Clinical Consult: Language and speech delays

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Like all developmental milestones, children learn to communicate at different rates. But delays in speech and language development are important to recognize as early as possible. A child’s early understanding and expression of language will often impact other important developmental milestones such as play skills, social interactions and behavioral regulation.

When should a parent or clinician be concerned about delayed language acquisition, and when is further evaluation by a specialist such as a developmental-behavioral pediatrician or child neurologist warranted? Notes consulted with Carol Wilkinson, MD, PhD, a fellow in Boston Children’s Division of Developmental Medicine, and David Urion, MD, FAAN, of the hospital’s Department of Neurology, for advice and tips on what to watch for.

  1. Don’t wait too long. While there is huge variability in when children start to speak, every child should make steady progress over time. If you are concerned about a toddler’s language development at 18 months, don’t wait until the 24-month visit to decide whether he or she should be evaluated. Follow up in 1 to 2 months to determine whether the child making sufficient progress. Early Intervention programs in many states provide in-home speech therapy to children under 3 years of age, but setting up these services takes time.
  1. Social communication. It’s easy to focus on expressive language, but the first form of communication for most children is social. Before 6 months of age, babies should be interested in their parents’ faces and have a social smile. By 1 year, they should respond to the sound of their name. Before they have their first words, babies typically point or gesture at things they want, look at their parent for reassurance or share their joy of a new toy with family members. If you are concerned about a child’s social communication, with or without expressive language concerns, we recommend an autism evaluation. At Boston Children’s Hospital, this is done through our Autism Spectrum Center. Be sure to refer to Early Intervention at the same time to avoid delays in accessing services.
  1. Receptive language and behavior: A child’s difficulty in understanding language can often be overlooked. In preschool-aged children, struggles with receptive language can often present as behavioral difficulties or anxiety. Often, these children have strong social communication skills that enable them to use the visual cues around them to determine what is being said. A full developmental evaluation can help determine whether a child has difficulties with language or weaknesses in specific cognitive tasks, or both.
  1. Two languages: While many children raised in bilingual homes start talking slightly later, studies have consistently shown that they begin talking within the normal range (between 8 and 15 months) and meet language milestones on time. Make sure you ask about language development in both languages so you better understand their full ability. It’s important not to delay referral just because a child is raised in a bilingual environment.


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  1. Check hearing: If you are filling out a referral for further language evaluation, also refer the child for a formal audiology evaluation.
  1. Model a language-rich environment: We know that early language environment plays an important role in language development. Teaching parents how to create a language-rich experience for their babies, before they are talking, can make a huge difference. Use your well child visits to model how parents can tune into their baby’s nonverbal communication and talk and sing to their baby during everyday activities.
  1. True regression: If a child loses a language capacity he or she once had — for example, sentences and phrases become shorter, like a telegram or text message — this bears investigation. The same is true for social behaviors that are part of a child’s language capacity, such as eye contact, turn-taking and understanding tone or facial expression. If any of these capabilities are lost, further investigation by a specialist is usually wise.
  1. Hitting a plateau: While all development occurs in a step-like fashion — periods of rapid growth, followed by a period of consolidation of the new skill, then another period of growth — a child who fails to continue to develop new language skills over several months should probably be evaluated by a specialist. That would include a child who acquires no new words for several months, whose sentences do not continue to get longer and more complex or who fails to develop an understanding of figurative language.
  1. Disordered sleep. Sleep deprivation is known to impair children’s cognitive development, including language acquisition. Restless legs/periodic leg movements of sleep/ADHD complex in particular is associated with delayed language development.
  1. Relatives with similar problems: Language delay can have a hereditary component if the child comes from family with language disorders. Though it may not change immediate treatment, a genetic analysis can give a family a better sense of what their child’s trajectory might be based on the experience of other children with similar genetic findings. Evaluation by a specialist to help determine if such tests are useful is usually wise.