Use of Gesture Development in Profiling Children s ... · gestures can only be interpreted by their context and can be used with a variety of objects and events (e.g., reaching for

Use of Gesture Development in ProfilingChildren’s Prelinguistic Communication Skills

Elizabeth R. CraisLinda R. WatsonGrace T. BaranekThe University of North Carolina, Chapel Hill

Purpose: Comparing children’s skills across andwithin domains of development has become astandard in providing early intervention services.Profiling a child’s strengths and challenges canhelp in making decisions regarding eligibility,diagnosis, and intervention. Profiling is particu-larly important for children who are not yet talking,due to the variability in production skills and thelack of guidelines as to which children are “at risk”for communication deficits versus those who are“late talkers.” One area underutilized in profilingis gesture development, despite the fact thatresearch has indicated that the amount and typeof gesture use can help in early identification andis predictive of later language.Method: To guide practicing professionals andresearchers in using gesture development to

profile children’s communication skills, this articleprovides an overview of the types of gestures andtheir development, describes assessment meth-ods and tools to document gesture development,pinpoints behaviors and factors important in iden-tifying children with disabilities, and ends withbrief examples of using profiling in assessmentand intervention planning.Conclusions: Gesture use should be an impor-tant component in profiling children’s commu-nication skills, and this type of profiling canenhance both the assessment and interventionprocess.

Key Words: prelinguistic communication,gesture development, gesture assessment

Current recommended practices within early interven-tion focus on comparing a child’s skills across andwithin domains to provide a clearer picture of the

child’s overall development and to identify more specificallythe child’s relative strengths and challenges (Crais &Roberts,2004; McCathren, Warren, & Yoder, 1996; Wetherby, Prizant,& Hutchinson, 1998). This type of developmental “profiling” isnot only required by law (Individuals with Disabilities Edu-cation Improvement Act of 2004) but is also thought toprovide the best overall portrait of the child. Profiling a child’sstrengths and challenges is necessary across the spectrumof early intervention services, including screening, evaluationto determine eligibility, assessment to identify interventionplans, implementing interventions, and monitoring child pro-gress to document change (or lack of change) and the needfor program modification. At each step, a child’s profile ofskills should be utilized to help families and professionalsmake the most informed decisions.

In early intervention services, profiling typically consistsof broad developmental domains such as cognitive, motor,social, communicative, and adaptive/self-help skills. For ex-ample, if a child has deficits in all or most domains, both

diagnosis and intervention planning would be aimed towardseeking explanations and intervention strategies for thesemore global deficits. In contrast, for the child who hascommunication-only deficits, more specific diagnoses andinterventions would be considered.

Within the area of communication, there is also a strongimperative to compare a child’s strengths and challengesfor both comprehension and production across syntax, pho-nology, semantics, morphology, and pragmatics (Paul, 2007).Although these linguistic components are often viewed sep-arately for practical purposes, it is important to acknowledgethe dynamic and interactive associations among the compo-nents as well as their transactions with the contexts surround-ing them (Chapman, 2000; Mitchell, 1995). In addition, thechild’s linguistic skills are built on a foundation of prelinguisticskills that may serve as both an indicator of the child’s currentskill level and a strong predictor of the child’s potential forlanguage competence in later years. For very young children,especially those who are not yet talking, it is important toidentify the key components of prelinguistic communicationthat can serve as indicators of immediate and future develop-ment. For example, amount of prelinguistic communication

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American Journal of Speech-Language Pathology • Vol. 18 • 95–108 • February 2009 • A American Speech-Language-Hearing Association1058-0360/09/1801-0095

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has been shown to be predictive of later symbolic communi-cation in children with developmental delays (Calandrella &Wilcox, 2000; McCathren et al., 1996). In addition, individ-ual components of prelinguistic development such as vocalbehaviors, vocabulary comprehension, symbolic play, gestureuse, initiating and responding to joint attention, parental inter-actions, and familial history of language and/or learning im-pairments have been identified as strong indicators of laterlanguage development in both children with typical develop-ment (Hadley & Holt, 2006; Morissette, Ricard, & Decarie,1995; Mundy et al., 2007; Stoel-Gammon, 1999) and thosewith atypical development (Baron-Cohen, 1989; Calandrella& Wilcox, 2000; McCathren et al., 1996). Further, prelinguis-tic means are the primary avenue to express early intention-ality in typically developing children (M. Carpenter, Nagell, &Tomasello, 1998; Crais, Douglas, &Campbell, 2004), and theability to signal one’s intentions is highly predictive of thedevelopment of higher level communication in childrenwith disabilities (Brady, Marquis, Fleming, & McLean,2004). Thus, by examining the child’s prelinguistic skills,we can identify the child’s unique profile of communicationstrengths and challenges. This profile can then be used tofacilitate decision making in both assessment and interven-tion planning.

One area important to prelinguistic communication thathas gained recent attention in the developmental literatureis that of gesture development. There are numerous studiesacross a variety of disciplines extending the knowledge baseregarding gesture development and its link with later lan-guage skills (Capirci, Iverson, Pizzuto, & Volterra, 1996;M. Carpenter et al., 1998; Iverson, Capirci, & Caselli, 1994;Thal & Tobias, 1992, 1994; Thal, Tobias, & Morrison,1991). Gestures are one of the most consistent early indica-tors of intentionality and thus can provide a window intothe child’s developing communication skills (R. L. Carpenter,Mastergeorge, & Coggins, 1983; M. Carpenter et al., 1998;Crais et al., 2004). Further, in childrenwho are identified as “latetalkers,” gesture use has been predictive of which childrenwill or will not “catch up” eventually to their peers (Thal et al.,1991). In addition, there is increasing evidence that gesturedevelopment can be a key distinguishing feature to helpdifferentiate children with typical development from thosewith various types of disabilities (Mundy, Kasari, Sigman,& Ruskin, 1995; Zwaigenbaum et al., 2005).

The strong associations between gesture developmentand the emergence of language make it imperative that weassess gesture development in young children with languagedelays, and use the assessment information in interventionplanning. Many studies, however, have only examined alimited number of gestures. Furthermore, few researchershave translated these findings in ways that make them op-timally useful for clinical assessment or intervention. Inan attempt to link research and practice, this article providesan overview of the literature related to types of gestures andtheir developmental course, briefly describes current as-sessment methods and tools used to document gesture de-velopment, pinpoints behaviors and factors important inidentifying children with disabilities, and ends with examplesof how profiling could be used in assessment and interven-tion planning.

Types of Gestures and Early DevelopmentGestures are actions produced with the intent to commu-

nicate and are typically expressed using the fingers, hands,and arms, but can also include facial features (e.g., lip smack-ing for “eating”) and body motions (e.g., bouncing for “horsie”)as described by Iverson and Thal (1998). Iverson and Thaldistinguished between two primary categories of gestures:deictic and representational. Deictic gestures establish refer-ence by calling attention to or indicating an object or event(Bates, 1976). As noted by Iverson and Thal (1998), thesegestures can only be interpreted by their context and can beused with a variety of objects and events (e.g., reaching fora cup, pointing to a dog running).

Deictic gestures are often divided into contact and distalgestures (McLean, McLean, Brady, & Etter, 1991). Con-tact gestures require contact between a child and object/caregiver, such as giving a toy or pushing away an adult’shand, and are considered “early” gestures. Distal gestures,in contrast, require no contact with the caregiver/object,such as pointing and reaching, and are typically later appear-ing (10–12 months). One distinction that needs to be made,however, is that a few distal gestures (e.g., reaching towardobjects, reaching to be picked up), in fact, defy the typicalprogression of contact gestures preceding distal gestures. Oneexplanation, noted by Crais et al. (2004), may be that althoughreaching is considered distal, it is also more contextuallybound to the actions from which it emerges (e.g., grabbing,being lifted up).

The earliest deictic gestures have been reported to emergebetween 7 and 9months of age (M. Carpenter et al., 1998; Craiset al., 2004), depending on the setting (e.g., laboratory vs.home) and the methodology (e.g., experimental design, natu-ralistic observation, or parent report). Deictic gestures oftenfirst appear as open-handed reaching, reaching to be pickedup, ritualized gestures to indicate refusal (e.g., pushing away),or consistent attention-getting body movements such asrepeated leg and arm flailing (R. L. Carpenter et al., 1983;Crais et al., 2004; Thal & Tobias, 1992). As noted by Thaland Tobias (1992), deictic gestures account for nearly 88%of the gesture repertoire in young infants and toddlers.

The second major type of gestures, representational ges-tures, both establish reference and indicate a particular se-mantic content. They often appear around 12 months of age(Acredolo & Goodwyn, 1988; Bates, Benigni, Bretherton,Camaioni, & Volterra, 1979) and typically after the emer-gence of a few deictic gestures (Crais et al., 2004). UsingIverson and Thal’s (1998) categorization, representationalgestures can be object-related gestures that signify some fea-ture of the referent (e.g., cupped hand to mouth to repre-sent “drinking,” “sniffing” a flower), referred to by some as“symbolic” gestures (Acredolo & Goodwyn, 1988). Theycan also be culturally defined conventional gestures that areused socially (e.g., waving “bye,” finger to lips for “quiet”)and represent some action or concept rather than a specificobject.

It has been well documented that representational ges-tures emerge within familiar games and routines that parentsand other caregivers utilize to engage children (Acredolo& Goodwyn, 1988; Caselli, 1990; Goodwyn & Acredolo,1993; Iverson & Thal, 1998; Werner & Kaplan, 1963). Games

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and routines such as “Itsy Bitsy Spider” or exaggerated blow-ing and hand waving to signal “hot food” contain many inter-active opportunities for the child to observe and producerepresentational gestures. These gestures are then extractedfrom their ritualized routines and extended to novel instancesand in novel contexts (Werner & Kaplan, 1963). For ex-ample, Caselli’s (1990) young son first “danced” to musicin a social routine, whereas later he used it to request turningon the radio. As suggested by Werner and Kaplan (1963),this “decontextualization” may serve as a rehearsal for thesame phenomenon employed later with words. Similarly,when a child generalizes a gesture to a new context, Goodwyn,Acredelo, and Brown (2000) indicate the gesture has gained“context flexibility.”

Crais et al. (2004) noted a good deal of individual varia-bility in the emergence of representational gestures, andGoodwyn et al. (2000) reported a range of forms of repre-sentational gesture types used between 10 and 24 months.In Crais and colleagues’ (2004) longitudinal study, parentswere asked over an 18-month period to indicate on a series offorms when and in what context different gestures emerged.Although all the deictic gestures listed on the forms wereexhibited by all the children in at least one context in thestudy, some of the children never exhibited one or more ofthe listed representational gestures. For the children whonever used particular representational gestures, their parentsreported that they themselves did not use the gestures. Forexample, one family noted that they never used the fore-finger to the lips to signal “hush” in any context (e.g., askingfor quiet, pretending a baby doll was sleeping) as they didnot want to give their child the impression that they did notwant him to talk. In contrast, parents who reported playingfrequently with their children in pretend ways (e.g., pretend-ing to sleep, smacking lips to signal eating) had childrenwho also used these gestures. Zinober and Martlew (1985)argued that when compared to deictic gestures, representa-tional gestures are more dependent on modeling by care-givers. Their use therefore may be more reflective of parents’cultural beliefs and practices than are deictic gestures,and, as noted, professionals need to be mindful of individ-ual variability across children and families. Thus, repre-sentational gesture use appears to be affected by socialcontext, the amount of direct parental input, and familybeliefs.

Object-related or symbolic gestures are also importantcomponents of symbolic play acts and are strongly relatedto language skills. Indeed, the level of symbolic play exhib-ited by young children has frequently been shown to predictlater language skills (Lyytinen, Laakso, Poikkeus, & Rita,1999; Lyytinen, Poikkeus, Laakso, Eklund, & Lyytinen,2001). For example, Lyytinen and colleagues (2001) observedthat symbolic play skills at 14 months of age were predic-tive of receptive and expressive language at both 24 and42 months. In addition, for both typically developing children(Bates, Bretherton, & Snyder, 1988) and those with devel-opmental delays (Kennedy, Sheridan, Radlinski, & Beeghly,1991), higher levels of gestural production and play maturityhave been associated with higher levels of comprehension.Thus, examining a child’s use of gestures along with otherrelated communicative domains may provide additional

information about the child that can be used for clinicaldecision making.

An additional aspect important in the development ofgesture use is the communicative function of the gesture. Weknow from the work of Bruner (1981) that young children’searly communicative acts can be divided into three func-tional categories: behavior regulation (e.g., requesting objects,protesting), social interaction (e.g., greeting, showing off ),and joint attention (e.g., showing, commenting). Studies byR. L. Carpenter et al. (1983) and Crais and colleagues (2004)have documented the order of emergence of common com-municative functions. Across their studies, the median age ofprotest acquisition was 6–7 months; requesting objects,7–9months; requesting actions, 8–9months; commenting onactions, 9–10 months; commenting on objects, 9–10 months;answering, 15 months; and requesting information, 15 months.Although this sequence of emergence was the “most com-mon,” not all children followed the same order.

In an attempt to examine both deictic and representationalgestures (including some conventional gestures) and theirdevelopmental course from early to later infancy, Crais andcolleagues (2004) followed 12 typically developing, English-speaking, monolingual, Caucasian, middle-class childrenfrom 6 to 24 months of age using a parent report method-ology with monthly researcher home visits. The gesturestargeted represented Bruner’s (1981) three broad communi-cative functions along with more specific subcategories ofeach: behavior regulation (i.e., requesting objects, requestingactions, protesting), joint attention (i.e., commenting, request-ing information), and social interaction (i.e., representationalgestures, attention seeking, social games). Through thesemethods, Crais and colleagues were able to identify a varietyof gestures categorized by communicative function. A listof the gestures used by all 12 children by the end of the fourage ranges (9–12, 12–15, 15–18, and 18–24 months) is pro-vided in Table 1. However, because the data characterizeonly the 12 English-speaking monolingual, Caucasian, middle-class children and families who participated in the study,and there was a good deal of variability among the 12 chil-dren, caution is warranted when applying these data toindividual children from other demographic and geographicpopulations.

Tools and Methods Used in the Assessmentof Gestures

Multiple methods are available for assessing the use ofgestures in young children, ranging from standardized teststo more informal approaches. A brief discussion of stan-dardized instruments is presented first, followed by additionalstrategies for taking a more informal approach.

Standardized Assessment ToolsAlthough many practitioners and test developers recog-

nize that gesture development is an important aspect of over-all communication skills, a sizeable body of research fromwhich to draw developmental information has emerged onlyin recent years. Thus, most current assessment tools have notfocused specifically on gesture development. Indeed, most

Crais et al.: Using Gestures for Profiling 97

tests have few items related to gestures and/or lack normativedata. Sample tools that include a small number of itemsrelated to gestures are the Bayley Scales of Infant and ToddlerDevelopment—Third Edition (Bayley, 2005), Clinical Eval-uation of Language Fundamentals Preschool—Second Edi-tion (Wiig, Secord, & Semel, 2004), Preschool Language

Scale, Fourth Edition (Zimmerman, Steiner, & Pond, 2002),and the Receptive-Expressive Emergent Language Test,Third Edition (Bzoch, League, & Brown, 2003). Althoughthese few items can provide information as to whether achild is using any gestures, they typically fail to indicate whichgestures might likely be seen first or what communicative

TABLE 1. Gestures categorized by communicative function seen in 12 typically developing children age 9–24 months (Crais et al., 2004).

Function 9–12 months 12–15 months 15–18 months 18–24 months

Behavior Protest Request objects Protestregulation Child uses body to signal

refusal/protest (e.g., archingbody away when held inadult’s arms)

Child looks at object, thenadult, and then objectagain (or vice versa)

Child shakes head “no”

Child pushes away an objectwith hand(s)

Request actions

Request objects

Request objects

Child reaches while openingand closing hands (e.g.,being picked up, wantswindup toy wound)

Child reaches while openingand closing hand to getan object

Child reaches for an object Child gives an object to anadult to get help (e.g.,have it opened, fixed)

Request actions

Child makes contact with anadult’s hand to gain object

Child points to get someoneto do something (e.g.,open a door, carry themto another room)

Child points to obtain an object

Child takes the hand of anadult to guide his or herhand or body to do something(e.g., takes hand of adultand brings it towardstomach to get tickle)

Request actionsChild reaches to be picked upChild does an action to get it to

happen again (e.g., bouncesup and down for “horsie”)

Social Seek attention Representational gestures Representational gestures Seek attentioninteraction Child bangs objects to get

attentionChild shows functions of

objects (e.g., brush hairwith brush)

Child smacks lips like eating Child shows off (e.g., sticks outtongue, makes a funny faceto get a laugh)Child uses consistent body

movement to get attention(e.g., flapping arms, kickinglegs)

Child hugs objects Representational gestures

Child grabs an adult’s hand togain attention

Child claps for excitement/accomplishment (e.g.,claps after puttingblocks in bucket)

Child shrugs shoulders or putshands face-up for “All gone”or “Where did it go?”

Social games Child “dances” to music(e.g., bounces in seatfrom side to side witharms bent like dancing)

Child blows kisses to others

Child shows interest/anticipationin social games (e.g., movesbody in anticipation, holds uphands for adult to manipulate)

Child signals “shh” with fingersto lips

Child participates by imitatingan adult (e.g., begins toclap)

Child nods “yes”

Child initiates social games(e.g., puts blanket overhead to initiate peekaboo)

Child pretends to sleep withhands together by head

Representational gestures

Child uses conventional gestureof excitement (e.g., “high five”or “ touchdown”)

Child waves “bye bye”Child imitates others clapping

Joint Comment Comment Comment Commentattention Child shows objects Child points to object/event Child uses gesture as clarification

of word/word approximation(e.g., child says “pane” andthen points to airplane whennot understood)

Child gives objectsChild points to an object in

in response to an adult’srequest, such as “Showme the apple” or “Where’sthe doggie?”

Request informationChild points to object or event

to gain information (e.g.,child points to picture inbook for adult to name it)

Note. The gestures listed were seen in all 12 study children by the age ending the time period (e.g., 12 months for the 9–12-month period). Dueto the expected variations in parenting style and in individual children, caution should be taken in utilizing this information to apply to childrenwho differ substantially from the 12 participating children, who were White, English-speaking, monolingual, and middle class.


functions the gestures serve. One assessment tool with a largenumber of gesture items is the Rossetti Infant-Toddler Lan-guage Scale (Rossetti, 1990); however, without normative datato verify that the gestures are at the appropriate developmentallevel or sequenced in the correct order, professionals must usetheir own judgment and experience to make clinical decisions.

Two tools with a specific focus on gesture use by youngchildren are the Communication and Symbolic BehaviorScales Developmental Profile (CSBS-DP; Wetherby &Prizant, 2002) and the MacArthur–Bates CommunicativeDevelopment Inventories, Words and Gesture Form (CDI;Fenson et al., 2002). Using the CSBS-DP, professionals notonly can document whether a child displays one or moreof eight common gestures (e.g., reach or point) but also canindicate whether the child responds to an adult’s use of agesture to gain joint attention. An example of this type ofjoint attention bid is when an adult says, “Look,” and pointsand looks at an object with the intent of getting the child tolook at the object. Recent evidence has shown the predictivenature of the child’s ability to follow the gaze and point ofanother (Leekam, Baron-Cohen, Perrett, Milders, & Brown,1997; Leekam, Hunnisett, & Moore, 1998; Mundy et al.,2007; Sigman & Kasari, 1995). Evaluating the degree to whicha child can demonstrate such behavior can be important indifferential diagnosis and later intervention planning. Forexample, Baron-Cohen, Baldwin, and Crowson (1997) dem-onstrated that difficulties following the gaze and point ofanother can lead to mapping errors in vocabulary learning byyoung children with autism, in contrast to children with otherdevelopmental disabilities. Thus, this type of deficit in animportant skill area likely will affect language comprehen-sion in the immediate context as well as the acquisition oflanguage over time.

Of the currently available assessment tools, the CDI (Fensonet al., 2002) documents the largest number of gestures withnormative data. Through a parent-report methodology, theCDI identifies from a list of common deictic and represen-tational gestures whether the child has (either commonly,sometimes, or not yet) displayed each gesture. Thus, it can bevery useful (along with the vocabulary and play informa-tion provided) in assessment and determining eligibility. Onecomplication to using the CDI for intervention planning,however, is the lack of specific information related to thedevelopmental order of the gestures, thus making it difficultto make decisions about what “next steps” to take inintroducing new gestures.

In sum, one way to profile a child’s gesture developmentis to utilize one or more of the available assessment tools thatinclude some items focused on gesture use. Depending onthe number and type of items, professionals can then decidewhether further investigation into gesture use is necessary.However, as noted above, most standardized tools do notprovide a strong focus on these areas, and therefore it is alsotypically necessary to observe and document these skillsinformally.

Informal Assessment ApproachesFor prelinguistic children, frequency, type, and function

of gesture use should be examined and can be sampled in

interactive play contexts with caregivers and other adults.During caregiver–child interaction, professionals can watchfor (and/or ask the caregiver about) the reasons the childcommunicates intentionally (e.g., to get something, to protestsomething). In addition, professionals can set up situationsthat encourage the child to communicate her or his needs.Use of “temptations” such as those provided in the CSBS-DP(Wetherby & Prizant, 2002) is one example of how to usecommon toys to provide contexts in which gestures are likelyto be used, and then document the communicative functionsused by the child. For example, the professional can dem-onstrate a toy for the child (e.g., blow bubbles and close thecontainer, or wind up a toy and let it run down), then giveit to the child, and wait for the child to indicate wanting it orwanting something done with it.

In terms of representational gestures, a professional canask caregivers to describe and demonstrate social games thatthey play with their child, and “social” gestures they andtheir child use. Given that representational gestures may notbe a part of some parent interaction styles, professionals needto be mindful of using assessment tools that include themor interpreting results from such assessment tools withoutasking whether these types of gestures are used in the home.Asking families about their individual practices and crea-tively considering all types of social interactions can helpprofessionals evaluate both the child’s opportunities and useof gestures. In this way, we may be more responsive to theethnic, linguistic, and cultural background of the familyand tailor the assessment process and information gatheredto each child and family (Barrera & Corso, 2002).

An additional informal means for examining gesture de-velopment in prelinguistic and early-linguistic children is toconsult a list of commonly used gestures such as that pro-vided in Table 1 and identify which gestures a child may beusing. The list provides some “rough” hierarchical informa-tion on gesture development in the study children that maybe useful for professionals in informal observations and/orgaining parental report. However, due to the expected varia-tions in parenting style and in individual children, cautionshould be taken in utilizing this information to apply tochildren who differ substantially from the 12 participatingchildren, who were all English-speaking, White, monolin-gual, and middle class.

Behaviors and Factors Importantto Identifying Children With Disabilities

When documenting gesture use in children with or at riskfor disabilities, professionals should consider several impor-tant aspects of and transitions within gesture development,from both an assessment and an intervention planning per-spective. The following section provides a discussion ofthese aspects and transitions, and can serve to guide furtherthe informal process of documenting gesture development.

Frequency of Gesture UseThe frequency of overall intentional communication is an

important factor in identifying children with communicationdeficits. In the presence of responsive adults, 12-month-olds


typically communicate intentionally about one time per min-ute, 18-month-olds about two times per minute, and 24-month-olds about five times per minute (Wetherby, Cain, Yonclas,& Walker, 1988). Therefore, a slow rate (or lack) of inten-tional communication may signal deficits. To express theirintentions, 12-month-olds primarily use gestures and/or vo-calizations, 18-month-olds use a combination of gestures,vocalizations, and words or word approximations, and24-month-olds use primarily words or word combinations(Wetherby et al., 1988). In addition, the amount of gestureuse by infants and toddlers is related to later verbal develop-ment (Acredolo & Goodwyn, 1988; Bates, Shore, Bretherton,& McNew, 1983). Specifically, Acredolo and Goodwyn(1988) documented that children with more representationalobject gestures (e.g., flap arms for “bird” or sniff for “flower”)reached the 10-word verbal vocabulary level earlier thanthose with fewer gestures. Several studies also have indicatedthat the sheer number of gestures and the number of differentgestures used by children in their first 2 years of life arepredictive of later language levels (Butterworth & Morissette,1996; Calandrella & Wilcox, 2000). Further, as was docu-mented by Watson, Baranek, and Crais (2005), the totalnumber of gestures used at 9–12 months in children laterdiagnosed with autism was predictive of the communicationsubscores on the Vineland Adaptive Behavior Scales (Sparrow,Ciccetti, & Balla, 2006) at preschool age.

Amount of gesture use can also help differentiate childrenwith typical development from those with various devel-opmental disabilities such as autism (Zwaigenbaum et al.,2005) and Down syndrome (Mundy et al., 1995). For exam-ple, parents retrospectively have reported less babbling andgesturing during early development in children with autismcompared to typically developing children (Ornitz, Guthrie,& Farley, 1977). The early retrospective reports of thesebehaviors, however, did not discriminate children with au-tism from children with mental retardation (Hoshino et al.,1982). Recent work by Watson et al. (2005) using retrospec-tive video analysis of 9–12-month-old infants from threegroups (those later diagnosed with autism, those with otherdevelopmental disabilities, and typically developing children)confirmed these earlier reports of infant gesture use. Theirresults indicated that the two groups with disabilities couldnot be differentiated from one another at 9–12 months on theamount of their gesture use, but both groups had significantlyfewer gestures than the typically developing infants. Osterling,Dawson, and Munson (2002) also observed less gesturing inboth children with autism and developmental disabilities at1 year of age; lack of appropriate gestures between 12 and24 months was one characteristic that distinguished betweenchildren with autism and children with typical development(Adrien et al., 1993). Further, some studies have also shownthat there are nonverbal communicative differences withingroups of children with autism that are associated with laterlanguage and social skills (Charman et al., 2003; Stone &Yoder, 2001). Thus, assessment of the number or rate ofgesture use by young children can help in identifying thosechildren at high risk for persisting language and communi-cation deficits.

Specific gestures (especially pointing) have also provento be a strong predictor of later language skills in children

with typical development (Morissette et al., 1995), childrenwith Down syndrome (Franco & Butterworth, 1996), andchildren with autism (Baron-Cohen, 1989). The early onsetof pointing has been linked with greater numbers of differ-ent gestures used and increased comprehension, particularlyobject name comprehension (Butterworth & Morissette,1996; Harris, Barlow-Brown, & Chasin, 1995). Thus, docu-menting the frequency of specific types of communicativegestures is critical to estimates of both current functioningand future potential in communication skills.

Communicative FunctionThe communicative function expressed by children’s ges-

tures can also be used to help in decision making about achild’s developmental status and need for intervention. Interms of order of emergence across functional categories,behavior regulation and social interaction acts are typicallyseen before joint attention acts (R. L. Carpenter et al., 1983;Crais et al., 2004). By age 12months, at least two different func-tions and two acts for each function were most often ob-served, and by 15 months, all three functions were usedconsistently with a variety of means (R. L. Carpenter et al.,1983; Crais et al., 2004). Indeed, a limited variety of intentionalcommunicative acts in infants and toddlers as they near24 months of age has been shown to be linked (along withother key behaviors) to later diagnosis of autism and otherdevelopmental disabilities such as Down syndrome andfragile X syndrome (Lord, 1995; Stone et al., 1999). Further,an analysis of videotapes of 9–12-month-old infants whowere later diagnosed with autism revealed that a limitedvariety of social interaction gestures was what differentiatedthem from the typically developing infants, not the frequencyof social interaction gestures (Colgan et al., 2006). Thus, alimited variety of communicative gestures may indicate riskfor communicative disorders as early as 12 months of age.

The pattern of use of specific functions can also provideassistance in making differential diagnoses among children.Numerous reports of the communication of preschool-agechildren with autism have noted the preponderance of actsused for behavior regulation, the limited number related tosocial interaction, and few (or no) joint attention acts (McEvoy,Rogers, & Pennington, 1993; Mundy & Crowson, 1997). Infact, this pattern of communicative functions has been foundto discriminate with a high degree of reliability between chil-dren with autism and children with other developmentaldisabilities (Mundy, 1995; Osterling & Dawson, 1994). Fur-ther, limited use of joint attention gestures early in life hasbeen predictive of later diagnosis of autism (Mars, Mauk, &Dowrick, 1998; Osterling & Dawson, 1994), whereas chil-dren with Down syndrome do not show the same deficit injoint attention gestures when compared with typically devel-oping children who are matched on mental age (Mundy,Sigman, Kasari, & Yirmiya, 1989). Interestingly, Mundyand colleagues (1995) also found that children with Downsyndrome show a greater use of gestures related to socialinteraction and joint attention than behavior regulation. Simi-larly, Mundy et al. (1989) demonstrated that children withDown syndrome readily pointed to comment or show objectsto others, but these children rarely pointed to make requests.


Further, in examining the gestural skills in children withDown syndrome, several studies (e.g., Caselli et al., 1998;Singer Harris, Bellugi, Bates, Jones, & Rossen, 1997) havereported that these children have a “gestural advantage”whencompared with typically developing children with equivalentlexical comprehension and production skills. They also usemore symbolic gestures and pretending than the comparisonchildren. Because children with Down syndrome are olderthan typically developing children with similar verbal skills,they have had more social experiences than the control chil-dren, and that may account for their relative advantages ingesture use. In children with Down syndrome, gestures alsoserve as an effective means of communication for a longerperiod of time than is seen in typically developing children.Their developmental profile of gesture use differs not onlyfrom children with autism, as mentioned above, but also fromchildren with other forms of intellectual disability. For ex-ample, children with Down syndrome (at least those withmental ages up to 17–18 months) used more gestures whencompared to children with Williams syndrome who werematched for chronological age, comprehension, and produc-tion (Harris et al., 1995); thus, gesture use tends to be astrength for these children when compared to children withother disabilities. In contrast, childrenwithWilliams syndromehave been observed to produce referential speech beforebeginning to use communicative gestures (Mervis & Bertrand,1993).

Use of specific functions of gestures also plays a role inpredicting later language skills. For example, joint atten-tion skills have been shown to predict comprehension andproduction skills in typically developing infants and toddlers(Mundy et al., 2007; Mundy & Gomes, 1998), as well asyoung children with autism (Charman et al., 2003; Mundy,Sigman, & Kasari, 1990) and those with other developmentaldisabilities (Yoder, Warren, & McCathren, 1998). Infantstypically begin to use joint attention gestures such as “show-ing” and “giving” objects around 8 to 12 months and “point-ing” between 9 and 14months (M. Carpenter et al., 1998; Craiset al., 2004); thus, failure to use joint attention behaviorsin the 2nd year of life may be indicative of developmentaldeficits. In addition, frequency of requesting and comment-ing are predictive of later vocabulary size (McDuffie, Yoder,& Stone, 2005; Mundy, 1987; Sigman & Ruskin, 1999;Stone & Yoder, 2001). Use of social interaction gestures ispredictive of expressive vocabulary in typically developingchildren (Mundy & Gomes, 1998) and children with autism(Charman et al., 2003; McEvoy et al., 1993).

Use of Gestures Paired With Eye Gazeand/or Vocalizations

Bruner (1977) suggested that, initially, the behavioralbasis for referential skills occurs through eye gaze and motormovements. Somewhere between 8 and 9 months, infantsbegin to use eye gaze to direct other’s attention, and withexperience the child gains more efficient means, such asgestures and words. The emergence of joint attention abilitiesin the 9-month-old is a key landmark in communicative com-petence (M. Carpenter et al., 1998; Saxon, Frick, & Colombo,1997). However, using eye gaze consistently to alter others’

behavior is acquired over months and does not occur fre-quently until 12 months of age (M. Carpenter et al., 1998).

Early in development, infants also use vocalizationscombined with gestures to communicate. Between 8 and12 months, gestures and gesture/vocal combinations pre-dominate; approximately half of deictic gestures exhibitedbetween 8 and 11 months are accompanied by vocalizations(R. L. Carpenter et al., 1983). With increasing age, the use ofgestures or vocalizations alone decreases as gesture-vocalizationcombinations increase until a point when they predominateat 15months (M. Carpenter et al., 1998;Wetherby et al., 1988).Even as children enter into the one-word stage, gestures (withor without vocalizations) continue to play a prominent role.Thus, the transition to a predominant use of gestures combinedwith other means of communication (eye gaze and/or vocali-zations) can be a sign of advancing communicative sophisti-cation. Indeed, Mundy et al. (1995) documented that bothchildren with typical development and those with Down syn-drome who frequently combined gestures with vocalizationsto request concurrently had higher levels of expressive language.

Transition From Contact to Distal GesturesThe move from contact to distal gestures reflects the shift

in ability from dealing with objects as “things-of-action” to“objects-of-contemplation” (Werner & Kaplan, 1963). AsMcLean and colleagues (1991) suggested, the transition fromcontact to distal gestures may be related to the symbol acqui-sition process, and children or adults who use only contactgestures may be manifesting a pervasive symbolic deficit.The question then becomes one focused on whether the lackof (or delay in) distal gestures may signal a concurrent lackor delay of language. Certainly in observing children on theautism spectrum, there are examples of children who useprimarily contact gestures with little to no pointing or otherdistal gestures (Lord & Pickles, 1996). This population bydefinition is one with language and social deficits.

In addition, some young children with autism may showan overall deficit in early means to communicate (e.g., eyegaze or early gestures such as showing, giving, or pointing)and yet use means that are typically later to develop suchas taking someone’s hand to lead the person to an object ormanipulating another’s hand to open a door. For example,parents of 2-year-olds with autism are less likely than parentsof 2-year-olds with other developmental disabilities to reportthe coordination of gaze with other behaviors in request-ing, and more likely to report that their children use contactgestures such as using another person’s hand as a tool (Lord,1995). Although these “leading or manipulating” gesturesare used communicatively, they are still viewed as presym-bolic and may continue to be used long after the time thatchildren typically are using symbolic and conventional be-haviors such as gestures and words (Wetherby et al., 1998).Thus, the transition from the use of contact to distal gesturesand the developmental hierarchy of gestures used are im-portant developmental markers to consider.

Transition From Gesture to Word UseThe transition from the use of gestures (with or without

vocalizations) to a predominant use of words is another stage


that needs monitoring. As the data from Crais and colleagues(2004) indicated, both deictic gestures and some represen-tational gestures precede the emergence of words. In theirstudy, common early representational gestures included wav-ing “bye-bye,” “dancing” to music, and “hugging” objects.There are numerous links between gesture development andthe emergence of language (for an excellent review, seeCapone &McGregor, 2004). Indeed, Bates and Dick (2002)describe language and gesture as “close family.” Bates andcolleagues (Bates & Dick, 2002; Shore, Bates, Bretherton,Beeghly, & O’Connell, 1990) also argued that before theuse of words to name, children produce “recognitory” actionsassociated with objects (e.g., cup to lips, phone to ear).They suggested that these early recognitory gestures, orwhat Acredolo and Goodwyn (1988) call “gestural labels,”serve as “gestural names” in the same manner as early verbalnaming. Others (Acredelo & Goodwyn, 1988; Iverson et al.,1994; Namy & Waxman, 1998) suggested that these earlysymbolic gestures are also used for requests (e.g., Caselli’sson who “danced” to request turning on the radio).

By 16 months, infants use both words and representa-tional gestures interchangeably to name objects. However,by 20 months they have almost stopped using representa-tional gestures as names for objects or object categories infavor of the use of words (Iverson et al., 1994; Namy, Acredolo,& Goodwyn, 2000). Later in development, gestures andwords again emerge in a parallel nature as seen when gesture-word and/or gesture-gesture combinations accompany orprecede word combinations (Iverson&Goldin-Meadow, 1998).As word combinations become more prevalent, however,gesture-word and gesture-gesture combinations decline.

In sum, a variety of aspects and transitions related to ges-ture development and use should be considered in assess-ment and intervention planning for young children at risk orwith established communication deficits. Since gesture use iskey to children’s early and continuing communicative de-velopment, facilitating gesture development and use in chil-dren with limited or no gestures may be beneficial.

Examples of Profiling Gesture Use for DecisionMaking in Assessment

For children at risk for or with communication deficits,profiling the use (or lack of use) of gestures with other com-municative skills can help professionals make key decisionsin both assessment and intervention planning. For exam-ple, the pattern of gesture use across communicative functions(i.e., behavior regulation, joint attention, social interaction)can help distinguish (in conjunction with other informationgathered) between children with different types of disabilities(Mundy, 1995; Osterling & Dawson, 1994).

To illustrate how profiling may be useful in making bothassessment and intervention decisions, two children, “David”1

and “Sam,” who were both 24 months old and were referredto a university clinic because of parental concerns about their

delayed language skills will be highlighted. By parent report,neither boy was producing any words nor had a significantbirth or medical history. Both boys had hearing within normallimits and did not have a history of middle ear infections.Although David’s parents were concerned about both hisexpressive and receptive communication skills, Sam’s motherreported that she thought he had very good comprehensionskills. To provide a contrast of two different types of assess-ment measures, the boys were assessed with the Receptive-Expressive Emergent Language Test, Third Edition (REEL–3;Bzoch et al., 2003), which has a limited focus on gestures,and the MacArthur–Bates CDI,Words and Gestures (Fensonet al., 2002), which provides a more detailed look at gestureuse. Although both boys were older than the specified agerange of the normative sample for the Words and GesturesInventory (8–16 months), it was selected for use because ofthe boy’s reported expressive language delays and to gatherinformation across a range of prelinguistic skills (i.e., phrasesunderstood, vocabulary production, early gestures, and latergestures) and to get a detailed look at their vocabulary com-prehension skills. Within the CDI, the “early gestures” cate-gory includes both common gestures (e.g., reaches to bepicked up or waves “bye-bye”) and a list of six social games.The “later gestures” category includes functional play items(e.g., pushes truck or throws ball), pretend play items (e.g.,feeds or hugs doll/stuffed toy), and imitation of adults (e.g.,sweeps with broom or bangs with hammer). These itemscan give a preview of the child’s play skills as well as his orher ability to imitate the actions of others. The overall resultsfrom the testing for both boys appear in Table 2. As can beseen from the testing, both boys scored below the first per-centile on the REEL–3 on their overall language abilities;however, where David’s receptive and expressive scores weresimilar, Sam’s receptive score placed him within the averagerange. Clearly, there were also differences on the CDI con-firming David’s poorer comprehension skills, but also indi-cating that he had deficits relative to Sam in his gesture, play,and imitation skills.

As suggested previously, although these measures werevery helpful in narrowing down some of the challenges thatDavid and Sam face, the area of gesture use can be exploredfurther to help with decision making. From the parent inter-views about the boy’s communication skills and informalplay scenarios set up to examine their functions and means toexpress their intentions (see early discussion about informalmethods), further information about the boy’s use of gestureswas gathered. Overall, David’s functions and means of com-municating were more limited than Sam’s. For example,David signaled wanting to play “tickle” games by pulling uphis shirt (e.g., social interaction), and used few additionalmeans to communicate other than fussing when he did notwant something (i.e., behavior regulation), reaching to bepicked up (i.e., behavior regulation), and taking an adult’shand to get desired objects (i.e., behavior regulation). In ad-dition, he had very limited eye contact except during thetickle games; did not show, give, or point to objects or events;rapidly flipped through books, refusing to look at them withothers; and had some unusual play behaviors (e.g., lickingtoys, banging toys repeatedly, lacking functional play withtoys). In contrast, Sam used awide variety of gestures tomake

1The names of the children in this section are all pseudonyms, and thechildren represent hypothetical situations for the purposes of clinicaldecision making.


requests, protest, engage in social games and routines, anddirect others’ attention to things that interested him. He fre-quently engaged the professionals and his parents by showingthem toys, and played readily and functionally with all thetoys. He also demonstrated some symbolic play with thetrucks, using gestures and sound effects to illustrate thefarmer getting in to drive, falling out of the truck, then beinginjured.

In addition, since there is a strong relationship acrossgesture production, play maturity, and comprehension (Bateset al., 1988; Kennedy et al., 1991), the professionals alsolooked for individual variations in the children’s skills in eacharea. David, whose skills were low across all three areas,may have underlying global deficits affecting all three skills,whereas Sam, who exhibited poor skills in only one area (i.e.,production), is more likely to have a specific deficit. In ad-dition, because symbolic play has been shown to be predic-tive of both later receptive and expressive language skills(Lyytinen et al., 1999, 2001), David’s lack of symbolic playand Sam’s creative symbolic play provided the professionalswith added information for decision making in assessmentand intervention.

Further, looking within the domain of gestures for delaysor variations can also help in decision making in assessment.For example, examining the type of gestures (e.g., deicticvs. representational, contact vs. distal) used by the child caninform clinical practice. To illustrate this point, David, whoproduces only a few deictic gestures and no representationalgestures, is clearly delayed in this area of gesture development.

Similarly, he uses only contact gestures but no distal gesturesand therefore is less advanced in this type of gesture use.In addition, when David uses what might be viewed as a“higher level” gesture (e.g., taking an adult’s hand to guidehim or her to an object) but not “lower level” gestures such asshowing or giving, his gesture use shows a nontypical pat-tern of development.

In terms of conclusions about David and Sam, the compi-lation of test results, parent report, and informal play andobservations led to two different sets of outcomes and rec-ommendations. When discussing David, the professionalsand his parents shared their mutual concerns about manyareas of his development, specifically his low expressive andreceptive communication skills, limited and repetitive playskills, and lack of eye contact and social engagement. Inaddition, the profile of David’s gesture use (i.e., some socialinteraction and behavior regulation gestures, but no jointattention gestures), added to the other areas of challenge forhim, helped direct the discussion toward concerns of autism.This is not to say that all children with this profile of skillsand pattern of gesture use have autism; however, the profileof skills and pattern of gesture use have been shown to dis-criminate between groups of children and can augment otherinformation in making a differential diagnosis. In terms ofnext steps, it was recommended that David’s parents seeka multidisciplinary assessment to explore the possibilities ofan autism diagnosis and to gain more insight into his otherskill areas (e.g., cognition, gross and fine motor, and possiblesensory issues). In addition, the professionals (based on the

TABLE 2. Profile of 2 children with communication delays.

Variable

David Sam

Score/behaviors observed Percentile rank Score/behaviors observed Percentile rank

REEL–3 Receptive Language <55 85REEL–3 Expressive Language <55 58REEL–3 Language Ability <46 <1 66 1

MacArthur–Bates CDI, Wordsand GesturesPhrases understood 5/28 <5 for 16-month-old 28 —Vocabulary comprehension 15/396 words <5 for 16-month-old 345/396 words —Vocabulary production 0 <5 for 16-month-old 0 —Early gestures 3/18 <5 for 16-month-old 18/18 —Later gestures 8/45 <5 for 16-month-old 42/45 —Total gestures 11/63 <5 for 16-month-old 60/63 —

Hearing screening WNL WNL

Gesture functionsBehavior regulation Reach to be picked up, take

adult’s handReach to be picked up, reach

for object, point to object,push away object

Social interaction Lift shirt during tickle game Hands over eyes for peekaboo,“high five,” “touchdown”

Joint attention No behaviors observed orreported

Show, give, point to objects

Observed play levels Object manipulation/nofunctional or symbolic play

Symbolic play demonstrated

Note. Both children were 24 months old. REEL–3 = Receptive-Expressive Emergent Language Test, Third Edition (Bzoch et al., 2003);WNL = within normal limits. Dash indicates unable to compute because the MacArthur–Bates Communicative Development Inventories (CDI),Words and Gestures (Fenson et al., 2002) provides normative data for children age 8–16 months only.


dynamic interactive assessments they had conducted) pro-vided many concrete suggestions to his parents about ways toengage David and facilitate his communication skills. Theprofessionals recommended working on enhancing David’ssocial interaction skills through games, sound making, ges-tures, and eye contact. Further, they made suggestions abouthow to extend David’s few behavior regulation attempts toinclude more vocalizations, gestures, eye contact, and ex-changes of toys and objects in play. Finally, ideas for how toexpand his play skills were shared with the family.

In interpreting Sam’s profile and making assessment andintervention decisions, consideration of the work of Thal andher colleagues (Thal & Bates, 1988; Thal & Tobias, 1992,1994; Thal et al., 1991) was very useful. In their study ofa group of children who had commensurate productive lan-guage delays, Thal and colleagues used profiling of the chil-dren’s gesture use and comprehension skills to distinguishbetween the children who were “late talkers” and those whowere “truly delayed.” As noted by Thal et al. (1991), whenfaced with a child who is 2 years of age and is not yet usingwords to communicate, identifying whether the child usesgestures and the child’s level of comprehension can help inmaking predictions about the child’s future language skills.A child who has deficits across gestures, production, andcomprehension (like David) would be at higher risk for con-tinued language delay than a child who has productiondelays only (like Sam). In addition, a child who has a familyhistory of language and/or learning deficits would also beat higher risk for continued language deficits (Hadley &Holt, 2006; Tomblin et al., 1997). Therefore, in discussingthe overall results of Sam’s testing, parent information, andobservations, the professionals noted all the positive aspectsof Sam’s development and confirmed with the parents thatSam had no familial history of language/learning deficits.The professionals shared a brief overview of the literature on“late talkers”with Sam’s parents and discussed how his skillsacross areas seemed to meet the “late talker” profile. Theprofessionals gave the parents the option of enrolling Samin intervention but recommended that they first try someconsultation (with plenty of resources and support) alongwith professional monitoring to see if they could give Sam’sproduction skills a “jump start” without direct intervention.In sum, the profiling of skills across areas of developmentwas able to contribute to the decision-making process regard-ing these 2 boys, their potential diagnoses, and the futureplanning for them by the professionals and their families.

Examples of Profiling Gesture Use for DecisionMaking in Intervention

Gesture profiling can also help in identifying potentialtargets for intervention. For some children with limited ges-tures or atypical patterns of gesture development, increasingthe frequency and variety of developmentally appropriategestures may be beneficial. An increased use of gestures maynot only help the child communicate more effectively, itcan also provide the adults surrounding the child with morechild output on which to build language and other commu-nicative exchanges. For example, there is strong researchindicating that when children are more communicative,

their parents have additional opportunities to provide input(Calandrella &Wilcox, 2000; Yoder, 2006; Yoder &Warren,2002). Further, mothers of toddlers with developmentaldelays respond more consistently to intentional communica-tion than to preintentional communication; thus, enhancingchildren’s abilities to signal their intentions can facilitateparental responsivity (Yoder & Munson, 1995). Indeed,research has documented that when children use gesturessuch as pointing, their parents respond with additionallinguistic input that may facilitate language development(Calandrella & Wilcox, 2000; Yoder & Warren, 2002).

If a child is not producing any gestures, early deictic ges-tures could be targeted in intervention as they are develop-mentally appropriate, and most children display some deicticgestures before representational ones. An early goal couldbe helping the child develop a strong base of gestures andother means to communicate intentionally before moving tooquickly to higher levels (e.g., representational gestures orjoint attention). The diagram in Figure 1 may prove useful toprofessionals in assessing and planning intervention relatedto first or early gestures. The diagram shows the relativerelationship of the functions, with those appearing on thesame line as relatively equivalent and those appearing aboveas somewhat more complex. However, each function alsohas an internal hierarchy dependent on the type of act (e.g.,requesting) and the means (e.g., gesture, vocalization, oreye gaze) to accomplish the act. For example, in the Craiset al. (2004) data, overall requesting of objects (and protest-ing) typically were produced before overall requesting actions.For example, a young child who reaches for an unactivatedwindup toy and looks at the professional simply may wantto hold the toy, whereas later in development the child mayuse reaching and looking to get the adult to wind it up. Ascan be seen in Table 1, for the children studied by Crais andcolleagues, the relative relationship between the functionsalso changed depending on the means used to communicatethe functions. For example, although children typically useda few behavior regulation and social interaction gesturesbefore joint attention ones, there were gestures that wereused for joint attention purposes before using them for otherfunctions. A common example was giving an object to sharejoint attention, which was typically observed between 9

FIGURE 1. Hierarchy of early communicative functions.


and 12months, whereas giving an object to request an actionwas not seen until 12 to 15 months. Therefore, a child whoinitially hands over an object for an adult to look at it maylater in development seek the adult’s help to do somethingwith it (e.g., wind it or fix it). Thus, early games of back-and-forth turn taking with objects can be a fun way to helpdevelop the idea of sharing an object with another and draw-ing attention to it. The use of “sabotaged” toys (e.g., missingwheel, broken toy, or teddy bear with Band-Aid on its head)pulled out of a grab bag in alternating turns can be an idea tobegin giving (and showing) for sharing joint attention. Later,the same type of activity could be performed but this timewith objects that the child needs the adult’s help tomanipulate(e.g., closed bubble jar or pop-up with crank).

When planning intervention, professionals should alsoconsider how the developmental hierarchy of contact anddistal gestures may affect the acts within functions. For ex-ample, joint attention contact gestures (e.g., showing/giving)with objects would likely be seen before distal joint atten-tion gestures (e.g., pointing). Therefore, profiling a child’sgesture use by type of gesture and developmental hierarchycan help identify potential intervention targets. When en-hancing any gesture development, however, not only shouldthe various developmental hierarchies be considered, butalso the collateral skills that each child brings to the inter-action (e.g., motor, attention, cognitive, or social). For in-stance, modeling may be sufficient for some children, whereasothers need hand-over-hand demonstration. For children withphysical or cognitive impairments, individual approxima-tions of the targeted gestures can be fostered.

Further, cultural and parenting style variations will beapparent across children and families, particularly with rep-resentational gestures; thus, professionals should be mindfulof those gestures commonly used by parents and those thatare not. In terms of representational gestures, although Table 1displays varied types used by the study children, this list isnot provided to encourage targeting these gestures (and espe-cially not in any particular order) in intervention. The tableis provided to help professionals consider the potential rela-tive difficulty of these types of gestures for the study childrenand think about their own expectations for individual chil-dren’s development. A prime example may be the differ-ence demonstrated by the study children in their use ofhead shakes for “no” (12–15 months) and nods for “yes”(18–24 months). This suggests that professionals shouldnot expect both types of responses from children at a similarage. Thus, professionals may use this type of table (alongwith individual family beliefs and practices) to considercarefully the types of representational gestures they modelfor children and parents.

For a child who is using some early deictic gestures (e.g.,reaching or showing) but no representational gestures, socialgames that include these types of gestures (e.g., peekaboo,pat-a-cake, or family-generated games) may be appropriatemeans to facilitate their use. In addition, targeting early func-tional play acts such as stirring or drinking through model-ing and social play may enhance the child’s play as wellas the use of representational gestures. For a child who onlyuses contact gestures, professionals and parents may con-sider early distal gestures as targets for intervention (e.g.,

reaching to be picked up or reaching for objects). In contrast,targeting pointing (rather than reaching) as the first distalgesture would not be recommended because it defies thetypical developmental progression in much of the develop-mental literature (e.g., see Table 1).

For David, who has some early characteristics of autism,his particular pattern of gesture use can guide interventionplanning as to the type of gestures that could be targeted.Clearly, joint attention gestures could be an ultimate target,but given that he has few social interaction and behaviorregulation gestures, targeting gestures within these two func-tion areas first would typically be better early targets. Incontrast, with the pattern of gesture use in some children withDown syndrome (use of social interaction and joint attentiongestures with few behavior regulation gestures), clinicaltargets could include working on behavior regulation ges-tures as well as other means to express this function. Histor-ically, there have been a number of efforts to increase gestureuse in individuals with intellectual disabilities, with mostof the training focused on developing behavior regulationacts such as requesting or refusal behaviors (Duker, Dortmans,& Lodder, 1993; Duker & van Lent, 1991). Thus for somechildren, targeting gestures and communicative functions thatare not in their repertoire may be a likely choice for interven-tion. For other children, however, particularly those withlimited gestures and functions, building a strong foundationof more frequent early social interaction and behavior reg-ulation gestures and other means may be a more effectiveapproach than targeting the “missing” gestures or functions.

Conclusions and ImplicationsThe increasing research evidence documenting the strong

relationship between gesture use and later communicativeskills, the growing recognition of the limited or narrow rangeof gesture use in some populations of young children (e.g.,children with autism or Down syndrome), and the differingpatterns of gesture use across populations have helped spot-light the need to both assess and enhance gesture develop-ment in children with poor communication skills. Severalfactors further support the necessity of documenting a child’sgesture use. First, gestures are typically the first signs ofintentionality. Second, they are used by children as earlymeans of communication. Third, for some children withcommunication delays, gestures will continue to predomi-nate over verbal language for an extended period of time.Moreover, the profile of gesture use (compared with otherskill areas) can be utilized in making assessment decisionsand in intervention planning for children who have or areat risk for poor communication skills. If professionals are todevelop accurate and representative profiles of the commu-nication skills of young children, the use of gestures is clearlyan important component.

In terms of the future, this article highlights the impor-tance of research to explore additional questions related togesture development such as the generalizability of the hier-archies of gesture development described, especially forchildren from other sociocultural groups. Other questionsinclude the relationship of gesture type with other communi-cation skills (e.g., comprehension, production, and play), the


pattern of gesture use across populations of children withdisabilities, and the degree to which gestures can be taughtand the characteristics of children who might benefit themost from professionals and families targeting gesture en-hancement. In addition, the information may help guide thedevelopment of tools that could be used to document moreeffectively gesture use in young children, to aid in bothassessment and intervention planning.

In conclusion, this article has attempted to provide (a) guid-ance to practicing professionals, researchers, and caregiversabout the ways that gestures can be categorized and assessed,(b) relevant factors to consider in assessment and interven-tion, and (c) some examples of how developmental profilingcan be used in decision making. If the article has helped en-hance the role of gestures in the assessment and interven-tion process and added to the knowledge base used to enhanceresearch in the area of gestures, the ultimate goals have beenachieved.

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Received June 5, 2007Accepted June 29, 2008DOI: 10.1044/1058-0360(2008/07-0041)

Contact author: Elizabeth Crais, Division of Speech & HearingSciences, CB #7190, University of North Carolina, Chapel Hill,NC 27599-7190. E-mail: [email protected].


Use of Gesture Development in Profiling Children s ... · gestures can only be interpreted by their context and can be used with a variety of objects and events (e.g., reaching for

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