Background¹

Language is the process whereby we communicate with others. It involves an element of understanding and expression (speech). It is one of the most highly developed of all human skills, giving us a framework for thought and allowing us to communicate. Disorders of speech and language are common, ranging from unclear speech or a slight delay in development to more significant difficulties associated with serious disorders.

This record will give you an outline of the normal development, assessment of the child presenting with these difficulties and some of the more common causes.

Normal speech development

The following is only a rough guide but there is a wide variation of normal speech development:^2,3

• 1 to 6 months: coos in response to voice
• 6 to 9 months: babbling - initially 'da', 'ba' then combining syllables towards 7/8 months 'da-da', 'ba-ba'
• 10 to 11 months: imitation of sounds
• 12 months: says mama, dada or another simple word with meaning
• 13 to 15 months: vocabulary of four to seven words
• 15 months: jargon
• 16 to 18 months: vocabulary of 10 words
• 19 to 21 months: vocabulary of 20 words
• 22 to 24 months: vocabulary of more than 50 words; two-word phrases; most of speech is now understood by strangers
• 2 to 2½ years: vocabulary of 400 words, including names; two- to three-word phrases; use of pronouns; begins to talk incessantly
• 2½ to 3 years: use of plurals and past tense; knows age and sex; counts three objects correctly; three to five words per sentence
• 3 to 4 years: three to six words per sentence; asks questions, relates experiences, tells stories; almost all speech understood by strangers
• 4 to 5 years: six to eight words per sentence; names four colors; counts ten pennies correctly

Variations in development versus delay

It is important to clarify what the concern is as there can be a lot of variation in speech and language development. Consider whether either of the parents was a late speaker. There tends to be a gender difference with girls developing slightly faster than boys and it is traditionally said that bilingualism may delay speech (although there is emerging evidence to the contrary⁴ and the end result is thought to be the same⁵). Parents are usually the first to express concern - are they comparing to other children and simply observing normal variation? The health visitor may also refer the child. A full assessment should be made but, as a rule of thumb, lower your threshold for referral if:¹

• There is no double syllable babble at a year
• There are fewer than 6 words, or there is persistent drooling, at 18 months
• There are no 2- to 3- word sentences by 2½ years
• Speech remains unintelligible by 4 years

Epidemiology

• Speech delay is a common childhood problem that affects 3-10% of children.²
• The disorder is three to four times more common in boys than in girls.²

Aetiology¹

Problems can arise from:

• Speech or articulation difficulties
  • Cleft lip
  • Stammer
• Deafness
• Developmental problems
  • Maturational delay (often familial)
  • Environmental deprivation and neglect
  • Learning disability
  • Cerebral palsy
• Communication difficulties
  • Autism
• Other
  • Language disorder
  • Elective mutism (child selectively refuses to speak according to particular circumstances)

Assessment¹

History

These children may be particularly shy about talking so obtain a good history from the parents.

• Does the child appear to have difficulty in hearing?
• Does the child seem to understand what the parent is saying but is responding with unintelligible speech (speech problem) or are there comprehension difficulties too (language problem)?
• Are there delays in other physical or social skills which could suggest a more global delay?
• Are there abnormalities in nonverbal communication skills that might suggest autism?
• Obtain a complete developmental history.
• Check the past medical and perinatal history.
• Ask about a family history of deafness or language delay.

Examination

• Observe the child play and interact with the parent. Listen to any talking and note any imaginative play.
  • A stammer is associated with normal comprehension; however, speech is immature, stuttered or unintelligible.
  • Note that the ability to form interpersonal relationships is often normal in children with learning difficulties, as it is in all other causes except for autism.
  • Autism and language disorders may both be associated with delays in other developmental areas.
• Ask the child simple questions about pictures or their play: do they seem to understand you? Assess motor and social skills.
• Note any anatomical abnormalities, and examine mouth and ears.

Investigations

Organise a formal hearing test by an audiologist. If you think that there is some sort of language difficulty following your assessment, get a speech and language evaluation too.

Management

• Required management may be just explanation, simple advice and reassurance with the involvement of the Health Visitor.
• However early detection and intervention of speech delay may prevent, or at least reduce, the educational, emotional and social problems that may be caused.
• A referral for speech therapy may be required. However, although there is some evidence for the effectiveness of interventions for expressive speech difficulties, the evidence for interventions for expressive syntax is mixed and there is no evidence for interventions for receptive language difficulties.⁶
• Multidisciplinary involvement may be required and the involvement of the parents is vital.
• Management is dependent on cause and associated problems such as hearing impairment.
• If the underlying problem is related to the auditory apparatus and surgery is required, children still need targeted language therapy to complete their rehabilitation.⁷

There is currently no systematic child development and behaviour screening policy in place as this was not recommended at the last UK National Screening Committee (NSC) review. This will be re-evaluated in 2011/2012.⁸

Prognosis

• This is dependent on the cause of the speech delay.
• The prognosis is improved with early detection and intervention.

Document references

1. Rudolf MCJ, Levene MI. Paediatrics and Child Health, Blackwell Science (1999).
2. Leung AK, Kao CP; Evaluation and management of the child with speech delay; Am Fam Physician. 1999 Jun;59(11):3121-8, 3135 [abstract]
3. Illingworth R.S. The normal child, Churchill Livingstone (1991).
4. Werker JF, Byers-Heinlein K, Fennell CT; Bilingual beginnings to learning words. Philos Trans R Soc Lond B Biol Sci. 2009 Dec 27;364(1536):3649-63. [abstract]
5. Westman M, Korkman M, Mickos A, et al; Language profiles of monolingual and bilingual Finnish preschool children at risk Int J Lang Commun Disord. 2008 Nov-Dec;43(6):699-711. [abstract]
6. Law J, Garrett Z, Nye C; Speech and language therapy interventions for children with primary speech and language delay or disorder. Cochrane Database Syst Rev. 2003;(3):CD004110. [abstract]
7. Keegstra AL, Post WJ, Goorhuis-Brouwer SM; Effect of different treatments in young children with language problems. Int J Pediatr Otorhinolaryngol. 2009 May;73(5):663-6. Epub 2009 Feb 20. [abstract]
8. UK Screening Portal; (all conditions)

Internet and further reading

• Talking point; Information about speech, language and communication difficulties in children.

Acknowledgements