International Journal of Pediatric Otorhinolaryngology 79 (2015) 888–894
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International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Reliability, validity and normative data of a quick repetition test for Italian children Martina Tresoldi a, Federico Ambrogi b, Elena Favero c, Anna Colombo a, Maria Rosaria Barillari d, Patrizia Velardi c, Antonio Schindler a,* a
Department of Biomedical and Clinical Sciences ‘‘L. Sacco’’, University of Milan, Milan, Italy Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy Department of Audiology and Phoniatrics, University of Turin, Turin, Italy d Department of Audiology and Phoniatrics, Second University of Naples, Naples, Italy b c
A R T I C L E I N F O
A B S T R A C T
Article history: Received 19 January 2015 Received in revised form 27 March 2015 Accepted 28 March 2015 Available online 8 April 2015
Objectives: A quick repetition test can be useful as a screening or preliminary investigation to select children who need to be assessed with a more specific articulation test. Schindler’s repetition test lasts about 2 min and requires the repetition of a 30 words list, each word targeting a specific phoneme or cluster. The aims of the study are: to assess reliability of Schindler’s repetition test; to establish normative data for speech development in Italian-speaking children; to analyse validity of this instrument. Methods: Six-hundred-two Italian children, aged range between 3;0 and 10;8 years, were included in the study: 557 without clinical sign of speech impairment and 45 had a speech sound disorder. Reliability. One-hundred-five children were tested the same day by two examiners (inter-rater reliability); the administration of the repetition test to 45 children was audio-recorded (intra-rater reliability); 105 children underwent the repetition test twice, with a 2 weeks interval (test–retest reliability). Data were compared through Intraclass Correlation Coefficient (ICC). Normative data. Percentages of children without clinical sign of speech impairment in each age group who repeated correctly, omitted or produced distorted target phonemes of Schindler’s repetition test were reported. Validity. To assess the ability of the test to record improvement in mean values with age (construct validity), the proportion of correct repetitions obtained by children from different age groups were compared through logistic regression. The speech abilities of 45 children were also analysed through a more comprehensive articulation test (concurrent validity). Scores were compared through Bland–Altman plot. Results: Reliability. All ICC were superior to 0.9. Normative data. Despite language-specific pattern of acquisition emerged, data showed many similarities to data reported in international studies on speech sound development. Validity. Logistic regression demonstrated a significant effect of age groups. Bland–Altman plot showed relatively narrow limits of agreement between Schindler’s repetition and Rossi’s articulation test. Conclusions: Schindler’s repetition test can be considered a reliable and valid instrument for preliminary assessment of speech abilities in Italian-speaking children aged from 3 to 6 years old. Application of Schindler’s repetition test is recommended in clinical practice, as a screening test or as a first clinical assessment instrument. ß 2015 Elsevier Ireland Ltd. All rights reserved.
Keywords: Assessment Speech sound development Reliability Validity Repetition
1. Introduction 1.1. Assessment of speech disorder Speech disorder is a term used to describe a speech impairment of any origin, including a range of different conditions in early
* Corresponding author. Tel.: +39 02 39043207; fax: +39 02 39043526. E-mail address: [email protected] (A. Schindler). http://dx.doi.org/10.1016/j.ijporl.2015.03.025 0165-5876/ß 2015 Elsevier Ireland Ltd. All rights reserved.
childhood [1]. In fact, different causes may lead to speech impairment: hearing loss, autisms, cerebral palsy, cleft palate or other anatomical anomalies, stammering and selective mutism [2–5]. Besides, in some cases the speech impairment aetiology can be unknown, a condition also termed speech sound disorder (SSD) [6]. SSD are one of the most common communication disabilities in childhood: prevalence is estimated between 10 and 15% of preschooler and approximately 4% of 6-year-old children [7–9]. Therefore, children aged 3 to 6 years with speech disorders are frequently encountered in paediatric otorhinolaryngology practice
M. Tresoldi et al. / International Journal of Pediatric Otorhinolaryngology 79 (2015) 888–894
and represent an important cause of speech-language pathology caseload. Picture-naming test and repetition tests are generally used in clinical practice all over the world for speech assessment in childhood [10–13]. Also in Italy picture-naming tests are generally used in clinical practice to evaluate speech abilities of Italianspeaking children [14,15]. Their purpose is to assess the uttering of all Italian phonemes and clusters in all word-position. Therefore, the administration of Italian picture-naming tests requires the elicitation of more than one-hundred words and takes at least 30 min. Considered the high prevalence of speech disorders, the administration of a quick articulation test can be useful as a screening or preliminary investigation to select children who need to be assessed with a more specific articulation test [16,17]. Screening instruments need to compare child speech ability to clear speech development standards, so the availability of normative data is essential [18]. A quick, but reliable and valid repetition test could be particularly useful in paediatric otorhinolaryngology practice in order to select patients to be referred to a complete speech pathology assessment. To the best of our knowledge, there are no data on speech development in large cohorts of Italian-speaking children aged 3 to 6 years, while there are several studies in other languages, in particular in English-speaking children [18,19]. Furthermore, most studies including Italian children focused on earlier stages of language acquisition, considered small samples and specifically analysed the relationship between phonological skills and early lexical acquisition [20,21]. It can be generally assumed that the development of speech ability in Italian- and English-speaking children is similar; nonetheless, as each language has unique phonetic system and inventory, the need of normative data specifically from Italian-speaking children arises. The lack of normative data for Italian-speaking children speech development aged 3 to 6 years led to the need for a standardized instrument. Therefore, Schindler’s repetition test [22], based on the repetition of a 30 words list, each targeting a specific phoneme or cluster, was developed to be used with different purposes. Because its administration lasts about 2 min, Schindler’s repetition test can be used as a speech screening test or in a preliminary clinical assessment; data from its administration can also be useful for epidemiologic or research studies. The standardization of this instrument could improve his clinical usefulness. 1.2. Aim of the study The aim of the study is: (1) to assess inter-rater, intra-rater and test–retest reliability of Schindler’s repetition test; (2) to establish normative data for speech development in Italian children; (3) to analyse construct and concurrent validity of this instrument.
889
Table 1 Distribution of the sample (group 1). Age group (years;months)
N
Male gender
Female gender
Mean age (years;month)
SD (months)
% Of the sample
3;0–3;5 3;6–3;11 4;0–4;5 4;6–4;11 5;0–5;5 5;6–5;11 Total
77 93 92 90 95 110 557
47 38 49 49 48 51 282
30 55 43 41 47 59 275
3;2 3;7 4;2 4;7 5;2 5;7 4;5
1.7 1.6 1.9 1.7 1.8 1.6 10.4
13.8 16.7 16.5 16.2 17.1 19.7 100
2.1.1. Group 1 Five-hundred-seven children (282 male and 275 female), aged between 3;0 and 6;0 years, were included. Children were recruited in Italian kindergartens and were equally distributed into 6 age groups, each representing a 6-months interval (Table 1). According to their teacher/parent, each of the participants was reported to have none of the following exclusion criteria: walking age >14 months, deafness, cleft lip/palate, cerebral palsy, mental retardation, autistic spectrum disorders, one or both parents non Italian speaking. Besides, each child underwent a clinical speech assessment by a speech and language pathologist to exclude children with SSD. 2.1.2. Group 2 Forty-five children (29 male and 16 female), with age ranging between 3;2 and 10;8 years (mean age 5;9 1;6 years), were included. Children were recruited in speech and language services, according to the following inclusion criteria: normal hearing and diagnosis of SSD, according to DSM-V classification [23]. The presence of SSD was identified through the administration of Bortolini’s test and thorough clinical evaluation by a team including phoniatrician, speech and language pathologist, child neurologist [15]. SSD affecting children were subdivided in articulation disorders and phonological delays/disorders (Table 2), according to Dodd’s classification [24]. 2.2. Materials Children were tested and assessed by four experienced speech and language pathologists. The examiners had good knowledge on articulation testing and phonetic transcription. Schindler’s repetition test was administered to each child, in order to assess articulation skills. Schindler’s repetition test is made of a 30 words list, including all Italian phonemes and 8 clusters (Appendix A). Each word includes a different target phoneme or cluster. Most of the phonemes are present both in word-initial and -medial position. The task required to the child was to repeat the target words uttered by the examiner.
2. Materials and methods
2.3. Procedure
The study was carried out according to the Declaration of Helsinki and all parents of children enrolled in the study gave their written informed consent; all data were collected prospectively. The study consisted of 3 different phases: reliability analysis (phase 1), normative data generation (phase 2) and validity analysis (phase 3).
After parental consent was obtained, each child was tested individually. The assessor established rapport with the child before Table 2 Different types of speech sound disorder in group 2; age, gender and number of children with articulation and phonological disorders are reported. Speech sound disorder
N
Articulation disorder Phonological delay/disorder Total
18 27 45
Female
Male
Mean age
Mean score SD
9 8
9 19
6;6 5;3
16.22 3.62 14.59 2.62
40 60
17
28
5;8
15.20 3.15
100
2.1. Participants A total of 602 Italian children, aged between 3;0 and 10;8 years, were included in the study: 557 presented no clinical sign of speech impairment (group 1) and 45 had a SSD (group 2).
% Of the sample
890
M. Tresoldi et al. / International Journal of Pediatric Otorhinolaryngology 79 (2015) 888–894
administering Schindler’s repetition test in a quiet room. Each target word was uttered by the examiner and the child was asked to repeat it. On the basis of auditory perceptual evaluation, the rater scored for each word whether the target phoneme was uttered correctly (score of 1) or if it was omitted/distorted (score of 0). The total score ranges between 0 (all target phonemes are omitted/distorted) and 30 (all target phoneme uttered correctly). 2.3.1. Phase 1 Ninety children from group 1 (15 from each age group) and all the children of group 2 (n = 45) were tested the same day by two examiners, in order to evaluate inter-rater reliability of Schindler’s repetition test. The administration of the repetition test to all children of group 2 was audio-recorded, in order to evaluate intrarater reliability as well. Besides, the subgroup of 90 children from group 1 and all children of group 2 underwent the repetition test twice, with a 2 weeks interval between the two tests, in order to evaluate test–retest reliability. 2.3.2. Phase 2 Schindler’s repetition test was administered to each child of group 1 to establish normative data. 2.3.3. Phase 3 Data obtained from the administration of the test to children of group 1, subdivided into 6 age groups, were used to analyse the ability of the test to record improvement with age (construct validity). The data of 25 children from group 2 were compared to a gender and age match group of children from group 1 (clinical validity); only 25 children were recruited for this analysis as the remaining 20 children of group 2 were older than 6 year of age and no age match child with no clinical sign of speech impairment was present. The speech abilities of all children of group 2 were also analysed through a more comprehensive articulation test (Rossi’s articulation test [14]), a picture naming test of 180 words, including all Italian phonemes and clusters in different position within the word, in order to test concurrent validity of Schindler’s repetition test. 2.4. Measures and analyses Statistical tests were performed using SPSS 19.0 statistical software (SPSS, Inc., Chicago, IL) and R software. (R Core Team (2014). R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. URL http:// www.R-project.org/.) 2.4.1. Reliability Inter-rater, intra-rater and test–retest reliability were analysed through two-way random Intraclass Coefficient Correlation (ICC). 2.4.2. Normative data To establish normative data, percentage of children in each age group who repeated correctly each target phoneme/cluster was calculated. The acquisition of consonants and clusters was classified according to different criteria [25]: ‘‘age of mastery’’ (at least 90% of children in an age group produced the sound correctly), ‘‘age of acquisition’’ (at least 75% of children in an age group produced the sound correctly), ‘‘age of customary production’’ (at least 50% of children in an age group produced the sound correctly), ‘‘age of approximate production’’ (less than 50% of children in an age group produced the sound correctly). Furthermore, the percentage of children in each age group who omitted each target phoneme and percentage of children in each age group who produced a distorted phoneme was calculated.
2.4.3. Validity In order to assess construct validity, the proportion of correct answers in Schindler’s repetition test in different age groups was calculated. Furthermore, the proportion of correct repetitions obtained by children from different age groups were compared through logistic regression using as response the number of correct repetitions over the maximum possible, i.e. 30 repetitions. A quasibinomial model was used accounting for overdispersion. As a measure of the difference among the age groups, the odds ratios between adjacent categories were computed together with the 95% confidence intervals. The comparison of test results between normal and pathological children was performed through a matched (by sex and age) case-control study. A conditional logistic regression was used to evaluate the odds ratio of positive response between pathological and normal children. To assess concurrent validity, total scores awarded in Schindler’s repetition test were compared to total scores awarded in Rossi’s articulation test by the same child through Bland–Altman plot. For this analysis only the 30 pictures targeting the same phonemes as in Schindler repetition test were used. 3. Results 3.1. Reliability Inter-rater reliability of children with normal speech (group 1) presented an ICC of r = 0.97 (95%CI: 0.92–0.98). Inter-rater reliability of children with SSD (group 2) presented a ICC of r = 0.95 (95%CI: 0.91–0.96); intra-rater reliability of this group presented an ICC of r = 0.97 (95%CI: 0.94–0.98). Test–retest reliability of children from group 1 presented an ICC of r = 0.94 (95%CI: 0.92–0.97), while test– retest reliability of children from group 2 presented an ICC of r = 0.93 (95%CI: 0.91–0.96). 3.2. Normative data The assessors checked each child’s ability to repeat correctly all Italian phonemes and 8 clusters, evaluated as target in Schindler’s repetition test words. Normative data obtained from the administration of Schindler’s repetition test to children with normal speech development are summarized in Fig. 1, according to percentage of children who repeated the sound correctly both in word-initial and -medial position. All children in the sample were able to produce vowels correctly under examination. Plosives (except/g/), nasals (except/D/), labiodentals fricatives and the lateral/l/were already mastered by children aged 3–3;5 years. Affricates were mastered by the age of 4;5 years. The vibrant/r/, the lateral/^/and consonant clusters were acquired at last, generally by the age of 6;0 (except/fg/). Italian phonemes and clusters were rarely omitted: less than 5% of the children in the sample omitted plosives, nasals, laterals, fricatives (except/s/and/R/), affricates (except/dz/). Consonant clusters were omitted in less than 5% of the children of at least 4 years (except/fg/, omitted in less than 2% of the children of 5;6 years). More often phonemes and clusters were distorted: the percentages of children in each age group who distorted each target sound are summarized in Fig. 2. 3.3. Validity 3.3.1. Construct validity An improvement in the number of correct answers in Schindler’s repetition test across 6 age groups was observed (Fig. 3). The comparison of the number of correct answers among the different age classes showed in particular a statistically significant difference of the age class 4;0–4;5 with respect to 3;6–3;11 [OR: 1.64; 95%CI:
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Fig. 1. Phonetic development of children in 6-months age bands. Age of mastery (at least 90% of children in an age group produce the sound correctly). Age of acquisition (at least 75% of children in an age group produce the sound correctly). Age of customary production (at least 50% of children in an age group produce the sound correctly). & Age of approximate production (less than 50% of children in an age group produce the sound correctly)
1.27–2.11; p = 0.002], of the age class 4;6–4;11 with respect to 4;0– 4;5 [OR: 1.39; 95%CI: 1.04–1.86; p = 0.03] and finally of the age class 5;6–5;11 with respect to 5;0–5;5 [OR: 1.64; 1.17–2.29; p = 0.004]. There was no evidence for difference between age class 3;6–3;11 with respect to 3;0–3;5 [OR: 1.00; 0.78–1.29] and age class 5;0–5;5 with respect to 4;6–4;11 [OR: 1.17; 0.85–1.59]. 3.3.2. Clinical validity The comparison between pathological and normal children showed that the odds of positive response in normal children was about 3.6 times greater than that of pathological children [OR: 3.63; 95%CI 2.88–4.57; p < 0.001]. 3.3.3. Concurrent validity Bland–Altman plot is reported in Fig. 4. Limits of agreement were relatively narrow; in fact a score difference of 3/4 target words explained 95% of the difference between the Schindler’s repetition and Rossi’s articulation test. 4. Discussion The psychometric validation of Schindler’s repetition test, a quick repetition test to assess speech abilities in Italian-speaking children aged between 3 and 6 years, was reported. The study included 602 Italian children, 557 of which without clinical sign of impaired speech and 45 had a SSD.
The study demonstrated strong inter-rater, intra-rater and test– retest reliability of Schindler’s repetition test: all ICCs were superior to 0.9, values that are considered acceptable for group comparison and for individual measurements over time [26]. Besides, correlation values obtained are similar to those reported in other studies presenting speech assessment tools for children speaking different languages [11,12]. The study reported normative data developed through the administration of Schindler’s repetition test to a large sample of Italian-speaking children (n = 557). These data, compared to normative data reported in studies including children speaking other languages [18,19,25] show many similar tendencies in speech development. For example comparing Italian-speaking children to English-speaking children, they both acquired first plosives, nasals and labiodental fricatives, then affricates and lastly the fricative/R/[18]. This comparison support the hypothesis reported in other studies [19,25] concerning a probable universal trend in speech and sound development, like there is in language development, despite the fact that sound acquisition is also characterized by reversal and revisions, with considerable individual variation [18]. The study reported the analysis of validity of Schindler’s repetition test. The results of logistic regression showed in general an improvement in the percentage of correct repetitions in Schindler’s repetition test with age. These data reflected the improvement that occurs during normal development of children, as suggested in other studies [12].
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Fig. 2. Percentage of children who produced distorted phonemes in 6-months age bands. 0–4% of children produced distorted phonemes. 5–14% of children produced distorted phonemes. 15–24% of children produced distorted phonemes. 25–44% of children produced distorted phonemes. & 45–84% of children produced distorted phonemes
Scores in children with SSD and those obtained from age and gender matched children without clinical sign of impaired speech were significantly different. This datum has strong clinical importance as it suggests that Schindler repetition test might easily recognize children with impaired speech. Further studies are needed to further analyse this point. Besides, scores obtained by the same child in Schindler’s repetition test and in Rossi’s articulation test showed that limits of agreement were relatively narrow. In fact a difference of about four words in the scores between the two measures could be considered acceptable as there
is a major difference in the modality of stimuli elicitation: while Rossi’s articulation test is a picture naming test, Schindler’s repetition test is based on the repetition of a words list. Because Rossi’s articulation test is a detailed and common instrument used to assess speech abilities in Italian children, these results suggest the concurrent validity of Schindler’s repetition test is relatively strong. There are several limitation in the study. First, children with no clinical sign of impaired speech and children with SSD were recruited in two different settings (kindergartens and speech
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Fig. 3. Number of correct responses in Schindler’s repetition test in different age groups (with 95% confidence intervals) estimated using a generalized linear model with binomial error and overdispersion.
pathology services); therefore data on agreement should be interpreted with caution. Second, concurrent validity was analysed only in children with SSD; so, it is possible that Bland–Altman plot would be different in children without SSD. Third, the sample of children with SSD was relatively small and it did not include children with developmental apraxia of speech. Further studies are
necessary with larger samples of children with different severity and origin of SSD to better understand the role of Schindler’s repetition test in recognizing this population. Finally, no children with speech impairment due to hearing loss, cleft palate, cerebral palsy were included; so the possibility of Schindler’s repetition test to recognize speech impairment different from SSD it is not known.
Fig. 4. Bland–Altman plot of Schindler’s repetition and corresponding target words of Rossi’s articulation test scores; mean between Schindler’s repetition and Rossi articulation scores are reported on the x axis, while difference between these two measures are reported on the y axis. The inferior horizontal line on the plot represents the mean – 1.96 times the standard deviation of the difference between the two measures, while the superior horizontal line represents the mean + 1.96 times the standard deviation of the difference between the two measures. The middle horizontal line is the mean of difference between Schindler’s repetition and Rossi articulation scores.
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M. Tresoldi et al. / International Journal of Pediatric Otorhinolaryngology 79 (2015) 888–894 Appendix A (Continued )
5. Conclusion In conclusion Schindler’s repetition test can be considered a reliable and valid instrument to assess speech abilities in Italian speaking children aged from 3 to 6 years old. It appears easily applicable in clinical practice because of his shortness. The establishment of normative data from a large sample allows the comparison of child speech ability to clear speech development standards. Application of Schindler’s repetition test is recommended in clinical practice, as a screening test or as a first clinical assessment instrument. Besides, it can be used for epidemiologic or research studies. Financial disclosure
Target words
Phonetic transcription
Target phonemes
ramarro rana pugno foglia scopa spruzzo completo taxi cosmopolita saradnapalo Afghanistan jetzt
[ra’marro] [’rana] [’puDDo] [’f&^^a] [’skopa] [’spruttso] [kom’pleto] [’taksi] [kozmo’p&lita] [sardana’palo] [af’ganistan] [’jetst]
/r/ /r/ /D/ /^/ /sk/ /spr/ /mpl/ /ks/ /sm/ /rd/ /fg/ /tst/
References
No funding, nor financial relationship to disclose. Conflict of interest statement None. Author contributions Martina Tresoldi, SPL, Federico Ambrogi, Prof, MD, Elena Favero, MD, Anna Colombo, SPL, Maria Rosaria Barillari, MD, Patrizia Velardi, SPL, Antonio Schindler, MD. Martina Tresoldi, Speech and Language Pathologist who carried out the analysis and interpretation of the data, drafting the article, final approval of the version to be submitted; Federico Ambrogi, Bio-statistician, who revised methodology, statistical analysis, drafting the article, final approval of the version to be submitted; Elena Favero, phoniatrician, conception and design of the study, revision the article, final approval of the version to be submitted; Anna Colombo, Speech and Language Pathologist, conception and design, data collection, revision of the article, final approval of the version to be submitted; Maria Rosaria Barillari, phoniatrician, conception and design of the study, revision of the article, final approval the version to be submitted; Patrizia Velardi, Speech and Language Pathologist, data collection, revision of the article, final approval of the version to be submitted; Antonio Schindler, phoniatrician who carried out the conception and design of the study, analysis and interpretation of data, drafting the article, final approval of the version to be submitted.
Appendix A. Appendix A Schindler’ repetition test. Target words
Phonetic transcription
Target phonemes
papa babbo tetto dado cocco lago ciccio gigi mamma nonna fifa viva sasso rosa sciocco zia zanzara lulu`
[pa’pa] [’babbo] [’tetto] [’dado] [’k&kko] [’lago] [’tRittRio] [’daidai] [’mamma] [’n&nna] [’fifa] [’viva] [’sasso] [’r&za] [R’R&kko] [’tsia] [dzan’dzara] [lu’lu]
/p/ /b/ /t/ /d/ /k/ /g/ /tR/ /da/ /m/ /n/ /f/ /v/ /s/ /z/ /R/ /ts/ /dz/ /l/
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International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Reliability, validity and normative data of a quick repetition test for Italian children Martina Tresoldi a, Federico Ambrogi b, Elena Favero c, Anna Colombo a, Maria Rosaria Barillari d, Patrizia Velardi c, Antonio Schindler a,* a
Department of Biomedical and Clinical Sciences ‘‘L. Sacco’’, University of Milan, Milan, Italy Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy Department of Audiology and Phoniatrics, University of Turin, Turin, Italy d Department of Audiology and Phoniatrics, Second University of Naples, Naples, Italy b c
A R T I C L E I N F O
A B S T R A C T
Article history: Received 19 January 2015 Received in revised form 27 March 2015 Accepted 28 March 2015 Available online 8 April 2015
Objectives: A quick repetition test can be useful as a screening or preliminary investigation to select children who need to be assessed with a more specific articulation test. Schindler’s repetition test lasts about 2 min and requires the repetition of a 30 words list, each word targeting a specific phoneme or cluster. The aims of the study are: to assess reliability of Schindler’s repetition test; to establish normative data for speech development in Italian-speaking children; to analyse validity of this instrument. Methods: Six-hundred-two Italian children, aged range between 3;0 and 10;8 years, were included in the study: 557 without clinical sign of speech impairment and 45 had a speech sound disorder. Reliability. One-hundred-five children were tested the same day by two examiners (inter-rater reliability); the administration of the repetition test to 45 children was audio-recorded (intra-rater reliability); 105 children underwent the repetition test twice, with a 2 weeks interval (test–retest reliability). Data were compared through Intraclass Correlation Coefficient (ICC). Normative data. Percentages of children without clinical sign of speech impairment in each age group who repeated correctly, omitted or produced distorted target phonemes of Schindler’s repetition test were reported. Validity. To assess the ability of the test to record improvement in mean values with age (construct validity), the proportion of correct repetitions obtained by children from different age groups were compared through logistic regression. The speech abilities of 45 children were also analysed through a more comprehensive articulation test (concurrent validity). Scores were compared through Bland–Altman plot. Results: Reliability. All ICC were superior to 0.9. Normative data. Despite language-specific pattern of acquisition emerged, data showed many similarities to data reported in international studies on speech sound development. Validity. Logistic regression demonstrated a significant effect of age groups. Bland–Altman plot showed relatively narrow limits of agreement between Schindler’s repetition and Rossi’s articulation test. Conclusions: Schindler’s repetition test can be considered a reliable and valid instrument for preliminary assessment of speech abilities in Italian-speaking children aged from 3 to 6 years old. Application of Schindler’s repetition test is recommended in clinical practice, as a screening test or as a first clinical assessment instrument. ß 2015 Elsevier Ireland Ltd. All rights reserved.
Keywords: Assessment Speech sound development Reliability Validity Repetition
1. Introduction 1.1. Assessment of speech disorder Speech disorder is a term used to describe a speech impairment of any origin, including a range of different conditions in early
* Corresponding author. Tel.: +39 02 39043207; fax: +39 02 39043526. E-mail address: [email protected] (A. Schindler). http://dx.doi.org/10.1016/j.ijporl.2015.03.025 0165-5876/ß 2015 Elsevier Ireland Ltd. All rights reserved.
childhood [1]. In fact, different causes may lead to speech impairment: hearing loss, autisms, cerebral palsy, cleft palate or other anatomical anomalies, stammering and selective mutism [2–5]. Besides, in some cases the speech impairment aetiology can be unknown, a condition also termed speech sound disorder (SSD) [6]. SSD are one of the most common communication disabilities in childhood: prevalence is estimated between 10 and 15% of preschooler and approximately 4% of 6-year-old children [7–9]. Therefore, children aged 3 to 6 years with speech disorders are frequently encountered in paediatric otorhinolaryngology practice
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and represent an important cause of speech-language pathology caseload. Picture-naming test and repetition tests are generally used in clinical practice all over the world for speech assessment in childhood [10–13]. Also in Italy picture-naming tests are generally used in clinical practice to evaluate speech abilities of Italianspeaking children [14,15]. Their purpose is to assess the uttering of all Italian phonemes and clusters in all word-position. Therefore, the administration of Italian picture-naming tests requires the elicitation of more than one-hundred words and takes at least 30 min. Considered the high prevalence of speech disorders, the administration of a quick articulation test can be useful as a screening or preliminary investigation to select children who need to be assessed with a more specific articulation test [16,17]. Screening instruments need to compare child speech ability to clear speech development standards, so the availability of normative data is essential [18]. A quick, but reliable and valid repetition test could be particularly useful in paediatric otorhinolaryngology practice in order to select patients to be referred to a complete speech pathology assessment. To the best of our knowledge, there are no data on speech development in large cohorts of Italian-speaking children aged 3 to 6 years, while there are several studies in other languages, in particular in English-speaking children [18,19]. Furthermore, most studies including Italian children focused on earlier stages of language acquisition, considered small samples and specifically analysed the relationship between phonological skills and early lexical acquisition [20,21]. It can be generally assumed that the development of speech ability in Italian- and English-speaking children is similar; nonetheless, as each language has unique phonetic system and inventory, the need of normative data specifically from Italian-speaking children arises. The lack of normative data for Italian-speaking children speech development aged 3 to 6 years led to the need for a standardized instrument. Therefore, Schindler’s repetition test [22], based on the repetition of a 30 words list, each targeting a specific phoneme or cluster, was developed to be used with different purposes. Because its administration lasts about 2 min, Schindler’s repetition test can be used as a speech screening test or in a preliminary clinical assessment; data from its administration can also be useful for epidemiologic or research studies. The standardization of this instrument could improve his clinical usefulness. 1.2. Aim of the study The aim of the study is: (1) to assess inter-rater, intra-rater and test–retest reliability of Schindler’s repetition test; (2) to establish normative data for speech development in Italian children; (3) to analyse construct and concurrent validity of this instrument.
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Table 1 Distribution of the sample (group 1). Age group (years;months)
N
Male gender
Female gender
Mean age (years;month)
SD (months)
% Of the sample
3;0–3;5 3;6–3;11 4;0–4;5 4;6–4;11 5;0–5;5 5;6–5;11 Total
77 93 92 90 95 110 557
47 38 49 49 48 51 282
30 55 43 41 47 59 275
3;2 3;7 4;2 4;7 5;2 5;7 4;5
1.7 1.6 1.9 1.7 1.8 1.6 10.4
13.8 16.7 16.5 16.2 17.1 19.7 100
2.1.1. Group 1 Five-hundred-seven children (282 male and 275 female), aged between 3;0 and 6;0 years, were included. Children were recruited in Italian kindergartens and were equally distributed into 6 age groups, each representing a 6-months interval (Table 1). According to their teacher/parent, each of the participants was reported to have none of the following exclusion criteria: walking age >14 months, deafness, cleft lip/palate, cerebral palsy, mental retardation, autistic spectrum disorders, one or both parents non Italian speaking. Besides, each child underwent a clinical speech assessment by a speech and language pathologist to exclude children with SSD. 2.1.2. Group 2 Forty-five children (29 male and 16 female), with age ranging between 3;2 and 10;8 years (mean age 5;9 1;6 years), were included. Children were recruited in speech and language services, according to the following inclusion criteria: normal hearing and diagnosis of SSD, according to DSM-V classification [23]. The presence of SSD was identified through the administration of Bortolini’s test and thorough clinical evaluation by a team including phoniatrician, speech and language pathologist, child neurologist [15]. SSD affecting children were subdivided in articulation disorders and phonological delays/disorders (Table 2), according to Dodd’s classification [24]. 2.2. Materials Children were tested and assessed by four experienced speech and language pathologists. The examiners had good knowledge on articulation testing and phonetic transcription. Schindler’s repetition test was administered to each child, in order to assess articulation skills. Schindler’s repetition test is made of a 30 words list, including all Italian phonemes and 8 clusters (Appendix A). Each word includes a different target phoneme or cluster. Most of the phonemes are present both in word-initial and -medial position. The task required to the child was to repeat the target words uttered by the examiner.
2. Materials and methods
2.3. Procedure
The study was carried out according to the Declaration of Helsinki and all parents of children enrolled in the study gave their written informed consent; all data were collected prospectively. The study consisted of 3 different phases: reliability analysis (phase 1), normative data generation (phase 2) and validity analysis (phase 3).
After parental consent was obtained, each child was tested individually. The assessor established rapport with the child before Table 2 Different types of speech sound disorder in group 2; age, gender and number of children with articulation and phonological disorders are reported. Speech sound disorder
N
Articulation disorder Phonological delay/disorder Total
18 27 45
Female
Male
Mean age
Mean score SD
9 8
9 19
6;6 5;3
16.22 3.62 14.59 2.62
40 60
17
28
5;8
15.20 3.15
100
2.1. Participants A total of 602 Italian children, aged between 3;0 and 10;8 years, were included in the study: 557 presented no clinical sign of speech impairment (group 1) and 45 had a SSD (group 2).
% Of the sample
890
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administering Schindler’s repetition test in a quiet room. Each target word was uttered by the examiner and the child was asked to repeat it. On the basis of auditory perceptual evaluation, the rater scored for each word whether the target phoneme was uttered correctly (score of 1) or if it was omitted/distorted (score of 0). The total score ranges between 0 (all target phonemes are omitted/distorted) and 30 (all target phoneme uttered correctly). 2.3.1. Phase 1 Ninety children from group 1 (15 from each age group) and all the children of group 2 (n = 45) were tested the same day by two examiners, in order to evaluate inter-rater reliability of Schindler’s repetition test. The administration of the repetition test to all children of group 2 was audio-recorded, in order to evaluate intrarater reliability as well. Besides, the subgroup of 90 children from group 1 and all children of group 2 underwent the repetition test twice, with a 2 weeks interval between the two tests, in order to evaluate test–retest reliability. 2.3.2. Phase 2 Schindler’s repetition test was administered to each child of group 1 to establish normative data. 2.3.3. Phase 3 Data obtained from the administration of the test to children of group 1, subdivided into 6 age groups, were used to analyse the ability of the test to record improvement with age (construct validity). The data of 25 children from group 2 were compared to a gender and age match group of children from group 1 (clinical validity); only 25 children were recruited for this analysis as the remaining 20 children of group 2 were older than 6 year of age and no age match child with no clinical sign of speech impairment was present. The speech abilities of all children of group 2 were also analysed through a more comprehensive articulation test (Rossi’s articulation test [14]), a picture naming test of 180 words, including all Italian phonemes and clusters in different position within the word, in order to test concurrent validity of Schindler’s repetition test. 2.4. Measures and analyses Statistical tests were performed using SPSS 19.0 statistical software (SPSS, Inc., Chicago, IL) and R software. (R Core Team (2014). R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. URL http:// www.R-project.org/.) 2.4.1. Reliability Inter-rater, intra-rater and test–retest reliability were analysed through two-way random Intraclass Coefficient Correlation (ICC). 2.4.2. Normative data To establish normative data, percentage of children in each age group who repeated correctly each target phoneme/cluster was calculated. The acquisition of consonants and clusters was classified according to different criteria [25]: ‘‘age of mastery’’ (at least 90% of children in an age group produced the sound correctly), ‘‘age of acquisition’’ (at least 75% of children in an age group produced the sound correctly), ‘‘age of customary production’’ (at least 50% of children in an age group produced the sound correctly), ‘‘age of approximate production’’ (less than 50% of children in an age group produced the sound correctly). Furthermore, the percentage of children in each age group who omitted each target phoneme and percentage of children in each age group who produced a distorted phoneme was calculated.
2.4.3. Validity In order to assess construct validity, the proportion of correct answers in Schindler’s repetition test in different age groups was calculated. Furthermore, the proportion of correct repetitions obtained by children from different age groups were compared through logistic regression using as response the number of correct repetitions over the maximum possible, i.e. 30 repetitions. A quasibinomial model was used accounting for overdispersion. As a measure of the difference among the age groups, the odds ratios between adjacent categories were computed together with the 95% confidence intervals. The comparison of test results between normal and pathological children was performed through a matched (by sex and age) case-control study. A conditional logistic regression was used to evaluate the odds ratio of positive response between pathological and normal children. To assess concurrent validity, total scores awarded in Schindler’s repetition test were compared to total scores awarded in Rossi’s articulation test by the same child through Bland–Altman plot. For this analysis only the 30 pictures targeting the same phonemes as in Schindler repetition test were used. 3. Results 3.1. Reliability Inter-rater reliability of children with normal speech (group 1) presented an ICC of r = 0.97 (95%CI: 0.92–0.98). Inter-rater reliability of children with SSD (group 2) presented a ICC of r = 0.95 (95%CI: 0.91–0.96); intra-rater reliability of this group presented an ICC of r = 0.97 (95%CI: 0.94–0.98). Test–retest reliability of children from group 1 presented an ICC of r = 0.94 (95%CI: 0.92–0.97), while test– retest reliability of children from group 2 presented an ICC of r = 0.93 (95%CI: 0.91–0.96). 3.2. Normative data The assessors checked each child’s ability to repeat correctly all Italian phonemes and 8 clusters, evaluated as target in Schindler’s repetition test words. Normative data obtained from the administration of Schindler’s repetition test to children with normal speech development are summarized in Fig. 1, according to percentage of children who repeated the sound correctly both in word-initial and -medial position. All children in the sample were able to produce vowels correctly under examination. Plosives (except/g/), nasals (except/D/), labiodentals fricatives and the lateral/l/were already mastered by children aged 3–3;5 years. Affricates were mastered by the age of 4;5 years. The vibrant/r/, the lateral/^/and consonant clusters were acquired at last, generally by the age of 6;0 (except/fg/). Italian phonemes and clusters were rarely omitted: less than 5% of the children in the sample omitted plosives, nasals, laterals, fricatives (except/s/and/R/), affricates (except/dz/). Consonant clusters were omitted in less than 5% of the children of at least 4 years (except/fg/, omitted in less than 2% of the children of 5;6 years). More often phonemes and clusters were distorted: the percentages of children in each age group who distorted each target sound are summarized in Fig. 2. 3.3. Validity 3.3.1. Construct validity An improvement in the number of correct answers in Schindler’s repetition test across 6 age groups was observed (Fig. 3). The comparison of the number of correct answers among the different age classes showed in particular a statistically significant difference of the age class 4;0–4;5 with respect to 3;6–3;11 [OR: 1.64; 95%CI:
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Fig. 1. Phonetic development of children in 6-months age bands. Age of mastery (at least 90% of children in an age group produce the sound correctly). Age of acquisition (at least 75% of children in an age group produce the sound correctly). Age of customary production (at least 50% of children in an age group produce the sound correctly). & Age of approximate production (less than 50% of children in an age group produce the sound correctly)
1.27–2.11; p = 0.002], of the age class 4;6–4;11 with respect to 4;0– 4;5 [OR: 1.39; 95%CI: 1.04–1.86; p = 0.03] and finally of the age class 5;6–5;11 with respect to 5;0–5;5 [OR: 1.64; 1.17–2.29; p = 0.004]. There was no evidence for difference between age class 3;6–3;11 with respect to 3;0–3;5 [OR: 1.00; 0.78–1.29] and age class 5;0–5;5 with respect to 4;6–4;11 [OR: 1.17; 0.85–1.59]. 3.3.2. Clinical validity The comparison between pathological and normal children showed that the odds of positive response in normal children was about 3.6 times greater than that of pathological children [OR: 3.63; 95%CI 2.88–4.57; p < 0.001]. 3.3.3. Concurrent validity Bland–Altman plot is reported in Fig. 4. Limits of agreement were relatively narrow; in fact a score difference of 3/4 target words explained 95% of the difference between the Schindler’s repetition and Rossi’s articulation test. 4. Discussion The psychometric validation of Schindler’s repetition test, a quick repetition test to assess speech abilities in Italian-speaking children aged between 3 and 6 years, was reported. The study included 602 Italian children, 557 of which without clinical sign of impaired speech and 45 had a SSD.
The study demonstrated strong inter-rater, intra-rater and test– retest reliability of Schindler’s repetition test: all ICCs were superior to 0.9, values that are considered acceptable for group comparison and for individual measurements over time [26]. Besides, correlation values obtained are similar to those reported in other studies presenting speech assessment tools for children speaking different languages [11,12]. The study reported normative data developed through the administration of Schindler’s repetition test to a large sample of Italian-speaking children (n = 557). These data, compared to normative data reported in studies including children speaking other languages [18,19,25] show many similar tendencies in speech development. For example comparing Italian-speaking children to English-speaking children, they both acquired first plosives, nasals and labiodental fricatives, then affricates and lastly the fricative/R/[18]. This comparison support the hypothesis reported in other studies [19,25] concerning a probable universal trend in speech and sound development, like there is in language development, despite the fact that sound acquisition is also characterized by reversal and revisions, with considerable individual variation [18]. The study reported the analysis of validity of Schindler’s repetition test. The results of logistic regression showed in general an improvement in the percentage of correct repetitions in Schindler’s repetition test with age. These data reflected the improvement that occurs during normal development of children, as suggested in other studies [12].
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Fig. 2. Percentage of children who produced distorted phonemes in 6-months age bands. 0–4% of children produced distorted phonemes. 5–14% of children produced distorted phonemes. 15–24% of children produced distorted phonemes. 25–44% of children produced distorted phonemes. & 45–84% of children produced distorted phonemes
Scores in children with SSD and those obtained from age and gender matched children without clinical sign of impaired speech were significantly different. This datum has strong clinical importance as it suggests that Schindler repetition test might easily recognize children with impaired speech. Further studies are needed to further analyse this point. Besides, scores obtained by the same child in Schindler’s repetition test and in Rossi’s articulation test showed that limits of agreement were relatively narrow. In fact a difference of about four words in the scores between the two measures could be considered acceptable as there
is a major difference in the modality of stimuli elicitation: while Rossi’s articulation test is a picture naming test, Schindler’s repetition test is based on the repetition of a words list. Because Rossi’s articulation test is a detailed and common instrument used to assess speech abilities in Italian children, these results suggest the concurrent validity of Schindler’s repetition test is relatively strong. There are several limitation in the study. First, children with no clinical sign of impaired speech and children with SSD were recruited in two different settings (kindergartens and speech
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Fig. 3. Number of correct responses in Schindler’s repetition test in different age groups (with 95% confidence intervals) estimated using a generalized linear model with binomial error and overdispersion.
pathology services); therefore data on agreement should be interpreted with caution. Second, concurrent validity was analysed only in children with SSD; so, it is possible that Bland–Altman plot would be different in children without SSD. Third, the sample of children with SSD was relatively small and it did not include children with developmental apraxia of speech. Further studies are
necessary with larger samples of children with different severity and origin of SSD to better understand the role of Schindler’s repetition test in recognizing this population. Finally, no children with speech impairment due to hearing loss, cleft palate, cerebral palsy were included; so the possibility of Schindler’s repetition test to recognize speech impairment different from SSD it is not known.
Fig. 4. Bland–Altman plot of Schindler’s repetition and corresponding target words of Rossi’s articulation test scores; mean between Schindler’s repetition and Rossi articulation scores are reported on the x axis, while difference between these two measures are reported on the y axis. The inferior horizontal line on the plot represents the mean – 1.96 times the standard deviation of the difference between the two measures, while the superior horizontal line represents the mean + 1.96 times the standard deviation of the difference between the two measures. The middle horizontal line is the mean of difference between Schindler’s repetition and Rossi articulation scores.
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M. Tresoldi et al. / International Journal of Pediatric Otorhinolaryngology 79 (2015) 888–894 Appendix A (Continued )
5. Conclusion In conclusion Schindler’s repetition test can be considered a reliable and valid instrument to assess speech abilities in Italian speaking children aged from 3 to 6 years old. It appears easily applicable in clinical practice because of his shortness. The establishment of normative data from a large sample allows the comparison of child speech ability to clear speech development standards. Application of Schindler’s repetition test is recommended in clinical practice, as a screening test or as a first clinical assessment instrument. Besides, it can be used for epidemiologic or research studies. Financial disclosure
Target words
Phonetic transcription
Target phonemes
ramarro rana pugno foglia scopa spruzzo completo taxi cosmopolita saradnapalo Afghanistan jetzt
[ra’marro] [’rana] [’puDDo] [’f&^^a] [’skopa] [’spruttso] [kom’pleto] [’taksi] [kozmo’p&lita] [sardana’palo] [af’ganistan] [’jetst]
/r/ /r/ /D/ /^/ /sk/ /spr/ /mpl/ /ks/ /sm/ /rd/ /fg/ /tst/
References
No funding, nor financial relationship to disclose. Conflict of interest statement None. Author contributions Martina Tresoldi, SPL, Federico Ambrogi, Prof, MD, Elena Favero, MD, Anna Colombo, SPL, Maria Rosaria Barillari, MD, Patrizia Velardi, SPL, Antonio Schindler, MD. Martina Tresoldi, Speech and Language Pathologist who carried out the analysis and interpretation of the data, drafting the article, final approval of the version to be submitted; Federico Ambrogi, Bio-statistician, who revised methodology, statistical analysis, drafting the article, final approval of the version to be submitted; Elena Favero, phoniatrician, conception and design of the study, revision the article, final approval of the version to be submitted; Anna Colombo, Speech and Language Pathologist, conception and design, data collection, revision of the article, final approval of the version to be submitted; Maria Rosaria Barillari, phoniatrician, conception and design of the study, revision of the article, final approval the version to be submitted; Patrizia Velardi, Speech and Language Pathologist, data collection, revision of the article, final approval of the version to be submitted; Antonio Schindler, phoniatrician who carried out the conception and design of the study, analysis and interpretation of data, drafting the article, final approval of the version to be submitted.
Appendix A. Appendix A Schindler’ repetition test. Target words
Phonetic transcription
Target phonemes
papa babbo tetto dado cocco lago ciccio gigi mamma nonna fifa viva sasso rosa sciocco zia zanzara lulu`
[pa’pa] [’babbo] [’tetto] [’dado] [’k&kko] [’lago] [’tRittRio] [’daidai] [’mamma] [’n&nna] [’fifa] [’viva] [’sasso] [’r&za] [R’R&kko] [’tsia] [dzan’dzara] [lu’lu]
/p/ /b/ /t/ /d/ /k/ /g/ /tR/ /da/ /m/ /n/ /f/ /v/ /s/ /z/ /R/ /ts/ /dz/ /l/
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