Late Blooming or Language Problem?

Parents are smart. They listen to their child talk and know how he or she communicates. They also listen to his or her playmates who are about the same age and may even remember what older brothers and sisters did at the same age. Then the parents mentally compare their child's performance with the performance of these other children. What results is an impression of whether or not their child is developing speech and language at a normal rate.

If parents think that development is slow, they may check out their impression with other parents, relatives, or their pediatrician. They may get an answer such as "My son was slow too. Now he won't shut up" or "Don't worry, she'll outgrow it."

But suppose (s)he doesn' t? I' d feel guilty waiting and then finding out that I should have acted earlier. Waiting is so hard, especially when I' m concerned and only want what' s best for my child. What' s a parent to do? How will I know for sure what to do?

You won' t know for sure. Although the stages that children pass through in the development of speech and language are very consistent, the exact age when they hit these milestones varies a lot. Factors such as the child' s inborn ability to learn language, other skills the child is learning, the amount and kind of language the child hears, and how people respond to communication attempts can slow down or accelerate the speed of speech and language development. This makes it difficult to say with certainty where any young child' s speech and language development will be in 3 months, or 1 year.

There are, however, certain factors that may increase the risk that a late-talking child in the 18- to 30-month-old age range, and with normal intelligence, will have continuing language problems. These factors include:

Receptive language: Understanding language generally precedes expression and use. Some studies that have followed-up late-talking children in this age range have found, after a year, that age-appropriate receptive language discriminated late bloomers from children who had true language delays. Other researchers doing follow-up studies included only children whose receptive language was within normal limits because they believed that delay in this area was likely to produce worse outcomes.
Use of gestures: One study has found that the number of gestures used by late-talking children with comparably low expressive language can indicate later language abilities. Children with a greater number of gestures used for different communication purposes are more likely to catch up with peers. Such a result is supported by findings that some older children who are taught non-verbal communication systems show a spontaneous increase in oral communication.
Age of diagnosis: More than one study has indicated that the older the child at time of diagnosis, the less positive the outcome. Obviously, older children in a study have had a longer time to bloom than younger children but have not done so, indicating that the language delay may be more serious. Also, if a child is only developing slowly during an age range when other children are rapidly progressing (e.g. 24-30 months) that child will be falling farther behind.
Progress in language development: Although a child may be slow in language development, he or she should still be doing new things with language at least every month. New words may be added. The same words may be used for different purposes. For example, "bottle" may one day mean "That is my bottle," the next, "I want my bottle," and the next week, "Where is my bottle? I don' t see it." Words may be combined into longer utterances ("want bottle" "no bottle"), or such longer utterances may occur more often.

It should be re-emphasized that negative aspects of these factors increase the risk of a true language problem but do not mandate its presence. For example, one research group found that one of their 25- or 26-month-old children with the worst receptive language had the best expressive language outcome 10 months later. On the other hand, children on the positive side of these factors may turn out to show less progress than predicted. The research group found that the child with the poorest outcome had the best receptive language and the largest vocabulary at the beginning of the study.

One study has found that the number of gestures used by late-talking children with comparably low expressive language can indicate later language abilities.

Individual children may not behave like children in a group. Group data can only be used to predict what most children who are very similar to the children in a study might do. Predictions, by their very nature, are not always correct.

So what' s a parent to do?

Parents don' t have to rely on the predictions of others or to guess that their child will be just like a friend' s and eventually catch up in language development. If parents are concerned about their child' s speech and language development, they should see a speech-language pathologist certified by the American Speech-Language-Hearing Association for a professional evaluation. The speech-language pathologist can administer tests of receptive and expressive language, analyze a child' s utterances in various situations, determine factors that may be slowing down language development, and counsel parents on the next steps to take.

The speech-language pathologist may give suggestions on stimulating language development, and ask that the parent and child return if parental concern continues. Or, the speech-language pathologist may want to schedule a re-evaluation right then. In more severe cases, the speech-language pathologist may want the parent and child to become involved in an early intervention program. The programs typically consist of demonstrating language stimulation techniques for home use, and more frequent monitoring of the child' s progress. In the most severe cases, a more formal treatment program may be recommended.

Waiting to find out if your child will catch up will still be hard, but you won't feel guilty that you did not do everything you could.

Childhood Apraxia of Speech

Childhood apraxia of speech is a disorder of the nervous system that affects the ability to sequence and say sounds, syllables, and words. It is not due to muscular weakness or paralysis. The problem is in the brain's planning to move the body parts needed for speech (e.g., lips, jaw, tongue). The child knows what he or she wants to say, but the brain is not sending the correct instructions to move the body parts of speech the way they need to be moved.

Signs of Childhood Apraxia of Speech

In Very Young Children

The child:

does not coo or babble as an infant
produces first words after some delay, but these words are missing sounds
produces only a few different consonant sounds
is unsuccessful at combining sounds
simplifies words by replacing difficult sounds with easier ones or by deleting difficult sounds (Although all children do this, the child with developmental apraxia of speech does so more often).
may have feeding problems.

In Older Children

The child:

makes inconsistent sound errors that are not the result of immaturity
can understand language much better than he or she can produce it
has difficulty imitating speech
may appear to be groping when attempting to produce sounds or to coordinate the lips, tongue, and jaw for purposeful movement
has more difficulty saying longer phrases than shorter ones
appears to be worse when he or she is anxious
is hard for listeners to understand.

Some children may have other problems as well. These problems can include weakness of the lips, jaw, or tongue; delayed language development; other expressive language problems; difficulties with fine motor movement; and problems with oral-sensory perception (identifying an object in the mouth through the sense of touch).

Assessment

In order to rule out hearing loss as a possible cause of the child's speech production difficulties, an audiologist certified by the American Speech-Language-Hearing Association (ASHA) should perform a hearing evaluation. Use our “ Find a Professional ” service to help locate an audiologist near you).

An ASHA-certified speech-language pathologist (use our “ Find a Professional ” service to help locate a provider near you) should examine the child's speech mechanism. He or she assesses the muscle development of his lips, jaw, and tongue, checking for signs of weakness or low muscle tone (dysarthria). He or she evaluates the coordination of the speech mechanism for purposeful movement by having the client imitate non-speech actions (e.g., moving the tongue from side to side, smiling, frowning, puckering the lips, etc.). The speech-language pathologist will also evaluate the coordination and sequencing of muscle movements for speaking by having the child repeat strings of sounds (e.g., puh-tuh-kuh) as fast as possible. The child's skills in functional or "real life" situations (e.g., licking a lollipop) will be compared to his or her skills in non-functional or "pretend" situations (e.g., pretending to lick a lollipop).

The child's intonation (the melody of speech) is also important to evaluate, as some children with apraxia have difficulties in this area. The speech-language pathologist will listen to the child to make sure that he or she is able to appropriately stress syllables in words and words in sentences. She or he will also determine whether the child can use pitch and pauses to mark different types of sentences (e.g., questions versus statements) and to mark off different portions of the sentence (e.g., to pause between the subject and the verb).

Speech articulation (pronunciation of sounds in words) is evaluated, including both vowel and consonant sounds. Along with pronunciation of individual sounds and combined sounds (syllables and word shapes), overall intelligibility of the child's speech is assessed, in single words as well as in conversation.

The speech-language pathologist evaluates expressive and receptive language skills to determine if speech difficulties are part of a larger language problem. The speech-language pathologist also tries to determine the social effects of the problem. For example, does the child refuse to participate in classroom discussions because he or she is ashamed of and/or frustrated by his or her speech?

Pre-reading or reading skills should also be addressed for children who are 4-5 years old or above. Children with speech and language disorders or delays are at higher risk of reading problems.

Based on these findings, an appropriate plan for treatment is developed.

Treatment

Intervention for the child diagnosed with apraxia of speech often focuses on improving the planning, sequencing, and coordination of motor movements for speech production. Exercises that strengthen the oral muscles will not help. Childhood apraxia of speech is a disorder of speech coordination, not strength. To improve speech, the child must practice speech. However, feedback from a number of senses, such as tactile "touch" cues and visual cues (e.g., watching him/herself in the mirror or watching a visual representation of some aspect of his or her speech on a computer screen) as well as auditory feedback are often helpful. With this feedback, the child repeats syllables, words, sentences and longer utterances to improve muscle coordination and sequencing for speech. If assessment reveals expressive and/or receptive language deficits, or pre-reading or reading problems, treatment will include improving these skill areas as well.

Some clients may be taught to use an augmentative or alternative communication system (e.g., a portable computer that writes and produces speech) if the apraxia significantly hinders speech production. This communication system provides them with a means to communicate their ideas when communication through speaking is not a viable option. Once speech production is more effective, the system is used less often or withdrawn completely. Our site has more information on augmentative and alternative communication .

The client and his family are provided with home assignments to accelerate progress and to facilitate carryover of newly learned strategies outside of the treatment room.

One of the most important things for the family to remember is that treatment of apraxia of speech takes time, commitment, and a supportive environment that helps the child feel successful with communication. Without this, the disorder can persist into adulthood with years of speech-related anxiety and frustration.