Speech Impairment

Concerned About Speech Delay

West Virginia University

Ms Mueller is a medical student at West Virginia University School of Medicine in Morgantown.

LINDA S. NIELD, MD—Series Editor: Dr Nield is associate professor of pediatrics at West Virginia University School of Medicine in Morgantown.

My 18-month-old son can say only 5 words. According to my baby book, he should be saying about 20. He seems developmentally appropriate in other ways. Is there something wrong with him or will he outgrow this? Can I do anything to improve his speech?

Hearing a child’s first words is an exciting time for parents because it signals a greater level of communication. Parents naturally monitor their child’s speech acquisition closely and want to be reassured that all developmental milestones are being reached as expected. Speech delay is not uncommon and can have many causes. In some children, it can signal an underlying developmental disorder. To answer this parent’s question adequately, we first need to review normal language development.

Normal language development. There are 2 parts of language development: speech, or the actual act of making sounds; and language, which involves both perceiving and understanding what is said and formulating a response.1 Preverbal skills, or the ability to sense and comprehend spoken words, are acquired first. Verbal skills develop later and result in the vocalization of words.2

Language development begins early in life. A fetus can sense its mother’s voice usually by the end of the second trimester.2 By 2 to 4 months of age, children coo and recognize where and when different sounds occur around them. Babbling occurs in the following months.3 At about 8 to 12 months, a child should say his or her first word and make an attempt to follow simple commands.3 Once a child reaches 1 year, a new word is added to the vocabulary at a rate of about 1 per week.4

Keep in mind that the rate at which language develops can vary significantly in children with healthy development; some children may not say their first word until about age 10 to 15 months.4,5 Clinicians should make parents aware that the experts on language development may differ on the exact number of words that should be acquired at various ages. One reliable source provided by the American Academy of Pediatrics states that a 15 to 18 month old will use “5 to 50 words with mixed jargon,”6 while a reliable pediatric textbook states that an 18 month old will use “10 to 50 words.”3

By 2 years of age, children should start putting together 2-word phrases.5 At age 3 years, a child should be using 3-word sentences and most of the speech should be understandable to a stranger.2 By age 5 years, a child can answer who, what, where, when, and why questions—and how.2 Children who are 7 or 8 years old begin to understand complex linguistic concepts, such as humor and sarcasm.2

Causes of speech delay. Speech delay occurs in up to 20% of 2 year olds, and boys are twice as likely to have a problem with speech development.4 Of the many reasons for a child to have delayed or disordered speech, genetics can play a large role; as many as 30% of immediate relatives of the affected child have or have had language problems.4 The child’s social environment also has an effect on the development of language skills.7

The most frequent causes of delayed or disordered language development are hearing disorders, intellectual disability or developmental delay, and autism spectrum disorders. Developmental language disorders, dysarthria, neuromotor speech disorders, structural problems of the oropharynx and upper respiratory tract, selective mutism, or even child abuse and neglect may be the underlying cause of speech delay. Low maternal literacy can be a risk factor for developmental delay.8 It is important to note that of children with language delay, 50% also have some form of delayed development in at least one other area.3

Delay or disorder? For the child in whom there is concern about missing language milestones or abnormal development, it is crucial to differentiate between language delay and language disorder.4 This can be done by assessing the child’s hearing, anatomy, neurological status, respiration, and psychological well-being as well as completing a speech and language evaluation and thorough medical and family history.3,4 In the child with an underlying disorder, the presence of other signs and symptoms and physical examination findings will provide clues to the diagnosis.

It is recommended that all children have a full developmental surveillance at each well child visit and formal screening with a validated instrument at 9, 18, and either 24 or 30 months of age.9 Once it has been determined that the child has a language delay or a language disorder, a speech therapist would tailor management to meet the child’s needs. If the diagnosis is in doubt, referral to a developmental specialist would be prudent.

Speech therapy. Speech therapy encompasses a wide range of treatment options. Children younger than 3 years can participate in play-based therapy with their parents to help foster communication. Children in school can join group therapy or spend one-on-one time with a speech pathologist.5 The federal Individuals with Disabilities Education Act provides educational services for children aged 0 to 21 years with learning difficulties, including language disorders.4 These services may vary from state to state but typically include programs such as Birth to Three, Early Childhood, and Early Learning.4

Children with more severe language impairment may better their communication abilities with sign language, pictures, or computers that speak for them.4 At home, parents can promote language development by reading to their children, repeating what their children babble, teaching new words, and talking to their children whenever they can.10 A multidisciplinary approach, including referral to other specialists, such as psychologists or occupational therapists, may be needed to address all the needs of the child with more severe language impairment and potential comorbidities.

What parents can do to improve their child’s speech. For the child in this scenario, the lack of other health or development red flags and the boy’s acquisition of at least 5 words are reassuring. Pediatricians may differ in their approach to this patient at this time. In an informal poll of the general pediatricians at our institution, we found that most would recommend having parents monitor the child’s development at home and revisiting the issue at the 2-year well-child checkup. A few physicians may perform a hearing screen. All would want to ensure that the results of developmental and autism screening tests are normal for the child. All the polled pediatricians also advocated parental promotion of more speech at home, using measures similar to the ones described above.10

Practical suggestions to promote more speech include weaning a child from a pacifier (if it is constantly in use) and habitual naming out loud the objects to which the child comes in contact. Turning off the television is another practical measure that may have positive effects on language development in children younger than 2 years.11 Buschmann and colleagues12 recommend further diagnostic evaluation when language screening shows abnormal results at age 2 years.

Parents’ inquiries about speech concerns should prompt the pediatrician to promote reading in the home. The provision of interactive reading experiences and reading aloud to children in the home is associated with improved expressive language skills.7 Pediatricians can incorporate “Reach Out and Read” programs in their practices.13 By promoting shared reading experiences, clinicians can improve children’s language development.7