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The Prelinguistic Development of Multiple Birth, Low Birth Weight, and Premature Infants

Permanent Link: http://ufdc.ufl.edu/UFE0042247/00001

Material Information

Title: The Prelinguistic Development of Multiple Birth, Low Birth Weight, and Premature Infants Clinical Application of Foundational Research
Physical Description: 1 online resource (72 p.)
Language: english
Creator: Lewandowski, Kristen
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2010

Subjects

Subjects / Keywords: birth, child, language, low, multiple, premature, weight
Communication Sciences and Disorders -- Dissertations, Academic -- UF
Genre: Communication Sciences and Disorders thesis, M.A.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: The Prelinguistic Development of Multiple Birth, Low Birth Weight, and Premature Infants: Clinical Application of Foundational Research Over the past two decades, the rate of multiple birth, premature, and low birth weight deliveries has increased (Martin, 2009). To date, however, there is relatively little information that parents, caregivers, and healthcare professionals can access related to the development of prelinguistic skills within these populations. Parents, caregivers and healthcare professionals would benefit from foundational research aimed at investigating the prelinguistic development of multiple birth infants. Such research could lead to the creation of accessible resources that are designed to educate parents and professionals on key prelinguistic growth and development of this population. The goal of this thesis is to expand research on the prelinguistic development of multiple birth infants. Data are presented to report on a longitudinal case series of a set of quadruplets. The infants were administered two formal tests between the ages of 6 and 14 months and their interactions with each other and with adult caregivers were videotaped during this same period. Based on the formal testing, the infants show delays in regards to prelinguistic development, which supports previous research done on low birth weight and premature infants; however, by the age of 14 months the infants were all typically developing. The results provide a basis for understanding the dynamic nature of the prelinguistic development of infants with multiple birth status. Results from the longitudinal study of the quadruplets will also yield preliminary insights into the challenges associated with collecting data with this population, as well as additional details about the communicative development of children from multiple-birth, premature, and low-birth-weight pregnancies.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Kristen Lewandowski.
Thesis: Thesis (M.A.)--University of Florida, 2010.
Local: Adviser: Logan, Kenneth J.

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2010
System ID: UFE0042247:00001

Permanent Link: http://ufdc.ufl.edu/UFE0042247/00001

Material Information

Title: The Prelinguistic Development of Multiple Birth, Low Birth Weight, and Premature Infants Clinical Application of Foundational Research
Physical Description: 1 online resource (72 p.)
Language: english
Creator: Lewandowski, Kristen
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2010

Subjects

Subjects / Keywords: birth, child, language, low, multiple, premature, weight
Communication Sciences and Disorders -- Dissertations, Academic -- UF
Genre: Communication Sciences and Disorders thesis, M.A.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: The Prelinguistic Development of Multiple Birth, Low Birth Weight, and Premature Infants: Clinical Application of Foundational Research Over the past two decades, the rate of multiple birth, premature, and low birth weight deliveries has increased (Martin, 2009). To date, however, there is relatively little information that parents, caregivers, and healthcare professionals can access related to the development of prelinguistic skills within these populations. Parents, caregivers and healthcare professionals would benefit from foundational research aimed at investigating the prelinguistic development of multiple birth infants. Such research could lead to the creation of accessible resources that are designed to educate parents and professionals on key prelinguistic growth and development of this population. The goal of this thesis is to expand research on the prelinguistic development of multiple birth infants. Data are presented to report on a longitudinal case series of a set of quadruplets. The infants were administered two formal tests between the ages of 6 and 14 months and their interactions with each other and with adult caregivers were videotaped during this same period. Based on the formal testing, the infants show delays in regards to prelinguistic development, which supports previous research done on low birth weight and premature infants; however, by the age of 14 months the infants were all typically developing. The results provide a basis for understanding the dynamic nature of the prelinguistic development of infants with multiple birth status. Results from the longitudinal study of the quadruplets will also yield preliminary insights into the challenges associated with collecting data with this population, as well as additional details about the communicative development of children from multiple-birth, premature, and low-birth-weight pregnancies.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Kristen Lewandowski.
Thesis: Thesis (M.A.)--University of Florida, 2010.
Local: Adviser: Logan, Kenneth J.

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2010
System ID: UFE0042247:00001


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THE PRELINGUISTIC DEVELOPMENT OF MULTIPLE BIRTH, LOW BIRTH WEIGHT,
AND PREMATURE INFANTS: CLINICAL APPLICATION OF FOUNDATIONAL
RESEARCH



















By

KRISTEN M. LEWANDOWSKI


A THESIS PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
MASTER OF ARTS

UNIVERSITY OF FLORIDA

2010

































2010 Kristen M. Lewandowski
































To the Quad Lew's, their big brothers, and their devoted parents









ACKNOWLEDGMENTS

First and foremost, I thank my brother, sister-in-law and their incredible family for

their involvement, support and encouragement throughout the duration of this study.

The vision for this research comes from their children and their inspirational view on life.

I also thank my sister and brother-in-law for all their efforts in maintaining the safety of

the external hard drive and my sanity. I thank my thesis advisors for their endless

knowledge and advice. The completion of this study would not have been possible

without their direction and guidance. I would like to thank my classmates within the

Department of Communication Sciences and Disorders for their encouraging words and

technical support. I wouldn't have survived the last two years without them. Lastly, I

would like to thank my Georgia Bulldog for his positive attitude and for playing Beatle's

music on his guitar while I worked through the craziness.









TABLE OF CONTENTS

page

ACKNOW LEDGM ENTS ....................... ..... .. ........... ......................................... 4

LIST OF TABLES .......... ..... .. ...................... ............. ...... ............... 7

LIS T O F F IG U R E S .................................................................. 8

ABSTRACT ............... ................................................. 9

CHAPTER

1 INTRODUCTION ................ .......... .......... ......... 11

Multiple Birth, Prematurity, and Low Birth Weight................. ............. 11
Rates .......... ........ .. .. ..................................... 11
Low birth weight rates ....... .................... ............ 11
Premature birth rates ............................ ........ 12
M u ltip le b irth ra te s ........................... ....... .... ... ..................... .. 12
Impact of Premature Birth, Multiple Birth, and Low Birth Weight Rates ......... 13
Prelinguistic Development of Typical Infants ............. .......... ................ 15
Speech Development .................................................................................. 15
Vegetative/reflexive responses .............. ....................... 16
C ooing ......................................... 16
M arginal babbling.............................. ............... 17
C anonical babbling ........................................ 17
Variegated babbling ............................. .. ............_. ..... ............ 18
Transition to first words .............. .... ................... ......... 18
Communication Development. ...................................... 18
Classification of Prelinguistic Behaviors ........... ......... .......................... 20
Joint attention...................... ..................... ............... 20
Eye gaze ............. ......... ............... ................................................. 21
Gesture development..................... .................... 22
Importance of Pragmatic Development during the Prelinguistic Period ............... 23
Rationale for a Longitudinal Case Study of a Set of Quadruplets ....................... 24

2 METHODS.............................................. ........ 27

P a rticipa nts ............... .................................. ... ......... 2 7
D ata C o lle ctio n .................. ......... ..... .. .... .... ............... ... ..... ............. 2 9
MacArthur-Bates Communication Development Inventory: CDI....................... 29
Communication and Symbolic Behavior Scales Developmental Profile ........... 31
Data Collection from Video Recorded Observations ...................... ....... 35
D a ta A n a ly s is .......... ......... ............. ................ ....... ............... 3 5

3 R E S U LT S ......... ...... ... ....... .................... ......................................... 3 8









B a b y A ............. .................. .................. ................................................... 3 8
CDI Results ....................................................................... ............................ 38
CSBS DP Results............................................. ........ 39
B a b y B ........................................................................................................ 4 2
CDI Results ....................................................................... ............................ 42
CSBS DP Results............................................. ........ 43
Baby C ............................ .................................... 46
CDI Results ....................................................................... ............................ 46
CSBS DP Results............................................. ........ 48
Baby D ............................ .................................... 50
CDI Results ....................................................................... ............................ 50
CSBS DP Results.............................................. 52
Data Collection from Video Recordings .................................. 54

4 DISCUSSION ................ .. ......... .................. 60

Prelinguistic Developm ent ...................... ....... ......... .. ............................ 60
Speech Production ................................. ................. 60
Language Comprehension ...... ............. .................. ......... 61
Nonverbal Communication Skills ................ ....... ............. ... ......... 61
How the Participants' Performance Relates to Typical Development and what is
Expected of Infants with LBW, Short Gestation, and Multiple Birth Status .......... 63
Foundation for R research .......................................... .......................... ........... 64
Lim stations ......... ...... ......... ....................................................................... 64
Clinical Application...................... ... ......... 66
Future Research and Direction ...... .............................. ............... 66

5 C O N C LU S IO N .......................................... ................. ............... 68

LIST O F R EFE R EN C ES ........... ............................................................. ... ............... 69

BIOGRAPHICAL SKETCH ................................. ............................. 72


















6









LIST OF TABLES


Table page

1-1 Speech Development ................ ............................ 26

2-1 Participants' Ages when Standardized Tests Were Completed....................... 36

2-2 Definition of CSBS DP scales measured during the CSBS DP Behavior
Sample (W etherby & Prizant, 2002) ........... .............................. ...... ............. 37

3-1 Baby A's CDI Percentile Rank Results........ ..... ......... ............. ......... 55

3-2 Baby A's CSBS DP Caregiver Questionnaire Percentile Rank Results ............. 55

3-3 Baby B's CDI Percentile Rank Results ................ ........ ............. ......... 55

3-4 Baby B's CSBS DP Caregiver Questionnaire Percentile Rank Results ............. 55

3-5 Baby C's CDI Percentile Rank Results ................. ........ ............. ......... 56

3-6 Baby C's CSBS DP Caregiver Questionnaire Percentile Rank Results........... 56

3-7 Baby D's CDI Percentile Rank Results ................... ....... ............. ......... 56

3-8 Baby D's CSBS DP Caregiver Questionnaire Percentile Rank Results........... 56

3-9 Baby A CSBS DP Behavior Sample Percentile Rank Results.......................... 57

3-10 Baby B CSBS DP Behavior Sample Percentile Rank Results.......................... 57

3-12 Baby D CSBS DP Behavior Sample Percentile Rank Results........................ 57









LIST OF FIGURES


Figure page

3-1 Baby A CSBS DP Behavior Sample Percentile Rank Results (CA =
chronological age) ............... ......... ........ ......... 58

3-2 Baby B CSBS DP Behavior Sample Percentile Rank Results (CA =
chronological age) ............... ......... ........ ......... 58

3-3 Baby C CSBS DP Behavior Sample Percentile Rank Results (CA =
chronological age) ............... ......... ........ ......... 59

3-4 Baby D CSBS DP Behavior Sample Percentile Rank Results (CA =
chronological age .................. ............................... .............. .............. 59









Abstract of Thesis Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Master of Arts

THE PRELINGUISTIC DEVELOPMENT OF MULTIPLE BIRTH, LOW BIRTH WEIGHT,
AND PREMATURE INFANTS: CLINICAL APPLICATION OF FOUNDATIONAL
RESEARCH
By

Kristen M. Lewandowski

August 2010

Chair: Kenneth Logan
Major: Communication Sciences and Disorders

Over the past two decades, the rate of multiple birth, premature, and low birth

weight deliveries has increased (Martin, 2009). To date, however, there is relatively

little information that parents, caregivers, and healthcare professionals can access

related to the development of prelinguistic skills within these populations. Parents,

caregivers and healthcare professionals would benefit from foundational research

aimed at investigating the prelinguistic development of multiple birth infants. Such

research could lead to the creation of accessible resources that are designed to

educate parents and professionals on key prelinguistic growth and development of this

population.

The goal of this thesis is to expand research on the prelinguistic development of

multiple birth infants. Data are presented to report on a longitudinal case series of a set

of quadruplets. The infants were administered two formal tests between the ages of 6

and 14 months and their interactions with each other and with adult caregivers were

videotaped during this same period. Based on the formal testing, the infants show

delays in regards to prelinguistic development, which supports previous research done









on low birth weight and premature infants; however, by the age of 14 months the infants

were all typically developing. The results provide a basis for understanding the dynamic

nature of the prelinguistic development of infants with multiple birth status. Results from

the longitudinal study of the quadruplets will also yield preliminary insights into the

challenges associated with collecting data with this population, as well as additional

details about the communicative development of children from multiple-birth, premature,

and low-birth-weight pregnancies.









CHAPTER 1
INTRODUCTION

Multiple Birth, Prematurity, and Low Birth Weight

Rates

In 2009, the U.S. Department of Health and Human Services Centers for Disease

Control and Prevention (CDC) published its finalized data regarding 2006 birth data.

The data in this report represent U.S. births across settings and various birth

classifications, including multiple birth, low birth weight (LBW) and prematurity rates

(Martin et al., 2009). The 2006 data show that there was an increase in LBW rates as

well as premature birth rates relative to previous years for those categories. Multiple

birth rates, however, remained stable as compared to previous rates (Martin et al.,

2009). Specific details about the prevalence of these rates are presented in the

following sections and are based on 2006 birth data provided by the CDC.

Low birth weight rates

The World Health Organization defines LBW infants as infants who are born

weighing less than 2,500 grams or 5 pounds 8 ounces (World Health Organization ICD-

10, 2007). The average birth weight for singletons born in the United States in 2006

was 3,298 grams (Martin et al., 2009). From 2000 to 2006, the rate of LBW infants had

progressively increased by 9%. Of 4,265,555 births in the United States in 2006, 8.3%

were LBW births, which is up from 2005 (8.2%) and which represented an increase of

24% since the mid-1980s (Martin et al., 2009). The 2006 rate (8.3%) is the largest

recorded for the LBW category in the United States for the past four decades (Martin et

al., 2009).









Premature birth rates

In 2006, premature birth rates accounted for 12.8% of the 4,265,555 births in the

United States (Martin et al., 2009). A birth is classified as premature if the gestation

period is less than 37 weeks (World Health Organization ICD-10, 2007). In the United

States, prematurity rates have increased by 20% since 1990, when the rate was only

9.7% (Martin et al., 2009). More specifically, the number of late preterm births (or births

with a gestation period of 34 to 36 weeks) has increased by over 25% during this time

frame. This could be due in part to the increase in multiple birth rates (listed in the next

section) over the past few decades as well as an increase in medical intervention, such

as cesarean deliveries performed, earlier in the pregnancy. Maternal health and

demographics also impact gestation period.

Multiple birth rates

In 2006, the data for twin birth rates remained stable relative to the 2005 rates

(32.1 twins per 1,000 births) and the rates for triplet births decreased by 5% (153.3 per

100,000 births) relative to 2005 rates (Martin et al., 2009). It is important to note,

however, that between 1980 and 2004 the rate of multiple birth pregnancies jumped

70% (Martin et al., 2009). The multiple birth rate in 1980 was 18.9 per 1,000 births

(Martin et al., 2009). Of the more than 4.2 million births in 2006, 137,085 were twins,

6,118 were triplets, and 355 were quadruplets; these numbers represent 3.37% of all

the births in the United States during 2006. There were 4,121,930 singleton births in

the United States in 2006 (Martin et al., 2009). Multiple birth deliveries by women aged

30-39 represented more than half the total multiple birth deliveries, (i.e. 3,983 of 6,540

births). The rate of women over age 30 delivering multiple births has risen continually

since 1980 (Martin et al., 2009). The rise in multiple birth deliveries in older women may









be attributed to the use of assistive reproductive technology (American Society for

Reproductive Medicine, 2006; Templeton & Morris, 1998).

It is unsurprising that rates for LBW births, premature births, and multiple births

have risen together. Keith et al. (1998) found that low birth weight and preterm delivery

were two of the most common risk factors for twins and triplets born in 2005. The CDC

released data in 1999 regarding trends in twin and triplet births from 1980-1997. The

trends reveal that although the rate of singleton low birth weight increased by 2%, the

rate of twin and triplet sets increased by 10% (Martin et al., 1999). Statistics regarding

trends in triplet births from 1971 to 1994 was also investigated by the CDC. The data

indicated that in the early 1990's triplets had an average birth weight of 1,698 grams (3

pounds, 12 ounces) which is half of the average birth weight for singleton births (3,358

grams or 7 pounds, 6 ounces) (Martin et al., 1997). The report also indicated that the

gestational period for triplets averaged 32 weeks, which is 7 weeks shorter than the

average gestational period for singleton gestational periods (Martin et al., 1997). Of the

143,558 multiple births in 2006, more than half involved pre-term and LBW infants

(Martin et al., 2009).

Impact of Premature Birth, Multiple Birth, and Low Birth Weight Rates

As a result of the increasing rates of premature, LBW and multiple birth infants,

parents, caregivers, pediatricians, and pediatric healthcare professionals who work with

these populations are likely to encounter developmental delays and/or learning deficits

(National Institute of Child Health and Human Development, 2002). Researchers have

found that LBW and prematurity are risk factors for speech and language delays

(Delgado & Vigi, 2004; Zubrick et al., 2007). For example, Delgado and Vigi (2004)

conducted a study with preschool-aged children to identify early risk factors for









language impairment. They found that both LBW and prematurity were risk factors in

the development of specific language impairment among preschoolers. Results from

the study also indicated that LBW and prematurity are risk factors for speech

impairment with a co-occurring language impairment (Delgado & Vigi, 2004). In a more

recent study, Zubrick et al. (2007) found that an infant's gestational age was a predictor

of late language emergence. In their study, a questionnaire was sent to the parents of

1,766 two-year-old children. Of the 1,766 toddlers, 1,528 had normal language

development and 238 had late language emergence. Within the group of 238 late

talking toddlers, 10.7% had a medical history significant for premature birth (Zubrick et

al., 2007).

Bishop and Bishop (1998) did an extensive study of the occurrence of language

impairment among twins. They conducted a retrospective study in which they asked

parents of school-age twins about various facets of their twins' early language

development. Based on parent report, the researchers found a higher presence of

language impairment in twins, particularly among twin sets in which the children

demonstrated idiosyncratic phonological development. This idiosyncratic development

resulted in the impression of the twins having created their own language (Bishop &

Bishop, 1998.) This idiosyncratic language involved use of what the investigators

termed jargon. Parents of these children described the twins' spoken language as

unintelligible and accompanied by strings of babbling, gibberish and other noises. In

the Bishop and Bishop study, twins who used jargon had a higher occurrence of

language impairment at school age.









These studies underscore the potential impact of risk factors such as LBW,

gestational age, and multiple birth status on speech and language development. With

the importance of early intervention to eliminate or reduce speech and language delays

or deficits, it is important for researchers to understand the impact these factors have on

development. Studies such as these provide information that may help to ensure that

parents and professionals working with pediatrics are properly educated on what to

expect.

Prelinguistic Development of Typical Infants

Before discussing delayed or deviant prelinguistic development it is necessary to

understand typical development. The time frame from birth to a child's first word is

considered the prelinguistic phase of communication development. Most children begin

to produce true words about 12 months after their birth. During the prelinguistic stage,

however, infants have yet to develop a "true" language (Watt et al., 2006). During this

phase, it is expected that infants will follow a predictable developmental pattern and that

they will attain several "goals" on their way to their first words. These "goals" are

referred to as milestones. Although individual infants will develop at slightly different

rates, the milestones typically are attained in a predictable, sequential manner.

Speech Development

Following birth, infants immediately begin making sounds and reacting to their

environment. As an infant develops, his or her vocal and gestural behaviors become

progressively more intentional and communicative in nature. Researchers have studied

patterns of infant speech development extensively during the first year of life and have

found strong evidence that infants follow a sequential order of vocal development

(Stoel-Gammon & Otomo, 1986; Stark, 1980). With regard to vocalizations, the major









periods that infants progress through during the first 12 months of life are as follows:

vegetative/reflexive responses, cooing, marginal babbling, canonical babbling and

finally, first words (Oller, 1980; Stark, 1980). Refer to Table 1-1 for a summary of these

periods.

Vegetative/reflexive responses

During the first month of life infants will typically produce tongue clicks, burps,

coughs and cries. These sounds are referred to as vegetative/reflexive responses.

Stark (1980) reported on the characteristics infants demonstrate during this period. The

vegetatitve/reflexive sounds are considered to be simple physiological responses that

an infant produces in response to external or internal stimuli. They are often produced

in conjunction with physiological states such as hunger, pain or pleasure (Stark, 1980).

The sounds are vowel-like approximations. Such sounds are not considered to be

produced intentionally. Thus, at this very early point of development, an infant is not yet

able to assign any meaning to specific sounds or noises, nor can he or she control

motor movements sufficiently in order to produce meaningful speech. The

vegetative/reflexive stage will typically last until approximately 4 weeks of age.

Cooing

Stark (1980) also reported on the characteristics infants demonstrate while in the

cooing period. From around one month of age to four months of age, infants will

produce vowel-like utterances in addition to the vegetative/reflexive responses already

noted. These utterances are known as cooing and often are produced during social

interaction with a caregiver or some communicative partner (Stark, 1980). Cooing

includes more vowel-like approximations that are sometimes combined with consonant-









like approximations, including velar sounds (Oller, 1980). As with vegetative/reflexive

responses, cooing is not considered to be communicative in nature.

Marginal babbling

Following cooing, parents can expect to hear their infants produce vocalizations

that may include consonant like sounds either before or after a vowel. This behavior,

beginning around four months, is known as marginal babbling. Oiler (1980) found that

the most common forms for marginal babbling are those that contain consonant-vowel

(CV, e.g. "bah"), and vowel-consonant (VC, e.g. "ub") syllables; however, these

syllables still are not consistent and do not include smooth vowel to consonant or

consonant to vowel transitions. The only similarity between mature adult speech and

marginal babbling is that infants' productions consist of both vowels and consonants.

Infants' syllables have yet to include the prosody found in mature adult speech.

Consonants typically heard during marginal babbling include [p, b, d, k, g].

Canonical babbling

As the infant nears 6 or 7 months of age, he or she will begin to produce patterned

babbling (Oller, 1980). Stark refers to this period as canonical babbling. This stage

consists of consonant-vowel vocalizations that are more sophisticated and precise than

those found in marginal babbling (Oller, 1980). Parents can expect to hear their infant

produce sequences of the same syllable reduplicatedd babbling), such as "dee dee dee"

or "bah bah bah." Infants' consonant and vowel productions now resemble more

mature adult speech with regards to the timing characteristics of syllable production

(Oller, 1980). Even though these vocalizations resemble mature adult speech, they do

not yet carry any communicative intent.









Variegated babbling

After canonical babbling, the infant will enter the variegated babbling (or

nonreduplicated babbling) stage. This usually occurs between 10 or 11 months (Stoel-

Gamon & Otomo, 1986). Oiler (1980) found that during this stage, infants produce

longer consonant-vowel vocalizations with more varied sounds in the syllables. For

example, a parent may hear their infant babble "gaba". In this stage, the infants'

intonation patterns sound much more mature, as well (Oller, 1980).

Transition to first words

Infants typically make the transition from the prelinguistic phase to the linguistic

phase at around 12 months of age (Stark, 1980). This transition is characterized by the

infant's first true words. This attainment is highly significant as it demonstrates that the

infant has the capability of linking standardized spoken patterns with meaning in order

to communicate intentionally.

To be considered a "true" word the infant must use the word consistently in a

specific context and the word must also resemble the adult form of the word (Oiler,

1980). Most first words include the following consonants within consonant-vowel, vowel

consonant, and/or consonant-vowel-consonant-vowel syllables: [p, b, t, d, m, n]. In

most cases, nouns make up the majority of an infant's growing lexicon during the

second year of life (McLaughlin, 2006).

Communication Development.

As was mentioned earlier this chapter, when an infant enters the one word stage

around their first birthday, their speech begins to carry communicative intent and

meaning. Just as with speech development, infants will follow a sequenced order of

communication development. Austin (1962) identified 3 stages of communication









development: (a) the perlocutionary stage; (b) the illocutionary stage; and (c) the

locutionary stage.

From birth through around 8 months of age, infants enter the perlocutionary stage.

During this stage, infants have yet to assign meaning to their speech and they have yet

to communicate intentionally. Thus, parents and caregivers step in to fill this void by

providing interpretation of what they think their infants are trying to communicate. In

other words, parents and caregivers infer their infant's communicative intents. For

example, a 4-month-old infant who smiles at his or her caregiver does not intentionally

produce this smile to represent any specific communicative intent; however, the infant's

parent may interpret the smile as an active attempt by the infant to "tell" the parent that

he or she is satisfied.

Around 11 months of age, infants usually begin to produce behaviors that

represent emergent communicative intent. This stage is referred to as the illocutionary

stage (Bates, 1976). During this period, children begin to realize that they can use their

gestures and/or vocalizations to influence the behaviors of others. In other words, the

infants develop intentional communication. Many times, infants will pair a vocalization

with a gesture. For example, an infant may learn that when he or she cries, the parent

or caregiver will give them attention. Although infants are producing vocalizations

during this stage, these vocalizations are not yet consistent with adult forms of speech.

During the late illocutionary stage, infants' begin to use vocalizations along with

gestures to signal a range of communicative intentions. During this stage, infants will

begin to demonstrate what Bates (1976) calls proto-imperatives and proto-declaratives.

When infants make requests, demands or commands, they are demonstrating proto-









imperatives. In other words, the infants are somehow, such as with a gesture plus a

vocalization, signaling to his or her parent that they need or want some particular object

(Bates, 1976). A proto-declarative is a behavior that attempts to gain the attention of a

parent or other communicative partner (Bates, 1976). The object of reference is not

desired by the infant with a proto-declarative; instead, the parent's attention is desired.

At around 12 months of age, infants begin to intentionally link consistent phonetic

forms with specific meanings to form their first words. The phonetic forms they use

resemble those that adults use to express the same meanings. When children are able

to produce true words, they are said to have entered the locutionary stage (Bates,

1976). For example, a 13-month-old child may look at a dog and say "doggy."

Classification of Prelinguistic Behaviors

Prelinguistic behaviors have been defined by researchers in many different ways.

Three types of prelinguistic behaviors, joint attention, eye gaze, and gestures, have

been frequently discussed in relation to communicative and linguistic development.

Each of these behaviors is discussed in detail in this section.

Joint attention

According to Mundy and Newell (2007), infants demonstrate two types of joint

attention. The first, responding to joint attention, refers to the manner in which infants

respond to others' communicative behaviors (Mundy & Newell, 2007). An example of

responding to joint attention is when an infant follows another's eye gaze or gesture.

The second type of joint attention is initiating joint attention. With this type of joint

attention the infant will spontaneously and independently initiate a communicative act

via his or her own eye gaze or use of gestures (Mundy & Newell, 2007).









Joint attention is a social communication skill that is considered to be a building

block for linguistic development (Mundy & Newell, 2007). Joint attention emerges within

the illocutionary stage, as defined in the previous section. Infants use this skill not only

to communicate and participate in a shared experience but also to demonstrate

affection and learn about their environment (Miller, 2006). For instance, an infant may

look at a juice cup that is sitting out of reach, and then look at the parent in order to alert

a parent or caregiver that he or she wants it. The parent then looks at the object as well

(shared experience), labels it for the infant ("cup"), and then gives the infant the cup

(reinforcement for the infant's communicative intention of getting the cup). This type of

event involves the coordination of object orientation and person orientation. Joint

attention is also an important prerequisite for linguistic development, as it provides a

foundation for developing "Theory of Mind;" that is the ability to understand other's

emotions, intentions, and thoughts (Miller, 2006).

Eye gaze

Before infants have developed language skills, they rely on other developing skills

to communicate with their caregivers (Shumway & Wetherby, 2009). One means of

prelinguistic social communication involves eye gaze. Infants utilize eye gaze to

engage in social interaction, initiate or engage in joint attention, and to regulate their

own behavior (Wetherby & Prizant, 2002). Gaze behavior emerges during the

illocutionary stage of communication development. Developmental specialists usually

identify 2 types of gaze as significant in prelinguistic development. These are (a) gaze

point follow and (b) three point eye gaze.

The gaze point follow (Wetherby & Prizant, 2002) involves the infant's ability to

follow the gaze of his or her communicative partner and engage in joint attention. This









communicative behavior is important because it lets the infant join in a shared

experience with a communicative partner.

When an infant looks at an object, then looks at their communication partner, and

then back at the object, it is called the three point gaze (Wetherby & Prizant, 2002).

The three point gaze enables the infant to communicate a message to their

communication partner. For example, the infant may look at the juice cup on the table,

look at their parent, and then look back at the cup to indicate a need (i.e. a request) for

the juice cup. The three point eye gaze can also be completed by looking at the

communication partner first, then the object of reference, and then back at the

communication partner.

Gesture development

When an infant uses his or her index finger to point at a juice cup, the gesture

communicates an intention such as "I want my juice" or "I am thirsty." Gestures are

another means, aside from spoken language, through which infants can communicate

intentionally (Crais et al., 2004; Thal & Tobias, 1994). As with speech and social

communication development, infants will progress through a developmental sequence

of gesture growth (Crais et al., 2004).

Iverson and Thal (1998) identified two stages of infant gesture development:

deictic and representational gestures. Deictic gestures, which emerge around 7 to 9

months of age, are used by infants to refer to or call attention to some object (Iverson &

Thal, 1998). Examples of deictic gestures are pointing and showing. Deictic gestures

emerge during the illocutionary stage of communication development. Representational

gestures have two functions. The first is to indicate reference and the second is to

assign semantic or symbolic meaning (Iverson & Thal, 1998). Examples of









representational gestures include waving hello or bringing a hand to the mouth as if

eating from a spoon. Representational gestures typically emerge following the

development of a few deictic gestures (Crais et al., 2004).

Reaching, showing, giving, and pointing are considered deictic gestures and have

been studied extensively (Crais et al., 2004). Reaching is the first deictic gesture to

emerge in infants and it develops around the age of 8 or 9 months. An infant will

demonstrate the reach gesture with either an open hand reach or by taking their

parent's hand and placing it on the object of reference. Following the development of

reaching, an infant will next demonstrate showing and then giving. These gestures will

develop between 9 and 13 months of age, with showing emerging first followed by

giving. The pointing gesture is a little more complex as the object's distance from the

infant as well as the infant's intentions for pointing are involved in defining it (Crais et al.,

2004 ) Therefore, pointing development includes two stages. The first is proximal

pointing, which emerges around 9 or 10 months of age. With proximal pointing, the

infant will point to an object of reference that is nearby. The second, called distal

pointing, emerges around 13 or 14 months of age, and involves the infant pointing to

some object further away from their body.

Importance of Pragmatic Development during the Prelinguistic Period

Researchers have found that the development of nonverbal communication skills,

including joint attention, eye gaze, and use of gestures, during the prelinguistic period

can be indicative of later language skills (Watt et al., 2006; Crais et al., 2009; Capone &

McGregor, 2004; Shumway et al., 2009). In 2006, Watt et al. investigated the

prelinguistic skills, including eye gaze, gestures and joint attention, of infants under 24

months of age. Watt et al. administered the Communication Symbolic Behavior Scales









Developmental Profile Behavior Sample, which targets eye gaze, joint attention and

gestures, amongst other abilities, to typically developing children during their second

and third years of life in order to determine any correlations between prelinguistic

abilities and later language development. Results indicated that joint attention and

gesture development in the second year of life were linked to later receptive language

ability in the third year of life. The study also found that joint attention skills correlated to

later expressive language ability.

Shumway & Wetherby (2009) investigated communicative acts in relation to

children with autism spectrum disorder. The investigators administered the

Communication Symbolic Behavior Scales Developmental Profile Behavior Sample to

18 to 24 month-old children with and without autism spectrum disorder. Communicative

acts, according to the investigators, had to include the coordination of eye gaze, joint

attention and gestures. The results indicated that children on the autism spectrum had

a lower rate of communicative acts (1.23 per minute) as compared to the typically

developing group (2.40 acts per minute). Shumway et al. also found that the group with

autism spectrum disorder demonstrated significantly lower rates of joint attention, with

just over 15% of their total acts including joint attention, as compared to the typically

developing group with 38%

Rationale for a Longitudinal Case Study of a Set of Quadruplets

Since the early 1950s, researchers have been exploring the development of

speech and language in infants, toddlers, and children. Consequently, parents and

pediatric professionals have resources at their disposal to educate them on prelinguistic

development. However, what types of resources do parents and pediatric professionals

reference when investigating the prelinguistic development of special infant populations,









such as those with multiple birth status? Researchers, such as Bishop and Bishop,

have investigated the speech and language of twins, however higher order multiples,

such as triplets and quadruplets, have yet to be investigated extensively. Parents and

professionals working with pediatric populations may benefit from research aimed at

describing the prelinguistic development of higher order multiple birth infants.

One way to begin research investigating the prelinguistic development of multiple

birth, LBW and premature infants is to conduct basic observational research. The case

study approach can be designed by an investigator to allow for the documentation of

individual children and their development within the first year of life. Such observations

can then be used in the future to develop more sophisticated psychometric assessment

tools. Such observations can also provide a good source of materials for developing

informational resources that parents can use. By video recording infants in the natural

environment, collecting parental reports, and other behavioral samples, a researcher

can develop informational booklets, videos, and other resources that can assist parents

Studying the prelinguistic development of a set of LBW and premature quadruplets

via a longitudinal case study will also provide insight into how this population attains

prelinguistic milestones and should begin to answer questions pediatric professionals

and parents may have regarding this population's development. Of particular interest

will be how a set of multiple birth infants performs on two widely used standardized tests

that target speech development, gesture development, and social communication

development. The results will be used to monitor and determine changes in

prelinguistic development over the period the participants are investigated.









The three primary research questions to be addressed in this case study are the

following: (1) Do any of the infants in the quadruplet set show evidence of

developmental delay? (2) Do any of the infants have a delay at an early stage of

development and eventually test within normal limits at a later age of development? (3)

Do the infants exhibit idiosyncratic communication skills of the sort described for twins

by Bishop and Bishop (1998)? Answering such questions should help provide

preliminary data regarding this unique subject. The testing will also provide information

regarding any similarities and differences in prelinguistic development within the set of

quadruplets as well as how their pattern of development relates at early and later stages

of development.

Table 1-1. Speech Development
Age (in
Stage months) Description
Physiological responses, such as burps and
Vegetative/Reflexive Birth to 1 cries
Cooing 1 to 4 Vowel-like, such as "oo" or "uh"
Marginal Babbling 4 to 6 Vowel plus consonant, such as "bah" or "ub"
Vowel plus consonant, such as "mama" or
Canonical Babbling 6 to 10 "aga"
Variegated Babbling 10 to 12 Vowel plus varied consonants, such as "gaba"
First Words 12 Adult-like form of a word used consistently









CHAPTER 2
METHODS

Participants

The participants in the case study were one set of quadruplets. They were

recruited for the present case study based on their birth weight, length of gestation and

multiple birth status. The participants were born on July 31st, 2008. For the purposes of

the case study, each of the participants was assigned a unique identifier, i.e. a letter.

Baby A is female and her birth weight was 2 pounds, 4 ounces. Baby B is male

and his birth weight was 2 pounds, 9 ounces. Baby C is male and his birth weight was

2 pounds, 13 ounces. Baby D is male and his birth weight was 2 pounds, 14 ounces.

These weights classify each participant as low birth weight according to the WHO, who

categorizes infants as LBW when born with a weight below 5 pounds, 8 ounces (World

Health Organization ICD-10, 2007).

All four newborns had Apgar scores above 8, which are considered within normal

limits. The term Apgar is an acronym which stands for activity, pulse, grimace,

appearance, and respiration (Apgar, 1953). Each of these variables is assessed at birth

and assigned a rating. The overall score is the average of all five areas.

Babies A, C, and D both received continuous positive airway pressure (CPAP) for

approximately 1 week following delivery. Baby B required a ventilator. Baby D had a

small hole in his lung that resolved itself during his stay in the neonatal intensive care

unit.

Babies A, C, and D had no cardiac abnormalities. Baby B, however, had a heart

valve that took longer than normal to close. It too resolved without any formal medical

intervention.









Babies A, B, and D had no frank neurological abnormalities and no evidence of

structural differences in their brains based on neuroimaging results. Baby C had an

enlarged ventricle in the brain that was ruled out as evidence of hydrocephalus. Baby C

also had 2 cysts in his brain that resolved without causing any long term brain damage.

At 2.5 weeks after delivery, Babies B, C, and D were receiving full feedings (about

26 milliliters) of breast milk through a gastric tube spread out over the course of the 24

hour day. Two days later breast feeding began. Baby A remained on IV support due to

a staph infection she acquired shortly after delivery. Consequently, Baby A did not

begin breast feeding until 3.5 weeks after delivery.

Although some respiratory conditions, cardiac abnormalities and neurological

abnormalities had to be addressed, the participants overall were considered healthy

given their premature birth and low birth weights. All four infants were released from the

neonatal intensive care unit within two months of delivery. Baby D came home first,

followed, in order, by Baby C, Baby B and Baby A.

Chronological age versus adjusted age. The participants were born two

months and three days premature. Therefore, whenever possible, their chronological

age and adjusted age were both used when scoring any assessments. The goal of

scoring their adjusted age was to see whether or not their scores would change if their

prematurity was taken into consideration. This also allowed the investigator to make

further comparisons of their prelinguistic development. In general, clinicians and other

pediatric professionals are not in agreement as to when to stop assessing premature

infants using their adjusted age. Some professionals suggest to stop using adjusted

age and begin using chronological age at 12 months; others suggest at 24 months. For









the purposes of this study, adjusted age will be used whenever possible (e.g. if norms

are provided for the participants' chronological age and adjusted age, then both will be

used.)

Data Collection

Two standardized assessment tools that are commonly used with infants and

toddlers were administered to all four participants: the MacArthur-Bates Communication

Development Inventory: Words and Gestures (Fenson et al., 2006) and the

Communication and Symbolic Behavior Scales Developmental Profile (Wetherby et al.,

2002). Each of these assessment tools is explained in more detail below. Refer to

Table 2-1 for a summary of the participants' ages when the formal tests were

completed.

MacArthur-Bates Communication Development Inventory: CDI

The CDI is in questionnaire format and it is administered to an infant's primary

caregiver in order to gather information regarding the child's prelinguistic development.

There are two versions of the test, Words and Gestures and Words and Sentences.

The Words and Sentences format is most appropriate for infants over the age of 18

months. Because the participants in the present study are under the age of 18 months,

the Words and Gestures format was used. The target communicative behaviors in CDI

are emergent receptive and expressive abilities as well as gesture development. The

test is standardized on infants who range in age from 8 to 18 months. The

questionnaire is divided into two parts and each part divided further into subsections.

Part I of the CDI covers early word development. The subsections of Part I

include the following categories: First Signs of Understanding, Phrases, Starting to Talk,

and a vocabulary checklist. Parents are to indicate whether or not their infant









understands or produces the various target words and behaviors that are listed on the

form.

Part II of the CDI covers actions and gestures. The subsections of Part II include

the following categories: First Communicative Gestures, Games and Routines, Actions

with Objects, Pretending to be a Parent, and Imitating Adult Actions. Parents are asked

to indicate whether or not their infant has demonstrated the target actions/gestures yet.

Scoring is reported on the Child Report Form by summing the different responses

within Parts I and II. The infant's raw scores are then converted to a percentile rank

which allows for comparison to other children of their age range. Percentile ranks are

provided in the following categories for Part I: Phrases Understood, Vocabulary

Comprehension, and Vocabulary Production. The percentile ranks for Part II are Early

Gestures, Later Gestures, and Total Gestures. Percentile rankings below the 16th

percentile are considered deviant, according to the CDI technical manual (Fenson et al.,

2006).

The participants' caregivers were asked to complete the CDI two times during the

course of the case study. The first completion occurred when the infants were 10

months of age and the second completion occurred when the infants were 14 months of

age (this is the infants' chronological age, not their adjusted age). The investigator gave

the caregivers a folder which was labeled by date. The investigator asked the

participants' mother to fill out the CDI questionnaire on the specific dates indicated

which corresponded to the infants' chronological age. After the participants' mother

completed the CDI, she mailed the forms back to the investigator for scoring.









Communication and Symbolic Behavior Scales Developmental Profile

The second formal test that the participants completed was the Communication

and Symbolic Behavior Scales Developmental Profile (CSBS DP). The CSBS DP

includes three components: the Infant-Toddler Checklist, the Caregiver Questionnaire

and the Behavior Sample. The CSBS DP (Wetherby and Prizant, 2002) was developed

to assess the communicative and symbolic behaviors of infants aged 6 months to 24

months. The assessment has three main purposes: (1) to identify children who are at

risk for communication delays; (2) to evaluate the extent of any delays that a child might

have; and (3) to document changes in a child's communicative behavior over time

(Wetherby & Prizant, 2002). A child's expressive language, symbolic play, and social

communication functioning are addressed on the scales.

The CSBS DP Infant-Toddler Checklist is a one page screener that is used to

determine if an infant needs to be referred for a comprehensive communication

evaluation. The screener has been standardized on typically developing infants as

young as 6 months, however if an infant is born prematurely, the evaluator must decide

whether to interpret the results using either the infant's corrected age or the

chronological age.

The Infant-Toddler Checklist is divided into three scales: Social, Speech and

Symbolic. Within the Social Scale are the subsections Emotion and Eye Gaze,

Communication and Gestures. Within the Speech Scale are the subsections Sounds

and Words. Within the Symbolic Scale are the subsections Understanding and Object

Use.

Each subscale item is given a point value and scoring is done by adding the points

to yield a raw score. The raw score is then converted to a standard score and/or









percentile rank that can be used to compare the child's performance to the appropriate

norms. If the infant's scores suggest that he or she is at risk for a delay then the

evaluator is instructed to make a recommendation for a more comprehensive

evaluation. All scores at or below the 10th percentile are considered a concern

(Wetherby et al., 2002).

The participants' caregivers were instructed to complete the CSBS-DP Infant-

Toddler Checklist when the participants were six months of age. The mother was given

a folder labeled by date and instructed to fill out the Infant-Toddler Checklist when the

date instructed. Once completed, the forms were mailed back to the investigator.

The second section of the CSBS DP is the Caregiver Questionnaire. It is a four

page questionnaire that covers speech, language, and play milestones. The

questionnaire has been standardized on typically developing infants; however, if an

infant is born prematurely, the evaluator can choose to norm it based on either the

infant's corrected age or the chronological age.

The CSBS-DP Caregiver Questionnaire is divided into three scales: Social,

Speech and Symbolic. Within the Social Scale are the subsections Emotion and Eye

Gaze, Communication and Gestures. Within the Speech Scale are the subsections

Sounds and Words. Within the Symbolic Scale are the subsections Understanding and

Object Use.

Each item in the various subsections is given a point value and scoring is done by

adding the points to yield a raw score. The raw score is then converted to a standard

score and percentile rank that are compared to the appropriate norms. Composite and









total scores at or below the 10th percentile are considered a concern (Wetherby et al.,

2002).

The participants' mother was instructed to complete the Caregiver Questionnaire

when the participants were 12 months and 14 months of chronological age. The mother

was given a folder labeled by date and instructed to fill out the Caregiver Questionnaire

when the date instructed. Once completed, the mother mailed the forms back to the

investigator.

The investigator also assessed the participants using the CSBS DP -Behavior

Sample when the participants were 12 months, and 14 months of chronological age.

One caregiver was present during each session. The samples were video recorded

then saved by recording date. The goal of the Behavior Sample is to assess the infant's

communicative and play behaviors during interaction with the caregiver. The Behavior

Sample has been standardized on typically developing infants as young as 12 months

of age and accounts for prematurity.

Just like with the CSBS DP Infant-Toddler Checklist and the Caregiver

Questionnaire, the Behavior Sample is divided into three scales: Social, Speech and

Symbolic. Within the Social Scale are the subsections Emotion and Eye Gaze,

Communication and Gestures. Within the Speech Scale are the subsections Sounds

and Words. Within the Symbolic Scale are the subsections Understanding and Object

Use. Each scale includes target behaviors that are to be elicited during communicative

acts (refer to Table 2-2 for definitions of the CSBS DP Behavior Sample measures).

Wetherby and Prizant (2002) define communicative acts as interactions that involve the









use of a gesture, a vocalization, or a verbalization directed at an adult. The act must

serve a communicative function.

The Behavior Sample is administered in six parts: a warm-up, communicative

temptations, book sharing, symbolic play probe, language comprehension probe, and

constructive play probe. During the warm-up the investigator provides the infant with a

bag of toys and initiates interaction in order to allow the infant to become comfortable

with the setting. Because the participants were already familiar with the investigator,

this warm-up section was omitted if possible (i.e., if the participant was resisting the first

sampling opportunity, as described in the next paragraph, the warm-up portion was

introduced to familiarize the infant to the toys and setting.) Next, the investigator went

through each of the six sampling opportunities, which include the use of wind-up toys, a

balloon, bubbles, a jar with food in it, a book, a stuffed animal, and blocks. Each

sampling opportunity provided the infants with a chance to demonstrate the target

behaviors.

The investigator video recorded each assessment in order to refer back to each

session for scoring. There were a total of 8 recorded assessments, four for each

participant at 12 months, and 14 months of age. The recordings were stored according

to recording date.

Each item in the subsections of the Behavior Sample is given a point value and

scoring is done by adding the points to yield a raw score. The raw score is then

converted to a standard score and percentile rank that will be compared to the

appropriate norms. Composite and total scores at or below the 10th percentile are

considered a concern (Wetherby et al., 2002).









Data Collection from Video Recorded Observations

A primary goal of this longitudinal study was to assess the participants in their

natural environment. Therefore, video observations were performed in the participants'

home with caregivers and siblings present. The recordings were collected over an eight

month period beginning when the participants were six months old and ending when the

participants were fourteen months old (January 31st, 2009 until October 1st, 2009.)

The investigator gave the caregivers a video camera and instructed them on how

to conduct the video recording observations. Recordings were to be done a minimum of

two times per week for 20 minutes per day. The recordings did not have to be

continuous. After the clips were recorded, they were stored according to recording date

on a computer hard drive.

The participants were recorded in isolation in order to observe individual

development. The participants' parents were instructed to record spontaneously during

various activities including, but not limited to, feeding time, changing time, play time,

bath time, and night time. They were also recorded as a set in order to observe

potential interactions among them. Again, the participants' cargivers were instructed to

record spontaneously during various activities including, but not limited to, feeding time,

changing time, play time, bath time, and night time.

Data Analysis

Data from formal testing was scored according to the standardized tests'

instructions. The description for scoring the two formal tests was described above

within the data collection section. Data from video recordings within the participants'

natural environment was reviewed and classified according to communication

development.









Table 2-1. Participants' Ages when Standardized Tests Were Completed
Chronological Age in Months
Standardized Test 6 7 8 9 10 11 12 13 14
CDI X X
CSBS DP Infant Toddler X
Checklist
CSBS DP Caregiver X X
Questionnaire
CSBS DP Behavior Sample X X










Table 2-2. Definition of CSBS DP scales measured during the CSBS DP Behavior
Sample (Wetherby & Prizant, 2002)


CSBS DP Behavior
Gaze shift


Shared positive affect


Gaze/point follow


Rate of communicating

Behavior regulation

Social interaction

Joint attention

Conventional gestures


Distal gestures


Syllables with consonants

Inventory of consonants

Words
Inventory of words
Word combinations

Inventory of word combinations

Language comprehension


Definition
Alternating eye gaze between a person
and an object and back.
Clear facial expression of pleasure or
excitement directed toward another
with eye gaze
Responding to another's gaze/point by
turning head or following with eye
gaze
Frequency of communicative acts
displayed per sampling opportunity
Use of communication to attract attention
to self
Use of communication to attract attention
to self
Use of communication to direct another's
attention to an object or event
Giving, showing, pushing/pulling away,
reaching, pointing, waving, nodding
head, shaking head
Gestures in which the child's hand does
not touch a person or object (i.e.
pointing at a distance, waving)
Vocal communicative acts that include
vowel plus consonant combinations
The variety of consonants produced during
communicative acts
Use of words during a communicative act
Sample of different words used
Use of multiword combinations in
communicative acts
Use of multiword combinations in
communicative acts
Comprehension of object names, person
names, and body parts









CHAPTER 3
RESULTS

Results of the CDI and all 3 sections of the CSBS DP standardized assessments

are presented below. Percentile ranks are provided per baby and per standardized

assessment in Tables 3-1 to 3-12, following the sections. Figures 3-1 to 3-4 include the

percentile ranks from both CSBS DP Behavior Samples for all four participants.

Baby A

CDI Results

The first administration of the CDI was performed on May 1, 2009. The

assessment was completed by the participant's mother. At this time, Baby A's

chronological age was 10 months and her adjusted age was 8 months. When scoring

the CDI using Baby A's chronological age (10 months), her results across all

subsections of the CDI fell within normal limits, as shown in Table 3-1, with the

exception of Later Gestures and Total Gestures. When the CDI was scored using Baby

A's adjusted age of 8 months, Later Gestures and Total Gestures fell within normal

limits, along with all other subsections. According to the CDI results, Baby A

understood 7 out of the 28 phrases targeted in the CDI, such as "Daddy's/Mommy's

home," and "Look here." She also understood one or more words from the following

categories: sound effects/animal sounds, such as "yum yum" and "meow," animal

names, such as "doggy," toys, food/drink, body parts, rooms, small household items,

outside things/places to go, people, games/routines, such as "night night" and "Hi,"

action words, including "drink" and "sleep," descriptive words, and quantifiers. Baby A's

mother reported that, at the time of test administration, Baby A demonstrated gestures,

including reaching, pointing, and showing.









The second assessment using the CDI was completed by the participant's mother

on October 5, 2009. The percentile ranks for this CDI assessment are also provided in

Table 3-1. At this time, Baby A's chronological age was 14 months, with an adjusted

age of 12 months. Baby A's scores across all subsections of the CD/ fell within normal

limits when scoring using her chronological age. Thus, when scoring using Baby A's

adjusted age, scores remained within normal limits. According to the CDI results, Baby

A continued to demonstrate the prelinguistic skills reported during the first CDI

assessment. The second CD/ assessment showed that Baby A understood 21 of the

28 phrases targeted by the CDI. Baby A expanded on the amount of vocabulary she

understood, as well. That is, in addition to the words Baby A understood at 12 months

chronological age, she understood one or more words from the following categories at

14 months chronological age: vehicles, clothing, and pronouns, including "mine" and

"you." According to Baby A's mother, Baby A had sometimes imitated words produced

by adults and labeled objects. Baby A had also produced some words independently,

including one or more words from the following categories: sound effects/animal

sounds, animals, vehicles, toys, food/drink, clothing, body parts, small household items,

people, and games/routines. CDI results also showed that Baby A had increased

gesture use. Baby A's mother reported that Baby A demonstrated new gestures, such

as shaking head "yes" and "no" and blowing kisses. Baby A also engaged in games,

such as peekaboo and patty cake and combined actions with objects.

CSBS DP Results

Additional information about Baby A's development was collected using all 3

sections of the CSBS DP. The Infant-Toddler Checklist was completed on January 31,

2009 by Baby A's mother. Baby A's chronological age was 6 months. Baby A's results









across all 3 scales of the Infant-Toddler Checklist (Social Composite, Speech

Composite, Symbolic Composite, and Total Score) fell below the 10th percentile.

On August 1, 2009, Baby A's mother completed the CSBS DP Caregiver

Questionnaire. At this time, Baby A's chronological age was 12 months and her

adjusted age was 10 months. Based on her mother's report, Baby A's results across all

scales of the Caregiver Questionnaire fell within normal limits, as shown by the Baby

A's percentile ranks provided in Table 3-2. According to the Caregiver Questionnaire

results, Baby A demonstrated several behaviors in the Emotion and Eye Gaze

subsection, including smiling while looking at her caregiver and gaze shifts. Baby A's

mother reported that Baby A has demonstrated communication behaviors, such as

letting her caregiver know she needs help, greeting her caregiver when enter/leave a

room, and attempting to get caregiver's attention. Results also showed that Baby A

demonstrated the following gestures: showing, pushing, reaching with an open hand

and pointing to something out of reach. Baby A's mother reported that, at 12 months

chronological age, Baby A used sounds, such as [m, n, d, g] to engage in vocal play;

however, her mother indicated that Baby A had yet to use intelligible words or word

approximations to communicate. Baby A understood 16 of the 36 target words included

in the Caregiver Questionnaire. Baby A's mother reported that Baby A combined

actions with objects, such as drinking with a cup and rolling a ball and also turns the

pages of books and looks/points at pictures in the book.

The second assessment using the CSBS DP Caregiver Questionnaire was

completed by Baby A's mother on October 5, 2009. Percentile rank results of the

Caregiver Questionnaire are provided in Table 3-2. Baby A's chronological age was 14









months and her adjusted age was 12 months. Results across all subsections of the

Caregiver Questionnaire as reported by the participant's mother fell within normal limits.

According to the Caregiver Questionnaire, Baby A continued to demonstrate all the

behaviors as reported by her mother in the first Caregiver Questionnaire assessment.

Results show that Baby A now demonstrates new gestures, such as giving, waving "hi"

and "bye," and shaking head "yes" and "no." Baby A also produced more sounds,

including [w, I, y]. Baby A's mother reported that Baby A could now communicate using

word approximations, including "mommy," "daddy," "all gone," "and "ball." Baby A

understands 21 of the 36 target words in the Caregiver Questionnaire. Results show

that Baby A could combine more actions with people or stuffed animals, such as

combing hair and hugging.

A CSBS DP Behavior Sample was taken on August 1, 2009, when Baby A was 12

months, chronologically. However, video recordings of the assessment were damaged

and therefore were unable to be analyzed.

The second CSBS DP Behavior Sample was completed on October 5, 2009.

Baby A's chronological age was 14 months and her adjusted age was 12 months.

Results of this Behavior Sample are provided in Table 3-9. Baby A demonstrated

scores within normal limits on all composite scores and the Total Score. During the

Behavior Sample, Baby A demonstrated the following behaviors: gaze shift, gaze follow,

shared positive affect, behavior regulation, social interaction, and joint attention (refer to

Table 2.2 for definitions of these behaviors.) She demonstrated several gestures,

including giving, showing, reaching and pointing to distal objects. Baby A produced [d,









t, g, k] during the sample. She demonstrated action plus object use by putting objects in

and drinking with a bottle.

Baby B

CDI Results

The first administration of the CDI was completed by Baby B's mother on May 1,

2009. Baby B's chronological age was 10 months and his adjusted age was 8 months.

When scoring the CDI using Baby B's chronological age (10 months), his results across

all subsections of the CDI fell within normal limits, as shown by the percentile ranks

provided in Table 3-3, with the exception of Vocabulary Production, Early Gestures,

Later Gestures and Total Gestures. When scoring using Baby B's adjusted age (8

months), Vocabulary Production, Early Gestures, and Total Gestures fell within normal

limits; however, Later Gestures remained below the 16th percentile. According to the

CDI results, Baby B understood 5 of the 28 phrases targeted in the CDI, such as "Open

your mouth," and "Look here." He also understood one or more words from the

following categories: sound effects/animal sounds, such as "ouch" and "meow," animal

names, such as "doggy," vehicles, toys, such as "ball" and "book," food/drink, clothing,

furniture, small household items, outside things/places to go, people, games/routines,

action words, descriptive words and prepositions/locations. Baby B's mother reported

that Baby B had demonstrated gestures, including reaching, pointing, and showing.

The second assessment of the CDI was completed by the Baby B's mother on

October 5, 2009. Baby B's chronological age was 14 months and his adjusted age was

12 months. Baby B's scores across all subsections of the CD/ fell within normal limits

when scoring using his chronological age, as shown in Table 3-3. Thus, when scoring

using Baby B's adjusted age, scores remained within normal limits. According to the









CDI results, Baby B continued to demonstrate the prelinguistic skills reported during the

first CDI assessment. The second CDI assessment showed that Baby B understood 21

of the 28 phrases targeted by the CDI, such as "Stop it," "Clap your hands," and "Come

here." Baby B had expanded on the amount of vocabulary understood. In addition to

the words Baby B understood at 12 months chronological age, he understood one or

more words from the following categories at 14 months chronological age: body parts,

pronouns, question words, prepositions, including "off" and "on," and quantifiers.

According to Baby B's mother, Baby B had sometimes labeled objects and produced

some words independently. The words Baby B had produced, as reported by his

mother, include one or more words from the following categories: sound effects/animal

sounds, animals, toys, food/drink, games/routines, and descriptive words. CDI results

also showed that Baby B had increased gesture use from the last CDI assessment.

Baby B's mother reported that at 14 months chronological age, Baby B demonstrated

new gestures, such as indicating "all gone" and gesturing "hush" by placing finger to

lips. Baby B also engaged in games, such as peekaboo and patty cake, combined

actions with objects and plays with stuffed animals/dolls, such as putting them to bed or

pushing in a stroller.

CSBS DP Results

Additional information about Baby B's development was collected using all 3

components of the CSBS DP. The first CSBS DP standardized assessment completed

by Baby B's mother was the Infant-Toddler Checklist. It was completed on January 31,

2009, when Baby B's chronological age was 6 months. Baby B's results across all 3

subsections of the Infant-Toddler Checklist (Social Composite, Speech Composite,

Symbolic Composite, and Total Score) fell below the 10th percentile.









On August 1, 2009, Baby B's mother completed the CSBS DP Caregiver

Questionnaire. Baby B's chronological age was 12 months and his adjusted age was

10 months. Baby B's results across all scales of the Caregiver Questionnaire, as

reported by Baby B's mother, fell within normal limits. Percentile rank results of the

Caregiver Questionnaire are provided in Table 3-4. According to the Caregiver

Questionnaire results, Baby B demonstrates several behaviors from the Emotion and

Eye Gaze section, including smiling while looking at his caregiver and gaze shifts. Baby

B's mother reported that Baby B had demonstrated communication behaviors such as

letting his caregiver know he needs help, greeting caregiver when enter/leave a room,

and attempting to get caregiver's attention. Results also showed that Baby B

demonstrated the following gestures: giving, showing, pushing, reaching with an open

hand, pointing to something out of reach and shaking head "no." Baby B's mother

reported that Baby B used sounds, such as [m, n, b, d, g] to engage in vocal play and

that Baby B had approximated words, including "mommy," "daddy," "no," and "night

night." Baby B understands 17 of the 36 target words included in the Caregiver

Questionnaire. Baby B's mother reports that Baby B had combined actions with

objects, such as drinking with cup and pushing a toy vehicle. At Baby B's chronological

age of 12 months, he had demonstrated putting objects in containers and taking them

out, and also turns the pages of books and looks/points at pictures in the book.

The second assessment of the CSBS DP Caregiver Questionnaire was completed

by the Baby B's mother on October 5, 2009. Baby B's chronological age wasl4 months

and his adjusted age was 12 months. Results across all subsections of the Caregiver

Questionnaire, as reported by the Baby B's mother fell within normal limits, as shown in









Table 3-4. According to the Caregiver Questionnaire, Baby B continued to demonstrate

all the behaviors as reported by his mother in the first Caregiver Questionnaire

assessment. Results showed that Baby B demonstrated new gestures, such as waving

"hi" and "bye," and pushing an object away. Baby B's mother reported that Baby B had

not increased his consonant inventory since what was reported on the last Caregiver

Questionnaire. Results showed that Baby B had not yet increased the amount of

understandable word approximations he produced and he had not increased the

amount of words he understood. At Baby B's chronological age of 14 months, he

combined more actions with people or stuffed animals, such as feeding with a spoon

and hugging/kissing.

The first CSBS DP Behavior Sample was completed on August 1, 2009, when

Baby B was 12 months, chronologically, with an adjusted age of 10 months. Percentile

rank results of the Behavior Sample are provided in Table 3-10. Baby B's results

placed him below normal limits in the Social and Symbolic Composites as well as with

the Total Score. However, Baby B had a Speech Composite within normal limits.

During the Behavior Sample, Baby B demonstrated the following behaviors: gaze shift,

gaze follow, shared positive affect, behavior regulation, social interaction, and joint

attention. Baby B did not produce any words during the sample. He demonstrated one

gesture, reaching. Baby B produced [b] and [p] during the sample. He demonstrated

action plus object use one time, by drinking with a bottle.

The second CSBS DP Behavior Sample was taken on October 5, 2009. Baby B's

chronological age was 14 months and his adjusted age was 12 months. Baby B's

results across all 3 scales and the total score placed him within normal limits, as shown









in Table 3-10. During the Behavior Sample, Baby B continued to demonstrate the

prelinguistic behaviors he demonstrated in the first sample. In addition to those

behaviors, Baby B demonstrated the following gestures: giving, pushing/pulling away,

pointing to proximal and distal objects, and nodding head "yes." Baby B produced the

sound [w.] He demonstrated increased action plus object use by putting objects in a

container and feeding with a utensil.

Baby C

CDI Results

The first administration of the CDI was completed by Baby C's mother on May 1,

2009. Baby C's chronological age was 10 months and his adjusted age was 8 months.

When scoring the CDI using Baby C's chronological age (10 months), his results across

all subsections of the CDI fell within normal limits, as shown in Table 3-5. Thus, when

scoring using Baby C's adjusted age (8 months), all scores increased and remained

within normal limits. According to the CDI results, Baby C understood 7 of the 28

phrases targeted in the CDI. Examples of these phrases include "Time to go night

night," and "Look here." He also understood one or more words from the following

categories: sound effects/animal sounds, such as "ouch" and "moo," animal names,

such as "doggy," toys, such as "ball," food/drink, body parts, furniture, small household

items, outside things/places to go, people, games/routines, such as "bye bye" and "night

night," action words, descriptive words, and quantifiers. Baby C's mother reported that

Baby C had demonstrated gestures, including reaching, pointing, and showing and

waving "bye bye."

The second assessment of the CDI was completed by Baby C's mother on

October 5, 2009. Baby C was 14 months chronological age with an adjusted age of 12









months. Percentile rank results of Baby C's CDI assessment are provided in Table 3-5.

Baby C's scores across all subsections of the CDI fell within normal limits when scoring

using his chronological age (14 months). Thus, when scoring using Baby C's adjusted

age (12 months), scores remained within normal limits. According to the CDI results,

Baby C continued to demonstrate the prelinguistic skills reported during the first CDI

assessment. The second CDI assessment showed that Baby C understood 22 of the

28 phrases targeted by the CDI, such as "Don't do that," "Stop it," and "Come here."

Baby C expanded on vocabulary understood. In addition to the words Baby C

understood at 10 months chronological age, he understood one or more words from the

following categories at 14 months chronological age: vehicles, clothing, words about

time, pronouns, question words, such as "mine," and "I," and prepositions, including "off"

and "on." According to Baby C's mother, Baby C had sometimes imitated words

produced by adults and labeled objects. Baby C also produced some words

independently, including one or more words from the following categories: sound

effects/animal sounds, animal names, vehicles, toys, food/drink, clothing, small

household items, outside things/places to go, people, games/routines, action words,

descriptive words, prepositions/locations, and quantifiers. CDI results also showed that

Baby C had increased gesture use from the last CDI assessment. Baby C's mother

reported that Baby C demonstrated new gestures including nodding head "yes" and

smacking lips to indicate "yum yum." Baby C also engaged in game playing, such as

peekaboo and patty cake, combined actions with objects and plays with stuffed

animals/dolls, such as putting them to bed or pushing in a stroller.









CSBS DP Results

Additional information about Baby C's development was collected using all 3

components of the CSBS DP. The first CSBS DP standardized assessment completed

by Baby C's mother was the Infant-Toddler Checklist. It was completed on January 31,

2009, when Baby C's chronological age was 6 months. Baby C's results across all 3

subsections of the Infant-Toddler Checklist fell below the 10th percentile.

On August 1, 2009, Baby C's mother completed the CSBS DP Caregiver

Questionnaire. Baby C's chronological age was 12 months and his adjusted age was

10 months. Results of the Caregiver Questionnaire are provided in Table 3-6. Baby C's

results across all scales of the Caregiver Questionnaire, based on his mother's report,

fell within normal limits. According to the Caregiver Questionnaire results, Baby C

demonstrated several behaviors from the Emotion and Eye Gaze section, such as

smiling while looking at his caregiver and gaze shift. Baby C's mother reported that

Baby C had demonstrated communication behaviors including letting his caregiver know

he needs help, greeting caregiver when enter/leave a room, and attempting to get

caregiver's attention. Results also showed that Baby C demonstrated the following

gestures: giving, showing, pushing, reaching with an open hand, pointing to proximal

and distal objects, and shaking head "no." Baby C's mother reported that Baby C used

sounds, such as [m, n, b, d, g] to engage in vocal play; however, his mother indicated

that Baby C had yet to produce intelligible word approximations to communicate. Baby

C understood 16 of the 18 target words included in the Caregiver Questionnaire. Baby

C's mother reported that Baby C combined actions with objects, such as drinking with

cup and rolling a ball. He also had demonstrated putting objects in a container and









taking them out as well as turning the pages of books and looking/pointing at pictures in

a book.

The second assessment of the CSBS DP Caregiver Questionnaire was completed

by the Baby C's mother on October 5, 2009. Baby C's chronological age was 14

months and his adjusted age was 12 months. Results across all scales of the Caregiver

Questionnaire fell within normal limits, as shown in Table 3-6. According to the

Caregiver Questionnaire, Baby C continued to demonstrate all the behaviors as

reported by his mother in the first Caregiver Questionnaire assessment. Baby C's

mother reported that Baby C produced more sounds in addition to those reported on the

last Caregiver Questionnaire, such as [w, I, y.] Results showed that Baby C now

produced understandable word approximations, such as "mommy," "daddy," and "baby."

He had also increased the amount of words he understood, from 18 of 36 to 24 of 36.

Results showed that Baby C combined more actions with people or stuffed animals,

such as covering with a blanket and hugging/kissing.

The first assessment of the CSBS DP Behavior Sample was completed on August

1, 2009, when Baby C was 12 months, chronologically, with an adjusted age of 10

months. Baby C's results fell below the norm in the Social and Symbolic Composites

and in the Total Composite, as shown in Table 3-11. Baby C's Speech Composite

result fell within normal limits. During the Behavior Sample, Baby C demonstrated the

following behaviors: gaze shift, gaze follow, shared positive affect, behavior regulation,

social interaction, and joint attention. He demonstrated one gesture, reaching. Baby C

did not produce any sounds or word approximations during the sample. He









demonstrated action plus object use two times, by drinking with a bottle and putting an

object in a container.

The second CSBS DP Behavior Sample was taken on October 5, 2009. Baby C's

chronological age was 14 months, with an adjusted age of 12 months. Baby C's

percentile rank results from the Behavior Sample are provided in Table 3-11. Baby C's

results on all 3 scales and the total score fell within normal limits. During the Behavior

Sample, Baby C continued to demonstrate the prelinguistic behaviors he demonstrated

in the first sample. In addition to those behaviors, Baby C demonstrated new gestures,

including giving, showing, pushing/pulling away and pointing to proximal and distal

objects. Baby C did not produce any sound or words during the sample. He

demonstrated increased action plus object use by kissing a stuffed animal, feeding with

a utensil, and scooping with a spoon.

Baby D

CDI Results

The first administration of the CDI was completed by Baby D's mother on May 1,

2009. Baby D's chronological age was 10 months and his adjusted age was 8 months.

When scoring the CD/ using Baby D's chronological age (10 months), his results across

all subsections of the CDI fell within normal limits, as shown in Table 3-7. Thus, when

scoring using Baby D's adjusted age (8 months), all scores remained within normal

limits. According to the CDI results, Baby D understood 7 of the 28 phrases targeted in

the CDI, such as "Daddy's/Mommy's home," and "Look here." He also understood one

or more words from the following categories: sound effects/animal sounds, such as

"ouch" and "baa baa," animal names, such as "doggy," toys, such as "ball" and "book,"

food/drink, furniture/rooms, small household items, outside things/places to go, people,









games/routines, such as "bath" and "bye bye," action words, descriptive words, and

quantifiers. Baby D's mother reported that Baby D had demonstrated gestures, such as

reaching, pointing, showing, waving "bye bye," and shaking head "no." Baby D also

combined a few actions with objects, as reported by his mother, such as pushing a toy

car or throwing a ball.

The second assessment of the CDI was completed by the Baby D's mother on

October 5, 2009. Percentile rank results from the CDI are provided in Table 3-7. Baby

D's scores across all subsections of the CD/ fell within normal limits when scoring using

his chronological age (14 months). Thus, when scoring using Baby D's adjusted age

(12 months), scores remained within normal limits. According to the CDI results, Baby

D continued to demonstrate the prelinguistic skills reported during the first CDI

assessment. The second CDI assessment showed that Baby D understood 24 of the

28 phrases targeted by the CDI, such as "Don't do that," "Stop it," and "Come here."

Baby D had expanded on vocabulary understood. In addition to the words Baby D

understood at 10 months chronological age, he understood one or more words from the

following categories at 14 months chronological age: vehicles, clothing, body parts,

words about time, pronouns, such as "mine," and "I," question words, and prepositions,

including "off" and "on." According to Baby D's mother, Baby D had sometimes imitated

words produced by adults and labeled objects. Baby D also produced some words

independently. As reported by his mother, Baby D produced one or more words in the

following categories: sound effects/animal sounds, animals, vehicles, toys, food/drink,

clothing, furniture/rooms, outside things/places to go, people, games/routines, action

words, descriptive words, prepositions/locations and quantifiers. Baby D's mother









reported that Baby D demonstrated new gestures including nodding head "yes" and

indicating "all gone." At Baby D's chronological age of 4 months, he also engaged in

games, such as peekaboo and patty cake, combined actions with objects and plays with

stuffed animals/dolls, such as putting them to bed and pushing in a stroller.

CSBS DP Results

Additional information about Baby D's development was collected using all 3

sections of the CSBS DP. The first CSBS DP standardized assessment completed by

Baby D's mother was the Infant-Toddler Checklist. It was completed on January 31,

2009 when Baby D's chronological age was 6 months. Baby D's results across all 3

subsections of the Infant-Toddler Checklist fell below the 10th percentile.

On August 1, 2009, Baby D's mother completed the CSBS DP Caregiver

Questionnaire. Baby D's chronological age was 12 months and his adjusted age was

10 months. Baby D's results across all scales of the Caregiver Questionnaire fell within

normal limits, as shown in Table 3-8. According to the Caregiver Questionnaire results,

Baby D demonstrated several behaviors from the Emotion and Eye Gaze section,

including smiling while looking at his caregiver and gaze shift. Baby D's mother

reported that Baby D had demonstrated communication behaviors including letting his

caregiver know he needs help, greeting caregiver when enter/leave a room, and

attempting to get caregiver's attention. Results also show that Baby D demonstrates

the following gestures: giving, showing, pushing, reaching with an open hand, and

pointing to proximal and distal objects. Baby D's mother reported that Baby D used

sounds, such as [m, n, b, d, g] to engage in vocal play. Baby D had not yet produced

word approximations. Baby D understood 16 of the 36 target words included in the

Caregiver Questionnaire. Baby D's mother reported that Baby D combines actions









with objects, such as drinking with a cup and pushing a toy vehicle. Baby D also had

demonstrated putting objects in containers and taking them out, and also turning the

pages of books and looking/pointing at pictures in a book.

The second assessment of the CSBS DP Caregiver Questionnaire was completed

by Baby D's mother on October 5, 2009. Baby D's chronological age was 14 months

and his adjusted age was 12 months. Baby D's percentile rank results from the

Caregiver Questionnaire are provided in Table 3-8. Results across all scales of the

Caregiver Questionnaire, as reported by Baby D's mother, fell within normal limits.

According to the Caregiver Questionnaire, Baby D continued to demonstrate all the

behaviors as reported by his mother in the first Caregiver Questionnaire assessment.

Results showed that Baby D demonstrated new gestures, such as waving "hi" and

"bye," and nodding head "yes." Baby D's mother reported that in addition to the sounds

reported on the last Caregiver Questionnaire, Baby D produced [w, I, y.] Results

showed that Baby D produced understandable word approximations, such as "mommy,"

"daddy," and "baby." Baby D understood 20 of the 36 target words included in the

Caregiver Questionnaire. According to Baby D's mother, Baby D combined more

actions with people or stuffed animals, such as drinking with a cup/bottle and

hugging/kissing.

The first CSBS DP Behavior Sample was completed on August 1, 2009, when

Baby D was 12 months, chronologically, with an adjusted age of 10 months. Baby D's

scores placed him below the norms in the Social and Symbolic Composite Scores and

in the Total Score; however, his Speech Composite Score fell within normal limits, as

shown in Table 3-12. During the Behavior Sample, Baby D demonstrated the following









behaviors: gaze shift, gaze follow, shared positive affect, social interaction, and joint

attention. Baby D demonstrated the following gestures during the sample: reaching and

pointing to distal objects. Baby D did not produce any sounds or words during the

sample. He demonstrated action plus object use one time, by drinking with a bottle.

The second CSBS DP Behavior Sample was taken on October 5, 2009. Baby D's

chronological age was 14 months and his adjusted age was 12 months. Results of the

Behavior Sample are provided in Table 3-12. All of Baby D's results fell within normal

limits. During the Behavior Sample, Baby D continued to demonstrate the prelinguistic

behaviors he demonstrated in the first sample. In addition to those behaviors, Baby D

demonstrated behavior regulation. He demonstrated new gestures, including giving,

showing, pushing/pulling away, pointing to proximal objects, and waving. Baby D

produced syllables with consonants and produced the sounds [d, t, g, k, w.] He did not

use any words during the sample. He demonstrated increased action plus object use

by putting objects in and feeding with a utensil.

Data Collection from Video Recordings

Video recordings of the infants were made in their natural environment during the

8-month period that the study lasted. The recordings captured the infants' behaviors

from ages 6 months to 14 months. The intent of the recordings was to develop a video-

based instructional guide on prelinguistic development for parents and caregivers of

multiple birth infants. The general structure of the instructional guide is discussed under

the section Future Research and Direction in Chapter IV. Video recordings were

reviewed by the investigator and excerpts were classified according to the following

behaviors: communication behaviors (including joint attention, eye gaze, and gestures),

play development, and speech development.









Table 3-1. Baby A's CDI Percentile Rank Results
Ages
CD/ Section CA 10 AA 8 CA 14 AA 12
Phrases Understood 40 70 50 70
Vocabulary Comprehension 55 80 55 80
Vocabulary Production 60 90 70 90
Early Gestures 30 99 95 99
Later Gestures 5 95 75 95
Total Gestures 15 99 85 99
Note: CA = chronological age; AA = adjusted age

Table 3-2. Baby A's CSBS DP Caregiver Questionnaire Percentile Rank Results
Ages
CSBS Section CA 10 AA 8 CA 14 AA 12
Social Composite 25 50 75 84
Speech Composite 50 63 91 95
Symbolic Composite 63 91 63 84
Total Score 40 68 83 93
Note: CA = chronological age; AA = adjusted age

Table 3-3. Baby B's CDI Percentile Rank Results
Ages
CD/ Section CA 10 AA 8 CA 14 AA 12
Phrases Understood 30 70 50 70
Vocabulary Comprehension 60 80 80 95
Vocabulary Production 5 90 55 85
Early Gestures 15 99 55 85
Later Gestures 5 95 35 75
Total Gestures 10 99 40 80
Note: CA = chronological age; AA = adjusted age

Table 3-4. Baby B's CSBS DP Caregiver Questionnaire Percentile Rank Results
Ages
CSBS DP Section CA 10 AA 8 CA 14 AA 12
Social Composite 75 95 63 75
Speech Composite 37 63 16 25
Symbolic Composite 63 91 63 84
Total Score 50 83 42 75
Note: CA = chronological age; AA = adjusted age










Table 3-5. Baby C's CDI Percentile Rank Results
Ages
CD/ Section CA 10 AA 8 CA 14 AA 12
Phrases Understood 45 70 70 85
Vocabulary Comprehension 65 80 80 95
Vocabulary Production 75 90 90 99
Early Gestures 70 99 85 95
Later Gestures 45 95 60 90
Total Gestures 35 99 65 90
Note: CA = chronological age; AA = adjusted age

Table 3-6. Baby C's CSBS DP Caregiver Questionnaire Percentile Rank Results
Ages
CSBS DP Section CA 10 AA 8 CA 14 AA 12
Social Composite 50 84 50 63
Speech Composite 37 63 95 98
Symbolic Composite 63 91 75 84
Total Score 47 79 83 93
Note: CA = chronological age; AA = adjusted age

Table 3-7. Baby D's CDI Percentile Rank Results
Ages
CD/ Section CA 10 AA 8 CA 14 AA 12
Phrases Understood 45 70 80 95
Vocabulary Comprehension 65 80 80 95
Vocabulary Production 70 90 90 99
Early Gestures 75 99 85 95
Later Gestures 60 95 65 95
Total Gestures 70 99 75 95
Note: CA = chronological age; AA = adjusted age

Table 3-8. Baby D's CSBS DP Caregiver Questionnaire Percentile Rank Results
Ages
CSBS DP Section CA 10 AA 8 CA 14 AA 12
Social Composite 75 95 91 95
Speech Composite 37 63 98 99
Symbolic Composite 50 84 63 84
Total Score 50 81 91 97
Note: CA = chronological age; AA = adjusted age









Table 3-9. Baby A CSBS DP Behavior Sample Percentile Rank Results
Age
CSBS DP Section Sample 1 CA 12 Sample 2 CA 14
Social Composite N/A 37
Speech Composite N/A 37
Symbolic Composite N/A 16
Total Score N/A 21
Note: CA = chronological age

Table 3-10. Baby B CSBS DP Behavior Sample Percentile Rank Results
Age
CSBS DP Section Sample 1 CA 12 Sample 2 CA 14
Social Composite 9 37
Speech Composite 25 25
Symbolic Composite 5 37
Total Score 8 25
Note: CA = chronological age

Table 3-11. Baby C CSBS DP Behavior Sample Percentile Rank Results
Age
CSBS DP Section Sample 1 CA 12 Sample 2 CA 14
Social Composite 9 25
Speech Composite 16 16
Symbolic Composite 9 50
Total Score 5 16
Note: CA = chronological age

Table 3-12. Baby D CSBS DP Behavior Sample Percentile Rank Results
Age
CSBS DP Section Sample 1 CA 12 Sample 2 CA 14
Social Composite 5 37
Speech Composite 16 50
Symbolic Composite 5 16
Total Score 5 27
Note: CA = chronological age

































Figure 3-1. Baby A CSBS DP Behavior Sample
chronological age)


Percentile Rank Results (CA =


Figure 3-2. Baby B CSBS DP Behavior Sample
chronological age)


Percentile Rank Results (CA =


50
45
40
35
30
25
20 *- Sample 2 CA 14
15
10
5
0
Social Speech Symbolic Total Score
Composite Composite Composite


50
45
40
35
30
25
SSample 1 CA 12
20
15 Sample 2 CA 14
10
5
0
Social Speech Symbolic Total Score
Composite Composite Composite
































Figure 3-3. Baby C CSBS DP Behavior Sample Percentile Rank Results (CA =
chronological age)


E Sample 1 CA 12
* Sample 2 CA 14


Social Speech Symbolic
Composite Composite Composite


Total Score


Figure 3-4. Baby D CSBS DP Behavior Sample
chronological age


Percentile Rank Results (CA =


E Sample 1 CA 12
SSample 2 CA 14


Social Speech Symbolic Total Score
Composite Composite Composite


i









CHAPTER 4
DISCUSSION

Prelinguistic Development

Speech Production

Results from the CSBS DP Caregiver Questionnaire Speech Scale show that all

four infants produced speech within normal limits at their chronological ages of 12 and

14 months. The Speech Scale reports scores on the infants' speech sound production,

including a consonant inventory and syllable productions, as reported by the infants'

mother. According to the CSBS DP Caregiver Questionnaire, by 12 months

chronological age, each infant was producing the consonants [m, n, b, d]. Interestingly,

Baby B was the only infant to not expand his consonant inventory by the age of 14

months when the second CSBS DP Caregiver Questionnaire was administered.

Although the infants' scores on The CSBS DP Behavior Sample Speech Scale fell

within normal limits at the infants' chronological ages of 12 and 14 months, the Behavior

Sample scores revealed different results. The infants did not produce [m] or [n] during

the samples. Baby A produced primarily alveolar and velar stops; Baby B produced

bilabial stops; Baby C did not produce any speech sounds during either sample; and

Baby D, who didn't produce any speech sounds during the sample taken when his

chronological age was 12 months, produced alveolar and velar stops when the sample

was taken at 14 months chronological age.

The CDI Vocabulary Production score reports results regarding the infants' word

production. Based on the results from both ages (10 and 14 months chronologically)

the infants demonstrated word production within normal limits. These results are









consistent with the results from the CSBS Caregiver Questionnaire Speech Scale which

also reports on word production.

Language Comprehension

The CDI Phrases Understood and Vocabulary Comprehension scores report

information on the infants' comprehension of phrases and single word vocabulary

comprehension, respectively. All four infants' results for these two CDI sections fell

within normal limits at both test administrations (10 and 14 months chronological age.)

The results of the CSBS DP Caregiver Questionnaire Symbolic Scale are consistent

with the CDI Vocabulary Comprehension results as this scale reports scores on single

word understanding as well. Results from the CSBS DP Behavior Sample Symbolic

Scale, which reports on comprehension of object names, person names, and body

parts, are not consistent with either the CDI Phrases Understood and Vocabulary

Comprehension scores or the CSBS DP Caregiver Questionnaire results.

Nonverbal Communication Skills

The CDI reports scores on Early Gestures, Later Gestures and Total Gestures.

These sections include questions on gestures, games, actions and pretend play. Based

on results at the infants' chronological age of 10 months, Baby A, Baby C, and Baby D

all exhibited early gestures, such as reaching and pointing, and also game playing and

combining actions with objects. Baby B, who had a percentile rank of 15, did not exhibit

game playing and demonstrated limited combinations of actions plus objects. His

score, however, increased to the 99th percentile when it was scored using his adjusted

age (8 months.) By 14 months chronological age, all four infants had scores on the CDI

Early Gestures, Later Gestures, and Total Gestures that fell within normal limits. The

CSBS DP Caregiver Questionnaire Social Scale reports information on gestures. At the









infants' chronological age of 12, Baby A had the lowest CSBS DP Caregiver

Questionnaire Social Scale (25th percentile); however, this score still fell within normal

limits. At 14 months chronological age, all four infants' results on the Social Scale

remained within normal limits, however, Baby B's score decreased from the 75th

percentile at 12 months chronological age to the 63rd percentile at 14 months

chronological age. Also, Baby C's score remained the same (50th percentile.) Both

infants did not demonstrate any notable gesture development from 12 to 14 months of

age based on their mother's report on the CSBS DP Caregiver Questionnaire.

Based on the CSBS DP Behavior Sample Social Scale, Baby B, Baby C, and

Baby D demonstrated gesture inventories that fell below normal limits at their

chronological age of 12 months. The infants only demonstrated the reaching gesture

during the sample, with the exception of Baby D who also demonstrated a pointing

gesture. However, the second Behavior Sample, which was taken at the infants'

chronological age of 14 months, indicated that all four infants had gesture inventories

that were within normal limits. At this age, they demonstrated a variety of gestures,

including waving, shaking head, showing and pushing away.

The CSBS DP Behavior Sample allows for observation of other nonverbal

communication skills, such as eye gaze and joint attention. On the first sample taken

when the infants' chronological age was 12 months, Baby B, Baby C, and Baby D had

Social Composite scores that fell below the norm. However, it is important to note that

the infants all exhibited eye gaze and joint attention behaviors, including gaze shift,

gaze follow, shared positive affect, behavior regulation, and social interaction. These

behaviors were also demonstrated during the second Behavior Sample taken when the









infants' chronological age was 14 months. The CSBS DP Caregiver Questionnaire also

indicated, based on the infants' mother's report, that all four infants demonstrated eye

gaze and joint attention behaviors since the infants' chronological age was 12 months.

How the Participants' Performance Relates to Typical Development and what is
Expected of Infants with LBW, Short Gestation, and Multiple Birth Status

Research by Bishop and Bishop (1998) indicates that it is not uncommon for twin

siblings to develop idiosyncratic phonological rules which suggest use of "private

language." Work by Zubrick et al. (2007) documents the extent to which premature

infants can present with atypical and/or delayed speech and language development.

Based on such findings, it was thought at the outset of the study that the infants who

participated in the present study might be at risk for the same or similar types of

developmental problems. These patterns, to date, have not been realized however.

That is, the participants have yet to demonstrate any idiosyncratic prelinguistic patterns.

Thus, the present findings underscore the concept of individual differences among

multiple birth children. Although many such children exhibit marked differences in

communication development when compared to singletons, not every child does.

The only delays noted in the present study occurred when the participants' speech

and gesture development tasks were scored using norms based upon their

chronological age. It is widely felt that such an approach penalizes children who are

born prematurely, and indeed that seemed to be the case in the present study. All of

the "delays" that were suggested through the use of chronological age norm references

were no longer present when scores were referenced against the infants' adjusted age,

with the exception of one score (Baby B's Later Gesture percentile rank on the CDI.)









Foundation for Research

Longitudinal case studies allow for extensive observation of a particular

population. In this case, the longitudinal study allowed for an in-depth look at

communication-related behaviors and general development within a set of LBW and

premature quadruplets. Studies into the early communicative development of higher

order multiples, such as triplets and quadruplets, is limited. In fact, to our knowledge,

this is the first study in which these issues have been examined in a quadruplet set.

Therefore, this study provides preliminary information regarding the prelinguistic

development of this population using standardized testing and observation.

Limitations

One of the goals of this research was to observe a set of LBW and premature

quadruplets in their natural environment in order to report data on prelinguistic

development, including speech and gesture development, during the first year of life.

The participants were video recorded within their home with caregivers, siblings and

other volunteers present. Although this environment provides advantages to observing

natural behavior; it also provides disadvantages.

One disadvantage concerns the logistic of conducting the video recordings with

this population. In short, it is very difficult to execute high quality recordings of four

siblings simultaneously. This became apparent as the investigator attempted to review

and analyze recordings made in this study. Once the analysis commenced, it became

apparent that background noise levels were loud enough to make it difficult to determine

which infant was verbalizing at a particular time and what the infant was verbalizing. In

future research, this issue might be resolved by fitting each infant with a microphone.









Such an approach would reduce the effect of background noise (i.e. from other infants

and other family members) on the quality of the recordings.

One aspect of prelinguistic development the investigator wanted to analyze using

the video recordings was babbling development. However, when the video recordings

were reviewed it became apparent that not only was it difficult to determine who was

babbling and what the sounds were. Also, also the frequency with which the infants

were babbling during recording times made it difficult to collect useful samples.

It is also important to note that this type of longitudinal study requires time

commitment and responsibility from the parents. Although the participants' parents

were timely with filling out the required standardized tests and adhered quite closely to

the basic procedures for recording and completing the parental reports, external factors,

such as having to take care of the participants' older siblings, made it challenging for

them to devote as much time and attention to the project as they may have otherwise

been able to do. Thus, it would benefit future studies of this type to have a dedicated

researcher or research assistant, such as a graduate student clinician, present to help

deal with such factors.

Both the CDI and the CSBS DP Caregiver Questionnaire rely on parental report.

Although this is a practical way to gather information on an infant's developmental

history, it also has some limitations as parents and caregivers may not remember

accurately or understand the behaviors being assessed. With this longitudinal case

study, the parents' of the participants had to complete questionnaires on all four of their

infants which poses even further possibility for parental error when reporting on the

development of each child.









Clinical Application

As pediatric professionals encounter infants with multiple birth status, it becomes

necessary for them to have an adequate understanding of the infants' development

across all systems, including speech and language development. Providing pediatric

professionals, such as pediatricians, speech pathologists, neonatal nurses, and more,

with information regarding prelinguistic development should educate them on important

developmental differences, if any, they should expect. The results from this study begin

to address these differences within one set of multiple birth infants.

Future Research and Direction

Data collection included weekly video recordings taken within the participants'

natural environment. This video footage has potential to also be analyzed and

classified according to communication and play behaviors. The results of coding the

information in this way could benefit both pediatric professionals and parents as it could

be used to create an educational tool defining the prelinguistic development of LBW,

premature, and multiple birth infants. The video recordings provide actual examples of

specific behaviors and when put together with an informational book may be a practical

way to educate those involved with the prelinguistic development of not only LBW,

premature, and multiple birth infants, but also typically developing infants.

Clinicians sometimes rely on parent report when evaluating infants. Parents are a

reliable resource; however it would be interesting to know how reliable their reports are

as compared to formal testing. Data for this study was collected from the standardized

assessments in two ways; (a) caregiver questionnaires; and (b) formal testing

completed by a graduate student clinician. This could allow for a future study to be

done on the relationship between caregiver questionnaires and formal testing. It would









be interesting to see how the results of caregiver questionnaires relate to the results of

formal testing (e.g. Are the results of both the caregiver questionnaires and formal

testing completed by a professional similar? Does one report delay and the other report

no delay?).









CHAPTER 5
CONCLUSION

When a family discovers they are expecting a child, several questions and

concerns are raised. These questions and concerns take on a new, scary and exciting

twist when parents discover they are expecting more than one child, when the child is

delivered premature, and/or when the child is born at a low birth weight. Their search

for education may include questions regarding the prelinguistic development of their

infants) and what the significance of different behaviors mean. Given the lack of

research regarding these populations it appears necessary to investigate further the

prelinguistic development of multiple birth infants. This longitudinal case study of a set

of premature, low birth weight quadruplets should provide the appropriate preliminary

data regarding this important period of development. The results and future research

expanding upon what was attained may benefit parents and pediatric professionals by

providing education and information they both deserve regarding prelinguistic

development of infants with multiple birth status.









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Apgar, V. (1953). A Proposal for a New Method of Evaluation of the Newborn Infant.
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Austin, J.L. (1962). How to do Things With Words. Cambridge: Harvard University
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Capone, N. C., & McGregor, K. K. (2004). Gesture Development: A Review for
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Crais, E.R., Douglas, D.D., & Cox-Campbell, C. (2004). The Intersection of the
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Crais, E. R., Watson, Linda R., & Baranek, Grace T. (2009). Use of Gesture
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Delgado, C. E. F., & Vagi, S. J. (2004). Early Risk Factors for Preschool Speech and
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Martin, J., MacDorman, M., & Mathews, T.J. (2007). Triplet Births: Trends and
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Martin, J., & Park, M. (1999). Trends in Twin and Triplet Births: 1980-97. National
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Miller, C. (2006). Developmental Relationships Between Language and Theory of
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Directions in Psychological Science, 16 (5), 269-274.

National Institute of Child Health and Human Development. (2002). Even
Moderately Premature Birth Poses Risk for Developmental Delays. Retrieved from
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Oiler, D.K. (1980). The emergence of the sounds of speech in infancy. In G. Yeni-
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Barrett, Y., & Ukoumunne, O. C. (2007). Predicting Language at 2 Years of Age: A
Prospective Community Study. Pediatrics, 120(6), 1441-1449.

Shumway, S., & Wetherby, A. (2009). Communicative Acts of Children with Autism
Spectrum Disorders in the Second Year of Life. Journal of Speech, Language, and
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Stark, R.E. (1980). Stages of speech development in the first year of life. In G. Yeni-
Komshian, J.F. Kavanagh & C.A. Ferguson (Eds.), Child Phonology (1st ed., pp. 93-
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of Two Embryos After In Vitro Fertilization. The New England Journal of Medicine,
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BIOGRAPHICAL SKETCH

Kristen M. Lewandowski received her Master of Arts from the Department of

Communication Sciences and Disorders at the University of Florida in August of 2010.

She received her Bachelor's Degree in Linguistics at Oakland University in Auburn Hills,

Michigan. During that time she spent a semester studying French in Orleans, France

and focused her undergraduate thesis in linguistics studies on French phonology. After

receiving her bachelor's degree in 2007, she went on to post-bachelor's studies in

Communication Sciences and Disorders at Wayne State University in Detroit, Michigan.

In fall of 2008, she began graduate studies within the Department of Communication

Sciences and Disorders at the University of Florida.





PAGE 1

1 THE PRELINGUISTIC DEVELOPMENT OF MULTIPLE BIRTH, LOW BIRTH WEIGHT, AND PREMATURE INFANTS: CLINICAL APPLICATION OF FOUNDATIONAL RESEARCH By KRISTEN M. LEWANDOWSKI A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS UNIVERSITY OF FLORIDA 2010

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2 2010 Kristen M. Lewandowski

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3 To the Quad Lew's, their big brot hers, and their devoted parents

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4 ACKNOWLEDGMENTS First and foremost, I thank my brother, sister in law and their incredible family for their involvement, support and encouragement throughout the duration of this study. The vision for this research comes from their children and their inspirational view on life I also thank my sister and brother in law for all their efforts in maintaining the safety of the external hard drive and my sanity. I thank my thesis advisors for their endless knowledge and advice. The completion of this study would not have been possibl e with out their direction and guidance I would like to thank my classmates within the Department of Communication S ciences and Disorders for their encouraging words and technical support I wouldnt have survived the last two years without them Lastly I would like to thank my Georgia Bulldog for his positive attitude and for playing Beatles music on his guitar while I worked through the craziness.

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5 TABLE OF CONTENTS page ACKNOWLEDGMENTS .................................................................................................. 4 L IST OF TABLES ............................................................................................................ 7 LIST OF FIGURES .......................................................................................................... 8 ABSTRACT ..................................................................................................................... 9 C H A P T E R 1 INTRODUCTION .................................................................................................... 11 Multiple Birt h, Prematurity, and Low Birth Weight ................................................... 11 Rates ................................................................................................................ 11 Low birth weight rates ................................................................................ 11 Premature birth rates ................................................................................. 12 Multiple birth rates ...................................................................................... 12 Impact of Premature Birth, Multiple Birth, and Low Birth Weight Rates .................. 13 Prelinguistic Development of Typical Infants .......................................................... 15 Speech D evelopment ....................................................................................... 15 Vegetative/reflexive responses .................................................................. 16 Cooing ....................................................................................................... 16 Marginal babbling ....................................................................................... 17 Canonical babbling .................................................................................... 17 Variegated babbling ................................................................................... 18 Transition to first words .............................................................................. 18 Communication Development. ......................................................................... 18 Classification of Prelinguistic Behaviors ........................................................... 20 Joint attention ............................................................................................. 20 Eye gaze .................................................................................................... 21 Gesture development ................................................................................. 22 Importance of Pragmatic Developme nt during the Prelinguistic Period .................. 23 Rationale for a Longitudinal Case Study of a Set of Quadruplets ........................... 24 2 METHODS .............................................................................................................. 27 Participants ............................................................................................................. 27 Data Collection ....................................................................................................... 29 MacArthur Bates Communication Development Inventory: CDI ....................... 29 Communication and Symbolic Behavior Scales Developmental Profile ........... 31 Data Collection from Video Recorded Observations ........................................ 35 Data Analysis .......................................................................................................... 35 3 RESULTS ............................................................................................................... 38

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6 Baby A .................................................................................................................... 38 CDI Results ...................................................................................................... 38 CSBS DP Results ............................................................................................. 39 Baby B .................................................................................................................... 42 CDI Results ...................................................................................................... 42 CSBS DP Results ............................................................................................. 43 Baby C .................................................................................................................... 46 CDI Results ...................................................................................................... 46 CSBS DP Results ............................................................................................. 48 Baby D .................................................................................................................... 50 CDI Results ...................................................................................................... 50 CSBS DP Results ............................................................................................. 52 Data Collection from Video Recordings .................................................................. 54 4 DISCUSSION ......................................................................................................... 60 Prelinguistic Development ...................................................................................... 60 Speech Production ........................................................................................... 60 Language Comprehension ............................................................................... 61 Nonverbal Communication Skills ...................................................................... 61 How the Participants Performance Relates to Typical Development and what is Expected of Infants with LBW, Short Gestation, and Multiple Birth Status .......... 63 Foundation for Research ........................................................................................ 64 Limitations ............................................................................................................... 64 Clinical Application .................................................................................................. 66 Future Research and Direction ............................................................................... 66 5 CONCLUSION ........................................................................................................ 68 LIST OF REFERENCES ............................................................................................... 69 BIOGRAPHICAL SKETCH ............................................................................................ 72

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7 LIST OF TABLES Table page 1 1 Speech Development ......................................................................................... 26 2 1 Participants Ages when Standardized Tests Were Completed .......................... 36 2 2 Definition of CSBS DP scales measured during the CSBS DP Behavior Sample (Wetherby & Prizant, 2002) ................................................................... 37 3 1 Baby As CDI Percentile Rank Results ............................................................... 55 3 2 Baby As CSBS DP Caregiver Question naire Percentile Rank Results .............. 55 3 3 Baby Bs CDI Percentile Rank Results ............................................................... 55 3 4 Baby Bs CSBS DP Caregiver Questionnaire Percentile Rank Results .............. 55 3 5 Baby Cs CDI Percentile Rank Results ............................................................... 56 3 6 Baby Cs CSBS DP Caregiver Questionnaire Percentile Rank Results .............. 56 3 7 Baby Ds CDI Percentile Rank Results ............................................................... 56 3 8 Baby Ds CSBS DP Caregiver Questionnaire Percentile Rank Results .............. 56 3 9 Baby A CSBS DP Behavior Sample Percentile Rank Results ............................ 57 3 10 Baby B CSBS DP Behavior Sample Percentile Rank Results ............................ 57 3 12 Baby D CSBS DP Behavior Sample Percentile Rank Results ............................ 57

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8 LIST OF FIGURES Figure page 3 1 Baby A CSBS DP Behavior Sample Percentile Rank Results (CA = chronological age) .............................................................................................. 58 3 2 Baby B CSBS DP Behavior Sample Percentile Rank Results (CA = chronological age) .............................................................................................. 58 3 3 Baby C CSBS DP Behavior Sample Percentile Rank Results (CA = chronological age) .............................................................................................. 59 3 4 Baby D CSBS DP Behavior Sample Per centile Rank Results (CA = chronological age ............................................................................................... 59

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9 Abstract of Thesis Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Arts THE PRELINGUISTIC DEVELOPMENT OF MULTIPLE BIRTH, LOW BIRTH WEIGHT, AND PREMATURE INFANTS: CLINICAL APPLICATION OF FOUNDATIONAL RESEARCH By K risten M. Lewandowski August 2010 Chair: Ken neth Logan Major: Communication Sciences and Disorders Over the past two decades the rate of multiple birth, premature, and low birth w eight deliveries has increased (Martin, 2009 ) To date, however, there is relatively little information that parents, caregivers, and healthcare professionals can access re lated to the development of prelinguistic skills with in these populations. Parents caregivers and healthcare professionals would benefit from foundational research aimed at investigating the prelinguistic development of multiple birth infants Such research could lead to the creation of accessible resources that are designed to educat e parents and professionals on key prelinguistic growth and development of this population. The goal of this thesis is to expand research on the prelinguistic development o f multiple birth infants. Data are presented to report on a longitudinal case serie s of a set of quadruplets The infants were administered two formal tests between the ages of 6 and 14 months and their interactions with each other and with adult caregivers were videotaped during this same period. Based on the formal testing, the infants show delays in regards to prelinguistic development, which supports previous research done

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10 on low birth weight and premature infants; however, by the age of 14 months the infants were all typically developing. The results provide a basis for understanding the dynamic nature of the prelinguistic development of infants with multiple birth status. Results from the longitudinal study of the quadruplets will also yield preliminary insights in to the challenges associated with collecting data with this population as well as additional details about the communicative development of children from multiplebirth premature, and low birth weight pregnancies.

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11 CHAPTER 1 INTRODUCTION Multiple Birth, Prematurity, and Low Bir th Weight Rates In 2009, the U.S. Depa rtment of Health and Human Services Centers for Disease Control and Prevention (CDC) published its finalized data regarding 2006 birth data. Th e data in this report represent U.S. births across settings and various birth classifications including multipl e birth, low birth weight (LBW) and prematurity rates ( Martin et al., 2009). The 2006 data show that there was an increase in LBW rates as well as premature birth rates relative to previous years for those categories. Multiple b irth rates however, remai ned stable as compared to previous rates ( Martin et al., 2009). Specific details about the prevalence of these rates are presented in the following sections and are based on 2006 birth data provided by the CDC. L ow birth weight rates The World Health Organization defines LBW infants as infants who are born wei gh ing less than 2,500 grams or 5 pounds 8 ounces (World Health Organization ICD 10, 2007). The average birth weight for singletons born in the United States in 2006 was 3,298 grams ( Martin et al., 20 09). From 2000 to 2006, the rate of LBW infants had progressively increased by 9%. Of 4,265,555 births in the United States in 2006, 8.3% were LBW births, which is up from 2005 (8.2%) and which represented an increase of 24% since the mid1980s ( Martin e t al., 2009). The 2006 rate (8.3%) is the largest recorded for the LBW category in the United States for the past four decades ( Martin et al., 2009).

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12 Premature birth rates In 2006 premature birth rates acco unted for 12.8% of the 4,265,555 births in the U nited States ( Martin et al., 2009). A birth is classified as premature if the gestation period is less than 37 weeks (World Health Organization ICD 10, 2007). In the United States, p rematurity rates have increased by 20% since 1990, when the rate was onl y 9.7% (Martin et al., 2009). More specifically, the number of late preterm births (or births with a gestation period of 34 to 36 weeks) has increased by over 25% during this time frame. This could be due in part to the increase in multiple birth rates ( listed in the next section) over the past few decades as well as an increase in medical intervention, such as cesarean deliveries performed, earlier in the pregnancy Maternal health and demographics also impact gestation period. Multiple birth rates In 2 006 the data for twin birth rates remai ned stable relative to the 2005 rates (32.1 twins per 1,000 births) and the rates for triplet births decreased by 5% (153.3 per 100,000 births) relative to 2005 rates ( Martin et al., 2009). It is important to note, however, that between 1980 and 2004 the rate of multiple birth pregnancies jumped 70% (Martin et al., 2009). The multiple birth rate in 1980 was 18.9 per 1,000 births (Martin et al., 2009). Of the more than 4 .2 million births in 2006 137,085 were twins, 6,118 were tri plets, and 355 were quadruplets; these numbers represent 3.37% of all the births in the United States during 2006. T here were 4,121,930 singleton births in the United States in 2006 ( Martin et al., 2009). M ultiple birth deliveries by women aged 3039 represented more than half the total multiple birth deliveries, (i.e. 3,983 of 6,540 births) The rate of women over age 30 delivering multiple births has risen continually since 1980 (Martin et al., 2009). The rise in multiple birth deliveri es in older women may

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13 be attributed to the use of assistive reproductiv e technology (American Society for Reproductive Medicine, 2006; Templeton & Morris, 1998). It is unsurprising that rates for LBW births, premature births, and multiple births have risen together. Keith et al. (1998) found that low birth weight and preterm delivery were two of the most common risk factors for twins and triplets born in 2005. The CDC released data in 1999 regarding trends in twin and triplet births from 19801997. The t rends reveal that although the rate of singleton low birth weight increased by 2% t he rate of twin and triplet sets increased by 10% (Martin et al., 1999). Statistics regarding trends in triplet births from 1971 to 1994 was also investigated by the CDC. The data indicated that in the early 1990s triplets had an average birth weight of 1,698 grams (3 pounds, 12 ounces) which is half of the average birth weight for singleton births (3,358 grams or 7 pounds, 6 ounces) (Martin et al., 1997). The report als o indicated that the gestational period for triplets averaged 32 weeks, which is 7 weeks shorter than the average gestational period for singleton gestational periods (Martin et al., 1997). Of the 143,558 multiple births in 2006, more than half involved pre term and LBW infants ( Martin et al., 2009). Impact of Premature B irth, Multiple Birth, and L ow B irth W eight Rates As a result of the increasing rates of premature, LBW and multiple birth infants, parents, caregivers pediatricians, and pediatric healthcare professionals who work with these populations are likely to encounter developmental delays and/or learning deficits ( National Institute of Child Health and Human Development, 2002). Researchers have found that LBW and prematurity are risk factors for speech and language delays ( Delgado & Vigi, 2004; Zubri ck et al., 2007). For example, Delgado and Vigi (2004) conducted a study with preschool aged children to identify early risk factors for

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14 language impairment They found that both LBW and prematur ity were risk factors in the development of specific language impairment among preschoolers Results from t he study also indicated that LBW and prematurity are risk factors for speech impairment with a cooccurring language impairment (Delgado & Vigi, 2004). In a more recent study, Zubrick et al. (2007) found that an infants gestational age was a predictor of late language emergence. In their study, a questionnaire was sent to the parent s of 1,766 twoyear old children. Of the 1,766 toddlers, 1,528 had normal language development and 238 had late language emergence. Within the group of 238 late talking toddlers 10.7% had a medical history significant for premature birth (Zubrick et al., 2007). Bishop and Bishop (1998) did an extensive study of the occurrence of language impairment among twins. They conducted a retrospective study in whi ch they asked parents of school age twins about various facets of their twins early language development. Based on parent report, the researchers found a higher presence of language impairment in twins particularly among twin sets in which the children demonstrated idiosyncratic phonological development. This idiosyncratic development resulted in the impression of the twins having created their own language (Bishop & Bishop, 1998.) This idiosyncratic language involved use of what the investigators termed jargon. Parents of these children described the twins spoken language as unintelligible and accompanied by strings of babbling, gibberish and other noises. In t he Bishop and Bishop study, t wins who used jargon had a higher occurrence of lang uage impairment at school age.

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15 These studies underscore the potential impact of risk factors such as LBW, gestational age, and multiple birth status on speech and language dev elopment. With the importance of early intervention to eliminate or reduce speech and language delays or deficits it is important for researchers to understand the impact th es e factors have on development. S tudies such as these provide information that may help to ensure tha t parents and professionals working with pediatrics are properly educated on what to expect Prelinguistic Development of Typical Infants Before discussing delayed or deviant prelinguistic development it is necessary to understand typical development. The time frame from birth to a childs fir st word is cons idered the prelinguistic phase of communication development Most children begin to produce true words about 12 months after their birth. During the prelinguistic stage, however, infants have yet to develop a true language (Watt et al., 2006). During this phase, it is expected that infant s will follow a predictable developmental pattern and that they will attain several goals on their way to their firs t words. These goals are referred to as milestones. Although individual infant s w ill develop at slightly different rates, the milestones typically are attained in a predictable, sequential manner Speech D evelopment Following birth, infants immediately begin making sounds and reacting to their environment. As an infant develops, his or her vocal and gestural behaviors become progressively more intentional and communicative in nature. Researchers have studied patterns of infant speech development extensively during the first year of life and have found strong evidence that infants fo llow a sequential order of vocal development (Stoel Gammon & Otomo, 1986; Stark, 1980 ). With regard to vocalizations the major

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16 periods that infants progress through during the first 12 months of life are as follows : vegetative/reflexive responses, cooing marginal babbling, canonical babbling and finally, first words ( O ller, 1980; Stark, 1980 ). Refer to T able 11 for a summary of these periods. Vegetative/reflexive responses During the first month of life infants will typically produce tongue clicks, bur ps, coughs and cries. These sounds are referred to as vegetative/reflexive responses Stark (1980) reported on the characteristics infants demonstrate during this period. T he vegetatitve/reflexive sounds are considered to be simple physiological respons es that an infant produces in response to external or internal stimuli. They are often produced in conjunction with physiological states such as h unger, pain or pleasure (Stark, 1980) The sounds are vowel like approximations. Such sounds are not considered to be produced intentional ly Thus, at this very early point of development an infant is not yet able to assign any meaning to specific sounds or noises, nor can he or she control motor movements sufficiently in order to produce meaningful speech. The vegetative/ reflexive stage will typically last until approximately 4 weeks of age. Cooing Stark (1980) also reported on the characteristics infants demonstrate while in the cooing period. From around one month of age to four months of age, infant s wil l produce vowel like utterances in addition to the vegetative/reflexive responses already noted. These utterances are known as cooing and often are produced during social interaction with a caregiver or some communicative partner (Stark, 1980). C ooing in cludes m ore vowel like approximations that are s ometimes combined wit h conson ant -

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17 like approximations including velar sounds (Oller, 1980) As with vegetative/reflexive responses, cooing is not considered to be communicative in nature. Marginal babbling F ollowing cooing, parents can expect to hear their infants produce v ocalizations that may include consonant like sounds either before or after a vowel This behavior, beginning around four months, is known as marginal babbling. Oller (1980) found that the most common forms for m arginal babbling are those that contain consonant vowel (CV, e.g. bah), and vowel consonant (VC, e.g. ub) syllables ; however, these syllables still are not consistent and do not include smooth vowel to consonant or consonant to vowel transitions The only similarity between mature adult speech and marginal babbling is that infants productions consist of both vowels and consonants. Infants syllables have yet to include the prosody found in mature adult speech. Consonants typi cally heard during marginal babbling include [p, b d, k, g ] Canonical babbling As the infant nears 6 or 7 months of age he or she will begin to produce patterned babbling (Oller, 1980) Stark refers to this period as canonical babbling. T his stage con sists of consonant vowel vocalizations that are more sophisticated and precise than those found in marginal babbling (Oller, 1980). P arents can expect to hear their infant produce sequences of the same syllable ( reduplicated babbling), such as dee dee de e or bah bah bah. Infants consonant and vowel productions now resemble more mature adult speech with regards to the timing characteristics of syllable production (Oller, 1980). Even though t hese vocalizations resemble mature adult speech, they do not yet carry any communicative intent.

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18 Variegated babbling After canonical babbling, the infant will enter the variegated babbling (or nonreduplicated babbling) stage. This usually occurs between 10 or 11 months (Stoel Gamon & Otomo, 1986) Oller (1980) found that during this stage, i nfants produce longer consonant vowel vocalizations with more varied sounds in the syllables For example, a parent may hear their infant babble gaba. In this stage, the infants intonation patterns sound much more mature, as well ( Oller 1980) Transition to first words Infants typically make the transition from the prelinguistic phase to the linguistic phase at around 12 months of age (Stark, 1980) This transition is characterized by the infants first true words. This attainment is highly significant as it demonstrates that the infant has the capability of linking standardized spoken patterns w ith meaning in order to communicate intentionally To be considered a true word the infant must use the word consistently in a specific context and the word must also resemble the adult form of the word (Oller, 1980) Most first words include the following consonants within consonant vowel, vowel consonant, and/or consonant vowel consonant vowel syllables : [p, b, t, d m, n] I n most cases, n ouns make up the majority of an infants growing lexicon during the second year of life (McLaughlin, 2006). Co mmunication D evelopment As was mentioned earlier this chapter, when an infant enter s the one word stage around their first bir thday, their speech begins to carry communicative intent and meaning. Just as with speech development, infants will follow a sequenced order of communication development. Austin ( 1962) identified 3 stages of communication

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19 development: (a) the perlocution ary stage ; (b) the illocutionary stage ; and (c) the locutionary stage From birth through ar ound 8 months of age infants enter the perlocutionary stage. During this stage, infants have yet to assign meaning to their speech and they have yet to communicat e intentionally Thus, parents and caregivers step in to fill this void by providing interpretation of what they think the ir infants are trying to communicate. In other words, parents and caregivers infer their infants communicative intents. For exampl e, a 4 month old infant who smile s at his or her caregiver does not intentionally produce this smile to represent any specific communicative intent; however, the infants parent may interpret the smile as an active attempt by the infant to tell the parent that he or she is satisfied. Around 11 months of age infants usually begin to produce behaviors that represent emergent communicative intent This stage is referred to as t he illocutionary stage (Bates, 1976). During this period, children begin to re alize that they can use their gestures and/or vocalizations to influence the behaviors of others. In other words, the infants develop intentional communication. Many times, infants will pair a vocalization with a gesture. For example, an infant may lear n that when he or she cries, the parent or care giver will give them attention. Although infants are producing vocalizations during this stage, these vocalizations are not yet consistent with adult forms of speech. During the late illocutionary stage, inf ants begin to use vocalizations along with gestures to signal a range of communicative intentions During this stage, infants will begin to demonstrate what Bates (1976) calls protoimperatives and protodeclaratives When infants make requests, demands or commands, they are demonstrating proto -

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20 imperatives In other words, the infants are somehow, such as with a gesture plus a vocalization, signaling to his or her parent that they need or want some particular object ( Bates, 1976) A proto declarative i s a behavior that attempts to gain the attention of a parent or other communicative partner ( Bates, 1976) The object of reference is not desired by the infant with a protodeclarative; instead, the parents attention is desired. At around 12 months of ag e, infants begin to intentionally link consistent phonetic forms with specific meanings to form their first words. The phonetic forms they use resemble those that adults use to express the same meanings. When children are able to produce true words, they are said to have entered the locutionary stage ( Bates, 1976). Fo r example, a 13monthold child may look at a dog and say doggy. Classification of P relinguistic B ehaviors Prelinguistic behaviors have been defined by researchers in many different ways. Three types of prelinguistic behaviors, joint attention, eye gaze, and gestur es have been frequently discussed in relation to communicative and linguistic development. Each of these behaviors is discussed in detail in this section. Joint attention Accord ing to Mundy and Newell (2007), infants demonstrate two types of joint attention. The first, responding to joint attention, refers to the manner in which infants respond to others communicative behaviors (Mundy & Newell, 2007). An example of responding to joint attention is when an infant follow s anothers eye gaze or gesture. The second type of joint attention is i nitiating jo int attention. With this type of joint attention the infant will spontaneously and independently initiate a communicative act v ia his or her own eye gaze or use of gestures (Mundy & Newell, 2007).

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21 Joint attention is a social communication s kill that is considered to be a building block for linguistic development (Mundy & Newell, 2007). Joint attention emerges within the illocutio nary stage, as defined in the previous section. Infants use this skill not only to communicate and participate in a shared experience but also to demonstrate affection and learn about their environment ( Miller, 2006) For instance, an infant may look at a juice cup that is sitting out of reach, and then look at the parent in order to alert a parent or caregiver that he or she want s it. The parent then looks at the object as well (shared experience), labels it for the infant (cup), and then gives the in fant the cup (reinforcement for the infants communicative intent ion of getting the cup). This type of event involves the coordination of object orientation and person orientation Joint attention is also an important prerequisite for linguistic developm ent as it provides a foundation for developing Theory of Mind; that is the ability to understand others emotions, intentions and thoughts (Miller, 2006). Eye gaze Before infants have developed language skills they rely on other developing skills to c ommunicate with their caregivers (Shumway & Wetherby, 2009) One means of prelinguistic social communication involves eye gaze. Infants utilize eye gaze to engage in social interaction, initiate or engage in joint attention, and to regulate their own behavior (Wetherby & Prizant, 2002). Gaze behavior emerges during the illocutionary stage of communication development. Developmental specialists usually identify 2 types of gaze as significant in prelinguistic de velopment. These are (a) gaze point follow and (b) three point eye gaze. The gaze point follow (Wetherby & Prizant, 2002) involves the infants ability to follow the gaze of his or her communicative partner and engage in joint attention. This

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22 communicative behavior is important because it lets the infant join in a shared experience with a communicative partner. When an infant looks at an object, then looks at their communication partner, and then back at the object, it is called the three point gaze (Wetherby & Prizant, 2002) The three point gaze enables the infant to communicate a message to their communication partner. For example, the infant may look at the juice cup on the table, look at their parent, and then look back at the cup to indicate a need (i.e. a request) for the juice cup. The th ree point eye gaze can also be completed by looking at the communication partner first, then the object of reference, and then back at the communication partner. Gesture development When an infant uses his or her index finger to point at a juice cup, the g esture communicates an intention such as I wan t my juice or I am thirsty Gestures are another means, aside from spoken language, through which infants can communicate intentionally ( Crais et al., 2004; Thal & Tobias, 1994). As with speech and social communication development, infants will progress through a developmental sequence of gesture growth (Crais et al., 2004) Iverson and Thal (1998) identified two stages of infant gesture development: deictic and representational gestures Deictic gestures which emerge around 7 to 9 months of age, are used by infants to refer to or call attention to some object (Iverson & Thal, 1998). Examples of deictic gestures are pointing and showing Deictic gestures emerge during the illocutionary stage of communic ation development. Re presentational gestures have two functions The first is to indicate reference and the second is to assign semantic or symbolic meaning (Iverson & Thal, 1998). Examples of

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23 representational gestures include waving hello or bringing a hand to the mouth as if eating from a spoon. Representational gestures typically emerge following the development of a few deictic gestures (Crais et al., 2004). Reaching showing, giving, and pointing are considered deictic gestures and have been stud ied extensively (Crais et al., 2004). Reaching is the first deictic gesture to emerge in infants and it develops around the age of 8 or 9 months. An infant will demonstrate the reach gesture with either an open hand reach or by taking their parents hand and placing it on the object of reference. Following the development of reaching an infant will next demonstrate showing and then giving These gestures will develop between 9 and 13 months of age with showing emerging first followed by giving The p ointing gesture is a little more complex as the objects distance from the infant as well as the infants intentions for pointing are involved in defining it (Crais et al., 2004 ) Therefore, pointing development includes two stages. The first is proximal pointing, which emerges around 9 or 10 months of age. With proximal pointing, the infant will point to an object of ref erence that is nearby The second, called distal pointing, emerge s around 13 or 14 months of age, and involves the infant pointing to some object further away from their body. Importance of Pragmatic D evelopment during the Prelinguistic P eriod Researchers have found that the development of nonverbal communication skills including joint attention, eye gaze, and use of gestures, during th e prelinguistic period can be indicative of later language skills (Watt et al., 2006; Crais et al., 2009 ; Capone & McGregor, 2004 ; Shumway et al., 2009). In 2006, Watt et al. invest igated the prelinguistic skills including eye gaze, gestures and joint att ention, of infants under 24 months of age Watt et al. administered the Communication Symbolic Behavior Scales

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24 Developmental Profile Behavior Sample, which targets eye gaze, joint attention and gestures, amongst other abilities, to typically developing children during their second and third years of life in order to determine any correlations between prelinguistic abilities and later language development Results indicated that joint attention and gesture development in the second year of life were linked to later receptive language ability in the third year of life. The study also found that joint attention skills correlated to later expressive language ability. Shumway & Wetherby (2009) investigated communicative acts in relation to children with autism spectrum disorder The investigators administered the Communication Symbolic Behavior Scales Developmental Profile Behavior Sample to 18 to 24 monthold children with and without autism spectrum disorder. Communicative acts, according to the investigators, had to include the coordination of eye gaze, joint attention and gestures. The results indicated that children on the autism spectrum had a lower rate of communicative acts (1.23 per minute) as compared to the typically developing group ( 2.40 acts per minute). Shumway et al. also found that the group with autism spectrum disorder demonstrated significantly lower rates of joint attention, with just over 15% of their total acts including joint attention, as compared to the typi cally developing group wit h 38% Rationale for a Longitudinal Case Study of a Set of Quadruplets Since the early 1950s, researchers have been exploring the development of speech and language in infants, toddlers, and children. Consequently, parents and pediatric professionals have resources at their disposal to educate them on prelinguistic development. However, what types of resources do parents and pediatric professionals reference when investigating the prelinguistic development of special infant populations,

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25 such as those with multiple birth status? Researchers, such as Bishop and Bishop, have investigated the speech and language of twins, however higher order multiples, such a s triplets and quadruplets, have yet to be investigated extensively. Parents and professionals working with pediatric populations may benefit from research aimed at describing the prelinguistic development of higher order multiple birth infants. One way to begin research investigating the prelinguistic development of multiple birth, LBW and premature infa nts is to conduct basic observational research. The case study approach can be designed by an investigator to allow for the documentation of individual children and their development within the first year of life. Such observations can then be used in th e future to develop more sophisticated psychometric assessment tools. Such observations can also provide a good source of materials for developing informational resources that parents can use. By video recording infants in the natural environment, collec ting parental reports, and other behavioral samples, a researcher can develop informational booklets, videos, and other resources that can assist parents Studying the prelinguistic development of a set of LBW and premature quadruplets via a longitudinal case study will also provide insight into how this population attains prelinguistic milestones and should begin to answer questions pediatric professionals and parents may have regarding this populations development. Of particular interest will be how a set of multiple birth infants performs on two widely used standardized tests that target speech development, gesture development, and social communication development. The results will be used to monitor and determine changes in prelinguistic development ov er the period the participants are investigated.

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26 The three primary research questions to be addressed in this case study are the following: (1) D o any of the infants in the quadruplet set show evidence of developmental delay? (2) Do any of the infants hav e a delay at an early stage of development and eventually test within normal limits at a later age of development? (3) Do the infants exhibit idiosyncratic communication skills of the sort described for twins by Bishop and Bishop (1998)? Answering such q uestions should help provide preliminary data regarding this unique subject. The testing will also provide information regarding any similarities and differences in prelinguistic development within the set of quadruplets as well as how their pattern of de velopment relates at early and later stages of development. Table 1 1. Speech Development Stage Age (in months) Description Vegetative/Reflexive Birth to 1 Physiological responses, such as burps and cries Cooing 1 to 4 Vowel like, such as "oo" or "uh Marginal Babbling 4 to 6 Vowel plus consonant, such as "bah" or "ub" Canonical Babbling 6 to 10 Vowel plus consonant, such as "mama" or "aga" Variegated Babbling 10 to 12 Vowel plus varied consonants, such as "gaba" First Words 12 Adult like form of a word used consistently

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27 CHAPTER 2 METHODS Participants The participants in the case study were one set of quadruplets. They were recruited for the present case study based on their birth weight, length o f gestation and multiple birth status The parti cipants were born on July 31st, 2008. For the purposes of the case study, each of the participants was assigned a unique identifier i.e. a letter. Baby A is female and her birth weight was 2 pounds, 4 ounces. Baby B is male and his birth weight was 2 pounds, 9 ounces. Baby C is male and his birth weight was 2 pounds, 13 ounces. Baby D is male and his birth weight was 2 pounds, 14 ounces. These weights classify each participant as low birth weight according to the WHO, who categorizes infants as LBW when born with a weight below 5 pounds, 8 ounces (World Health Organization ICD 10, 2007). All four new borns had Apgar scores above 8, which are considered within normal limits. The term Apgar is an acronym which stands for activity pulse, grimace, appearance and respiration (Apgar, 1953) Each of these variables is assessed at birth and assigned a rating The overall score is the average of all five areas. Babies A, C and D both received continuous positive airway pressure (CPAP) for approximately 1 week follo wing deliver y. Baby B required a ventilator Baby D had a small hole in his lung that resolved itself during his stay in the neonatal intensive care unit. Babies A, C, and D had no cardiac abnormalities. Baby B however, had a heart valve th at took longer than normal to close. It too resolved without any formal medical intervention.

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28 Babies A, B, and D had no frank neurological abnormalities and no evidence of structural differences in their brains based on neuroimaging results. Baby C had an enlarged ventricle in the brain that was ruled out as evidence of hydrocephalus Baby C also had 2 cyst s in his brain t hat resolved without causing any long term brain damage. At 2.5 weeks after delivery Babies B, C, and D were receiving full feeding s (about 26 milliliters) of breast milk through a gastric tube spread out over the course of the 24 hour day. Two days later breast feeding began. Baby A remained on IV support due to a staph infection she acquired shortly after delivery. Consequently, B aby A did not begin breast feeding until 3.5 weeks after delivery Although some respiratory conditions, cardiac abnormalities and neurological abnormalities had to be addressed, the participants overall were considered healthy given their premature birth and low birth weights All four infants were released from the neonatal intensive care unit within two months of delivery. B aby D came home first, followed, in order, by B aby C, Baby B and Baby A. Chronological age versus adjusted age. The participants were born two months and three days premature. Therefore, whenever possible, their chronological age and adjusted age were both used when scoring any assessments. The goal of scoring their adjusted age was to see whether or not their scores would change if their prematurity was taken into consideration. This also allowed the investigator to make further comparisons of their prelinguistic development. In general, clinicians and other pediatric professionals are not in agreement as to when to stop assess ing premature infants using their adjusted age. S ome professionals suggest to stop using adjusted age and begin using chronological age at 12 months; others suggest at 24 months. For

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29 the purposes of this study, adjusted age will be used whenever possible (e.g. if norms are provided for the participants chronological age and adjusted age, then both will be used.) Data Collection Two standardized assessment tools that are commonly used with infants and toddlers were administered to all four participants : t he MacArthurBates Communication Development Inventory: Words and Gestures (Fenson et al., 2006) and the Communication and Symbolic Behavior Scales Developmental Profile (Wetherby et al., 2002). Each of these assessment tools is explained in more detail below. R efer to Table 21 for a summary of the participants ages when the formal tests were completed. MacArthur Bates Communication Development Inventory: CDI The CDI is in questionnaire format and it is administered to an infants primary caregiver in order to gather information regarding the childs prelinguistic development. There are two versions of the test, Words and Gestures and Words and Sentences The Words and Sentences format is most appropriate for infants over the age of 18 months. Because the participants in the present study are under the age of 18 months, the Words and Gestures format was used. The target communicative behaviors in CDI are emergent receptive and expressive abilities as well as gesture development. The test is standardi zed on infants who range in age from 8 to 18 months. The questionnaire is divided into two parts and each part divided further into subsections. Part I of the CDI covers early word development The subsections of Part I include the following categories: First Signs of U nderstanding, P hrases Starting to T alk and a vocabulary checklist. Parents are to indicate whether or not their infant

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30 understands or produces the various ta rget word s and behaviors that are listed on the form Part II of the CDI covers actions and gestures. The subsections of Part II include the following categories: F irst Communicative G estures Games and R outines Actions with O bjects Pretending to be a P arent and Imitating Adult A ctions Parents are asked to indicate whether or not their infant has demonstrate d the target actions/gestures yet. Scoring is reported on the Child Report Form by summing the different responses within Parts I and II. The infants raw scores are then converted to a percentile rank which allows for compari son to other children of their age range. Percentile ranks are provided in the followi ng categories for Part I: P hrases U nderstood Vocabulary C omprehension, and Vocabulary P roduction The percentile ranks for Part II are E arly G estures Later G estures and Total G estures Percentile rankings below the 16th percentile ar e considered deviant according to the CDI technical manual (Fenson et al., 2006) The participants caregivers were asked to complete the CDI two times during the course of the case study. The first completion occurred when the infants were 10 months of age and the second completion occurred when the infants were 14 months of age (this is the infants chronological age, not their adjusted age) The investigator gave the caregivers a fol der which was labeled by date The investigator asked the participants mother to fill out the CDI questi onnaire on the specific dates indicated which corresponded to the infants chronological age. After the participants mother completed the CDI she m ailed the forms back to the investigator for scoring.

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31 Communication and Symbolic Behavior Scales Developmental Profile The second formal test that the participants completed was the Communication and Symbolic Behavior Scales Developmental Profile ( CSBS DP ) The CSBS DP includes three components: the Infant Toddler Checklist the Caregiver Questionnaire and the Behavior Sample. The CSBS DP (Wetherby and Prizant, 2002) was developed to assess the communicative and symbolic behaviors of infants aged 6 months to 24 months. The assessment has three main purposes: (1) to identify children who are a t risk for communication delays; (2) to evaluate the extent of any delays that a child might have; and (3) to document changes in a childs communicative behavior ove r time (Wetherby & P r izant, 2002). A childs expressive language, symbolic play, and social communication functioning are addressed on the scales. The CSBS DP Infant Toddler C hecklist is a one page screener that is used to determine if an infant needs t o be referred for a comprehensive communication evaluation. The screener has been standardized on typically developing infants as young as 6 months however if an infant is born prematurely, the evaluator must decide whether to interpret the results using either the infants corrected age or the chronological age. The Infant Toddler Checklist is divided into three scales: Social Speech and S ymbolic Within the Social Scale are the subsections Emotion and Eye G aze Co mmunication and G estures Within the Speech Scale are the subsections S ounds and W ords Within the Symbolic Scale are the subsections U nderstanding and O bject U se Each subscale item is given a point value and scoring is done by adding the points to yield a raw score. The raw score is then converted to a standard score and/or

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32 percentile rank that can be used to compare the childs performance to the appropriate norms. If the infants scores suggest that he or she is at risk for a delay then the evaluator is instructed to make a recommendati on for a more comprehensive evaluation. All scores at or below the 10th percentile are considered a concern (Wetherby et al., 2002). The participants caregivers were instructed to complete the CSBS DP InfantToddler Checklist when the participants were six months of age. The mother was given a folder labeled by date and instructed to fill out the Infant Toddler Checklist when the date instructed. Once completed, the forms were mailed back to the investigator. The second section of the CSBS DP is the Caregiver Questionnaire It is a four page questionnaire that covers speech, language, and play milestones. The questionnaire has been standardized on typically developing infants; however if an infant is born prematurely, the evaluator can choose to norm it based on either the infants corrected age or the chronological age. The CSBS DP Caregiver Questionnaire i s divided into thr ee scales: Social Speech and S ymbolic Within the Social Scale are the subsections Emotion and Eye G aze C ommunication and G estures Within the Speech Scale are the subsections S ounds and W ords Within the Symbolic Scale are the subsections U nderstandi ng and Object U se Each item in the various subsections is given a point value and scoring is done by adding the points to yield a raw score. The raw score is then converted to a standard score and percentile rank that ar e compared to the appropriate norm s. Composite and

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33 total scores at or below the 10th percentile are considered a concern (Wetherby et al., 2002). The participants mother was instructed to complete the Caregiver Questionnaire when the participants were 12 months and 14 months of chronolog ical age. The mother was given a folder labeled by date and instructed to fill out the Caregiver Questionnaire when the date instructed. Once completed, the mother mailed the forms back to the investigator. The investigator also assessed the participants using the CSBS DP Behavior Sample when the participants were 12 months, and 14 months of chronological age. One caregiver was present during each session. The samples were video recorded then saved by recording date. The goal of the Behavior Sample is to assess the infants communicative and play behaviors during interaction with the caregiver. T he Behavior Sample has been standardized on typically developing infants as young as 12 months of age and accounts for prematurity Just like with the CSBS DP InfantToddler Checklist and the Caregiver Questionnaire the Behavior Sample i s divided into three scales : Social Speech and S ymbolic Within the Social Scale are the subsections Emotion and Eye G aze C ommunication and G estures Within the Speech Sc ale are the subsections S ounds and W ords Within the Symbolic Scale are the subsections U nderstanding and Object U se Each scale includes target behaviors that are to be elicited during communicative acts (refer to Table 22 for definitions of the CSBS D P Behavior Sample measures). Wetherby and Prizant (2002) define communicative acts as interactions that involve the

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34 use of a gesture, a vocalization, or a verbalization directed at an adult. The act must serve a communicative function. The Behavior Sampl e is administered in six parts: a warm up, communicative temptations, book sharing, symbolic play probe, language comprehension probe, and constructive play probe. During the warm up the investigator provides the infant with a bag of toys and initiates interaction in order to allow the infant to become comfortable with the setting Because the participants were already familiar with the investigator, this warm up section was omitted if possible (i.e., if the participant was resisting the first sampling opportunity, as described in the next paragraph, the warm up portion was introduced to familiarize the infant to th e toys and setting ) Next, the investigator went through each of the six sampling opportunities, which include the use of wind up toy s, a ballo on, bubbl es, a jar with food in it, a book, a stuffed animal and blocks. Ea ch sampling opportunity provided the infant s with a chance to dem onstrate the target behaviors. The investigator video recorded each assessment in order to refer back to each session for scoring. There were a total of 8 recorded assessments, four for each participant at 12 months, and 14 months of age. The recordings were stored according to recording date. Each item in the subsections of the Behavior Sample is given a point value and scori ng is done by adding the points to yield a raw score. The raw score is then converted to a standard score and percentile rank that will be compared to the appropriate norms. Composite and total scores at or below the 10th percentile are considered a conc ern (Wetherby et al., 2002).

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35 Data Collection from Video Recorded Observations A primary goal of this longitudinal study was to assess the participants in their natural environment. Therefore, video observations were performed in the participants home wit h caregivers and siblings present. The recordings were collected over an eight month period beginning when the participants were six months old and ending when the participants were fourteen months old (January 31st, 2009 until October 1st, 2009.) The i nvestigator gave the caregivers a video camera and instructed them on how to conduct the video recording observations. Recordings were to be done a minimum of two times per week for 20 minutes per day. The recordings did not have to be continuous. After the clips were recorded, they were stored according to recording date on a computer hard drive. The participants were recorded in isolation in order to observe individual development. The participants parents were instructed to record spontaneously duri ng various activities including, but not limited to, feeding time, changing time, play time, bath time, and night time. They were also recorded as a set in order to observe potential interactions among them Again, t he participants cargivers were instructed to record spontaneously during various activities including, but not limited to, feeding time, changing time, play t ime, bath time, and night time. Data Analysis Data from formal testing was scored acc ording to the standardized test s instructio ns. The descr iption for scoring the two formal tests was described above within the dat a collection section. Data from video recordings within the participants natural environment was reviewed and classified according to communication development.

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36 Table 2 1. Participants Ages when Standardized Tests Were Completed Chronological Age in Months Standardized Test 6 7 8 9 10 11 12 13 14 CDI X X CSBS DP Infant Toddler Checklist X CSBS DP Caregiver Questionnaire X X CSBS DP Behavior Sample X X

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37 Table 22. De finition of CSBS DP scales measured during the CSBS DP Behavior Sample (Wetherby & Prizant, 2002) CSBS DP Behavior Definition Gaze shift Alternating eye gaze between a person and an object and back. Shared positive af fect Clear facial expression of pleasure or excitement directed toward another with eye gaze Gaze/point follow Responding to anothers gaze/point by turning head or following with eye gaze Rate of communicating Frequency of communicative acts displayed p er sampling opportunity Behavior regulation Use of communication to attract attention to self Social interaction Use of communication to attract attention to self Joint attention Use of communication to direct anothers attention to an object or event Conventional gestures Giving, showing, pushing/pulling away, reaching, pointing, waving, nodding head, shaking head Distal gestures Gestures in which the childs hand does not touch a person or object (i.e. pointing at a distance, waving) Syllables with consonants Vo cal communicative acts that include vowel plus consonant combinations Inventory of consonants The variety of consonants produced during communicative acts Words Use of words during a communicative act Inventory of words Sample of different words used Word combinations Use of multiword combinations in communicative acts Inventory of word combinations Use of multiword combinations in communicative acts Language comprehension Comprehension of object names, person names, and body parts

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38 CHA PTER 3 RESULTS Results of the CDI and all 3 sections of the CSBS DP standardized assessments are pr esented below. Percentile ranks are provided per baby and per s tandardized assessment in Tables 31 to 312 following the sections Figure s 3 1 to 34 inc lude the percentile ranks from both CSBS DP Behavior Samples for all four participants. Baby A CDI Results The first administration of the CDI was performed on May 1, 2009. The assessment was completed by the participants mother. At this time, Baby A s chronological age was 10 months and her adjusted age was 8 months. When scoring the CDI usin g Baby As chronological age ( 10 months ) her results across all subsections of the CDI fell within normal limits as shown in Table 3 1 with the exception of La ter G estures and Total G estures When the CDI was scored using Baby As adjusted age of 8 months, Later G estures and Total G estures fell within normal limits along with all other subsections According to the CDI results, Baby A understood 7 out of the 28 phrases targeted in the CDI such as Daddys/Mommys home, and Look here. She also understood one or more words from the following categories: sound effects/ animal sounds such as yum yum and meow, animal names such as doggy, toys, food/drink, body parts rooms small household items outside things/places to go people games/ routines such as night night and Hi, action words, including drink and sleep, descriptive words and quantifiers Baby As mother reported that, at the time o f test administration, Baby A demonstrated gestures, including reaching, pointing, and showing.

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39 The second assessment using the CDI was completed by the participants mother on October 5, 2009. The percentile ranks for this CDI asse ssment are also provided in Table 31 At this time, Baby As chronological age was 14 months, with an adjusted age of 12 months. Baby As scores across all subsections of the CDI fell within normal limits when scoring using her chronological age. Thus, when scoring using Baby As adjusted age, scores remained within normal limits. According to the CDI results, Baby A continued to demonstrate the prelinguistic skills reported during the first CDI assessment The second CDI assessment showed that Baby A understood 21 of the 2 8 phrases targeted by the CDI Baby A expanded on the amount of vocabulary she understood, as well That is, in addition to the words Baby A understood at 12 months chronological age, she understood one or more words from the following catergories at 14 months chronological age: vehicl es clothing, and pronouns including mine and you. According to Baby As mother, Baby A had sometimes imitated words produced by adults and labeled objects. Baby A had also produced some words independently, including one or more words from the following categories: sound effects/ animal sounds anima ls vehicl es toys, food/drink clothing, body parts small household items people, and games/routines CDI results also show ed that Baby A had increased gesture use. B aby As mother r eported that Baby A demonstrated new gestures, such as shaking head yes and no and blowing kisses Baby A a lso engaged in games, such as peek aboo and patty cake and combined actions with objects. CSBS DP Results Additional information about Baby As development was collected using all 3 sections of the CSBS DP The Infant Toddler Checklist was completed on January 31, 2009 by Baby As mother. Baby A s chronological age was 6 months Baby As results

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40 across all 3 scales of the Infant T oddler Checklist ( Social Composite, Speech Composite, Symbolic Composite, and Total Score) fell below the 10th percentile. On August 1, 2009, Baby As mother completed the CSBS DP Caregiver Questionnaire At this time, Baby A s chronological age was 12 months and her adjusted age was 10 months. Based on her mothers report, Baby As results across all scales of the Caregiver Questionnaire fell within normal limits as shown by the Baby As percentile ranks provided in Table 32 According to the Caregiver Questionnaire results, Baby A demonstrated several behaviors in the Emotion and Eye Gaze subsection, including smiling while looking at her caregiver and gaze shifts Baby As mother reported that Baby A has demonstrated communication behaviors, such as letting her caregiver know she needs help, greeting her caregiver when enter/leave a room and attempting to get caregivers attention. Results also show ed that Baby A demonstrated the following gestures: showing pushing reaching with an open hand and pointing to something out of reach. Baby As mother reported that at 12 months chronological age, Baby A used sounds, such as [m n d, g ] to engage in vocal play; however, her mother indicated that Baby A had yet to use intelligible words or word approx imations to communicate. Baby A understood 16 of the 36 target words included in the Caregiver Questionnaire. Baby As mother reported that Baby A combined actions with objects, such as drink ing with a cup and rolling a ball and also turns the pages of books and looks/points at pictures in the book The second assessment using the CSBS DP Caregiver Questionnaire was completed by Baby As mother on October 5, 2009. Percentile rank results of the Caregiver Questionnaire are provided in Table 32. Baby A s chronological age was 14

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41 months and her adjusted age was 12 months. Results across all subsections of the Caregiver Questionnaire as reported by the participants mother fell within normal limits. According to the Caregiver Questionnaire, Baby A continued to demonstrate all the behaviors as reported by her mother in the first Caregiver Questionnaire assessment. Results show that Baby A now demonstrates new gestures, such as giving waving hi and bye, and shaking head yes and no. Baby A also produced more sounds, including [w, l, y]. Baby As mother reported that Baby A could now communicate using word approximations, including mommy, daddy, all gone, and ball. Baby A understands 21 of the 36 target words in the Caregiver Questionnaire. Results show that Baby A could combine more actions with people or stuffed animals, such as combing hair and hugging A CSBS DP Behavior Sample was taken on August 1, 2009, when Baby A was 12 months, chronologically. However, video recordings of the assessment were damaged and therefore were u nable to be analyzed. The second CSBS DP Behavior Sample was completed on October 5, 2009. Baby A s chronological age was 14 months and her adjusted age was 12 months Results of this Behavior Sample are provided in Table 39. Baby A demonstrated scores within normal limits on all composite s cores and the T otal S core During the Behavior Sampl e Baby A demonstrated the following behaviors: gaze shift gaze follow shared positive affect behavior regulation so cial interaction and joint attention (refer to Table 2.2 for definitions of these behaviors ) She demonstrated several gestures, including giving showing, reaching and pointing to di stal objects Baby A produced [d,

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42 t, g, k] during the sample. She dem onstrated action plus object use by putting objects in and drinking with a bottle. Baby B CDI Results The first administration of the CDI was completed by Baby Bs mother on May 1 2009. Ba by B s chronological age was 10 months and his adjusted age was 8 months. When scoring the CDI using Baby B s chr onological age ( 10 months ) his results across all subsections of the CDI fell within normal limits as shown by the percentile ranks provided in Table 33 with the exception of Vocabulary Production, E a rly Gestures, Later G estures and Total G estures When scoring using Baby B s adjusted age ( 8 months ) Vocabulary P roduction, Early G estures and Total G estures fell within normal limits ; however, Later G estures remained below the 16th percentile According t o the CDI results, Baby B understood 5 of the 28 phrases targeted in the CDI such as Open your mouth, and Look here. He also understood one or more words from the following categories: sound effects/ animal sounds such as ouch and meow animal n ames such as doggy, vehicles toys, such as ball and book, food/drink clothing furniture, small household items outside things/places to go, people, games/ routines action words descriptive words and prepositions/locations Baby B s mother reported that Baby B had demonstrated gestures, including reaching, pointing, and showing. The second assessment of the CDI was completed by the Baby Bs mother on October 5 2009. Baby Bs chronological age was 14 months and his adjusted age was 12 months. Baby B s scores across all subsections of the CDI fell within normal limits when scoring using his chronological age, as shown in Table 33 Thus, when scoring using Baby B s adjusted age, scores remained within normal limits. According to the

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43 CDI result s, Baby B continued to demonstrate the prelinguistic skills reported during the first CDI assessment. The second CDI assessment showed that Baby B understood 21 of the 28 phrases targeted by the CDI such as Stop it, Clap your hands, and Come here. Baby B had expanded on the amount of vocabulary understood. In addition to the words Baby B understood at 12 months chronological age, he understood one or more words from the following categories at 14 months chronological age: body parts pronouns, question words, prepositions including off and on, and quantifiers According to Baby Bs mother, Baby B had sometimes labeled objects and produced some words independently The words Baby B had produced, as reported by his mother, include one or more words from the following categories: sound effects/animal sounds animals toys, food/drink games/routines and descriptive words CDI results also showed that Baby B had increased gesture use from the last CDI assessment. Baby Bs mother reported that a t 14 months chronological age, Baby B demonstrated new gestures, such as indicating all gone and gesturing hush by placing finger to lips Baby B also engaged in games, such as p eekaboo and patty cake, combined actions with objects and plays with stuf fed animals/dolls, such as putting them to bed or pushing in a stroller CSBS DP Results Additional information about Baby Bs development was collected using all 3 components of the CSBS DP The first CSBS DP standardized assessment completed by Baby B s mother was the Infant Toddler Checklist It was completed on January 31, 2009, when Baby B s c hronological age was 6 months Baby B s results across all 3 subsections of the Infant Toddler Checklist ( Social Composite, Speech Composite, Symbolic Composit e and Total Score) fell below the 10th percentile.

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44 On August 1, 2009, Baby B s mother completed the CSBS DP Caregiver Questionnaire Baby B s chronological age was 12 months and his adjusted age was 10 months. Baby B s results across all scales of the C aregiver Questionnaire, as reported by Baby Bs mother, fell within normal limits. Percentile rank results of the Caregiver Questionnaire are provided in Table 34. According to the Caregiver Questionnaire results, Baby B demonstrates several behaviors f rom the E motion and Eye G aze section including smiling while looking at his caregiver and gaze shifts Baby Bs mother r eported that Baby B had demonstrated communication behaviors such as letting his caregiver know he needs help, greeting caregiver when enter/leave a room and attempting to get caregivers attention. Results also show ed that Baby B demonstrated the following gestures: giving showing, pushing, reaching with an open hand, pointing to something out of reach and shaking head no. Baby B s mother reported that Baby B used sounds, such as [m, n, b, d, g] to engage in vocal play and that Baby B had approximated words, including mommy, daddy, no, and night night. Baby B understands 17 of the 36 target words included in the Caregiver Questionnaire Baby Bs mother reports that Baby B had combined actions with objects, such as drinking with cup and pushing a toy vehicle. At Baby Bs chronological age of 12 months, he had demonstrated putting objects in containers and taking them out and also turns the pages of books and looks/points at pictures in the book The second assessment of the CSBS DP Caregiver Questionnaire was completed by the Baby Bs mother on October 5, 2009. Baby Bs chronological age was14 months and his adjusted age was 12 months. Results across all subsections of the Caregiver Questionnaire as reported by the Baby Bs mother fell within normal limits as shown in

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45 Table 34 According to the Caregiver Questionnaire, Baby B continued to demonstrate all the behaviors as reported by his mother in the first Caregiver Questionnaire assessment. Results showed that Baby B demon strated new gestures, such as waving hi and bye, and pushing an object away. Baby Bs mother reported that Baby B had not increased his consonant inventory since what was reported on the last Caregiver Questionnaire Results show ed that Baby B had not yet increased the amount of understandable word approximations he produced and he had not increased the amount of words he understood. At Baby B s chronological age of 14 months, he combined more actions with people or stuffed animals, such as feeding with a spoon and hugging /kissing The first CSBS DP Behavior Sample was completed on August 1, 2009, when Baby B was 12 months, chronologically wit h an adjusted age of 10 months Percentile rank results of the Behavior Sample are provided in Table 310. Baby Bs results placed him below normal limits in the S ocial and S ymbolic C omposites as well as with the T otal S core However, Baby B had a S peec h C omposite within normal limits. During the Behavior Sampl e Baby B demonstrated the following behaviors: gaze shift gaze follow shared positive affect behavior regulation, social interaction, and joint attention Baby B did not produce any words dur ing the sample. He demonstrated one gesture, reaching. Baby B produced [b] and [p] during the sample. He demonstrated act ion plus object use one time, by drinking with a bottle. The second CSBS DP Behavior Sample was taken on October 5, 2009. Baby B s chronological age was 14 months and his adjusted age was 12 months Baby Bs results across all 3 scales and the total score placed him within normal limits as shown

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46 in Table 310. During the Behavior Sampl e Baby B continued to demonstrate the prelinguistic behaviors he demonstrated in the first sample. In addition to those behaviors Baby B demonstrated the following gestures: giving pushing/pulling away pointing to proximal and distal objects and nodding head yes Baby B produced the sound [w.] He demonstrated increased action plus o bject use by putting objects in a container and feeding with a utensil Baby C CDI Results The first administration of the CDI was completed by Baby Cs mother on May 1, 2009. Baby C s chronological age was 10 mont hs and his adjusted age was 8 mo nths. When scoring the CDI using Baby C s chr onological age ( 10 months ) his results across all subsections of the CDI fell within normal limits as shown in Table 35 Thus, when scoring using Baby Cs adjusted age ( 8 mon ths ) all scores increased and remained within normal limits According to the CDI results, Baby C understood 7 of the 28 phrases targeted in the CDI Examples of these phrases include Time to go night night, and Look here. He also understood one or more words from the following categories: sound effects/animal sounds such as ouch and moo animal names such as doggy, toys, such as ball, food/drink body parts furniture, small household items outside things/places to go, people, games/ rou tines such as bye bye and night night, action words descriptive words and quantifiers Baby Cs mother reported that Baby C had demonstrated gestures, including reaching, pointing and showing and waving bye bye. The second assessment of the CDI was completed by Baby Cs mother on October 5, 2009. Baby C was 14 months chronological age with an adjusted age of 12

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47 months Percentile rank results of Baby Cs CDI assessment are provided in Table 35. B aby C s scores across all subsections of the CDI fell within normal limits when scoring using his chronological age (14 months) Thus, when scoring using Baby C s adjusted age (12 months) scores remained within normal limits. According to the CDI results, Baby C continued to demonstrate the prelinguistic skills reported during the first CDI assessment. The second CDI assessm ent showed that Baby C understood 22 of the 28 phrases targeted by the CDI such as Dont do that, Stop it, and Come here. Baby C expanded on vocabulary understood. In ad dition to the words Baby C understood at 10 months chronological age, he understood one or more words from the following categories at 14 months chronological age: vehicles clothing, words about time pronouns question words such as mine, and I, and prepositions including o ff and on According to Baby Cs mother, Baby C had sometimes imitated words produced by adults and labeled objects. Baby C also produced some words independently, including one or more words from the following categories: sound effects/animal sounds animal names vehicle s, toys, food/drink clothing, small household items outside things/places to go, people, games/routines action words descriptive words prepositions/locations and quantifiers CDI results also showed that Baby C had increased gesture use from the last CDI assessment. Baby Cs mother reported that Baby C demonstrated new gestures including nodding head yes and smacking lips to indicate yum yum. Baby C also engaged in game playing such as peekaboo a nd patty cake combined actions with objects and plays with stuffed animals/dolls, such as putting them to bed or pushing in a stroller

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48 CSBS DP Results Additional information about Baby Cs development was collected using all 3 components of the CSBS DP The first CSBS DP standardized assessment completed by Baby C s mother was the Infant Toddler Checklist It was completed on January 31, 2009, when Baby C s chronological age was 6 months. Baby C s results across all 3 subsections of the Infant Toddler Checklist fell below the 10th percentile. On August 1, 2009, Baby C s mother completed the CSBS DP Caregiver Questionnaire Baby Cs chronological age was 12 months and his adjusted age was 10 months. Results of the Caregiver Questionnaire are provided i n Table 36. Baby C s results across all scales of the Caregiver Questionnaire, based on his mothers report, fell within normal limits. According to the Caregiver Questionnaire results, Baby C demonstrated several behaviors from the E motion and E ye G aze section such as smiling while looking at his caregiver a nd gaze shift Baby Cs mother reported that Baby C had demonstrated communication behaviors including letting his caregiver know he needs help, greeting caregiver when enter/leave a room and atte mpting to get caregivers attention. Results also show ed that Baby C demonstrated the following gestures: giving showing pushing, reaching with an open hand, pointing to proximal and distal objects and shaking head no. Baby C s mother reported that Baby C used sounds, such as [m, n, b, d, g] to engage in vocal play; however, his mother indicated that Baby C h ad yet to produce intelligible word approximations to communicate. Baby C understood 16 of the 18 target words included in the Caregiver Questi onnaire. Baby Cs mother reported that Baby C combined actions with objects, such as drinking with cup and rolling a ball He also had demonstrated putting objects in a container and

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49 taking them out as well as t urning the pages of books and looking/point ing at pictures in a book The second assessment of the CSBS DP Caregiver Questionnaire was completed by the Baby Cs mother on October 5, 2009. Baby C s chronological age was 14 months and his adjusted age was 12 months. Results across all scales of the Caregiver Questionnaire fell within normal limits as shown in T able 36 According to the Caregiver Questionnaire, Baby C continued to demonstrate all the behaviors as reported by his mother in the first Caregiver Questionnaire assessment. Baby Cs mot her reported that Baby C produced more sounds in addition to those reported on the last Caregiver Questionnaire, such as [w, l, y ] Results show ed that Baby C now produced understandable word approximations such as mommy, daddy, and baby. He had a lso increased the amount of words he understood, from 18 of 36 to 24 of 36 Result s show ed that Baby C combined more actions with people or stuffed animals, such as covering with a blanket and hugging/kissing. The first assessment of the CSBS DP Behavior Sample was completed on August 1 2009, when Baby C was 12 months, chronologically with an adjusted age of 10 months Baby Cs results fell below the norm in the S ocial and S ymbolic C omposites and in the T ot al Composite, as shown in Table 311 Baby Cs S peech C omposite result fell within normal limits. During the Behavior Sampl e Baby C demonstrated the following behaviors: gaze shift gaze follow shared positive affect behavior regulation, social interaction, and joint attentio n He demonstrated one gesture, reaching. Baby C did not produce any sounds or word approximations during the sample. He

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50 demonstrated action plus object use two time s, by drinking with a bottle and putting an object in a container The second CSBS DP Behavior Sample was take n on October 5, 2009. Baby C s chronological age was 14 months with an adjusted age of 12 months Baby Cs percentile rank results from the Behavior Sample are provided in Table 311. Baby Cs results on all 3 scales and the total score fell within nor mal limits. During the Behavior Sampl e Baby C continued to demonstrate the prelinguistic behaviors he demonstrated in the first sample. In addition to those behaviors, Baby C demonstrated new gestures, including giving showing, pushing/pulling away and pointing to proximal and distal objects Baby C did not produce any sound or words during the sample. He demonstrated increased action plus object use by kissing a stuffed animal feeding with a utensil and scooping with a spoon. Baby D CDI Results The first administration of the CDI was completed by Baby Ds mother on May 1, 2009. Baby D s chronological age was 10 months and his adjusted age was 8 mo nths. When scoring the CDI using Baby D s chr onological age ( 10 months ) his results across all subsec tions of the CDI fell within normal limits as shown in Table 37 Thus, when scoring using Baby D s adjusted age ( 8 months ) all scores remained within normal limits. According to the CDI results, Baby D understood 7 of the 28 phrases targeted in the CDI such as Daddys/Mommys home, and Look here. He also understood one or more words from the following categories: sound effects/animal sounds such as ouch and baa baa, animal names such as doggy, toys, such as ball and book, food/drink furniture/rooms small household items outside things/places to go, people,

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51 games/ routines such as bath and bye bye, action words descriptive words and quantifiers Baby Ds mother r eported that Baby D had demonstrated gestures, such as reaching pointing showing, waving bye bye, and shaking head no. Baby D also combined a few actions with objects, as reported by his mother, such as pushing a toy car or throwing a ball The second assessment of the CDI was completed by the Baby Ds mother on October 5, 2009. Percentile rank results from the CDI are provided in Table 37. Baby D s scores across all subsections of the CDI fell within normal limits when scoring using his chronological age (14 months) Thus, when scoring using Baby D s adjuste d age (12 months) scores remained within normal limits. According to the CDI results, Baby D continued to demonstrate the prelinguistic skills reported during the first CDI assessment. The second CDI assessment showed that Baby D understood 24 of the 28 phrases targeted by the CDI such as Dont do that, Stop it, and Come here. Baby D had expanded on vocabulary understood. In addition to the words Baby D understood at 10 months chronological age, he understood one or more words from the following categories at 14 months chronological age: vehicle s, clothing, body parts words about time, pronouns such as mine, and I, question words and prepositions including off and on. According to Baby Ds mother, Baby D had sometimes imitated words produced by adults and labeled objects. Baby D also produced some words independently. As reported by his mother, Baby D produced one or more words in the following categories: sound effects/ animal sounds animal s, vehicle s, toys, food/drink clothing furniture/rooms outside things/places to go, people, games/routines action words descriptive words prepositions/locations and quantifiers Baby D s mother

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52 reported that Baby D demonstrated new gestures including nodding head yes and indicating all gone. At Baby Ds chronological age of 4 months, he also engaged in games, such as p eekaboo and patty cake combined actions with objects and plays with stuffed animals/dolls such as putting them to bed and pushing in a stroller CSBS DP Results Additi onal information about Baby Ds development was collected using all 3 sections of the CSBS DP The first CSBS DP standardized assessment completed by Baby D s mother was the Infant Toddler Checklist It was completed on January 31, 2009 when Baby Ds chr onological age was 6 months. Baby D s results across all 3 subsections of the Infant Toddler Checklist fell below the 10th percentile. On August 1, 2009, Baby D s mother completed the CSBS DP Caregiver Questionnaire Baby D s chronological age was 12 months and his adjusted age was 10 months. Baby D s results across all scales of the Caregiver Questionnaire fell within normal limits as shown in Table 38 According to the Caregiver Questionnaire results, Baby D demonstrated several behaviors from the E motion and Eye G aze section including smiling while looking at his caregiver a nd gaze shift Baby Ds mother reported that Baby D had demonstrated communication behaviors including letting his caregiver know he needs help, greeting caregiver when enter/l eave a room and attempting to get caregivers attention. R esults also show that Baby D demonstrates the following gestures: giving showing, pushing, reaching with an open hand, and pointing to proximal and distal objects Baby Ds mother reported that Baby D used sounds, such as [m, n, b, d, g] to engage in vocal play Baby D had not yet produced word approximations Baby D understood 16 of the 36 target words included in the Caregiver Questionnaire. Baby Ds mother reported that Baby D combines dact ions

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53 with objects, such as drinking with a cup and pushing a toy vehicle. Baby D also had demonstrated putting objects in containers and taking them out and also turning the pages of books and looking/pointing at pictures in a book The second assessment of the CSBS DP Caregiver Questionnaire was completed by Baby Ds mother on October 5, 2009. Baby D s chronological age was 14 months and his adjusted age was 12 months. Baby Ds percentile rank results from the Caregiver Questionnaire are provided in Ta ble 38. Results across all scales of the Caregiver Questionnaire, as repor ted by Baby Ds mother, fell within normal limits. According to the Caregiver Questionnaire, Baby D continued to demonstrate all the behaviors as reported by his mother in the fir st Caregiver Questionnaire assessment. Results show ed that Baby D demonstrated new gestures, such as waving hi and bye, and nodding head yes Baby Ds mother reported that in addition to the sounds reported on the last Caregiver Questionnaire, Baby D produced [ w l, y ] Results show ed that Baby D produced understandable word approximations such as mommy, daddy, and baby. Baby D understood 20 of the 36 target words included in the Caregiver Questionnaire. Accor ding to Baby Ds mother, Baby D combined more actions with people or stuffed animals, such as drinking with a cup/bottle and hugging/kissing. The first CSBS DP Behavior Sample was completed on August 1, 2009, when Baby D was 12 months, chronologically with an adjusted age of 10 months Baby Ds scores pl aced him below the norms in the S ocial and S ymbolic C omposite S cores and in the T otal S core ; however his S peech C omposite S core fell within no rmal limits, as shown in Table 312 During the Behavior Sampl e Baby D demonstrated the following

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54 behaviors: gaze shift gaze follow shared positive affect social interaction, and joint attention Baby D demonstrated the following gestures during the sample: reaching and pointing to distal objects Baby D did not produce any sounds or words during the sample. He demonstrated action plus object use one time, by drinking with a bottle The second CSBS DP Behavior Sample was taken on October 5, 2009. Baby D s chronological age was 14 months and his adjusted age was 12 months Results of the Behavior Sample are provided in Table 312. All of Baby Ds results fell within normal limits. During the Behavior Sampl e Baby D continued to demonstrate the prelinguistic behaviors he demonstrated in the first sample. In addition to those behaviors, B aby D demonstrated behavior regulation. He demonstrated new gestures, including giving showing, pushing/pulling away pointing to proximal objects and waving Baby D produced syllables with cons onants and produced the sounds [ d, t, g, k, w.] He did not use any words during the sample. He demonstrated increased action plus object use by putting objects in and feeding with a utensil Data Collection from Video Recordings Video recordings of the infants were made in their natural environment dur ing the 8 month period that the study lasted. The recordings captured the infants behaviors from ages 6 months to 14 months. The intent of the recordings was to develop a videobased instructional guide on prelinguistic development for parents and caregivers of m ultiple birth infants. The general structure of the instructional guide is discussed under the section Future R esearch and Direction in Chapter IV. Video recordings were reviewed by the investigator and excerpts were classified according to the following behaviors: communication behaviors (including joint attention, eye gaze, and gestures), play development, and speech development.

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55 Table 31. Baby As CDI Percentile Rank Results Ages CDI Section CA 10 AA 8 CA 14 AA 12 Phrases Understood 40 70 50 70 Vo cabulary Comprehension 55 80 55 80 Vocabulary Production 60 90 70 90 Early Gestures 30 99 95 99 Later Gestures 5 95 75 95 Total Gestures 15 99 85 99 Note : CA = chronological age; AA = adjust ed age Table 32. Baby As CSBS DP Caregiver Questionnaire Percentile Rank Results Ages CSBS Section CA 10 AA 8 CA 14 AA 12 Social Composite 25 50 75 84 Speech Composite 50 63 91 95 Symbolic Composite 63 91 63 84 Total Score 40 68 83 93 Note : CA = chronological age; AA = adjusted age Table 33. Baby Bs C DI Percentile Rank Results Ages CDI Section CA 10 AA 8 CA 14 AA 12 Phrases Understood 30 70 50 70 Vocabulary Comprehension 60 80 80 95 Vocabulary Production 5 90 55 85 Early Gestures 15 99 55 85 Later Gestures 5 95 35 75 Total Gestures 10 99 40 80 Note : CA = chronological age; AA = adjusted age Table 34. Baby Bs CSBS DP Caregiver Questionnaire Percentile Rank Results Ages CSBS DP Section CA 10 AA 8 CA 14 AA 12 Social Composite 75 95 63 75 Speech Composite 37 63 16 25 Symbolic Composite 63 91 63 84 Total Score 50 83 42 75 Note : CA = chronological age; AA = adjusted age

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56 Table 35. Baby Cs CDI Percentile Rank Results Ages CDI Section CA 10 AA 8 CA 14 AA 12 Phrases Understood 45 70 70 85 Vocabulary Comprehension 65 80 80 95 Vocabular y Production 75 90 90 99 Early Gestures 70 99 85 95 Later Gestures 45 95 60 90 Total Gestures 35 99 65 90 Note : CA = chronological age; AA = adjusted age Table 36. Baby Cs CSBS DP Caregiver Questionnaire Percentile Rank Results Ages CSBS DP Secti on CA 10 AA 8 CA 14 AA 12 Social Composite 50 84 50 63 Speech Composite 37 63 95 98 Symbolic Composite 63 91 75 84 Total Score 47 79 83 93 Note : CA = chronological age; AA = adjusted age Table 37. Baby Ds CDI Percentile Rank Results Ages CDI Sec tion CA 10 AA 8 CA 14 AA 12 Phrases Understood 45 70 80 95 Vocabulary Comprehension 65 80 80 95 Vocabulary Production 70 90 90 99 Early Gestures 75 99 85 95 Later Gestures 60 95 65 95 Total Gestures 70 99 75 95 Note : CA = chronological age; AA = adj usted age Table 38. Baby Ds CSBS DP Caregiver Questionnaire Percentile Rank Results Ages CSBS DP Section CA 10 AA 8 CA 14 AA 12 Social Composite 75 95 91 95 Speech Composite 37 63 98 99 Symbolic Composite 50 84 63 84 Total Score 50 81 91 97 Note : CA = chronological age; AA = adjusted age

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57 Table 39. Baby A CSBS DP Behavior Sample Percentile Rank Results Age CSBS DP S ection Sample 1 CA 12 Sample 2 CA 14 Social Composite N/A 37 Speech Composite N/A 37 Symbolic Composite N/A 16 Total Score N/ A 21 Note : CA = chronological age Table 310. Baby B CSBS DP Behavior Sample Percentile Rank Results Age CSBS DP Section Sample 1 CA 12 Sample 2 CA 14 Social Composite 9 37 Speech Composite 25 25 Symbolic Composite 5 37 Total Score 8 25 Note : CA = chronological age Table 311. Baby C CSBS DP Behavior Sample Percentile Rank Results Age CSBS DP Section Sample 1 CA 12 Sample 2 CA 14 Social Composite 9 25 Speech Composite 16 16 Symbolic Composite 9 50 Total Score 5 16 Note : CA = chronological age Table 312. Baby D CSBS DP Behavior Sample Percentile Rank Results Age CSBS DP Section Sample 1 CA 12 Sample 2 CA 14 Social Composite 5 37 Speech Composite 16 50 Symbolic Composite 5 16 Total Score 5 27 Note : CA = chronological age

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58 Figure 3 1. Baby A CSBS DP Behavior Sample Percentile Rank Results (CA = chronological age) Figure 32. Baby B CSBS DP Behavior Sample Percentile Rank Results (CA = chronological age)

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59 Figure 33. Baby C CSBS DP Behavior Sample Percentile Rank Results (CA = chronological age) Figure 34. Baby D CSBS DP Behavior Sample Percentile Rank Results (CA = chronological age

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60 CHAPTER 4 DISCUSSION Prelinguistic Development Speech Production Results from the CSBS DP Caregiver Questionnaire Speech Scale show that all four infants produced speech within normal limits at their chronological ages of 12 and 14 months. The Speech Scale reports scores on the infants speech sound production, including a consonant inventory and syllable productions, as reported by the inf ants mother. According to the CSBS DP Caregiver Questionnaire, b y 12 months chronological age, each infant was producing the consonants [m, n, b, d]. Interestingly, Baby B was the only infant to not expand his consonant inventory by the age of 14 months when the second CSBS DP Caregiver Questionnaire was administered. Although the infants scores on The CSBS DP Behavior Sample Speech Scale fell within normal limits at the infants chronological ages of 12 and 14 months, the Behavior Sample scores reveal ed different results The infants did not produce [m] or [n] during the samples. Baby A produced primarily alveolar and velar stops; Baby B produced bilabial stops; Baby C did not produce any speech sounds during either sample; and Baby D, who didnt pro duce any speech sounds during the sample taken when his chronological age was 12 months, produced alveolar and velar stops when the sample was taken at 14 months chronological age. The CDI Vocabulary Production score reports results regarding the infants word production. Based on the results from both ages (10 and 14 months chronologically) the infants demonstrated word production within normal limits. These results are

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61 consistent with the results from the CSBS Caregiver Questionnaire Speech Scale which also reports on word production. Language Comprehension The CDI Phrases Understood and Vocabulary Compr e hension scores report information on the infants comprehension of phrases and single word vocabulary comprehension, respectively All four infants re sults for these two CDI sections fell within normal limits at both test administrations (10 and 14 months chronological age. ) The results of the CSBS DP Caregiver Questionnaire Symbolic Scale are consistent with the CDI Vocabulary Comprehension results as this scale reports scores on single word understanding as well Results from the CSBS DP Behavior Sample Symbolic Scale which reports on comprehension of object names, person names, and body parts, are not consistent with either the CDI Phrases Understood and Vocabulary Comprehension scores or the CSBS DP Caregiver Questio nnaire results Nonverbal Communication Skills The CDI reports scores on Early Gestures Later Gestures and Total Gestures These sections include questions on gestures, games, actions and pretend play. Based on results at the infants chronological age of 10 months, Baby A, Baby C, and Baby D all exhibited early gestures, such as reaching and pointing, and also game playing and combining actions with objects. Baby B, who had a percentile rank of 15, did not exhibit game playing and demonstrated limited combinations of actions plus objects. His score, however, increased to the 99th percentile when it was scored using his adjusted age (8 months.) By 14 months chronological age, all fo ur infants had scores on the CDI Early Gestures, Later Gestures, and Total Gestures that fell within normal limits. The CSBS DP Caregiver Questionnaire Social Scale reports information on gestures. At the

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62 infants chronological age of 12, Baby A had the lowest CSBS DP Caregiver Questionnaire Social Scal e (25th percentile); however, this score still fell within normal limits. At 14 months chronological age, all four infants results on the Social Scale remained within normal limits, however, Baby Bs scor e decreased from the 75th percentile at 12 months chronological age to the 63rd percentile at 14 months chronological age. Also, Baby Cs score remained the same (50th percentile.) Both infants did not demonstrate any notable gesture development from 12 to 14 months of age based on their mothers report on the CSBS DP Caregiver Questionnaire. Based on the CSBS DP Behavior Sample Social Scale, Baby B, Baby C, and Baby D demonstrated gesture inventories that fell below normal limits at their chronological age of 12 months. The infants only demonstrated the reaching gesture during the sample, with the exception of Baby D who also demonstrated a pointing gesture. However, the second Behavior Sample, which was taken at the infants chronological age of 14 mont hs, indicated that all four infants had gesture inventories that were within normal limits. At this age, they demonstrated a variety of gestures, including waving, shaking head, showing and pushing away. The CSBS DP Behavior Sample allows for observation of other nonverbal communicati on skills, such as eye gaze and joint attention On the first sample taken when the infants chronological age was 12 months, Baby B, Baby C, and Baby D had Social Composite scores that fell below the norm. However, it is im portant to note that the infants all exhibited eye gaze and joint attention behaviors, including gaze shift, gaze follow, shared positive affect, behavior regulation, and social interaction. These behaviors were also demonstrated during the second Behavior S ample taken when the

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63 infants chronological age was 14 months. The CSBS DP Caregiver Questionnaire also indicated, based on the infants mothers report, that all four infants demonstrated eye gaze and joint attention behaviors since the infants chron ological age was 12 months. How the Participants Performance Relates to Typical Development and what is Expected of Infants with LBW, Short Gestation, and Multiple Birth Status Research by Bishop and Bishop (1998) indicates that it is not uncommon for twi n siblings to develop idiosyncratic phonological rules which suggest use of private language. Work by Zubrick et al. (2007) documents the extent to which premature infants can present with atypical and/or delayed speech and language development. Based on such findings, it was thought at the outset of the study that t he infants who participated in the present study might be at risk for the same or similar types of developmental problems. These patterns, to date, have not been realized however. That is, t he participants have yet to demonstrate any idiosyncratic prelinguistic patterns. Thus the present findings underscore the concept of individual differences among multiple birth children. Although many such children exhibit marked differences in commu nication development when compared to singletons, not every child does. The only delays noted in the present study occurred when the participants speech and gesture development tasks were scored using norms based upon their chronological age. It is widel y felt that such an approach penalizes children who are born prematurely, and indeed that seemed to be the case in the present study. All of the delays that were suggested through the use of chronological age norm references were no longer present when scores were referenced against the infants adjusted age, w ith the exception of one score (Baby Bs Later Gesture percentile rank on the CDI .)

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64 Foundation for Research Longitudinal case studies allow for extensive observation of a particular population. In this case, the longitudinal study allowed for an indepth look at communicationrelated behaviors and general development within a set of LBW and premature quadruplets. Studies into the early communicative development of higher order multiples, such as t riplets and quadruplets, is limited. In fact, to our knowledge, this is the first study in which these issues have been examined in a quadruplet set. Therefore, this study provides preliminary information regarding the prelinguistic development of this p opulation using standardized testing and observation. Limitations One of the goals of this research was to observe a set of LBW and premature quadruplets in their natural environment in order to report data on prelinguistic development, including speech a nd gesture development, during the first year of life. The part icipants were video recorded within their home with caregivers, siblings and other volunteers present. Although this environment provides advantages to observing natural behavior; it also provides disadvantages. One disadvantage concerns the logistic of conducting the video recordings with this population. In short, it is very difficult to execute high quality recordings of four siblings simultaneously. This became apparent as the investigat or attempt ed to review and analyze recordings made in this study. Once the analysis commenced, it became apparent that background noise levels were loud enough to make it difficult to determine which infant was verbalizing at a particular time and what the infant was verbalizing. In future research, this issue might be resolved by fitting each infant with a microphone.

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65 Such an approach would reduce the effect of background noise (i.e. from other infants and other family members) on the quality of the rec ordings. One aspect of prelinguistic development the investigator wanted to analyze using the video recordings was babbling development. However, w hen the video recordings were reviewed it became apparent that not only was it difficult to determine who was babbling and what the sounds were. Al so, also the frequency with which the infants were babbling during recording times made it difficult to collect useful samples. It is also important to note that t his type of longitudinal study requires time commitment and responsibility from the parents. Although the participants parents were timely with filling out the required standardized tests and adhered quite closely to the basic procedures for recording and completing the parental reports, external factors, such as having to take care of the participants older siblings, made it challenging for them to devote as much time and attention to the project as they may have otherwise been able to do. Thus, i t would benefit future studies of this type to have a dedicat ed researcher or research assistant, such as a graduate student clinician, present to help deal with such factors. Both the CDI and the CSBS DP Caregiver Questionnaire rely on parental report. Although this is a practical way to gather information on an infants developmental history, it also has some limitations as parents and caregivers may not remember accurately or understand the behaviors being assessed. With this longitudinal case study, the parents of the participants had to complete questionnai res on all four of their infants which poses even further possibility for parental error when reporting on the development of each child.

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66 Clinical Application As pediatric professionals encounter infants with multiple birth status, it becomes necessary for them to have an adequate understanding of the infants development across all systems, including speech and language development. Providing pediatric professionals, such as pediatricians, speech pathologists, neonatal nurses, and more, with information r egarding prelinguistic development should educate them on important developmental differences, if any, they should expect. The results from this study begin to address these differences within one set of multiple birth infants. Future Research and Direc tion Data collection included weekly video recordings taken within the participants natural environment. This video footage has potential to also be analyzed and classified according to communication and play behaviors. The results of coding the informa tion in this way could benefit both pediatric professionals and parents as it could be used to create an educational tool defining the prelinguistic development of LBW, premature, and multiple birth infants. The video recordings provide actual examples of specific behaviors and when put together with an informational book may be a practical way to educate those involved with the prelinguistic development of not only LBW, premature, and multiple birth infants, but also typically developing infants. Clinicia ns sometimes rely on parent report when evaluating infants. Parents are a reliable resource; however it would be interesting to know how reliable their reports are as compared to formal testing. Data for this study was collected from the standardized assessments in two ways; (a) caregiver questionnaires; and (b) formal testing completed by a graduate student clinician. This could allow for a future study to be done on the relationship between caregiver questionnaires and formal testing. It would

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67 be interesting to see how the results of caregiver questionnaires relate to the r esults of formal testing (e.g. A re the results of both the caregiver questionnaires and formal testing completed by a professional similar? Does one report delay and the other repor t no delay?).

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68 CHAPTER 5 CONCLUSION When a family disco vers they are expecting a child, several questions and concerns are raised. These questions and concerns take on a new, scary and exciting twist when parents discover they are expecting more than one child, when the child is delivered premature, and/or when the child is born at a low birth weight. Their search for education may include questions regarding the prelinguistic development of their infant(s) and what the significance of different behavior s mean. Given the lack of research regarding these populations it appears necessary to investigate further the prelinguistic development of multiple birth infants. This longitudinal case study of a set of premature, low birth weight quadruplets should pr ovide the appropriate preliminary data regarding this important period of development. The results and future research expanding upon what was attained may benefit parents and pediatric professionals by providing education and information they both deserv e regarding prelinguistic development of infants with multiple birth status

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69 LIST OF REFERENCES American Society for Reproductive Medicine (2006). Multiple Pregnancy Associated with Infertility Therapy. Fertility and Sterility 86(4) Elsevier Inc Apgar V (1953) A Proposal for a New Method of Evaluation of the Newborn Infant. Current Researches in Anesthesia and Analgesia, 32(4), 260267 Austin, J.L. (1962) How to do Things With Words. Cambridge: Harvard University Press. Bates, E. (1976) Lang uage and Context: The Acquisition of Pragmatics. New York: Academic Press, Inc. Bishop, D.V.M., & Bishop, S.J. (1998). Twin Language: A Risk Factor for Language Impairment? Journal of Speech, Language, and Hearing Research, 41, 150160. Calandrella, A. M., & Wilcox, M. J. (2000). Predicting Language Outcomes for Young Prelinguistic Children with Developmental Delay. Journal of Speech, Language, and Hearing Research, 43, 10611071. Capone, N. C., & McGregor, K. K. (2004). Gesture Development: A Review for Clinical and Research Practices, Journal of Speech, Language, and Hearing Research, 47, 173186. Crais, E.R., Douglas, D.D., & Cox Campbell, C. (2004). The Intersection of the Development of Gestures and Intentionality. Journal of Speech, Language, and Hearing Research, 47, 678694. Crais, E. R., Watson, Linda R., & Baranek, Grace T. (2009). Use of Gesture Development in Profiling Childrens Prelinguistic Communication Skills. American Journal of SpeechLanguage Pathology 18, 95 108. Delgado, C. E. F., & Vagi, S. J. (2004). Early Risk Factors for Preschool Speech and Language Impairments. Poster Presentation, International Conference on Infant Studies. May 2004. Chicago, IL. Fenson, L, Marchman, V., Thal, D., Dae, P., Reznick, S. & Bates, E. (2006) Mac Authur Bates Comm unication Development Inventory, Second Edition. Baltimore: Brookes: Keith, L.G., Cervantes, A., Mazela, J., Olesczuk, J.J., & Papiernik, E. (1998). Multiple Births and Preterm Delivery. Prenatal and Neonatal Medicine, 3, 125 129. Martin, J., MacDorman, M., & Mathews, T.J. (2007). Triplet Births: Trends and Outcomes, 19711994. National Center for Health Statistics. Vital and Health Statistics 21(55).

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70 Martin, J., & Park, M. (1999). Trends in Twin and Triplet Births : 1980 97. National Center for Health Statistics. Vital Health Statistics 47(24). Martin, J., Hamilton, B. E., Sutton, P. D., Ventura, S. J.., Menacker, F., Kirmeyer, S., & Mathews, T.J. (2009). Births: Final Data 2006. National Center for Health Stati stics. Vital Health Statistics 57(7). Miller, C. (2006). Developmental Relationships Between Language and Theory of Mind. American Journal of SpeechLanguage Pathology 15, 142154. Mundy, P. & Newell, L. (2007). Attention, Joint Attention, and Cognit ion. Current Directions in Psychological Science, 16 (5), 269274. National Institute of Child Health and Human Development ( 2002) Even Moderately Premature Birth Poses Risk for Developmental Delays Retrieved from http://www.nichd.nih.gov/news/releases/premature_risk.cfm Oller, D.K. (1980). The emergence of the so unds of speech in infancy. In G. Yeni Komshian, J.F. Kavanagh & C.A. Ferguson (Eds.), Child Phonology (1st ed., pp 93 112). New York, NY: Academic Press. Reilly, S., Wake, M., Bavin, E. L., Prior, M., Williams, J., Bretherton, L., Eadie, P., Barrett, Y., & Ukoumunne, O. C. (2007). Predicting Language at 2 Years of Age: A Prospective Community Study. Pediatrics 12 0(6), 14411449. Shumway, S., & Wetherby, A. (2009). Communicative Acts of Children with Autism Spectrum Disorders in the Second Year of Life. Journal of Speech, Language, and Hearing Research, 52, 11391156. Stark, R.E. (1980). Stages of speech development in the first year of life. In G. Yeni Komshian, J.F. Kavanagh & C.A. Ferguson (Eds.), Child Phonology (1st ed., pp. 93 112). New York, NY: Academic Press. Stoel Gammon, C., & Otomo, K. (1986). Babbling Development of Hearing Impaired and Normally H earing Subjects. Journal of Speech and Hearing Disorders 51, 33 41. Templeton, A. & Morris, J. K. (1998). Reducing the Risk of Multiple Births by Transfer of Two Embryos After In Vitro Fertilization. The New England Journal of Medicine, 339(9), 573577 Thal, D. & Tobias, S. (1994). Relationships Between Language and Gesture in Normally Developing and LateTalking Toddlers. Journal of Speech, Language, and Hearing Research, 37, 157170. Watt, N., Wetherby, A., & Shumway, S. (2006). Prelinguistic Pre dictors of Language Outcome at 3 Years of Age. Journal of Speech, Language, and Hearing Research, 49, 12241237.

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71 Wetherby, A., & Prizant, B. (2002). Communication Behavior and Symbolic Scales Developmental Profiles: First Normed Edition Baltimore: Brookes. World Health Organization. (2007). International Classification of Diseases and Related Health Problems : Tenth Revision. Geneva: World Health Organization. Zubrick, S. R., Taylor, C. L., Rice, M. L., &Slegers, D. W. (2007). Late Language Emergence at 24 Months: An Epidemiological Study of Prevalence, Predictors, and Covariates. Journal of Speech, Language and Hearing Research, 50, 15621592.

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72 BIOGRAPHICAL SKETCH Kristen M. Lewandowski received her Master of Arts from the Department of Communicatio n Sciences and Disorders at the University of Florida in August of 2010. She received her Bachel ors Degree in Linguistics at Oakland University in Auburn Hills, Michigan During that time she spent a semester studying French in Orl ans, France and focus ed her undergraduate thesis in linguistics studies on French phonology. After receiving her bachelors degree in 2007, she went on to post bachelors studies in Communication Sciences and Disorders at Wayne State University in Detroit, Michigan. In fall of 2008 she began graduate studies within the Department of Communication Sciences and Disorders at the University of Florida.