Title: Measuring Pragmatic Skills: Early Detection of Infants at Risk for Communication Problems

Mie Cocquyt¹, Maurice Yves Mommaerts², Hazel Dewart³ and Inge Zink⁴

¹University College Ghent, Ghent/Vrije Universiteit Brussel, Brussels, Belgium

²Universitair Ziekenhuis Brussel/VUB, Brussels, Belgium

³University of Westminster, Department of Psychology, London, UK

⁴KU Leuven, Department of Neurosciences, ExpORL, Leuven, Belgium

Running Title: Screening instrument to evaluate pragmatic skills

Keywords: Pragmatics, screening, instrument development, assessment, children

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Abstract

Background: For the early detection of children who are at risk for communication problems,

we need appropriate assessment instruments. Two Dutch-language standardized screening

instruments are available: the Dutch version of the Non Speech Test (NNST) and the Dutch

version of the MacArthur-Bates Communicative Development Inventories (N-CDIs). These

instruments gauge the precursors of language development, early vocabulary, and early

morphosyntactic skills. However, they do not adequately assess pragmatic skills.

Aims: The goal of the presented research was to develop a norm-referenced instrument, to

examine the pragmatic skills of Dutch-speaking infants, that is translatable into other

languages.

Methods and Procedures: The instrument: ‘Lists for the Evaluation of Pragmatic Skills in

infants’ is based on ‘The Pragmatics Profile of Everyday Communication Skills in Children’

published by Dewart and Summers in 1995. We translated the instrument into Dutch and

transformed the structured interview format into a parent questionnaire. The parent

questionnaire - Evaluatie van Pragmatische Vaardigheden, (EPV) - was created following

extensive research on item selection, norm table development, and reliability and validity

studies. The EPV1 is applicable to children 6 to 15 months old, and the EPV2 is applicable to

children 16 to 30 months old.

Outcomes and Results: We developed norm tables for the number of pragmatic skills

achieved by the child and also for how and to what extent the skills are exhibited. For the

norming study of EPV1 and EPV2 we included respectively 390 and 534 infants. The

reliability scores are high for both lists. Concept validity and criterion validity studies

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demonstrate adequate results for the overall lists, the sub-scale components and specific

items.

Conclusions and Implications: The parent questionnaire is a valuable tool that specifically

targets pragmatic skills in infants. The instrument can detect communication delays in

infants. It is translatable into other languages and avoids the infant having to be examined

by a stranger.

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Introduction

Delayed communication development is the most common type of developmental disability

and affects approximately 5% to 10% of children under three years of age (Rossetti, 2001).

Several researchers, e.g., Girolametto (1995), Rossetti (2001), Alston and St James-Roberts

(2005), and Cross (2011), have stressed the importance of prevention, early detection, and

early intervention for speech, language, and social problems. Despite these insights,

researchers have only recently come to realize that the functional aspects of language (i.e.,

pragmatics - the way children learn to use language in a social context) are as important for

speech and language development as the formal linguistic aspects (i.e., phonology,

semantics, morphology, and syntax).

Language acquisition is the product of social interactions between the child and their

parents and caregivers (Hulit & Howard, 2002). Lund and Duchan (1983) found that the

traditional approach to linguistic diagnostics within a clinical setting provided a limited view

of communication skills and suggested the need for a thorough evaluation of pragmatic skills

(Dewart & Summers, 1995).

This observation led to a worldwide search for ways to identify signs of communication

problems, e.g. the development of the ‘Parental Interview Schedule’, which was published in

1973 by Mogford. This schedule formed the basis for the structured interview called ‘The

Pragmatics Profile of Everyday Communication Skills in Children’ (Dewart & Summers, 1995).

This instrument maps the communication skills of toddlers and preschoolers and provides a

view of their communicative behavior in everyday situations outside of the clinical setting.

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Other instruments to detect early signs of communication problems, which were developed

for the English language, include the ‘Rossetti Infant-Toddler Language Scale’ (ITLS)

published in 1990 (Rossetti, 2001), the ‘Ward Infant Language Screening Test, Assessment,

Accelerations, and Remediation’ (WILSTAAR) published in 1992 by Ward (Alston & St.-James-

Roberts, 2005) and the ‘MacArthur Communicative Development Inventories’ (CDI)

published in 1993 (Fenson et al, 1993). Some recently developed instruments included either

parental interviews or parent questionnaires e.g. the Clinical Evaluation of Language

Fundamentals-Preschool, second edition (CELF-P-2) published by Semel, Wiig and Secord in

2004 and the Language Use Inventory (LUI) for Young Children, published in 2007 by O’Neill.

Language development research had previously established the validity and reliability of

parental reports (Fenson, Dale, Reznick, Bates, Thal & Pethick, 1994), particularly when

assessment is limited to current and emergent behaviors and a recognition format is used

(Fenson et al., 1993).

The CELF-P-2 is an American standardized, norm-referenced test that assesses language

ability in children aged 3:0 to 6:11 years. The instrument evaluates a broad range of

language skills including a pre-literacy scale, a phonological awareness subtest and a parent-

questionnaire to obtain information about the child’s language use at home and in school.

The subtests of the CELF-P-2 provide norms in six-month increments. The Pragmatics Profile

(parent-questionnaire format) is descriptive, but not norm-referenced (Semel, Wiig, &

Secord, 2004, www.pearsonclinical.com).

The LUI is a Canadian standardized, norm-referenced parent-report measure of pragmatic

language development for children between 18 and 47 months old and provides norms in

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six-month intervals (O’Neill, 2007; Pesco & O’Neill, 2012). It consists of three major parts: 1:

The child’s communication with gestures, 2: The child’s communication with words and 3:

The child’s communication with longer sentences. Every major part consists of respectively

two, three and nine (a total of 14) subscales covering a number of sample items (O’Neill,

2007).

The development of instruments to detect early signs of communication problems among

infants and toddlers in the Dutch language has been a more recent endeavor. Researchers at

the Catholic University of Louvain have developed two instruments for children with a

communication level under two years of age: the Dutch version of the Non Speech Test,

‘Nederlandstalige Non Speech Test’ (NNST), published by Zink and Lembrechts (2000) and

the Dutch version of the MacArthur Communicative Development Inventories,

‘Nederlandstalige Communicative Development Inventories’ (N-CDIs), published by Zink and

Lejaegere (2002). Both instruments evaluate different language aspects and their precursors.

The N-CDIs focus on early language comprehension, vocabulary, and morphosyntax. Both

instruments are useful for the early detection of communication problems. However, the

Dutch language still lacks an instrument that thoroughly examines the development of

pragmatic skills.

In 1999, a study entitled ‘The Effect of the Parent-Focused Approach (PFA) on

Communication Skills in Children with Cleft Lip and Palate’ was started in Flanders (the

Dutch-speaking region of Belgium), with the aim of improving the communicative outcomes

of children with cleft lip and palate. In this study, parents are trained to use strategies

developed by the Hanen Centre, as described in Pepper and Weitzman (2004), the Baby Talk

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Program (Ward 2000) and the Parent-Focused Intervention from Girolametto (Sprintzen &

Bardach, 1995). To measure the effect of the PFA, we needed an instrument to measure

pragmatic skills in infants and toddlers. This need provided the motivation for the

development of such an instrument.

The English language ‘Pragmatics Profile of Everyday Communication Skills’ (Dewart and

Summers, 1995) appeared to be an adequate tool to examine pragmatic skills, but had not

been standardized. Despite this disadvantage, this instrument has significant value. We

compared the content of this instrument with the existing literature and other instruments

available at that time. We used this instrument as the basis for the development of our new

Dutch language screening instrument (i.e., parent questionnaire): ‘EPVs: Lijsten voor

Evaluatie van Pragmatische Vaardigheden‘, (Cocquyt & Zink, 2010) which translates in

English to ‘Lists for the Evaluation of Pragmatic Skills’. We added this ‘s’ after the

abbreviation 'EPV' to indicate that the instrument contains two lists. In this paper we

describe how the tool was developed and how we assessed its quality.

Aims

Our aim was to develop a valid, reliable, and standardized instrument to examine the

pragmatic skills of very young Dutch-speaking children. This instrument needed to meet the

following criteria:

- measure the development of pragmatic skills in children between the ages of 6 and

30 months to detect the risk of communication problems;

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- integrate with the existing Dutch version of the MacArthur Communicative

Development Inventories: ‘Nederlandstalige Communicative Development

Inventories’ (N-CDIs) from Zink and Lejaegere (2002);

- be suitable for different clinical groups (e.g., language delay and language disorders,

cleft lip and palate, intellectual disability, autism spectrum disorders);

- apply to the entire Dutch-speaking region (i.e., Flanders and The Netherlands);

- have potential for translation into other languages.

Methods

In early 2000, we initiated the development of a screening instrument for the early detection

of communication delays in Dutch-speaking children at risk of communication problems.

Before the study started, permission for the project was given by the Commission for

Medical Ethics of the St. John's Hospital in Bruges. Following significant research, the new

screening instrument, called the EPVs, was ready to be used. In the following section, we

describe the development of the instrument, the instrument itself, the use of the instrument

and its psychometric background.

Development of the EPVs

We decided to take the instrument ‘Pragmatics Profile of Everyday Communication Skills in

Children’ (Dewart & Summers, 1995) as a basis for the development of the EPVs because of

its content and its four-part structure: A) communicative intentions (which are distributed

among different communicative functions); B) response to communication; C) interactions

and conversations; and D) contextual variations.

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In order to achieve a high level of content validity, we followed a strict procedure for the

development of the instrument. Converting the English structured interview into a parent

questionnaire was not an easy task, and only taken after long and careful consideration and

in several stages. The first stage was translating the interview 'Pragmatics Profile of Everyday

Communication Skills in Children' into Dutch by six persons. One of them ensured that the

language forms were usable for both Flanders and the Netherlands. In this way the EPVs

could be used throughout the Dutch language area. This was subsequently examined by

experts and users in the Netherlands. One Dutch language version arose from the various

translations, which was translated back into English by a native speaker of English and a

linguist. The linguist compared the final version with the original instrument. In the second

stage, we converted the translated structured interview into a parent questionnaire. We

interviewed the parents of 10 children between 0 and 4 years. Based on their answers,

supplemented with examples from the original instrument, data in the literature, a survey of

fourteen scientists and experts on the field of health care, five single case studies and

personal experiences, a first version of the parent questionnaire was developed. The experts

gave advice to take into account the specific characteristics of communication in children

with special needs (e.g. autism, motor, auditory and visual disabilities). In the third stage, we

presented this first version of the questionnaire to the parents of 83 children between 0 and

4 years. On the basis of the answers, we split the list into age categories: the EPV1 for babies

from 6 to 15 months and the EPV2 for toddlers from 16 to 30 months. The two lists were

differentiated by the level of verbal performance (one word utterance in EPV1, combination

of words in EPV2), and degree of difficulty of the items and examples. The age categories

were purposely chosen to cover the age range of the N-CDI/Words and Gestures (EPV1) and

the age range of the N-CDI/Words and Sentences (EPV2). The fourth stage consisted of a

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further refinement (adding some new questions, deleting others or reformulating questions)

based on a second review of the fourteen experts, parent feedback and trials that led to a

final version. In the fifth stage, we collected normative data and evaluated reliability and

validity of the EPVs.

Description of the EPVs

The EPVs consist of a manual, two parent questionnaires, score forms, percentile charts and

tables, and a decision-making scheme. A Microsoft Excel tool is included to automatically

calculate the raw and percentile scores and the age equivalents for each child. Each list

includes a total of 37 items that are divided between the four categories A: communicative

intentions (17 items in EPV1 and 18 items in EPV2), B: response to communication (8 items

in EPV1 and 7 items in EPV2), C: interactions and conversations (6 items in EPV1 and 7 items

in EPV2) and D: contextual variations (6 items in EPV1 and 5 items in EPV2). Table 1

enumerates all of the pragmatic skills that are evaluated by the EPV1 and/or EPV2.

Insert Table 1 here

All questions in the parent questionnaires have the same structure (for examples, see Fig. 1

in the Appendix). Each of the main questions is first answered with 'yes' or 'no'. The score for

‘yes’ responses can be compared with scores in the table of norms to determine whether

the child has developed an appropriate number of pragmatic skills for his/her age. This

constitutes the quantitative assessment. In addition, for 'yes' responses, parents are asked

to indicate on a 5-point Likert scale how and to what extent the statement applies to the

child’s reaction on that item. The Likert scale responses generate numerical scores, but since

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these represent the degree of development, they indicate whether the child demonstrates a

type of communication (non-verbal or verbal) that is appropriate for their age. Therefore we

call this a qualitative assessment. Non-verbal skills include emotional expressions (e.g.

smile), looking behaviors, and movements or gestures. Verbal skills may be pre-linguistic

vocalisations (e.g., sounds and varied babbles) or vocalizations with a symbolic function (e.g.,

proto-words, real words, and word combinations).

Application and scoring of the EPVs

The application and scoring of the EPVs can be executed by any professional that works with

children, e.g., speech and language therapists, educators, psychologists, general medical

practitioners, pediatricians, team members of the Flemish agency, called Kind en Gezin

(Child and Family), executives from daycare centers and services for child minders. The EPVs

can serve as a first screening when doubt about the child’s communicative development

arises. The screening serves as an intermediate step that avoids having the child examined

directly by a stranger.

A professional (in one of the disciplines described above) administers the questionnaire to

the parents or another caregiver who knows the child well. The professional calculates the

raw and percentile scores and the age equivalents for the completed questionnaire using the

Microsoft Excel tool. The professional can also calculate developmental delays using the

norm tables, which make it possible to identify how far a child differs from the majority of

children of the same age. The decision-making schemes provide an indicator whether further

assessment and intervention may be needed: whether there is (1) no problem; (2) a need for

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follow-up (monitoring the development of the child); or (3) a need to refer the child for

further assessment. A percentile score (pc) of 50 means that the child’s performance is

average. A pc score between 10 and 50 and/or a delay of less than 4 months on all parts of

the instrument suggest that the child is developing somewhat more slowly than peers but

problems should not be assumed. We suggest a follow-up in case of a score less than pc 10

or a delay of at least 4 months for the quantitative assessment and for multiple or all parts

of the qualitative assessment. Immediate referral is recommended in case of pc < 10 and a

delay of 4 months for all scores on the quantitative and qualitative assessments. We

recommend caution, however, with any presumption of a communicative problem. Close

collaboration with one or more experts who are specialized in pragmatics is of the greatest

importance for the interpretation of the EPV scores. An expert also can interpret the

contextual information from the D-items. These items provide information on contextual

variations such as: with whom, at what time of the day, in what situations and on what

subject the child communicates more. This information must be taken into consideration in

the treatment plan. The information from the completed parent questionnaires suggested

that context influences communication skills in younger children (EPV1) more than in older

children (EPV2). Hence, starting therapy in a trusted environment may be particularly

important for younger children.

We recommend always using the instruments EPVs and N-CDIs together, to provide a fuller

picture of a child’s problems in language development. The N-CDI questionnaires provide

information about the language forms that the child has already developed. The EPV

questionnaires provide a better idea of how, when, and with whom the child uses these

language forms.

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Psychometric background

The development of a clinical instrument requires careful research to determine the final

selection of items and coherence in the test components. In addition, standardization and

evaluation of quality must follow to demonstrate adequate reliability and validity (McCauley,

2001). In the following section we describe the development of norm tables for the EPVs and

the evaluation of their psychometric properties.

Development of norm tables

A total of 924 children participated in the normative study of the EPV1 and EPV2: 390

children for the EPV1 (186 boys and 204 girls) and 534 children for EPV2 (269 boys and 265

girls). We divided the norm groups into age categories of two months, which resulted in five

age categories for the EPV1 and eight age categories for the EPV2. Children with low birth

weight as well as children with general development problems were excluded from the

study. The sample consisted almost exclusively of monolingual Dutch-speaking children.

However, 13 of the 924 children (1.4%) were receiving a bilingual education. These children

were evenly distributed among the different age groups. The children were recruited from

nurseries, child minders, and randomly selected families in cities, as well as municipalities

and hamlets throughout the Flemish provinces. Children from the Brussels region were not

included in the study because of the larger probability of non-Dutch speakers. As an

indicator of the child's socioeconomic status (SES), we used the highest educational

achievement of one or both parents. We distinguished the following three groups: SES1:

Secondary school not completed, SES2: Secondary school completed, SES3: at least one year

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of higher education at University College or University completed. Table 2 shows the

distribution of SES for the EPV1 and EPV2.

Insert Table 2

SES information was available for the majority of children (877/924). SES 1 is weakly

represented for both EPV1 and EPV2, and SES 2 is clearly less well represented than SES 3.

The underrepresentation of children from SES 1 has less importance for the interpretation

and development of norm tables, because it is not the intention to provide separated tables

for each SES. All backgrounds are represented in all norm tables.

Norm tables for the quantitative and qualitative assessments of the EPV1 and EPV2 were

compiled on the basis of the results of this study. For the quantitative assessment, a total of

four norm tables were developed for each EPV based on the yes/no questions from

categories A, B, and C separately and combined.

For the EPV1 qualitative assessment, a total of six norm tables were developed. These were

based on the total Likert scale scores for questions related to non-verbal and verbal

behavior; non-verbal behavior only; verbal behavior only; emotional expressions; looking

behavior; and movements and gestures. The latter three categories represent different

aspects of non-verbal behavior. Only one norm table was developed for the EPV2 qualitative

assessment, based on the total Likert scale score for questions related to verbal behavior. It

was not possible to compile a norm table for non-verbal behavior on the EPV2 because

parents did not always complete the sub-questions about non-verbal behavior. They

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appeared to focus only on verbal behavior and no longer notice non-verbal communicative

signals from the moment that their child started talking.

Table 3 presents the mean and standard deviation (SD) for total scores on the EPVs

(maximum 37) according to age and gender, together with the results of statistical

comparison (F and p-values) according to gender. There was no significant difference

between genders except for the age group 24-25 months, so we did not develop separate

norm tables for boys and girls.

Insert Table 3 here

Evaluation of the EPVs

To evaluate the instrument, we examined item difficulty, reliability and validity.

Item difficulty

We calculated item difficulty for both EPV1 and EPV2 using the proportion of positive

responses (P) on each item. A percentage of 30% to 70% (.30 < P <.70) means that the item

differentiates well, because there are as many children who master the skill as children who

do not. Tables 4 and 5 respectively show the proportions (P) of positive responses on the

items of EPV1 and EPV2 (for all age categories together and separately). As expected the

number of difficult items decreases by age and the number of easy items increases.

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Insert Tables 4 and 5 here

From Table 4 we can deduce that 24% of the items differentiate well between the children of

the total test group. Table 5, on the other hand, shows that the items for the age category

16-30 months are too easy as far as the 'yes-no' questions are concerned. Only 3% of the

items differentiate well between the children of the total test group, and 81% of the items

are acquired by > 90% of all the children. However, we see some exceptions. Item 11 (let the

child know what happened while you were not there?) differentiates best for the ages 16-17

m, 18-19 m, 20-21 m and 22-23 m. For children from 16 to 17 months item 25 (Does the

child react when you ask it to wait?) also differentiates well. Most items on the EPV2 gauge

basic pragmatic skills. Therefore they may be better evaluated by the qualitative assessment.

For example, it is important to determine whether the older child continues to exhibit

pragmatic skills in a non-verbal way or in a simple verbal way rather than with age-

appropriate verbal expressions. Nevertheless measures that yield ceiling performance (and

therefore fail to differentiate abilities in typically developing children) may be clinically

informative because they can identify children who have deficits in these very basic

pragmatic skills.

Reliability

To examine reliability we assessed internal consistency and inter-rater agreement. To test

the internal consistency of the EPV1 and EPV2 we calculated the Cronbach's alpha

coefficient. The results, presented in tables 6 and 7, exhibit that the reliability of the EPV1

and EPV2 is more than sufficient: Cronbach's alpha values ranged from 0.88 to 0.99 for the

EPV1 and from 0.90 to 0.99 for the EPV2.

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Inserts Tables 6 and 7 here

Inter-rater reliability

To test inter-rater reliability, we calculated the Kappa coefficient (κ). We conducted a pilot

study in an inclusive nursery (ordinary nursery with full facilities for all children, with or

without developmental problems), to measure the inter-rater reliability of the EPV2. It was

intended to calculate the inter-rater agreement between three observers: the parent(s), the

nursery teacher and the researcher. Because some parents of children with special needs

had not completed all the questions and sub-questions, we could not use their data.

Therefore we could only compare the scores of two observers (the regular nursery teacher

of the group and a nearly graduated speech therapist, called the researcher). They

completed the EPV2 for five typically developing toddlers between 21 and 30 months of age

(mean = 25.6; SD = 3.72) and five children with special needs: 1) tuberous sclerosis complex

and autism, 2) speech and language problems, 3) presumption of an X-linked Alpha

Thalassaemia Mental Retardation Syndrome (ATRS-X), 4) epilepsy and fever after birth,

presumption of autism spectrum disorder, and 5) developmental communication problems

with concomitant social and emotional problems. These five children were between 27 and

40 months of age (mean 33; SD = 5.79) and had a developmental age between 16 and 30

months. The first observer knew the children very well. The second observer did not, but she

observed and also helped in the nursery during 12 sessions of five hours over a period of 3.5

months prior to the assessment. She was then ready to complete the EPV2 questionnaire at

the same time (but independently) of the first observer. We calculated the Kappa coefficient

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(κ) for each yes-no question, for the sub-scale scores from items A, B, C, and D and also for

the total score of the 37 items. As presented in table 8, we found a Kappa value < 1 for only

9 items. Following Fleiss (De Moor & Van Maele, 2009), only the Kappa value of A7 is weak, 3

items (A9, C 28 and C36) had a moderate Kappa value, 2 items (A2 and B23) had moderate

to good value, 2 items (B25 and C30) had a good value (almost excellent) and for 1 item

(A10) the Kappa value was excellent.

Insert Table 8 here

Kappa values were also calculated for the 4 sections of the EPV2 and for the total of the 37

items. According to Fleiss (De Moor & Van Maele, 2009), the Kappa value of subscales B (κ =

0.535) and D (κ=0.630) are moderate to good, but the value for the subscales A (κ = 0.277)

and C (κ = 0.306) and also for the total of the list (κ=0.158) are weak.

Validity

To examine the validity of the EPVs, we focused on content validity, construct validity and

criterion validity (specifically, concurrent validity).

Content validity

For content validity, we refer the reader to the appropriate and strictly followed methods

and procedures for the development of the instrument.

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Construct validity

To measure construct validity, we examined the age differentiation and coherence of the

four test components and employed the contrasting groups method.

Age differentiation

The norm tables (not included in the article, but available from the authors) for the EPV1 and

EPV2 show that the difficulty level of both lists increases with age. The raw scores are

normally distributed across all age categories, except for the oldest group in the quantitative

assessment score on the EPV1.

Coherence of the four test components

The coherence among various components of the EPVs was calculated using partial

correlations, controlling for age. For EPV1 and EPV2, we calculated the coherence between

the different components (A, B, C and D-items; see tables 9 and 10). Inter-correlation

coefficients below .30 are generally considered weak, .30 to .69 moderate and .70 to 1 high

(Brace, Kemp & Snelgar, 2006). Moderate inter-correlation coefficients were found for the

EPV1 (r between .30 and .56, p < 0.001), except for the correlation between C- and D-items

(r .28, p < 0.001). Moderate inter-correlation coefficients were also found for the EPV2

between the A, B and C-items (r between .40 and .57, p < 0.001). However inter-correlation

coefficients between these three components (pragmatic skills) and D items (contextual

variations) were weak (r between .25 and .26, p < 0.001). The D items (contextual variations)

are not pragmatic skills, but can provide important information for the treatment plan and

choice for indirect therapy.

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Insert Tables 9 and 10 here

Contrasting groups method

We employed the contrasting groups method in pilot studies of three clinical groups:

children with cleft lip and palate, children with Down's syndrome and children with autism

spectrum disorder (ASD). These studies showed that the pragmatics profile of each clinical

group differed from the others, a finding which is consistent with the literature and

contributes to construct validity. Details of these comparisons are not described here, but in

a separate article that focuses on construct validity of the EPVs evaluated by the 'contrasting

groups method'.

Criterion validity (Concurrent validity)

To evaluate the concurrent validity of the EPVs, we chose two standardized instruments, the

NNST (Zink & Lembrechts, 2000) and N-CDIs (Zink & Lejaegere, 2002). The EPV1 was

administered concurrently with the N-CDI/Words and Gestures (N-CDI/W&G) and the NNST

in 28 typically developing children between the ages of 10 and 16 months. The EPV2 was

administered concurrently with the N-CDI/Words and Sentences (N-CDI/W&S) and the NNST

in 22 typically developing children between the ages of 17 and 22 months.

In our evaluation of concurrent validity, we looked at the overall consistency between tests,

then consistency between comparable test components, and comparable items within these

instruments. We considered correlation coefficients below .30 weak, .30 to 0.60 moderate

and .70 to 1 high (Brace, Kemp & Snelgar, 2006). In this paper we only report the observed

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levels of significant correlations that provide the key evidence for concurrent validity of the

EPVs, but all details and full tables are available from the authors.

As Table 11 shows, correlations for EPV1 were largely moderate to strong, indicating good

concurrent validity. Correlations were high (r= .70 to.80) between the EPV1 total scores for

‘Verbal Behaviour’ and ‘Qualitative Assessment’ and almost all the scores for ‘Gestures’ of

the N-CDI/W&G. We found a high correlation (r= .75) between the EPV1 total score for

‘Quantitative Assessment’ and ‘Early gestures’ of N-CDI/W&G. Correlations between the

EPV1 total score for ‘Non-Verbal Behaviour’ and the other instruments were always

moderate (r = .32 to 57).

Insert table 11

Looking at comparable components of EPV1 ‘Non-Verbal Behaviour’ and N-CDI/W&G

‘Gestures’, all correlations were again moderate (r = .40 to .66), except between the

components ‘Movement and Gestures’ (EPV1) and ‘Early Gestures’ (N-CDI/W&G), which was

high (r = .70).

Focusing in on specific items of the EPV1, we see some interesting correlations, for example

for item A8 (Giving meaning/naming something) and item 31 (Interest in Booklets) and the

other instruments.

Table 12 shows that the EPV1 item A8 correlates moderately (r = .46 to .69) to highly (r = .70

to .75) with all sub-scores for the N-CDI/W&G and NNST. We see high correlations (r= .70

to .75) between item A8.6 (using proto/word-like forms for ‘giving meaning, naming’) and

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item A.8.7 (using words for ‘giving meaning, naming’) and N-CDI/W&G ‘Late gestures’ and

also high correlations with N-CDI/W&G ‘Total gestures’ (r= .71).

Insert table 12

In table 13 we see that the EPV1 item C31 ‘interest in booklets’ correlates moderately (r .38

to .69) to highly (r= .71 to .87) with the N-CDI/W&G and the NNST. Item C31.8 (using

proto/word-like forms to express interest) and C31.9 (using words to express interest)

correlate highly with the N-CDI/W&G ‘Vocabulary Comprehension’ (r= .74 to .87) and also

with the NNST ‘Expressive scale’ (r= .78 to .81) and the NNST ‘Total scale’ (r= .71).

Insert table 13

Besides these correlations the EPV1 item A8 also correlates moderately (r= .45 to.60) with 6

items of the NNST (mostly from the ‘Expressive scale).

Turning to the EPV2, Table 14 shows that the correlations were weaker, with only moderate

correlations found between the EPV2 ‘Verbal Behaviour’ and the N-CDI/W&S ‘Vocabulary

Comprehension’ (r= .48) and ‘Vocabulary production’ (r = .60) and the NNST subscale

’Expressive Language’ (r =.43). However, specific items/components show closer relations,

for example item A8 (Giving meaning/naming something).

22

Insert table 14

In Table 15 we see moderate correlations (r=.47 to .63) between EPV2 item A8.7 (Giving

meaning/naming something, by using existing words) and almost all components of the

other two instruments. The EPV2 item A8.6 (Giving meaning/naming something, by using

word-like forms) moderately correlates (r= .43 to .46) with all sub-scales of the NNST.

Insert table 15

Besides these correlations we also found moderate correlations (r= .44 to .62) between the

EPV2 item A8.6 and A8.7 (Giving meaning/naming something, using word-like forms as well

as existing words) and 9 items from the NNST.

Looking at the overall consistency and the consistency between subscales and comparable

components of the instruments, we clearly see indications for concurrent/criterion validity

for EPV1, but less evidence for EPV2. However, looking at the consistency of comparable

items within the instruments, we also see satisfactory evidence for the EPV2.

Discussion

Due to the lack of a Dutch language instrument to measure pragmatic skills in infants and

toddlers, we developed a new screening instrument (‘EPVs: Lists for Evaluation of Pragmatic

Skills’) using a parent questionnaire format. The development of the instrument, following

23

careful procedures, was a lengthy process. The research has its strengths and weaknesses

which we will discuss below.

The strengths are that we followed carefully considered and very strict procedures for the

translation of the structured interview 'Pragmatics Profile of Everyday Communication Skills

in Children', the conversion of the translated structured interview into a parent

questionnaire, the item selection, the two survey/feedback rounds with fourteen scientific

and health care experts, five single case studies and the choice of Dutch words (used in

Flanders and the Netherlands) to ensure that the instrument could serve for the entire

Dutch-speaking area.

Regarding the results, we see strengths in reliability, with high internal consistency for both

EPV1 and EPV2. Although most of the Kappa values for inter-rater reliability were excellent

or moderate to high, we also see some low values for some items which is a weakness that

will be considered below. Other strengths are the satisfactory results in construct validity

and concurrent validity. The set of normative data makes it possible to identify how far a

child differs from the majority of children of the same age. The instrument provides an

indicator whether or not further assessment and intervention may be needed. In addition

the Microsoft Excel tool (for automatic calculation of the scores) makes the new instrument

user-friendly.

However there are also some weaknesses. The analysis of the assessment of inter-rater

agreement was intended for parent(s), the nursery teacher and the almost graduated

speech therapist, but the scores of the parents were incomplete. For this reason we could

24

not use them. The scores of the two observers, who completed the questionnaires fully,

showed that the differences in the scores only appeared in the observations of three of the

children with special needs. For nine items with a Kappa value <1, the nursery nurse gave a

score ‘no’ (for at least one of the three children), while the researcher gave a score ‘yes’. The

qualitative analysis exhibited that the researcher sometimes noticed emotional expressions,

looking behavior, movements and gestures, and sounds. Perhaps this is explained by the fact

that she was an almost graduated speech therapist, and thus trained in recognizing minimal

(and often non-verbal) communicative signals of children with special needs. In addition, she

was also trained in the application of principles to stimulate the communicative

development of young children. We learned that it is necessary to give enough oral and

written explanation about possible minimal communicative signals. For children with special

needs, it is recommended that an expert helps the parents or care givers to complete the

questionnaire. In addition, it is also important to evaluate inter-rater reliability with

involvement of parents. It is possible that parents, as well as nursery staff/teachers, may

score ‘no’ because they fail to notice the minimal communicative signals, resulting in low

scores that lead the child to be referred for further assessment. If this is a true case of delay,

the child is detected early and early intervention is possible. The parents can be trained to

recognize the signals and to use strategies to improve interactions and language in the child.

Regarding SES, we see that SES 1 is weakly represented, but this can partially be explained by

compulsory schooling till the age of 18 years. As a result, many parents get at least SES 2.

Although the normative data that we provide are based on large samples and are very

useful, a more exact sampling of the population is required in order to achieve a full

standardization.

25

Regarding the norm tables of the EPV2, we only could compile a norm table for verbal

behavior (qualitative assessment) because parents did not always complete the sub-

questions about non-verbal behavior. This could be seen as a weakness. However, where a

child aged 16 to 30 months is recommended for immediate referral for further examination

based on the EPV2, it is recommended that the EPV1 is also administered in order to

evaluate non-verbal skills and also to calculate the age equivalent for the child.

The length of the lists may be viewed as a disadvantage of the instrument. However, our

experience during the administration of the EPVs, which were administered concurrently

with the N-CDIs, did not reveal the length of the list as a disadvantage. Parents wanted to

complete the questionnaire and viewed the questionnaire as a chance to track the

development of their child.

The EPVs have to be considered as a screening instrument, not as a diagnostic test.

Decision-making schemes are constructed to guide next steps according to the child’s

results: no problem, follow-up, or immediate referral. The information about contextual

variations can serve as additional information that may contribute to differential diagnosis

and help to refine an intervention plan.

During the period that the EPVs were developed, the LUI (O’Neill 2007) and the CELF-P-2

(Semel, Wiig, & Secord, 2004) were published. The LUI (18-47 months) overlaps with the age

category of the EPVs (6-30 months) and is also norm-referenced. Much of the content and

examples of our instrument are recognizable in the LUI, but the construction of this

26

instrument is different (e.g. use of gestures, use of words and longer sentences to express

different communicative functions). The age range of the CELF-P-2 (3:0 to 6:11 years) does

not overlap with the age range of the EPVs. The CELF-2-P also contains a parent survey

although this questionnaire is not norm-referenced. The content of the survey (non-verbal

communication skills, the declarative/representative communication function and

conversation function) is similar to the EPVs and is also surveyed on the basis of a 5-point

Likert scale. Compared with the LUI (O'Neill 2007), the CELF-P-2 (Semel, Wiig, & Secord,

2004) and the ‘Pragmatics Profile of Everyday Communication in Children (Dewart &

Summers, 1995), we see that the uniqueness of the screening instrument EPVs lies in the

combination of age range, scope of questions on pragmatic behaviours, and the

quantification of performance.

Based on the results of the current investigations, several areas of further research have

emerged. First, our results suggest the need for an EPV3 that includes the evaluation of

more difficult or complex skills, which will ensure a wider differentiation among the age

groups. We propose that this should be developed and standardized for children between

the ages of two and five years. Second, further research is needed to determine whether

children with special needs are detected earlier and receive more targeted intervention

(with involvement of parents), if they are screened with the EPVs than if they are only

detected at the point when the problem is obvious. An impact measurement could also

verify whether their final outcome is better than if they were detected without the

information from the EPVs. A further goal for future research is to extend evidence on the

usability and in formativeness of the EPVs among different clinical groups. Finally, the EPVs

27

lend themselves to translation into other languages with appropriate cultural adjustments if

necessary.

Conclusions

We fulfilled the objective of creating the EPVs to examine the pragmatic skills of very young

Dutch-speaking children. The new instrument is well-founded and reliable. The provision of a

set of normative data makes it possible to identify how far a child differs from the majority

of children of the same age. The data provide very useful guidelines for expected

performance in each age range and indicate whether further assessment and intervention

may be needed.

The uniqueness of the EPVs lies in the combination of age range, scope of pragmatic

behaviours rated, and the quantification of performance. These elements make the EPVs

original and potentially valuable in other languages. Through the EPVs, we hope to

contribute to the prevention and early detection of communication problems in children

who are vulnerable to delays in communication development.

Acknowledgements

This study was supported by the ‘Federaties van Centra voor Ambulante Revalidatie’

(Federations of Outpatient Rehabilitation Centers, http://www.revalidatie.be) and the

‘Adviesraad Wetenschappelijk Onderzoek’ (Scientific Research Advisory Board) of the

Flemish forming and training service Sig vzw. We thank all of the parents who completed the

parent questionnaires as well as the parents of the five children who participated in the case

studies (Matteo, Robbe, Lisa, Anna and Lana). We also thank all of the experts, students (of

28

the University College Ghent and the Catholic University of Louvain), and other participants

who contributed to the development of the EPVs. Also thanks to Prof. Annemie Desoete of

Ghent University and Prof. Paul Corthals of Ghent University and University College Ghent

for the help with the statistical analysis and interpretation of the results. Thanks to Prof.

Herbert Roeyers, for his specific advice regarding item selection and his help in developing

the scoring system. Also a big thank you to Mr. Tony Markus, Consultant Maxillofacial

Surgeon, Nuffield Hospital, Bournemouth (UK) for the content and linguistic advice. We

thank the parents of Hilde Gielkens (†2005) for providing us with all the data that their

daughter had collected.

29

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32

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33

Table 1: Overview of pragmatic skills in the EPV1 and EPV2

A. Communicative intentions 1. Attention directing (representation function)2. Requesting (control function) 3. Naming (representation function) 4. Commenting (representation function) 5. Asking and giving information (representation function) 6. Greeting (social function)7. Self-expression: expressing emotions (expression function)8. Protesting/rejecting (control function) 9. Asserting independence (control function)B. Response to communication 1. Interest in interactions 2. Understanding of gestures:3. Understanding the intents of the speaker4. Anticipating 5. Responding to ban/postponement C. Interactions and conversations 1. Participating in interactions/games 2. Initiating interactions/contact 3. Maintaining interactions and conversations 4. Terminating a conversation/interaction/contact 5. Repairing a conversational break down 6. Joining in peer activities 7. Showing interest in bookletsD. Contextual variations 1. Events (e.g., responding with amusement) 2. Using sounds/language during play 3. Person with whom the child is interacting4. Situation 5. Time of day 6. Topic

Table 2: Distribution of SES for EPV1 and EPV2

SES for EPV1 & EPV2 Secondary School Number of parents for EPV1

Number of parents for EPV2

SES 1 Not completed 13 34

SES 2 Completed 72 116

SES 3 At least one year of higher education

completed

290 352

34

Unknown 15 32

Total 390 534

Table 3: Mean and SD for pragmatic skills (maximum 37) according to age category and gender, with F and p-values for comparison according to genderSex N= Average Standard deviation F (df, error)

SignificanceAge category 6;00-15;00 months (EPV1) boy 186 28.65 6.10 F (1, 388) = 0,514

p = .474 (NS) girl 204 29.08 5.826;00-7;00 months boy 41 22.51 6.25 F (1, 73) = 3.389

p = .70 (NS) girl 34 24.94 4.928;00-9;00 months boy 25 27.52 4.81 F (1, 63) = 1.907

p = .172 (NS) girl 40 25.55 6.0310;00-11;00 months boy 37 28.43 5.00 F (1, 68) = .709

p = .403 (NS) girl 33 27.42 5.0012;00-13;00 months boy 45 31.51 3.96 F (1, 99) = .000

p = .993 (NS) girl 56 31.52 4.2414;00-15;00 months boy 38 32.84 3.91 F (1, 77) = 2.041

p = .157 (NS) girl 41 33.98 3.12Age category 16;00-30;00 months (EPV2) boy 269 35.16 2.51 F (1, 532) = 1.422

p = .234 (NS) girl 265 35.42 2.5016;00-17;00 months boy 33 34.18 3.90 F (1, 59) = 1.013

p = .318 (NS) girl 28 33.14 4.1518;00-19;00 months boy 42 34.88 2.23 F (1, 78) = .200

p = .656 (NS) girl 38 35.11 2.2520;00-21;00 months boy 34 35.06 2.36 F (1, 68) = .155

p = .695 (NS) girl 36 34.78 3.4722;00-23;00 months boy 31 34.94 2.24 F (1, 73) = 2.124

p = .149 (NS) girl 44 35.59 1.6624;00-25;00 months boy 37 34.95 3.17 F (1, 70) = 8.2917

p = .004 (Significant) girl 35 36.60 0.8526;00-27;00 months boy 35 36.00 1.51 F (1, 58) = .307

35

p = .581 (NS) girl 25 35.76 1.8328;00-29;00 months boy 42 35.83 1.56 F (1, 81) = 1.467

p = .229 (NS) girl 41 3622 1.3330;00 months boy 15 35.47 1.81 F (1, 31) = .529

p = .473 (NS) girl 18 35.89 1.53

Table 4: Distribution of proportions (P) of positive responses on EPV1 for age categories together and separately

Age category P < .30 .30 < P < .70 P >.70Total group 5% 24% 71%

6-7m 16% 32% 52%8-9m 8% 32% 60%

10-11m 5% 27% 68%12-13m 3% 8% 89%14-15m 0% 5% 95%

Table 5: Distribution of proportions (P) of positive responses on EPV2 for age categories together and separately

Age category P < .10 .10 < P < .30 .30 < P <.70 .70 < P < .90 P > .90Total group 0% 0% 3% 16% 81%

16-17 m 0% 0% 5% 27% 68%18-19 m 0% 0% 3% 11% 86%20-21 m 0% 0% 2% 14% 84%22-23 m 0% 0% 3% 8% 89%24-25 m 0% 0% 0% 8% 92%26-27 m 0% 0% 0% 5% 95%28-29 m 0% 0% 0% 8% 92%

30 m 0% 0% 0% 5% 95%

Table 6: Cronbach's alpha coefficients for EPV1 for the total group and separate age categories

Age category

TOTAL

A:‘communicative

intentions’

B:‘response to

communication’

C:‘interactions & conversations’

D :‘contextual variations’

Total group

.99 .97 .96 .95 .91

6-7m .97 .95 .90 .91 .908-9m .98 .98 .95 .92 .88

10-11m .98 .96 .93 .92 .9012-13m .98 .97 .95 .95 .9214-15m .98 .97 .95 .94 .90

36

Table 7: Cronbach's alpha coefficients for EPV2 for the total group and separate age categories

Age category

TOTAL A:‘communicative

intentions’

B:‘response to

communication’

C:‘interactions & conversations’

D :‘contextual variations’

total group

.98 .97 .93 .93 .92

16-17 m .98 .97 .95 .93 .9218-19 m .97 .94 .91 .92 .9220-21 m .98 .96 .92 .92 .9222-23 m .97 .95 .92 .93 .9024-25 m .98 .97 .93 .93 .9326-27 m .97 .96 .91 .91 .9328-29 m .98 .97 .94 .94 .94

30 m .99 .98 .96 .94 .92

Table 8: Inter-rater agreement (Kappa) for the EPV2

Item item κ agreement

A2 Attention directing to events, objects, other people 0.615 Moderate-good

A7 Asking for information by seeing something new in the house 0.286 weakA9 Commenting on objects that are of interest of the child and

someone is putting it away.0.412 moderate

A10 Commenting on disappearance of objects 0.783 excellentB23 Anticipating on routine games or favorite rhymes 0.615 Moderate-

goodB25 Child's reaction when you ask it to wait: ' soon ' or ' one minute ' 0.737 goodC28 Maintaining an interaction or conversation 0.400 moderateC30 Conversational repair 0.737 goodD36 Time of the day on which the child is the most communicative 0.444 moderate

Κ = ≥ 0.75 is excellent; 0.40 ≤ Κ < 0.75 is moderate to good; Κ < 0.40 is weak

Table 9: Coherence of the four test components of the EPV1

B-items: ‘response to

communication’

C-items: ‘interactions & conversations’

D-items: ‘contextual variations’

A-items:‘communicative intentions’

.47** .45** .41**

B-items: ‘response to communication’

.56** .30**

C-items: ‘interactions & conversations’

.28**

37

** p < 0.001

Table 10: Coherence of the four test components of the EPV2

B-items: ‘response to

communication’

C-items: ‘interactions & conversations’

D-items: ‘contextual variations’

A-items:‘communicative intentions’

.57** .40** .26**

B-items: ‘response to communication’

.49** .25**

C-items: ‘interactions & conversations’

.25**

** p < 0.001

Table 11: Significant correlations between the total and subscale scores of the EPV1 and scores on the N-CDI/W&G and NNST for 28 typically developing children aged 10 to 16 months

Age: 10 to 16 months, (n=28) EPV1Total quantitative

Total ‘non-verbal’

Total ‘verbal’

Total qualitative

N-CDI/W&G

Sentence comprehension

0.60** 0.44* 0.58** 0.59**

Vocabulary Comprehension

0.46* - 0.51** 0.47*

Vocabulary production - - 0.73** 0.50**Early gestures 0.75** 0.55** 0.66** 0.70**Late gestures 0.55** 0.53** 0.80** 0.77**Total gestures 0.63** 0.57** 0.79** 0.79**

NNSTReceptive 0.53** 0.32 0.62** 0.55**Expressive - - 0.66** 0.45**Total 0.43* - 0.69** 0.56**

*p < 0.05 ** p < 0.01 - means non-significant correlation

Table 12: Significant correlations between the items A8.6 and A8.7 of the EPV1 and scores on the N-CDI/W&G and NNST for 28 typically developing children aged 10 to 16 months

Age: 10;00-16;00 months

(n=28)

EPV1 - Item 8: ‘giving meaning, naming’

A8.6 proto-words A.8.7 words

Sentence comprehension

.54** .55**

Vocabulary comprehension

.46* .57**

38

N-CDI/W&G Vocabulary production

.65** .63**

Early gestures .57** .49**

Late gestures .70** .75**

Total gestures .69** .71**

NNST

Receptive .61** .61**

Expressive .67** .66**

Total .69** .68**

* p<.05 ** p<.01

Table 13: Significant correlations between item C31 of the EPV 1 and scores on the N-CDI/W&G and NNST for the first age group

Age:10;00-16;00 months (n=28)

EPV 1 Item C31: Interest in booklets

C31.5

Movements & gestures

C31.8 proto-words C31.9

words

N-CDI:

W&G

Sentence comprehension

.51** .50** .44*

Vocabulary Comprehension

.41* .74** .87**

Early gestures .53** .46* .38*

Late gestures .48** .50** .58**

Total gestures .53** .50** .55**

NNST

Receptive .59** .63** .58**

Expressive .42* .81** .78**

Total .50** .69** .71**

*p < 0.05 ** p < 0.01

Table 14: Significant correlations between the total and subscale scores of the EPV2 and scores on the N-CDI/W&S and NNST for the 28 typically developing children aged 17 to 22 months

39

Age: 17 to 22 months, (n=22) EPV2Total ‘verbal’

N-CDI/W&S

Sentence comprehension -Vocabulary comprehension 0.48*Vocabulary production .60**Early gestures -Late gestures -Total gestures -

NNSTReceptive -Expressive 0.43*Total -

*p < 0.05 ** p < 0.01 - means non-significant correlation

Table 15: Significant correlations between the items A8.6 and A8.7 of the EPV1 and scores on the N-CDI/W&S and NNST for 22 typically developing children aged 17 to 22 months

Age: 17;00-22;00 months

(n=22)

EPV2 - Item 8: giving meaning, naming

A8.6 proto-words A8.7 words

N-CDI/W&S Vocabulary comprehension

- .47*

Vocabulary production

- .63**

NNST

Receptive .43* -

Expressive .46* .63*

Total .46* .55**

* p<.05 ** p<.01

40

Appendix

Fig. 1: Question A.1 as an example

A. 1. Does your child attract attention to themselves?No: go to the next question Yes: indicate how and to what extent

1 = never 2 = rarely 3 = sometimes 4 = often 5 = always

1.1 By emotional expressions: e.g. a certain intonation (enthusiastic or panicky), calling ever-louder till I look, an expression on the face, smile, laugh out loud, cry, rant or squealing

1 2 3 4 5

1.2 By looking behavior: e.g.: looking to me, making eye contact with me 1 2 3 4 5

1.3 By making movements or gestures: e.g. moving with the body, pulling on my clothes, creating sounds with toys, showing something, putting the hand on my face and turning it towards himself, clapping hands, etc.

1 2 3 4 5

1.4 With voice sounds: e.g. vowel-like or consonant like sounds, klak sounds with the tongue, growling or calling/screaming (' aah ', ' oh ', ' Hey '!)

1 2 3 4 5

1.5 With varied babbling series : e.g. ‘bababa’, ‘gedebe’, ‘wewewa’, etc. 1 2 3 4 5

1.6 With a protoword: e.g. ' taa ' (hi!) or ' keke ' (look hé) 1 2 3 4 5

1.7 With an existing Word: e.g. ' look ' 1 2 3 4 5

1.8 The most typical reaction of the child:

41