Original Article

Ann Rehabil Med 2020;44(5):378-385

pISSN: 2234-0645 • eISSN: 2234-0653
https://doi.org/10.5535/arm.19198 Annals of Rehabilitation Medicine

The Predictive Value of Language Scales: Bayley

Scales of Infant and Toddler Development Third
Edition in Correlation With Korean Sequenced
Language Scale for Infant
Joung Hyun Doh, MD1, Soo A Kim, MD, PhD1, Kiyoung Oh, MD, PhD1,
Yuntae Kim, MD1, Nodam Park, MD1, Siha Park, MD1, Nam Hun Heo, MS2
1
Department of Physical Medicine and Rehabilitation, Soonchunhyang University Cheonan Hospital, Cheonan;
2
Clinical Trial Center, Soonchunhyang University Cheonan Hospital, Cheonan, Korea

Objective To compare the relationship of the Bayley Scales of Infant and Toddler Development 3rd Edition (K-BSID-III)
language score and the Sequenced Language Scale for Infant (SELSI) score and evaluate the sensitivity and specificity of
K-BSID-III language score and optimal cutoff value with receiver operator characteristic (ROC) curve analysis in infants
and toddlers with delayed language development.
Methods A total of 104 children with suspected language developmental delay were included in this retrospective study.
Subjects were tested using the K-BSID-III and SELSI and subdivided into several groups according to the severity of
language scores. ROC curve analysis was performed to assess K-BSID-III for delayed language development.
Results Receptive and expressive language subscales of the K-BSID-III showed markedly significant correlation with the
SELSI scores (p<0.001). ROC analysis showed an area under the curve of 0.877 (p<0.001) in SELSI receptive score and
0.935 (p<0.001) in SELSI expressive score. The optimal cutoff value where sensitivity of 85% and specificity of 81% were
achieved with the K-BSID-III receptive score was 1.50 (between average and low average) in the SELSI receptive score.
The optimal cutoff value where sensitivity of 96% and specificity of 82% were achieved with the K-BSID-III expressive
score was also 1.50 in the SELSI expressive score.
Conclusion In this study, the correlations between K-BSID-III and SELSI language scores were statistically significant.
However, the interpretation should be considered carefully in low average group due to tendency of underestimation of
delayed language development.

Keywords Language development, Receptive language, Expressive language, SELSI, K-BSID-III

Received November 20, 2019; Revised January 3, 2020; Accepted May 11, 2020; Published online September 28, 2020
Corresponding author: Soo A Kim
Department of Physical Medicine and Rehabilitation, Soonchunhyang University Cheonan Hospital, 31 Soonchunhyang 6-gil, Dongnam-gu, Cheonan
31151, Korea. Tel: +82-41-570-3874, Fax: +82-41-570-2776, E-mail: [email protected]
ORCID: Joung Hyun Doh (https://orcid.org/0000-0003-4656-0858); Soo A Kim (https://orcid.org/0000-0003-1578-0452); Kiyoung Oh (https://orcid.
org/0000-0002-1886-5462); Yuntae Kim (https://orcid.org/0000-0003-4063-4692); Nodam Park (https://orcid.org/0000-0002-2871-0202); Siha Park
(https://orcid.org/0000-0002-8673-1140); Nam Hun Heo (https://orcid.org/0000-0001-7278-2214).
This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/
licenses/by-nc/4.0) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Copyright © 2020 by Korean Academy of Rehabilitation Medicine
 Predictive Value of Language Scales Between K-BSID-III and SELSI

INTRODUCTION development test as a useful diagnostic test for language

development through mean comparison and correlation
Delayed language development is easily observed in analysis.
5%–8% of children in preschool years with learning,
socio-emotional, or behavior problems. Moreover, 20% of MATERIALS AND METHODS
2-year-old children showed delayed expressive language.
In 50%–75% of cases, the language delay resolves by 4–5 Subjects
years of age, but others have persistent delay [1-5]. In the The complete test scores of the K-BSID-III and SELSI
diagnosis, the standardized assessment tools for Korean were retrospectively assessed in 104 infants and toddlers
language are used. The most common tools are the Se- who visited Physical Medicine and Rehabilitation and
quenced Language Scale for Infants (SELSI) and the Pre- Pediatrics Department of Soonchunhyang University
school Receptive-Expressive Language Scale (PRES). The Cheonan Hospital from December 2014 to December
SELSI is used in infants and toddlers aged <36 months, 2018 for evaluation of language development. A total 104
and the PRES is used in preschoolers aged from 36 infants and toddlers were included in this study (Table
months to 6 years. The SELSI is subdivided into two sub- 1). All participants completed both tests in a maximum
categories, including receptive and expressive language duration of 3 months, and children aged 12–52 months
abilities. Delayed language development was diagnosed were included. Subjects who only performed one of
when language age is below two standard deviations in either test were excluded. Typically, children aged >36
the SELSI [6-8]. In case of children with severe language months have to perform the PRES other than the SELSI.
delay who are aged >36 months, the SELSI can be used However the children who have difficulties in performing
instead of the PRES [2]. the PRES, such as significant language delay at the time
The most widely used developmental assessment test of the language test, by language therapist and physician,
is the Bayley Scales of Infant and Toddler Development performed SELSI instead. Both tests were conducted ac-
3rd Edition (K-BSID-III), which is used in infants and cording to the manual guidelines, in a single or multiple
toddlers aged 1–42 months. It has five domains, namely,
cognition, language (receptive language, expressive
language), movement (large muscle movement, small Table 1. General characteristics of the subjects (n=104)
muscle movement), emotion/sociality, and adaptive be- Variable Number of subjects (%)
havior. In contrast to the K-BSID-II, K-BSID-III separated Sex
the language and cognition domains from mental de- Male 62 (59.6)
velopmental section. Both the K-BSID-III and SELSI can Female 42 (40.4)
evaluate the language function of infants and toddlers. Gestational age (wk)
Early delayed language is an important indicator of <37 49 (48.0)
neurodevelopmental disorders, which is the most promi- ≥37 53 (52.0)
nent problem showing superficially in infancy. Since Birth weight (g)
early diagnosis and intervention can provide an improve- <2,500 43 (42.2)
ment in the developmental function, an initial diagnosis ≥2,500 59 (57.8)
is crucial in adopting therapeutic intervention and re- K-BSID-III test age (mo)
ducing the sequelae of disabilities. A previous study com- ≥12 and <24 34 (32.7)
pared the K-BSID-III and PRES [9], but there has been ≥24 and <52 70 (67.3)
no study that showed a correlation between K-BSID-III SELSI test age (mo)
and SELSI. This study aimed to evaluate the relationship ≥12 and <24 34 (32.7)
between the K-BSID-III and SELSI, with a specific focus ≥24 and <52 70 (67.3)
on the receptive and expressive language subscales. In K-BSID-III, Korean version of Bayley Scales of Infant and
this study, the K-BSID-III was used concurrently with Toddler Development 3rd edition; SELSI, Sequenced
the SELSI to determine the value of the Korean infant Language Scale for Infant.

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sessions by reliable occupational therapist and language the mean scores.

therapist, to perform an objective study. This study was
approved by the Institutional Review Board of Soonchun- Statistical analysis
hyang University Cheonan Hospital, Korea (No. SCHCA To assess the statistical correlation and compare be-
2019-04-016). Informed consent was waived due to retro- tween the K-BSID-III and SELSI scores, analysis was
spective chart reviews. performed using linear-by-linear association, Spearman
correlation, Somers’ D, and Kendall’s tau-b methods.
Language assessment Sensitivity and specificity were assessed using the cutoff
The K-BSID-III is subdivided into five subcategories: scores on the K-BSID-III. Using the receiver operator
cognition, motor, language, emotion, and behavior characteristic (ROC) curve, the proper combination of
scales. In our study, we only focused on receptive and ex- sensitivity and specificity for the K-BSID-III results with
pressive language abilities and the corresponding scaled optimal cutoff score was determined. A p-value <0.5 was
scores. Moreover, the SELSI is also subdivided into two considered statistically significant. All statistical analyses
subcategories: receptive and expressive language abili- were estimated using SPSS version 25.0 (IBM SPSS, Ar-
ties. monk, NY, USA).
We compared each group and then analyzed the corre-
lation of these scores between language scaled scores of RESULTS
the K-BSID-III and two subcategories of the SELSI. In the
K-BSID-III, the raw scores of each items were converted This study included 104 children (62 male and 42 fe-
into scaled scores (mean=10, standard deviation [SD]=3), male). All children were tested using the K-BSID-III and
10 points is average, 7 points is -1 SD, and 4 points is -2 the SELSI. The general characteristics of the subjects are
SD. Based on means and SDs, the test scores were clas- presented in Table 1. There were no significant differ-
sified as follows: average (≥9); low average (≥7 and <9), ences between the groups with respect to sex, gestational
within -1 SD of the mean; mild delay (≥4 and <7), up to -2 age, and birth weight.
SD; and delay (<4), >-2 SDs below the mean scores [10]. The K-BSID-III-tested subjects were classified into
In the SELSI, the raw scores were classified in accordance four groups (average, low average, mild delay, and delay
with standard guidelines: average, within -1 SD of the groups) according to their language scale scores. More-
mean; mild delay, up to -2 SD; and delay, >-2 SDs below over, the SELSI-tested subjects were classified into three

Table 2. Comparison between K-BSID-III language score and SELSI score

K-BSID-III receptive language score
Total p-value
Average Low average Mild delay Delay
SELSI receptive language score
Average 13 (12.5) 2 (1.9) 1 (1.0) 0 (0.0) 16 (15.4) <0.001*
Mild delay 1 (1.0) 2 (1.9) 2 (1.9) 0 (0.0) 5 (4.8)
Delay 12 (11.5) 14 (13.5) 34 (32.7) 23 (22.1) 83 (79.8)
Total 26 (25.0) 18 (17.3) 37 (35.6) 23 (22.1) 104 (100)
SELSI expressive language score
Average 9 (8.7) 1 (1.0) 1 (1.0) 0 (0.0) 11 (10.6) <0.001*
Mild delay 2 (1.9) 3 (2.9) 1 (1.0) 0 (0.0) 6 (5.8)
Delay 2 (1.9) 10 (9.6) 41 (39.4) 34 (32.7) 87 (83.7)
Total 13 (12.5) 14 (13.5) 43 (41.3) 34 (32.7) 104 (100)
Values are presented as number (%).
K-BSID-III, Korean version of Bayley Scales of Infant and Toddler Development 3rd edition; SELSI, Sequenced Lan-
guage Scale for Infant.
*p<0.001 by linear by linear association & by Spearman correlation & by Somers’ D & by Kendall’s tau-b.

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 Predictive Value of Language Scales Between K-BSID-III and SELSI

groups (average, mild delay, and delay groups) accord- Correlation between K-BSID-III and SELSI scores
ing to their language raw score. A total of 34 children Evaluation of the receptive and expressive language test
(91.9%) in mild delay group and 23 children (100%) in the results between the K-BSID-III and SELSI are described
delay group of K-BSID-III showed delay in SELSI recep- in Table 2. The K-BSID-III receptive and expressive scores
tive language score, and 41 children (95.3%) in the mild were statistically significantly correlated with the SELSI
delay group and 34 children (100%) in the delay group of receptive and expressive scores.
K-BSID-III showed delay in SELSI expressive language
score. However, 12 children (46.2%) in the average group Sensitivity, specificity, and ROC curve of K-BSID-III
and 14 children (77.8%) in the low average group of K- language scores
BSID-III showed delay in SELSI receptive language score, ROC curve analysis was performed to evaluate the K-
and 10 children (71.4%) in the low average group of K- BSID-III test for language assessment. ROC analysis
BSID-III showed delay in SELSI expressive language showed an area under the curve (AUC) of 0.877 (95% con-
score. fidence interval [CI], 0.798–0.933; p<0.001) in the SELSI
receptive score and 0.935 (95% CI, 0.869–0.974; p<0.001)
in the SELSI expressive score (Fig. 1). The optimal cutoff

A ROC curve B ROC curve

1.0 1.0

0.8 0.8
Sensitivity

Sensitivity

0.6 0.6

0.4 0.4

0.2 0.2

0.0 0.0
0.0 0.2 0.4 0.6 0.8 1.0 0.0 0.2 0.4 0.6 0.8 1.0
1-Specificity 1-Specificity

Fig. 1. Receiver operating characteristic curves for SELSI according to different cutoff values of (A) K-BSID-III recep-
tive language (AUC=0.877; 95% CI, 0.798–0.933; p<0.001) and (B) K-BSID-III expressive language (AUC=0.935; 95% CI,
0.869–0.974; p<0.001). SELSI, Sequenced Language Scale for Infant; K-BSID-III, Korean version of Bayley Scales of In-
fant and Toddler Development 3rd edition; AUC, area under the curve; CI, confidence interval.

Table 3. ROC analysis of K-BSID-III language score based on SELSI as a standard test
Receptive K-BSID-III Expressive K-BSID-III
Cutoff value
of K-BSID-III Sensitivity Specificity False False False False
Sensitivity Specificity
positive negative positive negative
0.00 1.00 0.00 0.00 1.00 1.00 0.00 0.00 1.00
1.50a) 0.85 0.81 0.15 0.19 0.96 0.82 0.04 0.18
2.50 0.67 0.94 0.33 0.06 0.82 0.91 0.18 0.09
3.50 0.26 1.00 0.74 0.00 0.37 1.00 0.63 0.00
5.00 0.00 1.00 1.00 0.00 0.00 1.00 1.00 0.00
ROC, receiver operator characteristic; K-BSID-III, Korean version of Bayley Scales of Infant and Toddler Development
3rd edition; SELSI, Sequenced Language Scale for Infant.
a)
Optimal cutoff value of K-BSID-III score.

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Joung Hyun Doh, et al.

value with a sensitivity of 85% and specificity of 81% was hensive evaluation with long-term follow-up examina-
1.50 (between average and low average) in the receptive tion of language development and early intervention of
language of K-BSID-III, and that with a sensitivity of 96% learning ability from early childhood to the school period
and specificity of 82% was 1.50 (between average and low is needed.
average) in the expressive language of K-BSID-III (Table 3). For early detection of language developmental delay,
several tests were developed, such as the Ages and Stages
DISCUSSION Questionnaire, the Wechsler Preschool and Primary Scale
of Intelligence, the Korean Developmental Screening Test
Communication disorders and delayed language de- for Infants, and the Denver Developmental Screening
velopment comprised the highest proportion, approxi- Test (DDST). Presently, the most widely used language
mately 3%–20% of neurodevelopmental disorders [11,12]. development screening tools in Korea are PRES and SEL-
In addition, there are many cases showing language SI. The SELSI is used mainly in children aged <36 months
development delay that it is unknown in advance even to assess receptive and expressive language ability. The
though it is accompanied by intellectual disorder, autism SELSI is a proven standardized language test tool that can
spectrum disorder, psychosocial deprivation, hearing evaluate a wide range of language abilities, and validity
loss, and a lack of education, so the differential diagnosis and reliability of the SELSI were proved by previous stud-
of the causes of language delays is important [11,13,14]. ies in Korea. It is possible to analyze the developmental
In fact, other studies indicate that the more delays in age, percentile, and regional variation of receptive and
language development, the more severe the overlapping expressive language [8].
disability becomes [15,16]. Moreover, the final diagnosis Both the PRES and SELSI have the advantage of evalu-
of children who visited the hospital for delayed language ating language ability, but it takes a relatively long test
development showed that 40% of them had coexist- time of approximately 30–40 minutes. Moreover, since a
ing disabilities and 35% had simple language problems trained speech therapist is required to perform the test,
[17,18]. Especially when the receptive and expressive lan- if these facilities are unavailable, they will be transferred
guage is delayed, it is likely to be diagnosed as mental re- to a higher-level medical institution that can perform the
tardation or autism spectrum disorder later due to severe test [2,21].
language delay [18,19]. Therefore, there is a high possibil- Currently, the K-BSID-III is the most commonly used
ity that the problems of other developmental areas other developmental test globally. It is possible to conduct mul-
than the language area are duplicated, so it is important tidisciplinary examination and diagnosis of the child’s
to detect children with delayed language development at developmental status, provide comprehensive informa-
an appropriate time, to induce normal language develop- tion on various developmental areas, and collectively
ment and minimize complications through early treat- understand the relative strengths and weaknesses of the
ment. areas [22]. The K-BSID-III language scale is an extremely
Some children with delayed language development useful test tool in that it can accurately assess receptive
may improve spontaneously over time, but they often and expressive communication abilities in an integrated
experience speech, emotional, behavioral, and learning viewpoint. This K-BSID-III language scale proves high
problems if not treated properly. Therefore, it is greatly reliability as a tool for evaluating the language develop-
important to diagnose delayed language development ment of Korean infants and toddlers [9].
early and prevent appropriate complications by provid- Moreover, the K-BSID-III was highly correlated with the
ing appropriate treatment. Particularly, it is important existing recognized language assessment tools, PRES and
that the treatment is performed before the age of 3 years, M-B CDI-K (MacArthur-Bates Communicative Develop-
which is the time when the explosive power of the vocab- ment Inventories-Korean) [9]. Therefore, the K-BSID-III
ulary or comprehension ability starts to increase [2,20]. expressive language scale proved to be similar to the ex-
However, it is difficult to distinguish between normal and isting language evaluation tools despite the differences in
abnormal development because language developmental the age of measurement, sophisticated expert tests, and
range is large and difficult to evaluate. Thus, a compre- integrated developmental tests. However, the DDST, also

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 Predictive Value of Language Scales Between K-BSID-III and SELSI

commonly used as a developmental test, is less reliable the BSID-III underestimates the developmental delay
when there is language delay [11,23]. compared to the BSID-II. In our study, the result of the
The K-BSID-III is composed of phonology and seman- K-BSID-III was not significantly different from that of
tics to understand and express, morphology to respond the SELSI in the mild delay and delay groups in both re-
to numerous vocabularies in various forms, syntax to use ceptive and expressive language and the average group
words to understand and express long sentences, and in expressive language. However, the average group in
pragmatics to communicate with others [9]. The SELSI receptive language and low average group in both the
consisted of semantics related to cognitive abilities, syn- receptive and expressive language showed differences.
tax related to linguistic knowledge, and pragmatics re- It is presumed that the tendency of the BSID-III to un-
lated to social interaction skills [8]. derestimate language developmental delay has affected
The difference between two tests is the children’s age. the interpretation of results in clinical and research set-
The K-BSID-III’s age of testing ranges from 1 months to tings. In BSID-III standardization, 10% of children with
42 months, while that of the SELSI ranges from 1 months the possibility of developmental delays in the normative
to 36 months. However, there was no significant differ- population were included [22,24].
ence between the two tests in terms of the contents. The In our study data, we found that the K-BSID-III can be
questions were composed of easy to difficult questions. useful in predicting language development delays, es-
Furthermore, the question items of both tests were dis- pecially in the mild delay and delay groups. Therefore, it
tributed evenly according to the elements of language seems that the language scale of the K-BSID-III can as-
and arranged by importance at each age level. sess these deficiencies and includes linguistic factors that
Both the SELSI and K-BSID-III have already proven were not included in the existing language evaluation
that they are valid and reliable as a language domain and tools. We believe that the K-BSID-III is a useful test and
generalized developmental area, respectively. In this can effectively diagnose delayed language development
study, we attempted to understand the reliability of the to adapt the proper management for language rehabilita-
language developmental area of the K-BSID-III test by tion and provide opportunity to detect further neurode-
performing the SELSI and K-BSID-III tests simultane- velopmental delay. However, the children in the average
ously for children with language development delay who group in receptive language and the low average group
visited our clinic. in both the receptive and expressive language should al-
In our study, a significant correlation was found be- ways be considered carefully, and additional tests should
tween the K-BSID-III language scale and SELSI scores in be applied.
both receptive and expressive languages. ROC analysis There are few limitations in this study. First, analysis of
showed the K-BSID-III is a good performance model for this study is performed in a single center, so the conclu-
assessment of language development. Furthermore, the sions should be drawn with caution. In the future, more
optimal cutoff value with a sensitivity and specificity was extensive regional and environmental characteristics
high in both the receptive and expressive language of K- should be obtained to ensure that the questions are prop-
BSID-III between the average and low average groups. erly structured for Korean infants and toddlers around
However, the sensitivity and specificity of receptive lan- the country, and standards should be established to as-
guage was lower than those of expressive language. This sess the language skills more accurately. However, the
might be due to attachment disorder, cognitive impair- results of this study may be indicative of clinical tenden-
ment, and environmental factors, such as inadequate cies.
adaptation to unfamiliar situation at the time of the test. Second, significant language development delays can
However since this is a retrospective study, it is inevitable result from either environmental or biologic causes. Lan-
due to the nature of the data collection method. guage disorders can be observed more commonly in boys
Since the introduction of the K-BSID-III, there is a con- than in girls and especially among children who have a
cern that children’s neurodevelopment is overestimated family history of language or reading disorders in first-
because the score is generally highly rated compared to degree relatives. Moreover, some studies reported that
that of the previous version [24-26]. It was suggested that children of low socioeconomic status are more likely to

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Joung Hyun Doh, et al.

show language delays [14]. However, our findings only AUTHOR CONTRIBUTION
indicate a non-significant association with male sex and
demonstrated a significant result in gestational age, birth Conceptualization: Kim SA. Methodology: Kim SA, Park
weight, and tested age. Therefore, it is necessary to study S. Formal analysis: Heo NH, Park N. Project administra-
and analyze the differences in language development by tion: Kim SA. Visualization: Kim Y, Oh K, Park N, Park S.
evaluating environmental factors and family history as Writing – original draft: Doh JH, Kim SA. Writing – review
factors that influence language development in the fu- and editing: Kim SA. Approval of the final manuscript: all
ture. authors.
Lastly, both tests are mostly performed using an indi-
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