Screening for

Communication and
Continuing
Nursing
Cognitive Disorders in
Education
Series
Infants and Toddlers
Frances Scheffler Jeanel Burgess
Donald Vogel Tara Conneally
Rachel Astern Kathy Salerno
Pediatric nurse practitioners (PNPs) have a primary role in providing parent-inclusive well-child physical
and developmental examinations. Although routine physical examinations are well defined, developmental
assessments, including communication and cognition, are not. Currently a number of developmental
screening tests exist; however, none have become established as the “gold standard” for the primary
health care professional as none are convenient or time-efficient to employ. In particular, there is a need
for a screening tool that PNPs can use to evaluate early development in their youngest patients. This
article offers a screening instrument capable of being easily completed through parent interview in a
routine integrated well-child exam. The screening includes questions that probe communication and
cognition in infants and toddlers, and identifies atypical behaviors that are considered by developmental
specialists to be “red flags” and precursors to later communication and cognitive disorders. A brief
description of the nature of communication and cognitive disorders in young children is included.

n many medical settings, pediatric behaviors such as those found in chil-

Frances Scheffler, PhD, is Certified Speech-
Language Pathologist and Assistant Profes-
sor, Hunter College – CUNY, New York, NY.

Donald Vogel, AuD, MS, BA, is Certified

Audiologist and Assistant Professor,
Hunter College – CUNY, New York, NY.
Rachel Astern, MS, is a graduate of
Hunter College – CUNY, New York, NY.
Jeanel Burgess, MS, is a graduate of
Hunter College – CUNY, New York, NY.
Tara Conneally, MS, is a graduate of
Hunter College – CUNY, New York, NY.
Kathy Salerno, MS, is a graduate of
Hunter College – CUNY, New York, NY.
Note: The authors reported no actual or
potential conflict of interest in relation to
this continuing nursing education article.
Sally S. Russell, MN, CMSRN, Education
Director, Anthony J. Jannetti, Inc., dis-
closed that she is on the Advisory Board
for Roche/Abbott Labs.
The Pediatric Nursing Editorial Board
members reported no actual or potential
conflict of interest in relation to this con-
tinuing nursing education article.
The CNE Posttest
can be found
on pages 486-487.
I nurse practitioners (PNPs) have a
primary role in providing parent-
inclusive health examinations for
infants and toddlers during well-baby
visits. PNPs are well trained to admin-
ister physical examinations while
obtaining case history information
from the parent or caregiver. Beyond
the physical examination, PNPs are
expected to assess the developmental
(communication and cognition) status
of their young patients (New York
State Department of Education, 2004;
Sherwood, Brown, Vaunette, &
Wardell, 1997).
Early identification of developmen-
tal delays and disorders is crucial
(Guralnick, 1998). Many can be iden-
tified before the age of 24 months.
Delays and disorders that go undiag-
nosed and untreated put children
unnecessarily at risk for later poor
academic, social, and vocational
progress (Laing, Law, Levin, & Logan,
2002; Olswang, Rodriguez, & Timler,
1998; Ramey & Ramey, 1998;
Snowling, Adams, Bishop, & Stothard,
2001). Conversely, for many affected
children, early diagnosis leads to
appropriate treatment that, when initi-
ated during infancy and toddlerhood,
facilitates the emergence of many
skills that would otherwise lag behind
or fail to develop. Treatment also can
include goals to replace atypical
dren with autism, with behaviors that
are socially acceptable (Guralnick,
1998; Ward, 1999).
The American Academy of Pedia-
trics (AAP) (2001) recommends
developmental screenings for every
child on a regular basis during well-
child examinations, yet it is unknown
if such screenings are widely per-
formed. Although a number of screen-
ing tools exist (i.e., at least 11 are
available for use with children under 2
years of age), none are specifically
designed for the primary care practi-
tioner. None are convenient or time-
efficient for the PNP to employ during
well-baby visits (Nelson, Nygren,
Walker, & Panoscha, 2006). In addi-
tion, PNP educational curricula, as for
physicians and other primary health-
care providers, may only include cur-
sory preparation in these areas. PNPs
therefore need basic information
about early communication and cog-
nitive disorders, and a reliable screen-
ing procedure to identify those infants
and toddlers who should be referred
for further testing.
This article provides a brief
overview of typical and atypical com-
munication and cognitive develop-
ment in preschool-aged children (2.5-
5 years of age), describes the most
prevalent pre-linguistic precursors to
communication disorders that appear

PEDIATRIC NURSING/November-December 2007/Vol. 33/No. 6 473

in infants and toddlers, and suggests a
newly designed efficient screening
tool for PNPs to use during well-baby
visits in the first 24 months of life. The
screening tool relies on caregiver
observations of the child. It does not
require special toys or books and can
be completed seamlessly during each
routine well-child examination.
Typical and Atypical Language
and Cognitive Development in
Preschool-aged Children
Communication occurs when there
is an exchange of ideas between a
speaker and a listener. It is comprised
of several processes, including lan-
guage (the symbolic representation of
thoughts), speech (oral expression
using speech sounds to form words),
and gestures (i.e., facial expressions,
body language).
Cognition includes non-language
mental processes such as attention,
memory, and problem-solving abili-
ties. As the infant grows and matures,
communication and cognition develop
and interact with one another.
However, communication and cogni-
tion are comprised of separate sets of
mental functions. It is therefore em-
phasized that communication impair-
ments are separate and distinct from
cognitive impairments. These two
types of impairments are often co-
morbid. Impairments (i.e., delays or
disorders) in communication or cogni-
tion occur in approximately 8% of all
young children (National Institute of
Deafness and Other Communicative
Disorders [NIDCD], 2006).
Communication delays and disor-
ders. In preschoolers, communication
delays and disorders include any
atypical comprehension or production
of speech sounds (i.e., consonants
and vowels), words, phrases, or sen-
tences (American Speech-Language-
Hearing Association [ASHA], 2006;
Kent, 1994). Children with these con-
ditions may ignore or misunderstand
parental instructions and commands.
They may have few words, or exhibit
unintelligible speech. They may omit
many speech sounds or produce
unusual combinations of speech
sounds. Their vocabulary and gram-
mar develop slowly. They may grunt
or point to comment or request rather
than attempt to produce words. Some
children show disinterest in toys,
books, and games that other children
their age enjoy. Atypical social inter-
actions with family members and
peers are common. Children who are
considered shy, withdrawn, or prefer
to play alone may be speech and lan-
guage delayed or disordered. Young
474
children who exhibit aggressive
behaviors (e.g., biting, kicking,
tantrums) may, in fact, be frustrated
due to communication delays or dis-
orders.
Two groups of children display
communication delays or disorders
without cognitive delays or disorders:
(a) children who are ‘late talkers’
(Weismer, Murray-Branch, & Miller,
1994) and (b) children who have
Specific Language Impairment (SLI)
(Leonard, 1998). In infancy and tod-
dlerhood, these children exhibit simi-
lar communication and social behav-
iors. However, there are some subtle
differences.
Late talkers have better compre-
hension of spoken language than chil-
dren with SLI. They tend to under-
stand age-appropriate commands
whereas children with SLI may not.
Generally, both groups play appropri-
ately with toys, although children with
SLI tend to play on a more immature
level. Children who are late talkers
develop normal language skills during
their early school years. Children with
SLI have difficulty with language skills
throughout their school years and are
likely to exhibit reading and learning
disabilities as they mature (Weismer et
al., 1994).
Children who are late talkers and
children with SLI have normal hearing,
and age-appropriate nonverbal prob-
lem-solving skills. Both groups can
assemble age-appropriate puzzles.
These children have normal health
histories although otitis media with
effusion is common.
The speech-language pathologist
can differentiate between the young
child who is a late talker and the one
who will be SLI through extensive
standardized evaluation procedures.
However, the differentiation may not
be possible until after the age of 24-30
months: the late talker will begin to
show signs of “catching up” whereas
the child with SLI will continue to show
limited signs of language expansion.
Both groups nevertheless require
speech-language therapy. For the late
talker, the therapy will be short term.
For the child with SLI, it likely will be
long term. For both groups, the thera-
py focuses on developing language
skills, including those that will allow
positive interactions with peers so that
social isolation is minimized.
Cognitive delays and disorders.
Cognitive delays and disorders include
delays or deficits in problem— solving
skills, memory skills, and general
learning skills. Deficits in problem-
solving skills are exhibited as atypical
or delayed development of basic con-
PEDIATRIC NURSING/November-December 2007/Vol. 33/No. 6
cepts such as object permanence,
means-ends, and recognition of object
functions (Rice, 1983). Memory
deficits can be demonstrated as
reduced or absent fast-mapping abili-
ties (i.e., the ability to remember an
event after one instance of that event)
(Carey & Bartlett, 1978; Dollaghan,
1985). Deficits in general learning
skills occur as reduced ability to
acquire new skills or to generalize old
skills to new events comparably to
same-age cognitively normal peers
(Jepsen & VonThaden, 2002).
Preschool children with cognitive
deficits often play and interact similar-
ly to children who are chronologically
younger. Some may have positive
social interactions, but do not learn
simple tasks as quickly as their peers
(Nilholme, 1999). Others with cogni-
tive deficits may suffer atypical social
skills because of poor ability to assess
social situations, or atypical affect
(e.g., children with autism). Some
children with cognitive deficits may
have age-appropriate language skills
(e.g., children who are high function-
ing autistic). A number of children
with cognitive delays (e.g., some chil-
dren with mental retardation) have
cognitive deficits but normal lan-
guage.
Young children who have suffered
traumatic brain injury (TBI) may
demonstrate cognitive deficits in the
presence of normal language. They
may have age-appropriate vocabular-
ies and speak in well-formed sen-
tences. However, they have deficits in
nonverbal problem solving, and show
immature judgment in social situa-
tions.
Other children may exhibit com-
bined language and cognitive delays
or disorders. Cognitive disorders
occurring with language disorders
include some children with mental
retardation, most children with autism,
and some children with learning dis-
abilities (Tanner, 2003).
Communication and cognitive dis-
orders often are present in children
with physical impairments. Physical
disabilities that are commonly co-
morbid with communication or cogni-
tive disorders include hearing impair-
ment, visual impairment, cerebral
palsy, and other neuromuscular
impairments. Hearing impairment
affects language comprehension,
vocabulary and grammar develop-
ment, and speech production (Davis,
Elfenbein, Schum, & Bentler, 1986).
Visual impairments affect concept
development and may influence
vocabulary development (Recchia,
1997). Cerebral palsy affects the neu-
 Table 1. Common Conditions Co-Morbid with Language/Cognitive Disorders PNPs and Communication/
Cognitive Screenings
Condition Speech/Language/Cognitive Disorder PNPs are among the first profes-
Congenital, permanent hearing loss Language delay, speech disorders sionals to partner with parents. The
PNP can depend on the parent inter-
Otitis Media with Effusion and con- Language delay, speech disorders view as a source of accurate informa-
comitant conductive hearing loss tion about a baby’s behaviors and rou-
Autism Language disorder, cognitive disorder tines. Questioning parents in a case
history format about their child’s
Specific Language Impairment (SLI) Language disorder health is a standard procedure in med-
(often familial) ical practice. It is also a valid proce-
Cranio-facial disorders Speech disorders, language disorders, dure for determining the status of
cognitive disorders, hearing disorders communication and cognitive devel-
opment (Rescorla & Alley, 2001;
Cerebral palsy Speech disorders, language delay Stokes, 1997). As accurate observers
Poor social conditions (poverty, Language delay, language disorder of their child’s development, parents
parental substance abuse) become concerned should expected
behaviors occur rarely or not at all
Mental retardation Cognitive delay, language delay, speech (Billeaud, 2003). Parents notice atyp-
delays ical behaviors, too, and are relieved
when a primary care practitioner
responds to their concerns with advice
(AAP, Committee on Children with
romotor speech system that underlies or delayed emergence these behav- Disabilities, 2001).
coordination of respiration, phonation, iors are indicators of increased likeli- Although an array of language and
resonation, and articulation. Deficits in hood of later communication and cog- cognitive screening tests exist, few
these functions will affect speech intel- nitive delays and disorders. Speech- appear to be used currently in medical
ligibility. Children with speech motor language pathologists routinely ques- practices (Law, Boyle, Harris,
impairments are not necessarily lan- tion parents about the emergence of Harkness, & Nye, 1998; Nelson et al.,
guage impaired or cognitively im- pre-linguistic and early cognitive 2006; Sand et al., 2005; Sices,
paired. behaviors during communication Feudtner, McLaughlin, Drotar, &
Finally, language and cognitive assessments. Questions are based on Williams, 2004; Sturner et al., 1994).
delays and disorders may occur as a lists of commonly known develop- The screening tools available often
result of deprived social conditions. mental milestones. For example, even take 10 minutes or more to administer
Such conditions include children who before first words appear between the and many require the use of specific
are living in poverty (Fazio, Naremore ages of 12 to 15 months, typical toys and books to direct the observa-
& Connell, 1996) or in residence with infants smile, laugh, gurgle, babble, tion. Indeed, primary care practition-
parental drug or alcohol abusers point at desired objects, enjoy looking ers appreciate the need for communi-
(ASHA, 2003). Further, the likelihood at pictures and manipulating toys, and cation and cognitive screening tools,
of deficient communication and cog- begin to recognize some spoken yet they do not routinely include them
nitive development is increased for the words. In addition, very young infants in well-baby visits because the tools
child of a single teen-aged parent or a imitate facial expressions and body are too cumbersome or time-consum-
parent suffering from depression or gestures. These are important precur- ing. Although some screening tools
other mental illness (Coster & sors to the development of normal rely on parent report, none are
Cicchetti, 1993; Keown, Woodward, & language. designed specifically for primary care
Field, 2001; NICHD Early Child Care Conversely, many infants whose settings (Blackwell & Baker, 2002;
Research Network, 1999; Papero, communication skills will be poor later Dale, Bates, Reznick, & Morisset,
2005). In addition, some communica- on exhibit atypical pre-language 1989; Stokes, 1997; Sturner et al.,
tion and cognitive disorders have high behaviors. For example, some infants 1994). Currently, no available screen-
rates of incidence within members of are unusually quiet, show evidence of ing tool is considered to be a ‘gold
families and are therefore considered minimal babbling, vocalize with standard’ (Nelson et al., 2006).
to be genetically based (Shriberg et unusual sounds, or display limited By definition, a screening is a pro-
al., 2005). interest in family members, toys, or cedure that identifies a group as differ-
Table 1 summarizes the most com- books. These behaviors are alerts to ing from the larger population
mon conditions that are often co-mor- the presence of a disorder or a devel- (Nicolosi, Harryman, & Kresheck,
bid with language and cognitive disor- opmental delay. Similarly, other at-risk 2004). In the case of a communica-
ders. Despite these general guidelines, behaviors necessitating appropriate tion and cognitive screening, the tool
not all children with illnesses, injuries, investigation include minimal abilities must distinguish between children
high familial incidence, or deficient liv- to imitate, tendency to ignore people who have delays or disorders from
ing conditions exhibit poor communi- speaking, and failure to comprehend those who do not (Klee et al., 1998).
cation or cognitive skills. simple words and sentences that other A screening does not differentiate one
Screening for delays and disorders babies understand. Speech-language type of disorder from another. Rather,
in infants and toddlers. Typical pathologists routinely inquire about it must identify those children who are
infants and toddlers exhibit identifiable atypical behaviors that a parent or in need of a thorough evaluation, while
pre-linguistic and pre-cognitive be- caregiver may have observed in their screening out those who are develop-
haviors in developmental sequences child. Parent observations are impor- ing normally. In addition, the screen-
that are precursors to typical commu- tant as they are used as guidelines in ing must be brief enough for inclusion
nication and cognition. The absence assessing a child’s abilities. in a general physical examination.

PEDIATRIC NURSING/November-December 2007/Vol. 33/No. 6 475

 Figure 1. Screening for Communication and Cognition in Infants and Toddlers (SCCIT)

Screening for Communication
and Cognition in Infants and
Toddlers (SCCIT)
Presented here is the Screening for
Communication and Cognition in
Infants and Toddlers (SCCIT), which
is designed to be used by PNPs during
any or all well-baby examinations.
The tool is intended to quickly screen
infants and toddlers ages 6 to 24
months for the most common behav-
ioral precursors to later communica-
tion and cognitive delays or disorders.
Results can aid the PNP and parent in
determining if a more thorough evalu-
ation is warranted. In that case, the
PNP can suggest the parent seek a full
assessment by a speech-language
pathologist or other developmental
specialist.
Administration of the SCCIT. The
SCCIT is designed to be kept as a
cumulative record posted in each
child’s medical file (see Figure 1). The

476 PEDIATRIC NURSING/November-December 2007/Vol. 33/No. 6

 Table 2. SCCIT Questions, Examples of Tests that Probe with Similar/Related Questions, Rationale for Inclusion, and
Disorder Group(s) Most Likely to Show This Feature

SCCIT Tests with Disorder Group Most Likely to

Criterion Probes Comments/Rationale for Inclusion Show Deficits in this Feature
Is parent con- DDSTa; Rossettib This question allows parents to express general Hearing impairment, physical
cerned about concerns. Parents have been found to reliably disability (e.g., cerebral palsy),
feeding, identify problems in their young children cognitive delay (e.g., mental
speech, hear- (Rosetti, 1990; Stokes, 1997). Mothers report retardation), cognitive disorder
ing? concern over feeding difficulties in their children (e.g., autism)
with cerebral palsy (Motion, Northstone,
Emond, & Stucke, 2002).
Does baby DDST; MCHATc; Loud sounds should produce a startle response Hearing impairment, cognitive
ignore loud REEL-3d; in normally developing infants and in toddlers. disorder (e.g., autism)
sounds? Rossetti
Does baby DDST General feeding questions may be included in Physical deficits (e.g., cerebral
have difficulty some tests (e.g., Does baby drink from a cup?). palsy), cognitive delays (e.g.,
swallowing? Swallowing problems can occur in the first 12 mental retardation)
months of life. Observing feeding, preferably in
the home, is important (Reilly et al., 1996).
Is baby over- MCHAT; REEL-3; Hypersensitivity to auditory stimuli is a symptom Cognitive disorder (e.g., autism,
ly-sensitive to Rossetti of autism and Williams syndrome (Borsel, Curfs, mental retardation)
loud sounds? & Fryns, 1997; Klein, Armstrong, Greer, & Brown,
1990; Koegel, Openden, & Koegel, 2004).

Is baby quiet DDST; Rossetti Babies are expected to gurgle, coo, babble, or Language delay, cognitive delay
too often? utter other noises besides crying. Babbling is an (e.g., autism), speech delay (e.g.,
important precursor for speech development. cerebral palsy)

Has baby had Usually includ- It is important to pay attention to the language Speech delay, language delay
3 or more ear ed in case histo- development of children with middle ear fluid
infections ry questions: because although it is not conclusive, some
over the last 6 not included in researchers have found a negative effect on lan-
months? language tests. guage development (Bess, 1985; Hooper,
Ashley, Roberts., Zeisel, & Poe, 2006).

Does baby Quick Screen Abnormal prosody has been identified as a fea- Autism, cerebral palsy, traumatic
have an for Voice ture of autism (Paul, 2005). Deficient respiration, brain injury, some developmental
unusual Evaluatione abnormal laryngeal function can result in voice syndromes
voice? disorders in some infants.
Are there con- DDST; REEL-3; Paul (1991) considers children to have a lan- Language delay, language disor-
cerns about Rossetti guage delay if they produce less than 10 intelli- der, cognitive delay, cerebral
how many gible words by age 18-23 months. Parents have palsy
words baby been found to reliably identify problems in their
says? young children (Stokes, 1997). Thal and Bates
(1988) consider a language delay present when
no two-word combinations are used by 18-24
months.
Does baby fin- MCHAT Repetitive/stereotypic behaviors involving Autism, hearing impairment
ger-fidget for hand/finger mannerisms are often found in chil-
long periods dren with autism (see Prater & Zylstra, 2002 for
of time? a review).
Does baby MCHAT; DDST; Children with autism have been found to dis- Hearing impairment, autism
look at you as REEL-3; Rossetti play less eye gaze directed to people (Wetherby,
you talk? Gaze Prizant, & Hutchinson, 1998). Joint attention is
toward an important for language development (Wetherby
object you et al., 1998).
point to?

PEDIATRIC NURSING/November-December 2007/Vol. 33/No. 6 477

 Table 2. SCCIT Questions, Examples of Tests that Probe with Similar/Related Questions, Rationale for Inclusion, and
Disorder Group(s) Most Likely to Show This Feature (continued)

SCCIT Tests with Disorder Group Most Likely to

Criterion Probes Comments/Rationale for Inclusion Show Deficits in this Feature
Does baby MCHAT; DDST; Children with autism lack symbolic play Autism, mental retardation
show appro- REEL-3; Rossetti (Wetherby, Cain, Yonclas, & Walker, 1988).
priate interest Typically developing children are likely to use
in toys or joint attention, behavior regulation, and social
books? interaction even in the prelinguistic stage (Watt,
Wetherby, & Shumway, 2006; Wetherby et al.,
1988). AAP suggests that a pediatrician be con-
tacted if a child does not point to objects or pic-
tures by 8-12 months of age.
Does baby MCHAT; REEL-3; During the first year of life, babies begin to Hearing impairment, autism,
respond to Rossetti respond to their own name (ASHA, 2007; mental retardation
his/her name? NIDCD, 2000).
Does baby DDST; REEL-3; Most early speech sounds develop directly from Hearing impairment, language
make speech Rossetti early babbling (Stoel-Gammon, 1998). delay, autism
sounds?
Does baby MCHAT; DDST; This represents evidence of early receptive Hearing impairment, language
understand REEL-3; Rossetti language development. disorder, receptive language
you? delay, cognitive delays, cognitive
disorders
Does baby REEL-3; Rossetti This should be well established by nine months
gesture (e.g., of age. Babies who are developing good interac- Cognitive disorders (e.g., autism).
“hi”, “bye”, tive skills will show evidence of interactive ges-
“up”)? tures. Babies with poor interactive skills will not.

Does baby REEL-3; Rossetti This represents evidence of the emergence of Late talkers, language disorders,
say 15 or early expressive language development. cognitive disorders, hearing
more words? impairment, cerebral palsy
Are baby’s REEL-3; Rossetti Mothers and other caregivers should under- Hearing impairment, speech dis-
words under- stand baby’s utterances. A parent’s or caregiv- orders (e.g., cerebral palsy), lan-
stood most of er’s difficulty in understanding baby suggests guage disorders
the time? atypical speech development.
Does baby REEL-3; Rossetti By 24 months of age, baby is expected to have Hearing impairment, speech
say 50 words at least 50-word vocabulary and combine words delays and disorders, language
or more and into short sentences. delays and disorders, cognitive
combine delays and disorders
words into
sentences?

a
DDST: The Denver Developmental Screening Test (Frankenburg & Dodds, 1975).
b
Rosetti: The Rosetti Infant-Toddler Language Scale (Rosetti, 1990).
c
MCHAT: The modified checklist for autism in toddlers (Robbins, Fein, Barton, & Green, 2001)
d
REEL-3: Receptive-Expressive Emergent Language Scale (3rd ed.) (Bzoch, League, & Brown, 2000).
e
Quick Screen for Voice Evaluation (Lee, Stemple, Glaze, & Kelchner, 2004).

18 questions are divided into two sec-
tions with indicators for six age levels
(i.e., 6 months, 9 months, 12 months,
15 months, 18 months, 24 months).
Part A includes 9 questions and is for-
matted to reveal alerts if YES respons-
es are offered during any visit. Part B,
also contains 9 questions and is for-
matted to reveal alerts if NO respons-
es are offered during any visit. Referral
to a speech-language pathologist or
other qualified specialist should be
considered appropriate when three or
more alerts (i.e., any combination of
three YES and/or NO responses) are
accrued during a single visit or over
two or three visits.
Rationale for three alerts to indi-
cate a referral. The items on this test
are the most compelling ‘red flags’
known as indicators for referrals. A
child whose parent has expressed
concerns that included three problems
in one visit or one problem over three
visits should be seen by a develop-
mental specialist (e.g., speech-lan-
guage pathologist) who could use
more thorough instruments to deter-
mine the child’s potential to develop
normally or atypically.
Item analysis of the SCCIT:
Validity and reliability. Each of the
questions included on the SCCIT is
evidence-based as reported in pub-
lished tests or research and was
selected for its value as a proven indi-

478 PEDIATRIC NURSING/November-December 2007/Vol. 33/No. 6

cator of typical or atypical behavior
(i.e., content validity). Each question
is a common one asked routinely by
speech-language pathologists during
case history interviews, general devel-
opmental screening tests, or tests or
questionnaires that probe for particu-
lar disorders (see Table 2). Table 2
lists all the questions included in the
SCCIT and summarizes the sources of
each, provides a brief explanatory
comment describing the rationale
behind the selection of each question,
and notes the type of developmental
disorder for which the behavior is sig-
nificant. In that regard, content validi-
ty has been established (Schiavetti &
Metz, 2002).
Although sensitivity and specificity
data for the SCCIT are not currently
available, this screening has intrinsic
value as it presents a format for PNPs
to use that includes questions about
development that might otherwise be
omitted during well-child examina-
tions. The behaviors the SCCIT
probes, if absent or atypical (i.e., any
combination of three alerts) in any
child, warrants a referral. Further
research is planned to determine sta-
tistical reliability of the SCCIT.
Conclusion
The value of routine language and
cognitive screening in infants and tod-
dlers cannot be disqualified. The PNP
who screens young patients at each
well-baby visit can be instrumental in
noting early signs of later deficits in
language and cognition, and aiding
parents in determining when further
testing may be indicated. Early inter-
vention can be implemented in a time-
ly manner. Language and cognitive
delays and disorders that go undiag-
nosed and untreated put children
unnecessarily at risk for poor academ-
ic, social, and vocational progress
during their school years. Conversely,
for many affected children, treatment
initiated during infancy and toddler-
hood facilitates the emergence of
skills that would otherwise lag behind
or fail to develop. Although a number
of screening tools exist, none emerge
as a convenient, time-efficient tool for
the pediatric nurse practitioner to
employ during well-baby visits.
The brief two-part screening tool
included here (see Figure 1) provides
18 questions that probe precursor
behaviors to later development of lan-
guage and cognitive skills in infants
and toddlers. The screening is
designed to highlight the need for a
referral to a speech-language patholo-
gist for further assessment.
The authors give permission to
PEDIATRIC NURSING/November-December 2007/Vol. 33/No. 6
readers to make copies of the SCCIT Dollaghan, C. (1985). Child meets word:
screening form to be included in each “Fast Mapping” in preschool chil-
child’s medical file. dren. Journal of Speech and Hearing
Research, 28, 449-454.
Fazio, B., Naremore, R., & Connell, P.
(1996). Tracking children from pover-
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Posttest found on pages 486-487.
PEDIATRIC NURSING/November-December 2007/Vol. 33/No. 6
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 Infants and Toddlers
The purpose of this continuing nursing education series is to
increase the pediatric nurse’s understanding of selected issues relat-
ed to the care of infants, toddlers, and their families.
Infancy and toddlerhood are both periods of rapid development.
Nurses often are critically situated to assess and monitor early devel-
opment and to intervene when necessary. Separation is a primary
developmental issue for infants and toddlers who are hospitalized,
one that maximizing parental presence may help to alleviate. Keeping
updated on methods to identify and address concerns increases pedi-
atric nurses’ ability to promote development in infants and toddlers
who interact with the healthcare system.
This continuing nursing education series consists of two articles
that address infant-toddler issues. The first article describes a screen-
ing tool nurses can use to assess communication and cognitive dis-
orders in infants and toddlers. The second article presents findings
from a study that evaluated parent and staff perceptions of family-
centered care on an infant-toddler unit.
ASSIGNMENT
Scheffler, F., Vogel, D., Astern, R., Burgess, J., Conneally, T., &
Salerno, K. (2007). Screening for communication and cognitive
disorders in infants and toddlers. Pediatric Nursing, 33(6), 473-
480.
Neal, A., Frost, M., Kuhn, J., Green, A., Gance-Cleveland, B., &
Kersten, R. (2007). Family centered care within an infant-tod-
dler unit. Pediatric Nursing, 33(6), 481-485.
Earn 1.5 Contact Hours
Objectives:
1. Discuss the importance of a developmental/family-
centered approach in the care of infants and toddlers.
2. Describe a screening tool to assess communication
and cognitive disorders in infants and toddlers.
3. Compare and contrast parents’ and staff’s responses
to a survey evaluating family-centered care on an
infant-toddler unit.
4. Identify opportunities for pediatric nurses to keep cur-
rent on infant-toddler issues.
This offering for 1.5 contact hours is provided by Anthony J.
Jannetti, Inc.
Anthony J. Jannetti, Inc is accredited as a provider of continuing
nursing education by the American Nurses Credentialing Center's
Commission on Accreditation (ANCC-COA).
Anthony J. Jannetti, Inc. is an approved provider of continuing
education by the California Board of Registered Nursing, CEP No.
5387.
Articles accepted for publication in the continuing education
series are refereed manuscripts that are reviewed in the standard
Pediatric Nursing review process with other articles appearing in the
journal.
This test was reviewed and edited by Judy A. Rollins, PhD, RN,
Pediatric Nursing associate editor, and Veronica D. Feeg, PhD, RN,
FAAN, Pediatric Nursing editor.

1. Language may best be defined
as:
a. oral expression using consonants
and vowels to form words.
b. symbolic representation of
thoughts.
c. problem solving skills.
d. fast-mapping skills.
e. None of the above
2. Speech may best be defined as:
a. oral expression using consonants
and vowels to form words.
b. symbolic representation of
thoughts.
c. facial expressions.
d. body gestures.
e. None of the above
3. Preschool-aged children who
have delays in communication:
a. may ignore or misunderstand
parental instructions.
b. may show slow vocabulary
growth compared to same-age
peers.
c. may be very shy.
d. may be overly aggressive (bite or
kick).
e. All of the above
4. Behaviors in infants and toddlers
that are considered precursors to
communication and cognitive
delays and disorders include:
a. ignoring loud sounds.
b. minimal babbling.
c. minimal interest in toys and
objects.
d. lack of joint attention.
e. All of the above
Questions
5. Infants and toddlers can be
screened for delays and disorders
in communication and cognition
by questions that probe for:
a. the absence of typical behaviors
at expected ages.
b. the presence of atypical
behaviors.
c. concerns raised by parents about
their child’s development.
d. All of the above
e. None of the above
6. Which of the following is NOT
true of family centered care?
a. Recognizing parents as
information sources
b. Limiting parent involvement in
care
c. Respecting the diversity of
families
d. Building on family strengths
7. Which of the following best de-
scribes why family centered care
is important?
a. Families are responsible for
hospital bills.
b. Consumers demand family
centered care.
c. Families are a constant source of
support.
d. None of the above
8. What similarities did Neal et al.
identify between parent and staff
concerns?
a. Parents and staff were positive
about family centered care.
b. Parents and staff were congruent
in concern about pain
assessment.
c. Parents and staff were congruent
in concern over privacy.
d. None of the above
9. Which statement best describes
the major differences between
parent and staff concerns identi-
fied in the study?
a. Families were overall more
negative than staff.
b. Staff were overall more negative
than families.
c. Families were more concerned
with the environment.
d. Staff were more concerned about
pain assessment.
10. What can hospitals do to improve
family centered care?
a. Assess the current state of care
b. Involve staff and parents in plans
c. Educate staff involved in care
d. All of the above

486 PEDIATRIC NURSING/November-December 2007/Vol. 33/No. 6

 Infants and Toddlers
Answer Form: Infants and Toddlers *PED J0708
Check the box next to the correct answer.
1.  A 2.  A 3.  A 4.  A 5.  A 6.  A 7.  A 8.  A 9.  A 10.  A
B B B B B  B  B  B  B  B
C C C C C  C  C  C  C  C
D D D D D  D  D  D  D  D
E E E E E
This test may be copied for use by others.

COMPLETE THE FOLLOWING:

POSTTEST INSTRUCTIONS
Name: ______________________________________________________________ 1. Select the best answer and check the
corresponding box on the answer
Address: ____________________________________________________________ form. Retain the test questions as your
record.
____________________________________________________________ 2. Complete the information requested in
the space provided.
City: ___________________________State: _______________Zip:____________ 3. Detach the answer form or a copy of
the answer form and mail to: Pediatric
Strongly Strongly Nursing, CNE Series, Jannetti
Evaluation disagree agree Publications Inc.; East Holly Avenue
Box 56; Pitman, NJ 08071-0056 with a
1. The objectives relate to the overall 1 2 3 4 5
purpose/goals of the education activity.
check or money order payable to
2. The activity met the stated objectives. Jannetti Publications Inc. for $10.00
a. Discuss the importance of a developmental/ 1 2 3 4 5 (subscriber) or $15.00 (nonsubscriber).
family-centered approach in the care of infants 4. Test returns must be postmarked by
and toddlers. December 15, 2009. If you pass the test
b. Describe a screening tool to assess com- 1 2 3 4 5 (70% or better), a certificate for 1.5 con-
munication and cognitive disorders in infants tact hours will be awarded by Anthony
and toddlers. J. Jannetti, Inc.
c. Compare and contrast parents’ and staff’s 1 2 3 4 5
responses to a survey evaluating family-
centered care on an infant-toddler unit. Please allow 6–8 weeks for processing.
d. Identify opportunities for pediatric nurses to 1 2 3 4 5 For recertification purposes, the date that
keep current on infant-toddler issues. contact hours are awarded will reflect the
3. Home study format was appropriate. 1 2 3 4 5 date of processing.
4. The content was relevant to my practice. 1 2 3 4 5
5. The content met my needs. 1 2 3 4 5
6. How much time was used to complete reading
assignment and posttest: Test Scoring, CNE Awarding/Recording fees:
a. Less than 1 hour _______ b. 1-2 hours _______ PN Subscriber ■ $10.00
c. 2-3 hours _______ d. 3 hours or more _______ Nonsubscriber ■ $15.00
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Expir. Date _______________________
Signature ______________________________________________________________

Plan to Attend!
24th Annual
Pediatric Nursing
Conference
June 26-28, 2008
Las Vegas Hilton Hotel
Las Vegas, NV

PEDIATRIC NURSING/November-December 2007/Vol. 33/No. 6 487