119 5–36 BSID, SB, Leiter, REEL, PLS, 97 93 94 96
Williams (1982) and/or PPVT
  Walker, Gugenheim, Down, and 77 0–36 SICD (Initial Screen) 87 70  
Northern (1989)  SICD (Rescreen) 77 85  
  Black, Freeland, Nair, Rubin, and 48 14, 18 REEL, BSID 86 100  
Hutcheson (1988)
  Byrne, Ellsworth, Bowering, and 71 12, 24 SICD-R 0–68 80–100  
Vincer (1993)
ELM-2
  Costarides and Shulman (1998) 90 4, 12, 24 BSID-II .30*  
  Mirrett, Bailey, Roberts, and 18 9–18 REEL-2 .64–.93^  
Hatton (2004)
LDS
  Rescorla (1989; Study 3) 81 24–30 BSID, Reynell objects and .87*** 87 86  
pictures, and Reynell age
score
  Rescorla (1989; Study 4) 58 22–33 BSID and PLS objects and .79^  
pictures
 Rescorla, Hadicke-Wiley, and 108 22–30 BSID objects .78^ 90 95  
  Escarce (1993; Study 1)
  SB pictures 73 94  
 Rescorla, Hadicke-Wiley, and 92 24 BSID objects .82^ 100 90  
  Escarce (1993; Study 2)
  SB pictures 100 91  
  Klee et al. (1998; Study 1) 64 24–26 Mullen .72*** 91 87 18–37 >99
  Klee et al. (1998; Study 2) 36 36–40 Mullen .53** 67 90  
  Klee, Pearce, and Carson (2000) 64 24–26 Mullen 91 96 77 99
  Rescorla and Alley (2001; Study 1) 422 24–26 BSID objects .69*** 90 94 39 99
  SB pictures .74*** 64 94 39 98
  Rescorla and Alley (2001; Study 2) 66 24–26 Reynell .56–.81*** 94 67 52 97
  Mossabeb, Wade, Finnegan, Sivieri, 178 24, 26 BSID-III 61 82  
and Abbasi (2012)
CDI short-forms
  Fenson et al. (2000; Study 1) 483 8–18 CDI:WG .97**  
  Fenson et al. (2000; Study 2) 911 16–30 CDI:WS .99**  
  Pan, Rowe, Spier, and Tamis- 105 24 BSID-II .54 ***  
Lemonda (2004)  36 PPVT-III .50***  
  Rose, Feldman, and Jankowski 182 12 PPVT-R and verbal fluency .29–.49***  
(2009)

Note. SNS = sensitivity; SPC = specificity; PPV = positive predictive value; NPV = negative predictive value; CLAMS = Cognitive Linguistic Auditory Milestone Scale;
BSID = Bayley Scales of Infant Development; SICD = Sequenced Inventory of Communicative Development; WPPSI = Wechsler Preschool and Primary Scale of Intelligence;
SB = Stanford-Binet Intelligence Scale; ELM = Early Language Milestone Scale; REEL = Receptive-Expressive Emergent Language Scale; PLS = Preschool Language Scale;
PPVT = Peabody Picture Vocabulary Test; SICD-R = Sequenced Inventory of Communicative Development–Revised; LDS = Language Development Survey; CDI short-forms
= MacArthur-Bates Communicative Development Inventories–Short-Form; CDI:WG = MacArthur-Bates Communicative Development Inventories Words and Gestures;
CDI:WS = MacArthur-Bates Communicative Development Inventories Words and Sentences; PPVT-R = Peabody Picture Vocabulary Test–Revised.
^ = p not reported. *p < .05. **p < .01. ***p < .001.

at least one of five objects on the Bayley Scale or one of 14 Rescorla & Alley, 2001; Rescorla, Hadicke-Wiley, &
pictures on a subtest of the Stanford-Binet: Fourth Edition Escarce, 1993). Failure to name any objects or pictures in
(Thorndike, Hagen, & Sattler, 1986) was used as the stan- these studies resulted in classification of language delay.
dard for normal language development (Rescorla, 1989; Rescorla and Alley (2001) reported concerns with

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6 Communication Disorders Quarterly 
over-identification based on these criteria and suggested
that factors unrelated to vocabulary use (i.e., child being
uncooperative, shy, or difficult to engage) affected the
results. They attempted to use z-scores from the receptive
and expressive sections of the Reynell Expressive Language
Scale to remediate the problem with the language delay cri-
teria. Unfortunately, the Reynell, as well as the Infant
Mullen Scales of Early Learning (Mullen, 1993) used by
Klee et al. (1998), are based on age scores and are not
standardized.
In the most recent study examining the sensitivity and
specificity of the LDS, Mossabeb, Wade, Finnegan, Sivieri,
and Abbasi (2012) used the BSID-III (Bayley, 2006) and
compared Delay 3 criteria with standard scores and expres-
sive language scaled scores. When comparing LDS scores
with expressive scaled scores less than eight (<25th percen-
tile), authors found high levels of sensitivity (74%) and
specificity (87%) in this sample. When standardized lan-
guage scores were used, however, sensitivity decreased
noticeably (61%). In their study, Mossabeb et al. (2012)
used a cutoff score of less than 90 to denote language
delay—even though the BSID-III classifies scores of 80 to
89 as low average. Mossabeb et al. (2012) do not report on
the classification accuracy of the LDS with other compari-
son scores.
CDI
Like the LDS, the CDI includes a series of assessments that
use parent-completed vocabulary checklists. With an esti-
mated administration time of 30 min (Rescorla, 1989),
however, use of the CDI as a screening tool is impractical.
Instead, the CDI–Short Form (CDI-SF) can be used by
researchers and clinicians seeking a quick assessment of
early language (Fenson et al., 2000).
Fenson et al. (2000) developed the CDI-SF with simu-
lated short-form scores extracted from the original CDI
norming study (Fenson et al., 1994). The Level I form,
designed for young children between 8 and 18 months,
asks parents to review an 89-word vocabulary list for words
their child understands or understands and says. The Level
II form, designed for children 16 to 30 months, presents
100 words on either Form A or Form B and asks parents to
select words their child can say. The Level II form also
includes a question asking the parents if their child has
begun to combine words. Total vocabulary scores can be
converted to percentiles using normative data (Fenson et
al., 2000). Across age ranges, Fenson et al. (2000) reported
correlations of .97 for Level I and .99 for Level II short-
forms when compared with their long-form versions. They
noted, however, that the normative group had above-aver-
age education levels and were less racially diverse than the
population, suggesting that results obtained through the
CDI-SF should be interpreted with caution when the tool is
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used with children from low-education, and low-income,
families.
Pan, Rowe, Spier, and Tamis-Lemonda (2004) used a
more diverse sample of 105 low-income children and their
mothers to examine correlations with the CDI-SF Level II
form and the BSID-II (r = .54, p < .001) at age 2. Researchers
found modest predictive validity when compared with the
PPVT-III (Dunn & Dunn, 1997) at age 3 (r = .50, p < .001).
Interestingly, Pan et al. (2004) noted differences in CDI-SF
scores depending on mother’s race—where White mothers
reported higher vocabulary scores than African American
or Hispanic mothers. They hypothesized that the difference
may exist due to limitations in assessing children in bilin-
gual households (41% of the sample), as well as potential
validity concerns with the PPVT-III in evaluating minority
children.
Rose, Feldman, and Jankowski (2009) used an economi-
cally and racially diverse sample of 182 preterm and full-
term 1-year-olds when they completed the first predictive
validity study of the CDI-SF Level I. They compared
CDI-SF Level I scores with Peabody Picture Vocabulary
Test–Revised (PPVT-R; Dunn & Dunn, 1981) and a test of
verbal fluency (Singer, Corley, Guiffrida, & Plomin, 1984)
2 years later. Correlations on the measures in this study
ranged from .29 to .49 (p < .001). Unfortunately, though,
Rose et al. (2009) used outdated measures to draw their
comparisons, with the rationale that the measures had previ-
ously related to other infant measures in their study.
One final study, by Deniz Can, Ginsburg-Block,
Golinkoff, and Hirsh-Pasek (2012), examined longitudinal
predictive validity of the CDI-SF Level II with language
outcomes in kindergarten. After controlling for age, Deniz
Can et al. (2012) found moderate correlations between the
picture vocabulary naming subtest (r =.41, p < .01) of the
Woodcock-Johnson Tests of Achievement–III (WJ-III;
Woodcock, McGrew, & Mather, 2001), and the syntax (r =
.32 p < .01) and semantics (r = .27 p < .05) domains of the
Diagnostic Evaluation of Language Variation Test (DELV;
Seymour, Roeper, & DeVilliers, 2005). Strengths of this
study include use of reputable comprehensive assessments
suggesting that the CDI-SF can be used to measure progress
over time, as well as a measure for predicting later language
ability. The sample tested by Deniz Can et al. (2012), how-
ever, was primarily White and middle- to upper-middle
class, with 79% of mothers reporting college graduation.
The lack of socioeconomic, racial, and parent education
diversity in this study makes it difficult to determine out-
comes for children from other backgrounds.
The available evidence on concurrent and predictive
validity supports use of the CDI-SF with young children;
however, across studies, authors noted that CDI-SF scores
should be interpreted cautiously in low SES and non-White
populations. No studies in this review reported on the clas-
sification accuracy of the CDI-SF as a screening tool.
Larson 7
Discussion
The purpose of this review was to examine the technical
adequacy and feasibility of four commercially available
language screening tools for use with children under age 3.
Early identification of infants and toddlers at risk for devel-
oping language delay can lead to early intervention that
may prevent later disabilities. In the following section, I
present summaries of the psychometric properties for early
language screening tools, as well as their potential useful-
ness within community-based settings with families who
are living in poverty. I also provide suggestions for future
research in the area of early language screening and outline
the limitations of the review. Last, I summarize implications
for speech-language pathology (SLP), early childhood
practitioners, and researchers.
Psychometric Properties
Across studies, researchers identified moderate to strong rela-
tionships between comprehensive language and cognitive
assessments and the CLAMS, ELM, LDS, and CDI-SF.
Unfortunately, almost all gold standard assessments used as
comparisons in these studies were dated before the turn of
the century—even when more recent comprehensive assess-
ments were available. For example, studies using the LDS
consistently demonstrated high levels of sensitivity and
specificity across a variety of populations; however, only
one study (Mossabeb et al., 2012) compared the LDS with
standard scores on a comprehensive assessment. Early
research on the LDS used arbitrary gold standards based on
portions of standardized assessments. Authors who repli-
cated these early studies continued using this criteria more
than 20 years later (e.g., Rescorla & Alley, 2001). In the
CLAMS study by Belcher et al. (1997), researchers used
comprehensive measures ranging in publication date from
1969 to 1986 when more recent tools such as the BSID-II
were available.
Research on the ELM-2 and CDI-SF has been completed
with more reputable and updated standardized instruments
(BSID-II, PPVT-III, REEL-2, and WJ-III); however, psy-
chometric data on these tools is quite limited. With the
ELM-2, for example, researchers only reported on correla-
tions. Similarly, despite a call for research on the sensitivity
of the CDI-SF (Fenson et al., 2000), more than a decade of
research reports only on concurrent and predictive validity.
Feasibility of Use
The tools in this review can be considered for use in screen-
ing children under 3 years of age. Each tool uses a recogni-
tion format, can be completed in under 10 min, and requires
little or no training by administrators. Parents’ report of
young children’s language skills is more reliable than tools
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assessing child performance in unfamiliar contexts with
unfamiliar communication partners (Dale, 1991). As fre-
quent observers of their child’s language across a variety of
contexts, parents are able to characterize their child’s lan-
guage and can understand the child’s developing articula-
tion for speech (Pan et al., 2004). Despite these advantages,
there is variability in the accuracy of reporting among dif-
ferent parent groups.
Parents who lack specialized training on identifying spe-
cific language milestones may overestimate their child’s
abilities (Dale, 1991); while caregivers with low SES may
underestimate their child’s vocabulary production (Roberts,
Burchinal, & Durham, 1999). Parent reporting may differ in
relation to the child’s age as well. Feldman et al. (2000)
found negative relationships between parent education and
CDI scores at 1 year of age, with a reverse relationship at
age 2. Early language screening tools must be reliable
enough to account for variation in parent reporting.
There are also differences related to administration of the
four tools that affect feasibility of use. Although the CLAMS
and ELM-2 rely on parent report, the tools are conducted
through parent interview and cannot be completed indepen-
dently. Vocabulary checklists can be completed indepen-
dently by parents, and are therefore considered to be more
flexible options for use as screening tools within community
settings. Studies with the LDS have been conducted in doc-
tor’s office waiting rooms (Rescorla, 1989) and through the
mail (Klee et al., 1998) with 90% and 50% return rates,
respectively. Authors of the LDS and CDI suggest that par-
ents can complete these screening tools independently; how-
ever, there may be less confusion when parents are provided
with verbal directions (Rose et al., 2009).
Future Research
Based on the current literature review and available
research, there are three areas of research needed to improve
the value of screening tools for infants and toddlers. First,
there is a need for increased diversity in study sample popu-
lations—given that more than half of children under age 1
are minorities (U.S. Census Bureau, 2012), and more than a
quarter (26%) of all children under age 5 are living in pov-
erty (Kids Count Data Center, 2014). With the exception of
studies using the LDS (Rescorla, 1989), the majority of par-
ticipants in early language screening research are middle to
upper SES and primarily White. Research that is inclusive
of diverse populations will help determine the effects of
parent reporting and allow more accurate identification of
language delay in children from a variety of backgrounds.
Second, researchers should determine the concurrent valid-
ity and classification accuracy of early language screening
tools as they compare with up-to-date comprehensive lan-
guage assessments. The PLS is the most widely used assess-
ment to determine language delay in young children (Caesar
8 Communication Disorders Quarterly 
& Kohler, 2009). Empirical studies are needed using the
most recent version of this, and other, comprehensive lan-
guage assessments.
Perhaps, most important, future research should be
community-based. Researchers should investigate the use
of screening tools within community settings to determine
the most effective ways to screen large groups of young
children in an efficient manner. Communities should
develop screening programs, a crucial step in identifying
children who may need early intervention (Bricker, Macy,
Squires, & Marks, 2013). Before intervention can be pro-
vided, however, researchers must first determine the most
appropriate ways to implement screening programs, com-
plete cost-benefit analyses, and determine any potential
negative impacts screening may have. Researchers need to
determine the best age(s) for screening and examine the
effects of using language-specific screening tools com-
pared with more comprehensive developmental screeners.
They should also explicitly compare the accuracy of par-
ent-report tools with practitioner-implemented observa-
tional measures.
Limitations
This review was limited to screening tools that exclusively
evaluate communication development—with two tools (LDS
and CDI-SF) relying on a child’s use and understanding of
vocabulary as opposed to other communication domains (i.e.,
social language and articulation). Although vocabulary is a
strong predictor of later academic ability, the use of more
comprehensive language screening tools may improve clas-
sification accuracy. The CLAMS, LDS, and CDI-SF are also
available in other languages; however, this review was lim-
ited to research examining the English versions of the screen-
ing tools. As the diversity of young children continues to
grow, reviews inclusive of research describing screening
tools in other languages will also be important.
Implications for Research and Practice
Researchers and practitioners should carefully consider how
language screening tools relate to the population they work
with. Each tool in this review has drawbacks in terms of sam-
ple characteristics, gold standard comparison tools, or lack of
data on sensitivity and specificity. Despite these concerns, the
tools that were identified can, and should, be useful for a vari-
ety of reasons. First, all tools in this review require parent
participation. The American Speech-Language-Hearing
Association (ASHA) suggests that SLPs involve families in
the identification and verification of concerns related to their
child’s early language development (ASHA, 2008). Parent
involvement in screening is also thought to increase aware-
ness of developmental expectations and increase acceptance
of screening outcomes—thus, potentially affecting a family’s
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willingness to move into a comprehensive evaluation and
receive intervention (Bricker et al., 2013).
The tools discussed in this review can also be considered
for use in evaluation and treatment. As a means of involving
families in the evaluation process, SLPs may find it useful
to have parents complete one of the above-mentioned tools
before initiating a comprehensive evaluation—to provide a
means of gathering parent input and comparing results with
standardized assessments. Similarly, as SLPs and parents
collaborate throughout intervention, SLPs might solicit par-
ent assistance in completing early language screening tools
as a means of monitoring progress and measuring the effects
of interventions over time. Researchers might consider
using these early language screening tools as brief measures
of language ability—to find populations of interest for a
specific study and to test between-group differences in
experimental designs.
Conclusion
The current research on early language screeners is some-
what outdated and primarily focused on White, middle-
class children. Although overall technical adequacy of early
language screening tools is acceptable, there is no identifi-
able gold standard. Effective early language screening tools
should help identify children at risk for language delays and
provide early intervention as soon as concerns arise.
Researchers and practitioners in the field of early childhood
must continue to work together to identify accurate screen-
ing tools for an increasingly diverse population of infants
and toddlers. This review provides a starting point for future
research that will continue exploring the feasibility of early
childhood screening programs, and the most efficient mea-
sures to identify young children who may benefit from lan-
guage intervention.
Acknowledgments
The author thanks Drs. Kristen McMaster and Scott McConnell
for ongoing support and assistance with this project.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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