Prevalence, co-occurring difficulties, and risk factors of developmental language disorder: first evidence for Mandarin-speaking children in a population-based study.

Background: Developmental language disorder (DLD) is a condition that significantly affects children's achievement but has been understudied. We aim to estimate the prevalence of DLD in Shanghai, compare the co-occurrence of difficulties between children with DLD and those with typical development (TD), and investigate the early risk factors for DLD. Methods: We estimated DLD prevalence using data from a population-based survey with a cluster random sampling design in Shanghai, China. A subsample of children (aged 5-6 years) received an onsite evaluation, and each child was categorized as TD or DLD. The proportions of children with socio-emotional behavior (SEB) difficulties, low non-verbal IQ (NVIQ), and poor school readiness were calculated among children with TD and DLD. We used multiple imputation to address the missing values of risk factors. Univariate and multivariate regression models adjusted with sampling weights were used to estimate the correlation of each risk factor with DLD. Findings: Of 1082 children who were approached for the onsite evaluation, 974 (90.0%) completed the language ability assessments, of whom 74 met the criteria for DLD, resulting in a prevalence of 8.5% (95% CI 6.3-11.5) when adjusted with sampling weights. Compared with TD children, children with DLD had higher rates of concurrent difficulties, including SEB (total difficulties score at-risk: 156 [17.3%] of 900 TD vs. 28 [37.8%] of 74 DLD, p < 0.0001), low NVIQ (3 [0.3%] of 900 TD vs. 8 [10.8%] of 74 DLD, p < 0.0001), and poor school readiness (71 [7.9%] of 900 TD vs. 13 [17.6%] of 74 DLD, p = 0.0040). After accounting for all other risk factors, a higher risk of DLD was associated with a lack of parent-child interaction diversity (adjusted odds ratio [aOR] = 3.08, 95% CI = 1.29-7.37; p = 0.012) and lower kindergarten levels (compared to demonstration and first level: third level (aOR = 6.15, 95% CI = 1.92-19.63; p = 0.0020)). Interpretation: The prevalence of DLD and its co-occurrence with other difficulties suggest the need for further attention. Family and kindergarten factors were found to contribute to DLD, suggesting that multi-sector coordinated efforts are needed to better identify and serve DLD populations at home, in schools, and in clinical settings. Funding: The study was supported by Shanghai Municipal Education Commission (No. 2022you1-2, D1502), the Innovative Research Team of High-level Local Universities in Shanghai (No. SHSMU-ZDCX20211900), Shanghai Municipal Health Commission (No.GWV-10.1-XK07), and the National Key Research and Development Program of China (No. 2022YFC2705201).

The development of a parent report instrument of early communication and language skills of infants and toddlers in mainland China.

OBJECTIVE: This study was designed to produce a new parent-report measure, the Diagnostic Receptive Expressive Assessment of Mandarin-Infant Toddler Assessment of Communication and Language (DREAM-IT) in order to provide norms for the developmental skills of children aged 0-36 months in four areas: expressive language, receptive language, cognitive play and social skills. METHODOLOGY: The scale was designed to be both broader and deeper than existing instruments that neglect one or more of these significant domains involved in early language. Items were chosen by a group of specialists with clinical experience working with the age group and with attention to the developmental literature. Caregivers were tested individually by a trained person who asked the questions and provided examples. In addition to an extensive health questionnaire, caregivers answered questions in Mandarin about their child's behaviour using a scale of 'not yet', 'sometimes' or 'always' or listing out words and/or sounds understood or said by the child. The 476 participating caregivers were recruited at maternal and child healthcare clinics centred in Chengdu, China, 191 of whom were tested a second time seven months later. The children were sampled in three-month age-bands from 0 to 36 months. The sample was balanced for child gender by age band, and parental education was balanced. Caregivers of 0-24-month-old children and caregivers of 12-36 months were each asked a different set of questions, to determine the appropriate age range and cutoff points for each question, requiring the sample size to be doubled for children aged 12-24 months. RESULTS: The results were subject to item-response theory analysis to remove outlying items, and the resulting internal reliability was high for each domain (average Cronbach's alpha=0.87). The final instrument (between 67 and 113 questions in total) was refined to include the least redundant questions that had the highest intercorrelations, with attention paid to coverage of all domains across the age range. Two scales were developed: one for children 0-18 months, the second for children aged 18-36 months. The longitudinal design permitted the creation of growth curves and norms for each domain for six-month intervals from 0 to 36 months. A small sample of 32 parents of children with Down syndrome aged 18-36 months provided validation that the scales are highly sensitive to developmental delay. CONCLUSION: The instrument shows considerable promise for detecting early communication problems in children in China. WHAT THIS PAPER ADDS: What is already known on the subject In China, efforts were made in recent years to develop language assessments for infants and toddlers, but limitations existed with the domains included and number of items included per age group. Many clinical practitioners also continued to rely on language subtests of general developmental scales, which were limited in depth and breadth of language skills tested and were never intended for diagnosis of language delay. What this paper adds to existing knowledge This paper discusses the development of a valid caregiver report instrument for early communication and language skills of infants and toddlers in mainland China. The Diagnostic Receptive Expressive Assessment of Mandarin-Infant Toddler (DREAM-IT) includes foundational domains necessary for language and communication development in young children (receptive language, expressive language, cognitive play and social communication domains). The results show strong internal reliability (Cronbach's alpha) for each domain on a sample of 716 children sampled in three-month age bands from 0 to 36 months. The external validity proved strong when tested on a group of 32 young children with Down syndrome. What are the potential or actual clinical implications of this work? Besides helping to inform the diagnosis of language delays in infants and toddlers in China, the caregiver report instrument has special features to support clinical practitioners in a field that is just emerging in China. The unique support features include the automatic generation of a profile of relative strengths and weaknesses of the child on the report and the recommendation of child-specific caregiver coaching videos on a companion app.

The characteristics of spontaneous language in young children identified as language delayed in Mandarin.

BACKGROUND: Little is known about the spontaneous speech characteristics of young children with language delay in Mandarin, relative to their peers. Until the recent development of standardized language assessments normed in China on Mandarin-speaking children, it was difficult to independently identify atypically developing children to study their spontaneous speech, and only case studies have been available. AIM: To investigate which aspects of spontaneous speech might be distinctive for atypical development in a short play session. METHODS & PROCEDURES: A total of 86 Mandarin-speaking children, boys and girls aged 2;6-4;6, were tested using the new standardized assessment for Mandarin, Diagnostic Receptive Expressive Assessment of Mandarin-Comprehensive (DREAM-C), at a major urban hospital in China. Of the children, 39 were identified by DREAM-C as atypically developing in language development (Total Standard score M = 72, SD = 8.9), and 47 scored in the typical range (Total Standard score M = 103, SD = 10.8), using the four scales of Receptive, Expressive Semantics and Syntax. All children then took part in a 15-min semi-structured play session during which their spontaneous speech was recorded by professionals. A variety of games and pictures were used in an attempt to elicit spontaneous questions, negatives and descriptions. Their recorded speech samples were then coded by linguists directly into a database in FilemakerPro for different aspects of vocabulary, sentence variety and grammatical morphemes/structures heard. OUTCOMES & RESULTS: The results describe the characteristics of the speech samples for the typical and atypical groups for age groups 2;6-3.5 (N = 52) and 3;6-4.6 (N = 34). Vocabulary diversity was indicated on an ordinal scale ranging from simple communicative signals including headshakes and words such as 'hi' to 'a rich variety of different content words'. Grammatical diversity similarly ranged from 'only yes/no answers', through to the appearance of multi-clause sentences. Morphosyntax was coded in terms of which morphemes were observed at all in the session, such as aspect markers (LE, ZAI, GUO), and nominal morphemes (DE, GE), and also whether function words such as pronouns, Wh-questions and classifiers were singular or varied in the session. There is considerable optionality in morpheme expression in Mandarin, so measurements such as the percentage supplied in obligatory contexts, though useful for languages such as English, are harder to compute. Nevertheless, the data show change over age in all these aspects of language, and reveal what a typically developing child might be expected to produce in a 15-min sample in such a session. For example, it was rare for the typically developing children by age 3.5 not to have at least simple sentences with some function words, and to use adjectives, nouns and verbs, unlike the children with atypical scores. The morphemes DE, LE and GUO showed significant differences in likelihood across groups for both ages, but BA and ZAI were significantly different only for the older age group. In contrast, GE was common in all groups. The atypical group has markedly lower frequency in several grammatical aspects such as the use of diverse questions, classifiers and pronouns, with much less change across age groups, implying slower growth. The results provide useful information on the relative likelihood of observing different varieties of words, sentence types and morphemes in a short speech sample, which are substantially different in the typical versus atypical groups in both age bands, and change over age. CONCLUSIONS & IMPLICATIONS: These data validate the DREAM-C classifications, but the details can also be used to inform the choice of targets for intervention for young children who experience delays in Mandarin language acquisition. WHAT THIS PAPER ADDS: What is already known on the subject Spontaneous language samples have been used as a means of studying language in China. However, because of the amount of training and time required to transcribe and analyse spontaneous language samples, there is not yet a sufficient basis for identifying language differences between children with and without language disorder in mainland China. What does this paper add to existing knowledge After using DREAM-C to provide an objective measurement of children with and without language disorders, an easy-to-administer spontaneous language assessment protocol and scoring record form allowed the comparison of the spontaneous language of 39 children with atypically developing language with 47 children who scored in the typical range to observe language differences between those with and without typical language development. What are the potential or actual clinical implications of this work? The study documents differences in vocabulary and sentence variety, and use of different morphemes such as classifiers, passives and aspect markers to aid in choosing targets for intervention by demonstrating the path of development. In addition, the spontaneous language assessment protocol and scoring record form holds promise for allowing clinicians and researchers to more easily study the language of individual children to personalize intervention, but also of groups of children to understand the emergence of basic Mandarin linguistic features.

Research to Establish the Validity, Reliability, and Clinical Utility of a Comprehensive Language Assessment of Mandarin.

Purpose: With no existing gold standard for comparison, challenges arise for establishing the validity of a new standardized Mandarin language assessment normed in mainland China. Method: A new assessment, Diagnostic Receptive and Expressive Assessment of Mandarin (DREAM), was normed with a stratified sample of 969 children ages 2;6 (years;months) to 7;11 in multiple urban and nonurban regions in northern and southern China. In this study of 230 children, the sensitivity and specificity of DREAM were examined against an a priori judgment of disorders. External validity was assessed using 2 indices of language production for different age groups. Results: External validity was assessed against spontaneous language indices (correlation range: r = .6-.7; all ps < .01) and narrative indices (overall: r = .45, p < .01). Sensitivity (.73) and specificity (.82) of DREAM are moderate to good using a priori judgment as the standard. The values improved to .95 and .82 when spontaneous language and narratives were added to a priori judgment to define typicality. Divergent validity was moderate with nonlinguistic indices. Conclusion: DREAM holds promise as a diagnostic test of Mandarin language impairment for children aged 2;6 to 7;11.

New language outcome measures for Mandarin speaking children with hearing loss.

OBJECTIVE: The paper discusses recent evidence on the assessment of language outcomes in children with hearing loss acquiring oral language. METHODS: Research emphasizes that language tests must be specific enough to capture subtle deficits in vocabulary and grammar learning at different developmental ages. The Diagnostic Receptive and Expressive Assessment of Mandarin (DREAM) was carefully designed to be a comprehensive standardized Mandarin assessment normed in Mainland China. RESULTS: This paper summarizes the evidence-based item design process and validity and reliability results of DREAM. A pilot study reported here shows that DREAM provided detailed information about hearing impaired children's language abilities and can be used to aid intervention planning to maximize progress. CONCLUSION: DREAM represents an example of translational science, transferring methods from empirical studies of language acquisition in research environments into applied domains such as assessment and intervention. Research on outcomes in China will advance significantly with the availability of evidence-based comprehensive language tests that measure a sufficient age range of skills, are normed on Mandarin speaking children in mainland China, and are designed to capture features central to Mandarin language acquisition.