Volume 23, Issue 3 (Autumn 2022)                   jrehab 2022, 23(3): 372-391 | Back to browse issues page


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Mokhtari F, Kazemi Y, Feizi A, Dale P. Psychometric Properties of the MacArthur-Bates Communicative Development Inventories-III (CDI-III) in 30 to 37 Months Old Persian-Speaking Children. jrehab 2022; 23 (3) :372-391
URL: http://rehabilitationj.uswr.ac.ir/article-1-2961-en.html
1- Department of Speech Therapy, School of Rehabilitation Sciences, Isfahan University of Medical Sciences, Isfahan, Iran.
2- Department of Speech Therapy, School of Rehabilitation Sciences, Isfahan University of Medical Sciences, Isfahan, Iran. , kazemi@rehab.mui.ac.ir
3- Department of Epidemiology and Biostatistics, School of Health, Isfahan University of Medical Sciences, Isfahan, Iran.
4- epartment of Speech and Hearing Sciences, Faculty of Speech and Hearing Sciences, University of New Mexico, Albuquerque, United States.
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Introduction
Early identification of language delay is a prerequisite for the prompt and effective intervention of language delay in children, which is recommended to be done via a brief and cost-effective screening that can be easily implemented and interpreted [1]. Official tests and other tests based on parents’ reports are used to screen and evaluate children’s language. Formal tests to assess children’s language development are complex and time-consuming. In contrast, parents’ reports are more suitable due to the ease of implementation and parents’ access to the realistic situations of observing their children. These tests are used in large-scale language development studies in line with clinical and research goals for infants and toddlers [1, 2]. Also, they are cost-effective because they do not need the presence of a speech therapist or other specialists to be completed [3]. The MacArthur-Bates Communicative Development Inventories (CDIs) are one of the most widely used tools for screening and evaluating children’s language development based on parent reports. Numerous studies have reported CDIs’ validity, reliability, and cost-effectiveness [3, 4]. 
According to studies, the prevalence rates of communication problems and developmental language disorders are 6.34% and 7.58%, respectively [5, 6]. The census of 2015 in Iran shows that more than 9700000 are children under 6 years old [7]. According to the presented statistics in Iran, many children need speech and language screening before school age to receive the necessary interventions. Currently, in screenings performed in Iran’s health centers, the age and stages questionnaire (ASQ) is used to screen for developmental problems. This questionnaire has a “communicative area” sub-section, which is used to screen children’s language problems. However, studies have shown that ASQ’s capability to screen communication problems, especially speech and language, is insufficient. The study conducted in the Korean language by comparing the information obtained from the ASQ and the short form of CDI in children with an average age of 29 months and 7 days who had language impairment showed that the sensitivity of the CDI form is 95.9, but the sensitivity of the communication area of ​​the ASQ form is 76.7. As a result, the screening ability of the ASQ form is not sufficient to identify children with developmental language delay, and it is necessary to use the CDI short form [8].
Despite the importance of using short forms for children›s language screening, no study has been conducted on specific forms of speech, language, and communication screening, including CDI short form, in the Persian language. The present study is carried out for the first time on the third form of MacArthur-Bates CDIs in the Persian language. Previous studies in the Persian language for the development of long forms of CDI in Persian and the examination of their psychometric properties have been carried out by Kazemi et al. which is related to the age range of 8 to 16 months (infants form or form I) and 16 to 30 months (children form or form II). The results of these studies showed that the long forms of CDI in the Persian language have good validity and reliability [9, 10, 11]. According to what was said, we aimed to adapt the CDI-III form from the MacArthur-Bates CDIs in the Persian language for 30- to 37-month-old Persian-speaking children. 
Materials and Methods 
The current study is a methodological cross-sectional study of the tools’ validation type. Based on the instructions of the English CDI-III form [12], this study was conducted on 356 children aged 30 to 37 months. Monolingual Persian-speaking children between 30 and 37 months old without any obvious neurodevelopmental disorder could participate in this study. If the form was not completed and submitted or the form is incompletely completed, the child will be removed from the sample.
Based on the recommendation of the developers of the form and also because CDI-III is a language-dependent tool, the process of translation-re-translation was not used for this form. However, in the stage of compiling the Persian form, the English form, the sub-sections of the form, and the objectives of each section were translated into Persian. Then, like the English form, the Persian form was compiled into three parts “vocabulary,” “sentences,” and “sentence usage.” To select the words for the vocabulary section, the previous study conducted on the second form of CDI-II in the Persian language [11], and the opinions of several experts were used. Thus, 132 words were selected for the vocabulary section of the Persian CDI-III form. To compile items in the sentence and use sentences sections, firstly, the grammar section of the second form of CDI-II in the Persian language (WS-CDI) [11] and, in some cases, the longitudinal study of sentence development scoring in the Persian language or Persian developmental sentence scoring (PDSS) [13] was used. Finally, 28 pairs of sentences were designed for the sentence section, and 21 questions were designed for the sentence use section. 
After compiling the initial form, the formal and content validities of the form were checked qualitatively using the opinions of 10 speech and language pathologists as members of the expert panel by calculating the content validity ratio (CVR) and content validity index (CVI) values. The members of the expert panel recorded their opinions about the clarity, necessity, and relevance of each item with the form. Based on the number of expert panel members, the items that had CVR less than 0.62 and CVI less than 0.7 were removed or revised based on the opinions of expert panel members and form makers, and the final CDI-III form was compiled.
After compiling the final form, this form was completed for 356 Persian-speaking children aged 30 to 37 months to check its internal consistency. Due to the prevalence of COVID-19, sampling and filling in the form was not performed in person. First, the families were contacted, and if the family was willing to participate in the study after completing the study entry conditions form, the link to the screening form designed in Porsline was sent to them via WhatsApp. 
The internal consistency of the form was calculated for the whole form, each part of the form, and each part was calculated by gender and age group. Also, the correlation of the scores of two sections and the correlation of each section with age were calculated, and due to the non-normality of the data distribution, the Spearman coefficient was used. 
Results
Table 1 presents the demographic characteristics of 356 children in this study by age group. 


The face validity of the form was confirmed based on the opinion of 9 members of the expert panel. In the content validity review, 100 items remained in the “vocabulary” section, 22 items in the “sentences” section, and 16 items in the “use of sentences” section. 
Internal consistency 
The internal consistency coefficient for the whole form was 0.97, which is more than the minimum acceptable value of 0.7. Also, this coefficient was 0.98 in the vocabulary section with 100 questions, 0.88 in the sentences section with 22 questions, and 0.88 in the section on using sentences. 
Norm scores 
Table 2 presents the normative scores of the entire studied population and table 3 shows the scores across two sexes.




Due to the non-normality of the data distribution, the Spearman coefficient was used to examine the correlation of the scores of the form sections, as well as the correlation of the scores of each section with age. The positive and significant correlation value of the three parts of the form shows that the whole form works in harmony for the language screening of children aged 30 to 37 months, and by increasing the score in one part, the child’s score in other parts also increases.
Table 4 presents the Spearman correlation values between the scores of the form sections together and each section with age.


These values show that by increasing the number of expressive words, the grammatical complexity of the child's sentences has also increased. Also, a positive and significant correlation has been observed between age and grades of all three parts of the form. The positive and significant correlation of each section with age shows that by increasing age, the number of expressive words of the child, the complexity of sentences, and the appropriate use of sentences have increased significantly. 
Discussion 
This study aimed to determine the psychometric properties of the third form of the MacArthur-Bates (CDI-III) in Persian-speaking children aged 30 to 37 months. 
Psychometric properties
According to the findings, the formal and content validities were approved by the expert panel members. Also, the content validity of the form is completely acceptable based on the positive and significant correlation of each part of the form with age as a quantitative continuous variable because the results showed that different parts of the form are sensitive to age. 
Internal consistency
The highest coefficient of internal consistency in all age groups was related to the vocabulary section. Westerland and colleagues reviewed the Swedish version of the MacArthur-Bates screening form. This study aimed to investigate the efficiency of different parts of the form to diagnose severe language disorders in 3-year-old children at 18 months. In the results of this study, it is stated that the number of expressive words is the best predictor of severe language disorders, and this screening test is superior to traditional methods [1]. According to the importance of expressive words, the high internal consistency of the form in this section can be one of the advantages of the form.
In the implementation of this study, the results and implementation method of past studies on CDI in the Persian language were used, and the shortcomings of the studies were tried to be compensated. For example, the number of items in the CDI-III form is smaller to be more consistent with the purpose of screening, and in this study, larger sample size was used to check the internal consistency, which can also be considered as a normative sample.
Norm scores 
In the present study, the large standard deviation in the vocabulary section indicates the high dispersion of the sample size and also shows the diversity of children's vocabulary in this age range. These results are similar to the findings of CDI studies among different languages. These studies show that children differ in the development of basic communication skills in their first three years of life. This diversity is clearly seen in the initial evolution of vocabulary, and its effects can be seen in the long term [14]. 
The comparison of norm scores between two groups of girls and boys shows that the average of all sections in the girls' group is higher than boys, and the standard deviation is lower in all sections. This means that girls performed better on average in all parts and the dispersion of results was less in this group than in boys.
Correlation 
The results show a strong positive correlation between the parts of the form, which is significant at a level of less than 0.05. The results of a study on CDI-III performed in Estonian to 34 to 39 month-old children show a strong direct relationship between vocabulary section scores and grammar section scores, which is consistent with results in other languages. Since the development of vocabulary precedes the development of grammar, it is expected that children with more expressive vocabularies will begin to combine words in more complex utterances and use grammar rules correctly [14]. The correlation results of the present study are consistent with the results of these studies. 
The correlation between the parts of the form also shows the internal consistency of the form. For example, people who expressed more words in the first part had more positive answers in the third part or the use of sentences. Although the correlation of the sections with age is lower than the correlation within the sections but these values ​​are statistically significant. One of the reasons for the low correlation value can be the low age range of the samples, which is only 6 months. In previous studies in Persian, a larger age range has been used for grouping children; for example, in the PDSS study conducted in the Persian language, children were grouped at 6-month intervals, and the results showed that this grouping could show the differences in sentence development score that occur gradually [13].
Also, the results of the PDSS study showed that at older ages, i.e. 54-59 months, the sentence growth score shows a significant increase. It seems that the speed of sentence growth in Persian-speaking children shows a clear increase in two age periods, before the age of 3 years and after the age of 4.5 years [13]. Since this study is in the age range of 30 to 37 months, it was not far from the expectation that the correlation of form scores, especially in the sentence section and the use of sentences, was significant with age.
In studies conducted in other languages, the age grouping of children has been performed at larger intervals. In the first study of sentence development scores for English-speaking children in 1971, Lee examined the sentence development score at 6-month intervals, but in a subsequent study in 1974, by adding the age group of 2-3 years, he reported the significance of the difference in sentence growth averages in one-year intervals. As a result, the difference between children was more obvious at younger ages, within one year [13].
Conclusion 
According to the findings of this research, the face and content validities of the CDI-III form are entirely acceptable for Persian-speaking children aged 30-37 months. Also, the internal consistency of the form was confirmed in this study. Normative scores of the CDI-III form can be used for screening and future studies in the field of examining diagnostic accuracy in different clinical groups.

Ethical Considerations
Compliance with ethical guidelines

The Ethics Committee of Isfahan University of Medical Sciences approved this research with code 196083. Also, all stages of obtaining informed consent from the participants are explained in the “Methods” section of the article.

Funding
The financial sponsor of this research is Isfahan University of Medical Sciences. The research was part of a study entitled “localization and standardization of valid tools for the assessment of primary and secondary language disorders in Isfahani children aged 1 to 6 years and their screening in a population-based epidemiological study.” The approval code 196083 belongs to the second author, Yalda Kazemi. The research was carried out in the form of the Speech Therapy Master’s thesis of the first author, Farzaneh Mokhtari. 

Authors' contributions
Conceptualization: Yalda Kazemi, Farzaneh Mokhtari, and Philip Dale; Study methods and analysis, editing and finalization: all authors; Validation, drafting, and resources: Farzaneh Mokhtari and Yalda Kazemi; Research and review: Farzaneh Mokhtari, Yalda Kazemi, and Avat Feizi; Supervision, project management, and financing: Yalda Kazemi.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
The authors thank all parents who kindly participated in this study. Also we thank Narges Khalifemahmoudi and Zahra Hajikarami for their help with sampling the participants. We thank the SLPs who participated in the phase of content validity as panel members. 


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Type of Study: Original | Subject: Speech & Language Pathology
Received: 18/07/2021 | Accepted: 1/01/2022 | Published: 23/09/2022

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