Assessing Nonverbal and Minimally Verbal Children

When a young child is nonverbal or speaking fewer words than expected according to developmental milestones, parents want to find out why. Will they eventually learn to talk on their own or could they struggle to speak throughout their life? Is this part of the range of typical development or a sign of something serious?

Some children might have autism spectrum disorder, intellectual developmental disorder, language disorder, speech-sound disorder, or apraxia of speech — so it’s important to get a child evaluated by a clinician to get the proper diagnosis.  

When a child can’t speak to respond to questions, it’s more difficult for clinicians to assess cognitive functioning and give a diagnosis — but it’s not impossible. Also, there are good reasons to get evaluations done for nonverbal children every few years, to make sure the interventions and treatments are at the right level as they grow and respond to supports.  

All children under the age of 18 months speak few words, so kids who don’t speak at that age are considered preverbal. Researchers consider a child over 18 months who doesn’t speak any words to be nonverbal. Kids who can say significantly fewer words than expected for their age are considered minimally verbal. For example, a child who is 30 months or older and can speak fewer than 50 words is below the 10^th percentile and would be minimally verbal. 

Babies who are preverbal just haven’t developed the ability to speak yet. Young kids who are nonverbal might still develop the ability to speak with time and therapy. Indeed, in one study of kids with autism who were minimally verbal at age 4, 70 percent went on to develop the ability to communicate in phrases or fluent speech by age 8.

But some children will remain nonverbal or minimally verbal through adulthood, and it is important not to let their lack of language get in the way of understanding and addressing their needs, says Daryaneh Badaly, PhD, ABPP, a senior neuropsychologist at the Gund Learning and Diagnostic Center at the Child Mind Institute.

While some children may not speak because of motor mechanism issues, language delays are thought to be related to differences in brain development. When neural development is so severely impacted that a child is nonverbal or minimally verbal, there is a higher likelihood that they also have other neurodevelopmental conditions, such as autism spectrum disorder or intellectual disability.

Kids with autism are impaired in their social communication skills and have restricted or repetitive behaviors and interests. Intellectual disability involves limitations in reasoning, problem-solving, and decision-making skills as well as in adaptive skills (abilities to function in daily life).

Evaluating for conditions such as autism and intellectual disability helps figure out the broader spectrum of a child’s needs, but it doesn’t always get done in young children. In particular, assessments for intellectual disability can be delayed in children with reduced language skills.

It may seem like cognitive testing is not feasible until a child can use language to follow directions and respond to prompts. However, that is not the case. Cognitive testing is still possible with nonverbal and minimally verbal kids.

For example, tests of nonverbal intelligence, combined with background information from parents and others in a child’s life, can help understand if a child meets criteria for intellectual disability. Tests with no (or minimal) language demands can also help to evaluate children’s attention, inhibitory control, visuospatial skills, and learning and memory.

Evaluations help families understand where the child stands and what might be most useful at that moment, Dr. Badaly says. Too often, she finds that families bringing in an older child don’t have a complete view of their child’s functioning.

Understanding a child holistically means that you can help tailor their education to meet their academic and adaptive needs in way that not only maximizes their skills but reduces frustration, she says. “If a lesson is too far beyond what a child can do, they will disengage and get upset,” she explains. “If it is too far below their ability level, they will get bored and miss out on the opportunity for further skill development.”

Even if focusing on verbal fluency is not the right goal for a child, improving their communication might be. “We might want to focus more on adaptive skills,” Dr. Badaly says. “We might aim to get them 10 extra words they can express, gestures they can use, or visuals they can designate, because that’s going to put them in a better position to stay safe.”

Most tests require kids to understand directions and give a verbal response, but there are several assessments that clinicians can use for nonverbal and minimally verbal children. To determine if a child meets criteria for autism, for example, the Autism Diagnostic Observational Scale, Second Edition (ADOS-2), includes modules for children who are preverbal or have single words as well as those who speak fluently. In addition, structured interviews with parents can provide rich information on social and behavioral adjustment.

Clinicians will look for other signs that a child is socially engaged even if they have limited language, Dr. Badaly says: “They might smile and wave to others in greeting, use their eye gaze to get and direct others’ attention, attempt to play with others, and share their toys.” Those signs would indicate a child has developed social communication skills even if they are limited in oral expressive language. Clinicians will also look for signs of restrictive and repetitive behaviors and interests that would suggest of concerns beyond the impact of limited language skills. Examples might be stereotyped behaviors such as spinning in circles and highly focused interests such as watching the same cartoon over and over.

Similarly, observations and reports from families and others in a child’s life can help understand if a child meets criteria for attention-deficit hyperactivity disorder (ADHD).

Some nonverbal kids cannot speak but can understand oral language. Others have very limited comprehension of spoken instructions, which makes assessments of intelligence more difficult. For those children, clinicians can use mimed instructions with the Leiter International Performance Scale (for children ages 3 and up), for example.

Even if a child has few spoken words, understanding what they grasp of language is important. Clinicians might assess a child’s understanding of language by testing their vocabulary or understanding of sentences, having them point or tap a picture on an iPad to give an answer. Some examples of receptive vocabulary measures include the Peabody Picture Vocabulary Test, Fourth Edition, or the Ortiz Picture Vocabulary Acquisition Test, the latter of which has a scoring system that look at expectations for children from either monolingual or bi/multilingual homes. 

Clinicians will also ask other people in the child’s life, especially parents, to give input on their ability to communicate. “We’ll use something called the Communications Matrix, for instance, which goes from the first levels of communication that you’re gaining typically in your first month of life and forward,” Dr. Badaly says. “For example, can they intentionally ask for something? If so, then how are they asking? Are they dragging your hand? Can they point to it? Are they using eye contact?” Such tools can give a better description of a child’s means of communication to then help their educators and service providers work with them.

Getting a fuller picture of a minimally verbal child’s abilities can help clinicians and families figure out what would be most helpful.

“Let’s take a family for whom the whole focus was on language ability, and maybe the child’s autism was missed,” Dr. Badaly explains. “Now, with an autism diagnosis, we’re in a position where we can better understand some of the behavioral struggles that the child has.” It might have been assumed that the child had behavioral challenges because they could not speak. While that may be part of the story, they may also be overwhelmed by the sensory stimulation in their environment and struggle to deal with changes — factors that can be addressed with different strategies. “You might have this gut feeling as a parent that your child needs something different, but you don’t have anything to back that up,” says Dr. Badaly. “An assessment helps give you guidance to figure out what’s needed.”