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Communicative and Motor Aspects of Preschooler Development
Elizabeth K. Stanford, MD
Communication
Changes in speech and language are the most dramatic transformation during the preschool period. Communication proceeds from largely unintelligible bullets of speech to language that allows him to ask complex questions, describe events, share feelings, and enter into independent relationships and learning. Children master most of the rules of grammar (syntax) by age 6, largely without direct instruction or correction.
Communication Skills in Preschoolers |
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2-YEAR VISIT |
3-YEAR VISIT |
4-YEAR VISIT |
5-YEAR VISIT |
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Vocabulary |
No jargon; 150 to 500 words |
Definitions |
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Sentence length/MLU* |
2 words/1.5 to 2.5 |
3 to 4 words/2.5 to 5.0 |
4 to 5 words/3.5 to 6.5 in paragraphs |
|
Intelligibility to stranger |
25% |
75% |
100% |
|
Grammatic forms |
Verbs, some adjectives and adverbs |
Plurals, pronouns |
Past tense |
Future tense |
Typical examples |
Talks about current action, no jargon, names pictures* |
Tells own age and sex, counts to 3, metacognitive language (eg, "He said"; "I know") |
Describes recent experiences, can sing songs, gives first and last names, counts to 4, identifies gender of self and others |
Counts to 10 or more, recognizes most letters of the alphabet, knows telephone number and address |
Fluency |
Dysfluency is common |
Dysfluency is common |
Some dysfluency |
Dysfuencies not expected |
*MLU = mean length of utterance measured by the number of meaningful units or morphemes rather than words. |
The 2-year-old child uses words for communication. Although such speech usually is not very intelligible to a stranger, it does consist of words rather than jargon. The child still is acquiring language rapidly and has a vocabulary of approximately 150 to 500 words. The child would be expected to be speaking in two-word utterances consisting initially of primarily the simplest noun phrases (eg, noun plus modifier such as "my Mommy" or "more milk") or verb phrases (eg, "Mommy go" or "baby sleep"). Sentence structure typically becomes more complicated by 2.5 years of age, with nouns moving to the object position (eg, "in that box"), emergence of the present progressive ("ing"), and appearance of the earliest "helper" verbs (eg, "I gonna play"). They use rising inflection in asking questions and can express negation by saying "no." They often mimic what others say exactly in whole or in part (echolalia) up to age 2.5 years. Thus, even by that early point in the preschool period, expected sentence complexity is too elaborate for parents to report reliably. A simple, but efficient criterion for referral at 2 years of age is a less than a 50-word vocabulary or not putting two words together. Sentence length refers to words that are put together spontaneously, not in rote repetition of a cliche such as "thank you." Children who have expressive language disorders often exhibit
a very restricted set of speech sounds in their early words. Those 2-year-olds who have an expressive language delay but normal comprehension (see next section) have a significantly better prognosis for future language development. However, these children are prone to temper tantrums because of frustration in trying to communicate.
The typical 3-year-old speaks in well-formed, simple sentences of three or four words. A child of this age who produces few spontaneous utterances of three words or more in length should raise concern. Sentence length increases by one or two words annually throughout the preschool period, with at least the same number of words that the child is old. The typical 3-year-old can count three items and a 4-year-old can count four items, although they often can recite more of the numbers. A 4-year-old who cannot converse at some length with familiar people about "here and now" topics with sentences averaging three words or who uses word reversals or a telegraphic style (which is not dialectic) should be evaluated.
A 5-year-old can be expected to use complete sentences tending to contain about five words. However, the parallel with counting ability ends at this stage; the 5-year-old can count as many as ten objects or more. At this point, children should have mastered past and future tenses; irregular verbs; understanding of "before," "after," and "until"; and conditional sentences that include "if, then." They still may have trouble with sentences that use "would," "should," "must," or "might." However, they can discuss emotions and tell jokes. Preschool children who have expressive language disorders tend to speak less often and convey less information than their peers. Their speech generally consists of short simple sentences, and they have a tendency to omit small, soft-sounding, grammatically important words such as "the," "is," and "of."
The 2-year-old's speech is tied to the action of the moment. Because they live in the pressure and impulse of the moment, there is no need for any past or future tenses in their speech. As language and cognitive structures mature, the child begins to be freed from immediate needs and open to new possibilities for imagination, reflection, and future planning. The 3-year-old's speech begins to show a new metacognitive capacity to think beyond actions and objects to discussion about language and thought itself (eg, "He said..." and "I know..."). These children also have a new-found capacity for imagination. The 3-year-old may be said to be bound to fantasy as the 2-year-old is tied up with moment-to-moment reality. The increasing linguistic capacity to distinguish and express occurrences that are not part of the child's current reality, as in the expression of past tense and description of past experiences at the age of 4 and expression of the future at age 5, parallels an increasing ability to distinguish between reality and fantasy.
Beginning at the 3-year health supervision visit, the examiner should note use of a few grammatic forms that deserve comment to avoid confusion. The acquisition of grammatic word endings follows a rather predictable order. There appears to be a steady increase in the use of suffixes to designate plurals and other grammatic meaning (eg, possessive [-s], progressive [-ing], and past tense [-ed]) between 16 and 30 months of age. At 16 months, few children are reported to use these forms by their parents, but by 30 months, most children are using all four of them. Use of pronouns follows a similar pattern: The commonly used pronouns 'I" "me," and "you" are expected at the 2-year visit, but the child may not refer to him- or herself as 'T' or "me" for another 6 months, and reference to a few others (eg, "their," "these," "those") is not expected until 30 months. Therefore, the "possible response" at 3 years for "use of plurals, pronouns" is an expectation that these forms are fully in place, not just used rarely.
There are no screening tests for articulation available for children younger than 3 years of age, probably because poor articulation is so common during that period. The expectation is for strangers to be able to understand only 25% to 50% of what the 2-year-old child says. By 3 years of age, strangers should be able to understand the child 75% of the time, and the child should be producing all vowel sounds and many consonant sounds in the final position correctly. By the age of 4, strangers usually can understand the child nearly 100% ot the time, although some errors in producing later developing sounds such as "r," "s," "l," "sh," and "th" are not uncommon and may continue until age 7.
During the 4- to 5-year age range, parents generally are quite accurate in their concerns about articulation, such as in response to a general question as to whether they have any doubt about the clearness of their child's speech. Their impressions are confirmed about 50% of the time when compared with results of standard diagnostic tests, but surprisingly, most children found by testing to have articulation problems are not identified by their parents. A global estimate of percent comprehensibility either by parental report or clinical impression is a useful screen for the 3 years and younger group, but for ages 4 and older, parental concern must be taken seriously, although it may not be sufficient to identify children who can benefit from speech therapy directed at articulation.
Dysfluency (aberration of speech rate and rhythm) occurs transiently between about 2.5 and 4 years of age. Persistent and worsening stuttering beyond the age of 4 should be taken seriously. Other signs of the need for referral include: grimacing with blocking of speech, self-consciousness, delayed language forms, or stuttering that persists for more than 6 months. The family history is often positive for stuttering. Families should be counseled to make eye contact, speak more slowly in the child's presence, and allow adequate time for the child to speak, but otherwise not point out the stuttering to the child. One percent of prepubertal children are diagnosed with stuttering.
As a group, girls are more advanced than boys in language acquisition. Three to five percent of children may be affected by the developmental type of expressive language disorder. Children who have superior language skills have fewer behavior problems (especially with aggression), are more amenable to parental discipline, can negotiate better with peers, are more resilient to stress, and are less likely to have reading-related academic problems.
The Clinician's Interview of the Child
Direct observation and examination of the system of concern by the clinician always is indicated for developmental surveillance. The physician always should attempt to communicate meaningfully with the child to obtain his or her own history and impressions or at least to establish rapport and a basis for later communication and to model respect for the child as an individual. Unfortunately, such direct verbal dialogue with the child is rare. A typical physician-preschool child encounter includes a question such as, "How old are you now?" to which the 4-year-old holds up his or her fingers to answer. The clinician should expect to achieve some verbal dialogue with the 3-year-old child and gain an impression of his or her competency as a verbal communicator. The most common errors we have observed in conversing with preschool children have been reliance on closed-ended questions that the child could answer with a simple "yes" or "no" and failure to orient the interview to the child's current interest and perspective. The clinician might notice, for example, that the preschool child has brought a stuffed animal and begin talking about that to obtain a clue to his or her interests. Other questions that children 3 through 5 years of age can answer that provide a perspective on their perceptions include: Who is your best friend? What do you like to do together? Who lives at your house? What do you like to do with ? What does he do that you don't like? What happens at your house when a kid does something bad? What jobs do you do at your house? The child should have specific answers to each of these questions. Inability to name a friend, a pleasurable activity, a standard for behavior, or a chore could be clues to potential dysfunction (if language skills and engagement are adequate).
DRAWING INTERVIEW
The "drawing interview" creates a conversation piece that has the child's interest and attention--his or her own drawing of a person. This procedure also provides an opportunity to observe the child's perceptual motor performance and to elicit standard cognitive and emotional indicators in the drawing. The child is asked to draw a human figure while the clinician is interviewing the parents and then is asked a series of standard questions about the drawing (Table 3). This procedure has been as successful at eliciting speech from preschoolers as established standard language elicitation probes in both normal children and children whose language is impaired.
TABLE 3. Drawing Interview
1. Elicit drawing: "Here is a piece of paper and a pencil. Please draw something like a picture of a boy or girl."
2. If no response, draw a simple stick figure for the child.
3. Compliment the child's effort on the picture, if completed, and record any spontaneous comments.
4. "Do you think it is a picture Of a boy or a girl?"
5. "Please tell me a make-believe story about this boy (or girl depending on previous response)."
6. If no response, restate the above, ie, "Just tell me something about the boy/girl."
7. If response, repeat what the child says and add, "Ah Ha or Humm," followed by an expectant pause.
8. If no response or stops, add, "What else is he doing?"
9. When the child stops, repeat what he said or the essence of it. Add, "What else happens to him?"
10. "Tell me more."
11. When the child finishes, ask, "How does it end?"
Comprehension
To assess comprehension through the second year of life, the clinician must consider how the child responds to parental commands (Table 4) and distinguish "simple requests," the possible response at the 1-year visit, from "simple instructions without gestured cues" for the 15-, 18-, and 24-month visits. An example of the 1-year "simple request" would be to ask the child for the toy or tongue depressor he or she is holding and prompt him or her by holding out a hand for it or accept a parental report of a similar response. Expectations for following verbal-only instructions range from the child ever having been noted to follow an instruction at home (at the 15-month visit) to being able to demonstrate it rather consistently (by the 24-month visit). The physician could ask for the object being held, then ask that the child "put it on the table, chair, etc," with an expectation that compliance would be at about 50% at the 18-month visit and 100% at the 2-year visit.
TABLE 4. Comprehension |
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2-YEAR VISIT |
3-YEAR VISIT |
4-YEAR VISIT |
5-YEAR VISIT |
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Number step command |
100% for 1 without gesture |
2 |
3 |
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Number of body parts |
names 1, identifies 7 |
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Number of colors |
2 named |
4 named |
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Gender |
self |
self and others |
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Own names |
refers to self by name |
first and last |
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Numbers counted |
says "2" (not counted) |
counts to 3 |
10, knows number |
|
Relationships |
which is bigger, on, under |
which is longer,2 opposites |
The comprehension ability of "naming body parts" is a "possible response" for the 15-, 18-, and 24-month visits. However, "identifies body parts" would be a better marker to look for at the 15-month and probably 18-month visit because naming a body part (usually parts of the face initially) emerges as an expected item at 18 months, while identifying by correctly pointing on themselves (or a doll) can be expected by 15 months of age. These "body parts" responses would be considered a lag if not in place by the 18-month visit. Understanding the "names of seven body parts," as shown by the ability to point to them, probably is a good 2-year visit comprehension item.
Comprehension of different prepositions has a developmental progression related to both language development and what is considered to be cognitive development. At age 3, the child should be able to understand at least three commands involving "in," "on," "under," "in back of, .... in front of," or "beside" as well as demonstrate "up," "down," "loud," and "soft." Not until laterality is well established can they follow instructions that include "to the right or left of." Children can pick the "longer" of two lines at 3 years, but they cannot make comparisons reliably of "same" versus "different" until age 4. Strength in comprehension reassures parents about the child's intelligence, even when expressive language is delayed.
School Readiness
Communication skills are often of concern because of their importance to schooling. Evidence during the visit may include: ability to answer questions asked by the clinician during the visit, such as name, age, colors, numbers, alphabet, general information; problems noted on the pure tone hearing test; or immature responses to the drawing and conversation about the drawing or other aspects of the interview with the child.
The years from 3 to 6 historically are called "preschool," in part because of their importance for preparing the child for the tasks of school soon to come. Even though most children in the United States attend some structured group learning prior to entering elementary school at age 6, qualitative changes in cognitive development still must occur with age to allow mastery of academics. From sensorimotor schemas at age 2, children progress through what Piaget called preoperational thinking to concrete operational thought around 6 years of age, which is governed by orderly rules regarding concepts of causality, transformations, and numbers. Preoperational thought is prelogical. Fantasy is indistinguishable from reality, coincidence is confused with causation, and only one aspect of two things can be compared at once or used to classify objects (eg, judging amount by either height or width of a container but not by both). Children progress from being nearly totally egocentric in their thinking of how to solve problems to being able to take another person's point of view.
Parents are eager and often anxious about their preschooler's school readiness, especially for the ultimate skill of reading. Although reading is not expected before age 6, prereading skills can be present, such as knowledge of letters, words, and symbols such as signs and awareness of letters and syllables as sub-components of words. Many can recognize and even print letters and numbers and pretend to read. They often enjoy rhyming games to the point of silliness.
Gross Motor Skills
Gross motor skills are a joy to the preschooler, who endlessly practices and shows them off. By age 2, children generally can walk, run, and balance at least a little, but refinements continue in balance, coordination, speed, and strength (Table 5). The slightly bent-over stance of the 2-year-old while running with changing speed and direction gives way to the more upright 3-year-old who swings arms in time with the strides. Movement forward and upstairs precedes the more difficult tasks of proceeding backwards or downstairs, which require slightly longer use of support. Mastery of a task with one leg is followed fairly soon by mastery with the other leg. Using both legs to jump simultaneously or both arms to bounce pass is more difficult than using one successfully.
TABLE 5 Motor development |
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2-YEAR VISIT |
3-YEAR VISIT |
4-YEAR VISIT |
5-YEAR VISIT |
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Walks forward |
slightly bent |
swings arms |
tandem walks |
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Walks backward |
10 ft |
tandem |
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Runs |
changing direction |
alternating arms |
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Climbs |
out of crib (2.5 y) |
high equipment |
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Jumps |
both feet off floor |
26 to 30 in from both feet, 6 in from one foot |
32 in, one foot leads |
over 10 in string |
Jumps down |
step with both feet |
16 in, lands on one foot first |
18 in, lands on both feet |
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Stairs-up |
1, one step at a time |
4, without rail alternating |
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Stairs-down |
4, one step at a time |
alternating, no rail |
4, alternating |
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Stands on one foot |
tries |
1 sec on 1 foot |
5 to 6 sec on each foot |
10 sec |
Kicks |
kicks ball 6 ft |
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Hops |
3 hops in place |
5 forward |
20 ft forward 10 times |
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Throws |
throws 5 ft |
bounce, overhand |
10 ft, 1 or 2 arms |
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Catches |
straight arms |
bent arm |
bounce pass |
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Skips |
skips |
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Pedals |
10 ft, tricycle |