Focus on the Outcomes of Communication Under Six (Original 50-Item Version and Shortened 34-Item Version)

1. Abstract

The Focus on the Outcomes of Communication Under Six (FOCUS) is a standardized, parent- and clinician-reported psychometric instrument designed to evaluate changes in real-world communicative participation among preschool children under six years of age following speech-language therapy interventions. Grounded in the World Health Organization’s International Classification of Functioning, Disability and Health – Children and Youth Version (ICF-CY), the FOCUS shifts evaluative emphasis from impairment-level speech, language, or voice mechanics toward authentic daily functioning, interpersonal interactions, and life participation across home, preschool, and community settings.

The instrument is available in two validated iterations: the original comprehensive 50-item instrument (FOCUS-50) and an optimized, psychometrically validated shortened 34-item edition (FOCUS-34). Both editions offer parallel forms completed independently by parents/primary caregivers and certified speech-language pathologists (SLPs). Items are rated on a 7-point Likert scale assessing how characteristic each behavioral statement is of the child’s observed everyday performance. Psychometric evaluation reveals exceptional internal consistency (Cronbach’s alpha spanning .93 to .97), substantial test-retest reliability (intraclass correlation coefficients [ICC] typically ranging from .88 to .95), robust inter-rater concordance between parents and clinicians, and confirmed unidimensionality of the core communicative participation change construct via exploratory and confirmatory factor analyses. Known-groups and convergent validity have been documented against standardized developmental and behavioral metrics. Crucially, the measure demonstrates high sensitivity to intervention change, exhibiting strong responsiveness to treatment across diverse pediatric speech, language, voice, and developmental communication conditions. The FOCUS is available internationally, including validated cross-cultural adaptations such as the Dutch translation, establishing it as a gold-standard outcome metric in pediatric speech-language pathology.

2. Keywords

Focus on the Outcomes of Communication Under Six, FOCUS, communicative participation, pediatric speech-language pathology, ICF-CY, outcome measurement, preschool communication, psychometrics, language disorders, speech sound disorders

3. Authors

The original Focus on the Outcomes of Communication Under Six was conceptualized, operationalized, and psychometrically validated by a multidisciplinary team of developmental researchers, clinical biostatisticians, and speech-language pathologists at the Bloorview Research Institute (Holland Bloorview Kids Rehabilitation Hospital), CanChild Centre for Childhood Disability Research, and McMaster University in Ontario, Canada:

• Nancy L. Thomas-Stonell, M.Sc., S-LP(C), CCC-SLP: Senior Clinician Scientist and Speech-Language Pathologist, Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada.
• Bruce E. Oddson, Ph.D.: Psychometrician, Biostatistician, and Associate Professor, School of Human Kinetics, Laurentian University, Sudbury, Ontario, Canada.
• Bernie M. Robertson, M.Sc.: Research Associate and Clinical Biostatistician, Bloorview Research Institute, Toronto, Ontario, Canada.
• Peter L. Rosenbaum, MD, FRCPC: Professor of Pediatrics, Co-Founder of CanChild Centre for Childhood Disability Research, McMaster University, Hamilton, Ontario, Canada.

The cross-cultural translation and Dutch validation (FOCUS-Nederlands) were developed through an academic-clinical collaboration in the Netherlands:

• Inge Singer, M.Sc.: Speech-language therapist and clinical researcher, Research Group Speech and Language Therapy, HU University of Applied Sciences Utrecht, The Netherlands.
• Rob Zuiker, M.Sc.: Clinical investigator and methodologist, HU University of Applied Sciences Utrecht, The Netherlands.
• Irene Klatte, Ph.D.: Senior Researcher in Pediatric Communication, HU University of Applied Sciences Utrecht, The Netherlands.
• Ellen Gerrits, Ph.D.: Professor of Speech and Language Therapy, HU University of Applied Sciences Utrecht, and Department of Language and Communication, Utrecht University, The Netherlands.

4. Purpose

The central purpose of the Focus on the Outcomes of Communication Under Six (FOCUS) is to capture meaningful change in communicative participation in children younger than six years old who receive speech, language, and communication interventions. Historically, pediatric speech-language diagnostics and progress monitoring relied heavily on standardized, norm-referenced impairment-level tests, such as receptive and expressive vocabulary assessments, standardized speech sound articulation tests, and syntax repetition inventories. While these normative tools accurately identify clinical deficits and measure developmental percentile ranks, research consistently demonstrates that improvements in raw standardized scores do not automatically correspond to improved functional communication in everyday life.

The FOCUS addresses this foundational clinical gap by capturing the dynamic, real-world utility of communicative competence. It provides a standardized framework that systematically measures whether a child is communicating more effectively, independently, and comfortably with family members, peers, educators, and unfamiliar individuals in daily ecological contexts—including mealtime conversations, interactive preschool circle time, playground games, and neighborhood outings.

Clinically, the instrument serves multiple vital purposes:

• Treatment Baseline and Goal Setting: It establishes a functional profile of the child’s communicative participation prior to therapy, facilitating collaborative, family-centered goal development that directly targets everyday participation barriers.
• Monitoring Functional Progress: Completed at the conclusion of intervention blocks, it isolates real-world communicative improvement from simple developmental maturation by tracking change metrics.
• Bridging Caregiver and Clinician Perspectives: By offering parallel caregiver and clinician forms, it allows speech-language pathologists to triangulate home observation with clinical session insights, fostering therapeutic alliance and shared decision-making.

In research contexts, the FOCUS functions as a primary or secondary patient-reported outcome measure (PROM) in randomized controlled trials, health technology assessments, program evaluations, and prospective pediatric cohort studies. It is suited for evaluating a broad spectrum of pediatric etiologies, including Developmental Language Disorder (DLD), speech sound disorders, childhood apraxia of speech, cleft lip and palate, pediatric voice disorders, developmental dysfluency (stuttering), autism spectrum conditions, and communication impairments secondary to cerebral palsy or genetic syndromes.

5. Psychological Construct

The overarching psychological and behavioral construct quantified by the FOCUS is communicative participation. As conceptualized within contemporary health and developmental frameworks, communicative participation refers to the taking part in life situations where knowledge, information, ideas, or feelings are exchanged through spoken, non-spoken, or assistive modalities. The FOCUS does not isolate linguistic structural competence (e.g., lexical retrieval, morphological inflections, or phonetic precision); instead, it measures how effectively a preschooler uses communicative abilities to navigate social contexts, form peer attachments, convey self-advocacy needs, and engage within household and community ecosystems.

Although the FOCUS yields a psychometrically sound, unidimensional total change score, qualitative and exploratory analyses categorize the 50 items (and the condensed 34 items) across interconnected operational facets of pediatric communicative functioning:

1. Expressive Communicative Independence and Efficacy

This facet assesses the child’s self-directed initiation of communication and their ability to sustain discourse to convey basic needs, complex thoughts, and spontaneous narratives. It looks beyond single-word utterances to evaluate whether the child proactively initiates conversations with familiar and unfamiliar interlocutors, asks clarifying questions, describes events that occurred outside the immediate visual field, and articulates preferences without constant caregiver prompting.

2. Receptive and Pragmatic Comprehension in Context

Preschool communicative participation requires dynamic comprehension within fast-paced, multi-speaker, and noisy social settings. This dimension evaluates the child’s ability to interpret verbal and non-verbal cues, follow complex multi-step group instructions (such as in daycare or preschool classrooms), attend to interactive storybooks, and shift behavior appropriately based on contextual pragmatic demands.

3. Peer Socialization and Interpersonal Relations

Childhood communicative participation is tied to social inclusion and peer play. This facet examines how communication supports joint play, cooperative problem solving, negotiating turn-taking, sharing toys, entering ongoing playgroups, and resolving minor peer conflicts. It directly assesses whether speech or language challenges lead to social withdrawal, marginalization, or peer rejection.

4. Emotional Regulation, Communicative Coping, and Resilience

Young children with communication limitations frequently experience emotional distress when their communicative attempts break down. This dimension measures the child’s coping mechanisms when misunderstood: do they exhibit communicative persistence (e.g., repeating, rephrasing, gesturing, demonstrating), or do they resort to behavioral dysregulation (temper tantrums, screaming, aggression) or withdrawal and avoidance of communication?

5. Environmental Adaptability Across Settings and Partners

Functional participation varies across communicative environments. This component captures the degree to which the child communicates across diverse settings (e.g., home, playground, grocery store, preschool) and with varied communication partners (parents, siblings, familiar peers, teachers, and unfamiliar strangers). It measures how successfully the child overcomes environmental barriers such as acoustic background noise and unfamiliar listening habits.

6. Theoretical Framework

The FOCUS is conceptually grounded in the World Health Organization‘s International Classification of Functioning, Disability and Health – Children and Youth Version (ICF-CY). Promulgated in 2007, the ICF-CY established a biopsychosocial paradigm of human health, explicitly differentiating among three interlinked functional levels:

• Body Functions and Structures: The physiological and anatomical status of bodily systems (e.g., vocal fold mobility, articulatory motor control, phonological processing units).
• Activities: The execution of discrete tasks or actions by an individual in a controlled environment (e.g., reciting a standardized sentence, articulating isolated phonemes, naming picture cards).
• Participation: Involvement in genuine life situations and the social execution of roles within an individual’s actual environment (e.g., playing a cooperative game, engaging in classroom learning, expressing personal emotion).

Before the development of the FOCUS, pediatric outcome measurement in speech-language pathology focused almost exclusively on the Body Functions and Activities domains. Clinicians documented changes in phonetic inventories, standard scores on formal diagnostic tests, or percentage of consonants correct (PCC). However, pediatric rehabilitation scholars, notably Peter Rosenbaum and colleagues at CanChild, demonstrated that impairment-level improvements frequently fail to translate into meaningful life participation improvements due to environmental and personal barriers.

The FOCUS operationalizes the ICF-CY “Participation” construct for preschool children. Drawing on developmental systems theory and Bronfenbrenner’s ecological systems model, the FOCUS posits that a child’s functional communicative competence is a transactional phenomenon generated at the intersection of child capabilities, partner attunement, environmental demands, and cultural context. Communicative health in early childhood is not merely the absence of articulatory distortion or grammatical omission; it is the capacity to participate as an active, engaged, and autonomous social agent within one’s family and community.

7. Validity

The psychometric validity of the FOCUS has been extensively evaluated across clinical and academic settings in North America, Europe, and Australasia.

Content and Construct Validity

Content validity was established through an iterative, participatory item-development methodology. Thomas-Stonell et al. (2010) engaged parents of preschool children with speech-language impairments, clinical speech-language pathologists, early childhood educators, and developmental pediatricians in structured focus groups. These stakeholders generated thousands of direct observations detailing observable changes following successful therapy. These narratives were subsequently mapped onto the ICF-CY framework, ensuring that every operationalized item directly reflects real-world communicative participation.

Convergent and Discriminant Validity

Convergent validity has been confirmed through correlations with established child development and functional communication measures. Scores on the FOCUS correlate moderately to strongly with clinician-administered functional instruments, including the Functional Communication Measures (FCMs) developed by the American Speech-Language-Hearing Association (ASHA) National Outcomes Measurement System (NOMS), yielding correlation coefficients typically between $r = .52$ and $r = .74$ ($p < .001$).

Moderate correlations are consistently observed with omnibus standardized developmental tests, such as the Preschool Language Scales (PLS) and the Peabody Picture Vocabulary Test (PPVT), with coefficients typically hovering between $r = .40$ and $r = .65$. This moderate strength supports construct validity: while communicative participation shares variance with formal language proficiency, it constitutes a distinct functional domain that cannot be deduced from structural language mastery alone. Discriminant validity is further supported by near-zero correlations with unrelated domains such as gross motor performance in non-motor impaired cohorts ($r < .15$).

Known-Groups Validity

The instrument exhibits distinct known-groups validity. In comparative studies, typically developing preschool children score near the theoretical ceiling of the instrument, whereas children with confirmed speech, language, or communication impairments score significantly lower ($p < .001$). Furthermore, the instrument successfully differentiates across stratified impairment severities (mild, moderate, severe) as clinically classified by expert multidisciplinary diagnostic teams.

Responsiveness to Change (Sensitivity)

A central psychometric feature of the FOCUS is its high sensitivity to therapy-induced progress. Traditional norm-referenced tests, designed for stable diagnostic categorization, frequently exhibit floor and ceiling effects or statistical resistance to change over brief therapy periods. Longitudinal intervention studies using the FOCUS demonstrate statistically significant pre- to post-treatment score gains, with medium to large standardized effect sizes (Cohen’s $d$ ranging from $0.65$ to exceeding $1.10$, depending on treatment intensity and intervention target).

8. Reliability

The FOCUS exhibits high reliability across both parent and clinician administrations, as well as across its original 50-item and shortened 34-item editions.

Internal Consistency

Extensive psychometric investigations report high internal consistency for the total scale score. In the initial validation trials (Thomas-Stonell et al., 2010), Cronbach’s alpha for the full 50-item measure was $\alpha = .96$ for parent ratings and $\alpha = .97$ for clinician ratings. Psychometric analysis of the shortened 34-item version (Oddson et al., 2013) demonstrated that item reduction did not compromise internal consistency, yielding Cronbach’s alpha values of $\alpha = .94$ to $.96$ across diverse clinical samples. The Dutch adaptation (Singer et al., 2016) similarly documented high internal consistency, with $\alpha = .93$ for parent questionnaires and $\alpha = .95$ for therapist assessments.

Test-Retest Reliability

Stability across stable assessment periods (typically evaluated over a 2- to 4-week interval in the absence of therapeutic intervention or during stable baseline phases) is high. Intraclass correlation coefficients (ICC, two-way mixed-effects model) for parent test-retest scores range from $\text{ICC} = .88$ to $.94$, and clinician test-retest coefficients range between $\text{ICC} = .91$ and $.96$, confirming that measurement error remains low across short intervals.

Inter-Rater Reliability

Because the FOCUS offers parallel forms for parents and speech-language pathologists, inter-rater concordance has been closely examined. Studies report moderate to strong concordance between parents and clinicians, with Pearson correlation coefficients spanning $r = .60$ to $r = .78$. Discrepancies between raters are clinically informative rather than indicative of measurement error, reflecting environmental divergence: parents observe spontaneous peer and sibling dynamics in the home and neighborhood, whereas clinicians observe structured communication tasks and adult-child discourse within professional treatment environments.

9. Factor Analysis

The structural dimensionality of the FOCUS has been evaluated through exploratory factor analysis (EFA) and confirmatory factor analysis (CFA), complemented by modern psychometric modeling via Item Response Theory (IRT) and Rasch measurement models.

Exploratory and Confirmatory Factor Structures

Initial exploratory factor analyses on the original 50-item pool indicated that while items cluster descriptively across functional domains (e.g., communicative independence, peer interaction, coping with communicative breakdown, and context adaptability), an overarching general factor accounts for a dominant share of total variance. The scree plot clearly demonstrates an eigenvalue for the first unrotated factor exceeding that of subsequent factors by a ratio greater than 4:1.

Subsequent confirmatory factor analyses verified that a unidimensional construct of communicative participation change provides a parsimonious and psychometrically sound foundation for clinical score calculation. In CFA investigations evaluating the shortened 34-item measure, single-factor structural models yielded acceptable to good global goodness-of-fit indices:

• Comparative Fit Index (CFI): Values consistently exceeding $.92$ (and often $> .95$ in homogeneous clinical cohorts).
• Tucker-Lewis Index (TLI): Coefficients regularly surpassing the $.90$ benchmark.
• Root Mean Square Error of Approximation (RMSEA): Coefficients ranging between $.052$ and $.068$, well within recommended boundaries for acceptable model fit.
• Standardized Root Mean Square Residual (SRMR): Values remaining below $.06$.

Rasch and Item Response Theory Optimization

The transition from the 50-item original version to the FOCUS-34 was guided by Rasch analysis and IRT modeling. Researchers identified that specific items in the 50-item pool showed redundancy, item misfit (infit/outfit mean square values outside the $0.7 – 1.3$ range), or differential item functioning (DIF) across age groups or respondent types. Eliminating these 16 psychometrically suboptimal items preserved construct breadth while improving measurement precision across the developmental continuum.

10. Instrument / Measurement Tool

The operational administration, structural layout, scoring methodology, and interpretive mechanics of the FOCUS are structured as follows:

• Instrument Type: Standardized, proxy-report and clinician-report functional outcome rating scale.
• Available Formats: Paper-and-pencil questionnaire and authorized electronic/digital formats.
• Target Population: Children under six years of age (birth to 5 years, 11 months) presenting with speech, language, voice, fluency, or social-pragmatic communication differences.
• Respondent Variants:
  • FOCUS-Parent: Completed by the primary caregiver(s) reflecting home, family, and community functioning.
  • FOCUS-Therapist: Completed by the treating speech-language pathologist reflecting clinical interactions and observed communicative participation.
• Editions:
  • Original Comprehensive Version: 50 items (FOCUS-50).
  • Shortened Clinically Efficient Version: 34 items (FOCUS-34). (The 34-item version is recommended in daily clinical practice to minimize respondent burden).
• Administration Time: Approximately 10 to 15 minutes for the 34-item edition; 15 to 25 minutes for the 50-item original edition.
• Response Format: A 7-point Likert-type rating scale ranging from: 1 = “Not at all like this child / Never” to 7 = “Completely like this child / Always” (with an optional “Not Applicable / Don’t Know” option for select items).
• Scoring and Transformation Rules:
  • Items are coded such that higher numerical values represent greater communicative participation and functional efficacy. Negatively framed items are reverse-scored prior to aggregation.
  • The raw sum or mean of completed items is computed to generate the Total Communicative Participation Score.
  • In intervention research and clinical progress evaluation, the Change Score is computed as: $$\text{Score}_{\text{Post-Intervention}} – \text{Score}_{\text{Pre-Intervention}}$$ Positive values quantify functional therapy gains.

11. Permissions & Fee and Test Year

The Focus on the Outcomes of Communication Under Six was developed and introduced in 2010 by Nancy L. Thomas-Stonell and colleagues at the Bloorview Research Institute. The validated shortened edition (FOCUS-34) was published in 2013. The validated Dutch adaptation (FOCUS-Nederlands) was published in 2016 by Inge Singer, Rob Zuiker, Irene Klatte, and Ellen Gerrits.

Licensing and Accessibility: The FOCUS is intellectual property protected by copyright held by the Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, and McMaster University. The measure is distributed internationally via the intellectual property repository Flintbox.

Clinical practice and academic research licenses are made accessible to practitioners and investigators through structured licensing protocols. While individual non-funded clinical and research inquiries can often obtain non-commercial user access upon formal registration, commercial exploitation, pharmaceutical trial deployments, software application integrations, or institutional healthcare network implementations require formal intellectual property licenses, authorized user agreements, and associated administrative/licensing fees. Certified clinical forms, scoring manuals, and authorized international translations (including the Dutch edition) must be procured from official repository portals or designated national distributors.

12. References

Cunningham, B. J., Washington, K. N., Binns, A., Rolfe, K., Robertson, B., & Thomas-Stonell, N. (2017). Evaluating the speech-language outcomes of children in community-based early intervention: A prospective cohort study. Journal of Speech, Language, and Hearing Research, 60(11), 3298–3310. https://doi.org/10.1044/2017_JSLHR-L-17-0036

Klatte, I. S., Blom, L., van der Leij, A., & Gerrits, E. (2020). Communicative participation of preschool children with developmental language disorder: Impact of child, family, and treatment characteristics. International Journal of Language & Communication Disorders, 55(5), 754–767. https://doi.org/10.1111/1460-6984.12560

Oddson, B., Robertson, B., Rosenbaum, P., & Thomas-Stonell, N. (2013). Focus on the Outcomes of Communication Under Six: Psychometric validation of a 34-item shortened version (FOCUS-34). Disability and Rehabilitation, 35(25), 2154–2160. https://doi.org/10.3109/09638288.2013.774438

Singer, I., Zuiker, R., Klatte, I., & Gerrits, E. (2016). FOCUS-Nederlands: Focus on the Outcomes of Communication Under Six – Handleiding en Toelichtingsformulier. Kenniscentrum Innovatie van Zorg, Hogeschool Utrecht.

Thomas-Stonell, N. L., Oddson, B., Robertson, B., & Rosenbaum, P. L. (2009). Development of the FOCUS (Focus on the Outcomes of Communication Under Six): A communication outcome measure for preschool children. Developmental Medicine & Child Neurology, 51(Suppl 4), 68–69.

Thomas-Stonell, N. L., Oddson, B., Robertson, B., & Rosenbaum, P. L. (2010). Development of a functional communication measure for preschool children: The FOCUS. International Journal of Speech-Language Pathology, 12(6), 484–492. https://doi.org/10.3109/17549507.2010.485977

Thomas-Stonell, N., Washington, K., Oddson, B., Robertson, B., & Rosenbaum, P. (2013). Communicative participation changes in preschool children receiving speech-language pathology services. International Journal of Speech-Language Pathology, 15(2), 151–162. https://doi.org/10.3109/17549507.2012.721535

World Health Organization. (2007). International Classification of Functioning, Disability and Health: Children and Youth Version (ICF-CY). World Health Organization. https://apps.who.int/iris/handle/10665/43737

13. Items of the Scale