EvaluationandManagementoftheChildwithSpeechDelay

ALEXANDERK.C.LEUNG,M.B.B.S.,AlbertaChildren'sHospitalandUniversityofCalgary,Alberta,Canada
C.PIONKAO,M.D.,AlbertaChildren'sHospital,Calgary,Alberta,Canada
AmFamPhysician.1999Jun159(11):31213128.
Seerelatedpatientinformationhandoutonthechildwithspeechdelay(http://www.aafp.org/afp/1999/0601/p3135),writtenbytheauthorsofthisarticle.
Adelayinspeechdevelopmentmaybeasymptomofmanydisorders,includingmentalretardation,hearingloss,anexpressivelanguagedisorder,
psychosocialdeprivation,autism,electivemutism,receptiveaphasiaandcerebralpalsy.Speechdelaymaybesecondarytomaturationdelayor
bilingualism.Beingfamiliarwiththefactorstolookforwhentakingthehistoryandperformingthephysicalexaminationallowsphysicianstomakea
promptdiagnosis.Timelydetectionandearlyinterventionmaymitigatetheemotional,socialandcognitivedeficitsofthisdisabilityandimprovethe
outcome.
Speechisthemotoractofcommunicatingbyarticulatingverbalexpression,whereaslanguageistheknowledgeofasymbolsystemusedforinterpersonal
communication.1Ingeneral,achildisconsideredtohavespeechdelayifthechild'sspeechdevelopmentissignificantlybelowthenormforchildrenofthesame
age.Achildwithspeechdelayhasspeechdevelopmentthatistypicalofanormallydevelopingchildofayoungerchronologicagethespeechdelayedchild'sskills
areacquiredinanormalsequence,butataslowerthannormalrate.2
Speechdelayhaslongbeenaconcernofphysicianswhocareforchildren.Theconcerniswellfounded,becauseanumberofdevelopmentalproblems
accompanydelayedonsetofspeech.Inaddition,speechdelaymayhaveasignificantimpactonpersonal,social,academicand,lateron,vocationallife.Early
identificationandappropriateinterventionmaymitigatetheemotional,socialandcognitivedeficitsofthisdisabilityandmayimprovetheoutcome.

NormalSpeechDevelopment
Todeterminewhetherachildhasspeechdelay,thephysicianmusthaveabasicknowledgeofspeechmilestones.Normalspeechprogressesthroughstagesof
cooing,babbling,echolalia,jargon,wordsandwordcombinations,andsentenceformation.ThenormalpatternofspeechdevelopmentisshowninTable1.3
View/PrintTable

TABLE1
NormalPatternofSpeechDevelopment
AGE

ACHIEVEMENT

1to6months

Coosinresponsetovoice

6to9months

Babbling

10to11
months

Imitationofsoundssaysmama/dadawithoutmeaning

12months

Saysmama/dadawithmeaningoftenimitatestwoandthreesyllablewords

13to15
months

Vocabularyoffourtosevenwordsinadditiontojargon<20%ofspeechunderstoodbystrangers

16to18
months

Vocabularyof10wordssomeecholaliaandextensivejargon20%to25%ofspeechunderstoodbystrangers

19to21
months

Vocabularyof20words50%ofspeechunderstoodbystrangers

22to24
months

Vocabulary>50wordstwowordphrasesdroppingoutofjargon60%to70%ofspeechunderstoodbystrangers

2to2years

Vocabularyof400words,includingnamestwotothreewordphrasesuseofpronounsdiminishingecholalia75%ofspeechunderstoodbystrangers

2to3years

Useofpluralsandpasttenseknowsageandsexcountsthreeobjectscorrectlythreetofivewordspersentence80%to90%ofspeechunderstoodby
strangers

3to4years

Threetosixwordspersentenceasksquestions,converses,relatesexperiences,tellsstoriesalmostallspeechunderstoodbystrangers

4to5years

Sixtoeightwordspersentencenamesfourcolorscounts10penniescorrectly

InformationfromSchwartzER.Speechandlanguagedisorders.In:SchwartzMW,ed.Pediatricprimarycare:aproblemorientedapproach.St.Louis:Mosby,1990:696700.

Epidemiology
Exactfiguresthatwoulddocumenttheprevalenceofspeechdelayinchildrenaredifficulttoobtainbecauseofconfusedterminology,differencesindiagnostic
criteria,unreliabilityofunconfirmedparentalobservations,lackofreliablediagnosticproceduresandmethodologicproblemsinsamplinganddataretrieval.Itcan
besaid,however,thatspeechdelayisacommonchildhoodproblemthataffects3to10percentofchildren.46Thedisorderisthreetofourtimesmorecommonin
boysthaningirls.5,7

Etiology
Speechdelaymaybeamanifestationofnumerousdisorders.CausesoftheproblemarelistedinTable2.
View/PrintTable

TABLE2
CausesofSpeechDelay
Mentalretardation
Hearingloss
Maturationdelay(developmentallanguagedelay)
Expressivelanguagedisorder(developmentalexpressiveaphasia)
Bilingualism
Psychosocialdeprivation
Autism
Electivemutism
Receptiveaphasia
Cerebralpalsy

MENTALRETARDATION
Mentalretardationisthemostcommoncauseofspeechdelay,accountingformorethan50percentofcases.8Amentallyretardedchilddemonstratesglobal
languagedelayandalsohasdelayedauditorycomprehensionanddelayeduseofgestures.Ingeneral,themoreseverethementalretardation,theslowerthe
acquisitionofcommunicativespeech.Speechdevelopmentisrelativelymoredelayedinmentallyretardedchildrenthanareotherfieldsofdevelopment.
Inapproximately30to40percentofchildrenwithmentalretardation,thecauseoftheretardationcannotbedetermined,evenafterextensiveinvestigation.9Known
causesofmentalretardationincludegeneticdefects,intrauterineinfection,placentalinsufficiency,maternalmedication,traumatothecentralnervoussystem,
hypoxia,kernicterus,hypothyroidism,poisoning,meningitisorencephalitis,andmetabolicdisorders.9

HEARINGLOSS
Intacthearinginthefirstfewyearsoflifeisvitaltolanguageandspeechdevelopment.Hearinglossatanearlystageofdevelopmentmayleadtoprofoundspeech
delay.
Hearinglossmaybeconductiveorsensorineural.Conductivelossiscommonlycausedbyotitismediawitheffusion.10Suchhearinglossisintermittentand
averagesfrom15to20dB.11Somestudieshaveshownthatchildrenwithconductivehearinglossassociatedwithmiddleearfluidduringthefirstfewyearsoflife
areatriskforspeechdelay.4,11However,notallstudiesfindthisassociation.12Conductivehearinglossmayalsobecausedbymalformationsofthemiddleear
structuresandatresiaoftheexternalauditorycanal.
Sensorineuralhearinglossmayresultfromintrauterineinfection,kernicterus,ototoxicdrugs,bacterialmeningitis,hypoxia,intracranialhemorrhage,certain
syndromes(e.g.,Pendredsyndrome,Waardenburgsyndrome,Ushersyndrome)andchromosomalabnormalities(e.g.,trisomysyndromes).Sensorineuralhearing
lossistypicallymostsevereinthehigherfrequencies.

MATURATIONDELAY
Maturationdelay(developmentallanguagedelay)accountsforaconsiderablepercentageoflatetalkers.Inthiscondition,adelayoccursinthematurationofthe
centralneurologicprocessrequiredtoproducespeech.Theconditionismorecommoninboys,andafamilyhistoryoflatebloomersisoftenpresent.13The
prognosisforthesechildrenisexcellent,howevertheyusuallyhavenormalspeechdevelopmentbytheageofschoolentry.14

EXPRESSIVELANGUAGEDISORDER

Childrenwithanexpressivelanguagedisorder(developmentalexpressiveaphasia)failtodeveloptheuseofspeechattheusualage.Thesechildrenhavenormal
intelligence,normalhearing,goodemotionalrelationshipsandnormalarticulationskills.Theprimarydeficitappearstobeabraindysfunctionthatresultsinan
inabilitytotranslateideasintospeech.Comprehensionofspeechisappropriatetotheageofthechild.Thesechildrenmayusegesturestosupplementtheirlimited
verbalexpression.Whilealatebloomerwilleventuallydevelopnormalspeech,thechildwithanexpressivelanguagedisorderwillnotdosowithoutintervention.13It
issometimesdifficult,ifnotimpossible,todistinguishatanearlyagealatebloomerfromachildwithanexpressivelanguagedisorder.Maturationdelay,however,
isamuchmorecommoncauseofspeechdelaythanisexpressivelanguagedisorder,whichaccountsforonlyasmallpercentageofcases.Achildwithexpressive
languagedisorderisatriskforlanguagebasedlearningdisabilities(dyslexia).Becausethisdisorderisnotselfcorrecting,activeinterventionisnecessary.

BILINGUALISM
Abilingualhomeenvironmentmaycauseatemporarydelayintheonsetofbothlanguages.Thebilingualchild'scomprehensionofthetwolanguagesisnormalfor
achildofthesameage,however,andthechildusuallybecomesproficientinbothlanguagesbeforetheageoffiveyears.

PSYCHOSOCIALDEPRIVATION
Physicaldeprivation(e.g.,poverty,poorhousing,malnutrition)andsocialdeprivation(e.g.,inadequatelinguisticstimulation,parentalabsenteeism,emotional
stress,childneglect)haveanadverseeffectonspeechdevelopment.Abusedchildrenwholivewiththeirfamiliesdonotseemtohavespeechdelayunlessthey
arealsosubjectedtoneglect.15Becauseabusiveparentsaremorelikelythanotherparentstoignoretheirchildrenandlesslikelytouseverbalmeansto
communicatewiththem,abusedchildrenhaveanincreasedincidenceofspeechdelay.16

AUTISM
Autismisaneurologicallybaseddevelopmentaldisorderonsetoccursbeforethechildreachestheageof36months.Autismischaracterizedbydelayedand
deviantlanguagedevelopment,failuretodeveloptheabilitytorelatetoothersandritualisticandcompulsivebehaviors,includingstereotypedrepetitivemotor
activity.Avarietyofspeechabnormalitieshavebeendescribed,suchasecholaliaandpronounreversal.Thespeechofsomeautisticchildrenhasanatonic,
woodenorsingsongquality.Autisticchildren,ingeneral,failtomakeeyecontact,smilesocially,respondtobeinghuggedorusegesturestocommunicate.Autism
isthreetofourtimesmorecommoninboysthaningirls.

ELECTIVEMUTISM
Electivemutismisaconditioninwhichchildrendonotspeakbecausetheydonotwantto.Typically,childrenwithelectivemutismwillspeakwhentheyareontheir
own,withtheirfriendsandsometimeswiththeirparents,buttheydonotspeakinschool,inpublicsituationsorwithstrangers.Theconditionoccurssomewhat
morefrequentlyingirlsthaninboys.17Asignificantproportionofchildrenwithelectivemutismalsohavearticulatoryorlanguagedeficits.
Thebasisofmutismisusuallyfamilypsychopathology.Electivelymutechildrenusuallymanifestothersymptomsofpooradjustment,suchaspoorpeer
relationshipsoroverdependenceontheirparents.Generally,thesechildrenarenegativistic,shy,timidandwithdrawn.Thedisordercanpersistformonthsoryears.

RECEPTIVEAPHASIA
Adeficitinthecomprehensionofspokenlanguageistheprimaryprobleminreceptiveaphasiaproductiondifficultiesandspeechdelaystemfromthisdisability.
Childrenwithreceptiveaphasiashownormalresponsestononverbalauditorystimuli.Theirparentsoftendescribesuchchildrenasnotlisteningratherthannot
hearing.Thespeechofthesechildrenisnotonlydelayedbutalsosparse,agrammaticandindistinctinarticulation.18Mostchildrenwithreceptiveaphasia
graduallyacquirealanguageoftheirown,understoodonlybythosewhoarefamiliarwiththem.

CEREBRALPALSY
Delayinspeechiscommoninchildrenwithcerebralpalsy.Speechdelayoccursmostofteninthosewithanathetoidtypeofcerebralpalsy.Thefollowingfactors,
aloneorincombination,mayaccountforthespeechdelay:hearingloss,incoordinationorspasticityofthemusclesofthetongue,coexistingmentalretardationora
defectinthecerebralcortex.

ClinicalEvaluation
Ahistoryandphysicalexaminationareimportantintheevaluationofchildrenwithspeechdelay.Theinformationobtainedwillhelpthephysicianselectappropriate
studiesforfurtherevaluation(Tables3and4).
View/PrintTable

TABLE3
HistoricalInformationintheEvaluationofSpeechDelayinChildren
HISTORICALDATA

POSSIBLEETIOLOGY

Developmentalhistory
Delayinlanguagemilestones

Speechdelay

Delayinmotormilestones

Cerebralpalsy

Generalizeddelayindevelopmentalmilestones

Mentalretardation

Maternalillnessduringpregnancy
Intrauterineinfection(e.g.,rubella,toxoplasmosis,cytomegalovirusinclusiondisease)

Hearingloss,mentalretardation

Maternalphenylketonuria

Mentalretardation

Maternalhypothyroidism

Mentalretardation

Maternaluseofdrugs(e.g.,alcohol)

Mentalretardation

Placentalinsufficiency

Mentalretardation,cerebralpalsy

Perinatalhistory
Prematurity

Cerebralpalsy

Hypoxia

Mentalretardation,cerebralpalsy,hearingloss

Birthtrauma

Cerebralpalsy

Intracranialhemorrhage

Mentalretardation,hearingloss,cerebralpalsy

Kernicterus

Mentalretardation,hearingloss,cerebralpalsy

Feedingdifficulties,excessivedrooling

Cerebralpalsy

Pasthealth
Encephalitis,meningitis

Mentalretardation,hearingloss

View/PrintTable

TABLE4
PhysicalExaminationFindingsintheEvaluationofChildrenWithSpeechDelay
PHYSICALFINDINGS

POSSIBLEETIOLOGY

Shortstature,obesity,hypogonadism

PraderWillisyndrome

Microcephaly,macrocephaly

Mentalretardation,cerebralpalsy,hearingloss

Deformitiesofauricleorexternalearcanal

Hearingloss

Enlargedpinna,macroorchidism

FragileXsyndrome

Upwardslantingeyes,Brushfieldspots,epicanthicfolds,brachycephaly,simiancreases

Downsyndrome

Goiter

Pendredsyndrome

Cafaulaitspots

Neurofibromatosis

Adenomasebaceum,shagreenpatches,hypopigmentedspots

Tuberoussclerosis

Whiteforelock,cutaneoushypopigmentation,hypertelorism,heterochromia

Waardenburgsyndrome

Retinitispigmentosa,obesity,hypogonadism,polydactyly

BardetBiedlsyndrome

Retinitispigmentosa,cataracts

Ushersyndrome

Chorioretinitis

Congenitaltoxoplasmosis,congenitalcytomegalovirus

Lackofeyecontact,stereotypedrepetitivemotoractivity

Autism

Spasticity,hyperreflexia,clonus,extensorplantarresponse,contractures

Cerebralpalsy

Athetosis,choreoathetosis,ataxia

Cerebralpalsy

Dysarthria

Cerebralpalsy

HISTORY
Athoroughdevelopmentalhistory,withspecialattentiontolanguagemilestones,isextremelyimportantinmakingthediagnosis.Thephysicianshouldbe
concernedifthechildisnotbabblingbytheageof12to15months,notcomprehendingsimplecommandsbytheageof18months,nottalkingbytwoyearsof
age,notmakingsentencesbythreeyearsofage,orishavingdifficultytellingasimplestorybyfourtofiveyearsofage.4,18Thephysicianshouldalsobe
concernedifthechild'sspeechislargelyunintelligibleafterthreeyearsofageorifthechild'sspeechismorethanayearlateinappearanceincomparisonwith
normalpatternsofspeechdevelopment.Generalizeddelayinallaspectsofdevelopmentalmilestonessuggestsmentalretardationasthecauseofachild'sspeech
delay.

Themedicalhistoryshouldincludeanymaternalillnessesduringthepregnancy,perinataltrauma,infectionsorasphyxia,gestationalageatbirth,birthweight,past
health,useofototoxicdrugs,psychosocialhistory,language(s)spokentothechild,andfamilyhistoryofsignificantillnessorspeechdelay.

PHYSICALEXAMINATIONANDSCREENINGTESTS
Aprecisemeasurementofthechild'sheight,weightandheadcircumferenceisnecessary.Areviewoftheappropriateparameteronthegrowthchartalsocanhelp
inearlyidentificationofsometypesofspeechdelay.Anydysmorphicfeaturesorabnormalphysicalfindingsshouldbenoted.Acompleteneurologicexamination
shouldbeperformedandshouldincludevisionandhearingevaluations.
TheEarlyLanguageMilestoneScale(Figure1)isasimpletoolthatcanbeusedtoassesslanguagedevelopmentinchildrenwhoareyoungerthanthreeyearsof
age.19Thetestfocusesonexpressive,receptiveandvisuallanguage.Itreliesprimarilyontheparents'report,withoccasionaltestingofthechild.Thetestcanbe
doneinthephysician'sofficeandtakesonlyafewminutestoadminister.7Forchildrentwoandonehalfto18yearsofage,thePeabodyPictureVocabularyTest
Revised20isausefulscreeninginstrumentforwordcomprehension.Ifthechildisbilingual,itisimportanttocomparethechild'slanguageperformancewiththatof
otherbilingualchildrenofsimilarculturalandlinguisticbackgrounds.
View/PrintFigure

FIGURE1.
EarlyLanguageMilestoneScale.
ReprintedwithpermissionfromCoplanJ.ELMscale:theearlylanguagemilestonescale.Austin,Tex.:ProEd,1987.

Acomprehensivedevelopmentalassessmentisessential,becauseadelayinspeechdevelopmentisthemostcommonearlymanifestationofglobalintellectual
impairment.TheDenverDevelopmentalScreeningTestisthemostpopulartestinclinicaluseforinfantsandyoungchildren.9,21
Childrenwhoseresultsindicateanabnormalconditionrequiremoredefinitivetestingwithoneofthestandardizedandvalidatedtestsofintelligence.Themost
widelyusedintelligencetestsforassessingtheintellectualandadaptivefunctioningofachildaretheStanfordBinetIntelligenceScale,theBayleyScalesofInfant
Development,theWechslerIntelligenceScaleforChildrenRevised(WISCR),andtheWechslerPreschoolandPrimaryScaleofIntelligence(WPPSI).

DIAGNOSTICEVALUATION
Allchildrenwithspeechdelayshouldbereferredforaudiometry,regardlessofhowwellthechildseemstohearinanofficesettingandregardlessofwhetherother
disabilitiesseemtoaccountforthespeechdelay.8Specialearphonesthatshutoutbackgroundnoisemayimprovethestudyresult.Tympanometryisauseful
diagnostictool.Whencoupledwithresultsfrompuretoneaudiometry,measurementofeardrumcompliancebymeansofatympanometerhelpstoidentifya
potentialconductivecomponent(e.g.,middleeareffusion)thatmightotherwisebemissed.Anauditorybrainstemresponseprovidesadefinitiveandquantitative
physiologicmeansofrulingoutperipheralhearingloss.22Itisespeciallyusefulininfantsanduncooperativechildren.22Theauditorybrainstemresponseisnot
affectedbysedationorgeneralanesthesia.
Additionaltestsshouldbeorderedonlywhentheyareindicatedbythehistoryorphysicalexamination.AkaryotypeforchromosomalabnormalitiesandaDNAtest
shouldbeconsideredinchildrenwhohavethephenotypicappearanceoffragileXsyndrome.Anelectroencephalogramshouldbeconsideredinchildrenwith
seizuresorwithsignificantreceptivelanguagedisabilities.Thelattermayoccasionallyberelatedtosubclinicalseizureactivitiesinthetemporallobe.4

Management
Themanagementofachildwithspeechdelayshouldbeindividualized.Thehealthcareteammightincludethephysician,aspeechlanguagepathologist,an
audiologist,apsychologist,anoccupationaltherapistandasocialworker.Thephysicianshouldprovidetheteamwithinformationaboutthecauseofthespeech
delayandberesponsibleforanymedicaltreatmentthatisavailabletocorrectorminimizethehandicap.

Aspeechlanguagepathologistplaysanessentialroleintheformulationoftreatmentplansandtargetgoals.Theprimarygoaloflanguageremediationistoteach
thechildstrategiesforcomprehendingspokenlanguageandproducingappropriatelinguisticorcommunicativebehavior.Thespeechlanguagepathologistcan
helpparentslearnwaysofencouragingandenhancingthechild'scommunicativeskills.
Inchildrenwithhearingloss,suchmeasuresashearingaids,auditorytraining,lipreadinginstructionandmyringotomymaybeindicatedoccasionally,
reconstructionoftheexternalauditorycanal,ossicularreconstructionandcochlearimplantationmaybenecessary.Theuseofahighriskregistryaswellas
universalhearingscreeningmayhelptoidentifyhearinglossatanearlyage.
Psychotherapyisindicatedforthechildwithelectivemutism.Itisalsorecommendedwhenthespeechdelayisaccompaniedbyundueanxietyordepression.In
autisticchildren,gainsinspeechacquisitionhavebeenreportedwithbehaviortherapythatincludesoperantconditioning.
Parentsandcaregiverswhoworkwithchildrenwithspeechdelayshouldbemadeawareoftheneedtoadjusttheirspeechtotheleveloftheparticularchild.
Teachersshouldconsidertheuseofsmallgroupinstructionforchildrenwithspeechdelay.23

Authors showallauthorinfo
ALEXANDERK.C.LEUNG,M.B.B.S.,isclinicalassociateprofessorofpediatricsattheUniversityofCalgary,Alberta,Canada.Heisalsoapediatricconsultantat
theAlbertaChildren'sHospital,andmedicaldirectoroftheAsianMedicalCentre,whichisaffiliatedwiththeUniversityofCalgaryMedicalClinic,allinCalgary.Dr.
LeunggraduatedfromtheUniversityofHongKongandcompletedaresidencyinpediatricsattheUniversityofCalgary....

REFERENCES showallreferences
1.BlumNJ,BaronMA.Speechandlanguagedisorders.In:SchwartzMW,ed.Pediatricprimarycare:aproblemorientedapproach.St.Louis:Mosby,1997:845

9....

COMMENTS
Youmustbeloggedintoviewthecomments.Login(http://www.aafp.org/cgibin/lg.pl?redirect=http%3A%2F%2Fwww.aafp.org%2Fafp%2F1999%2F0601%2Fp3121.html#commenting)

AllcommentsaremoderatedandwillberemovediftheyviolateourTermsofUse(http://www.aafp.org/journals/afp/permissions/termsuse.html).

ContinuereadingfromJune1,1999(http://www.aafp.org/afp/1999/0601/)
Previous:ManagingSomaticPreoccupation (http://www.aafp.org/afp/1999/0601/p3113.html)
Next:AngiotensinIIReceptorAntagonists:TheirPlaceinTherapy(http://www.aafp.org/afp/1999/0601/p3140.html)
Viewthefulltableofcontents>>(http://www.aafp.org/afp/1999/0601/)

Copyright1999bytheAmericanAcademyofFamilyPhysicians.
ThiscontentisownedbytheAAFP.Apersonviewingitonlinemaymakeoneprintoutofthematerialandmayusethatprintoutonlyforhisorherpersonal,non
commercialreference.Thismaterialmaynototherwisebedownloaded,copied,printed,stored,transmittedorreproducedinanymedium,whethernowknownor
laterinvented,exceptasauthorizedinwritingbytheAAFP.Contactafpserv@aafp.org(mailto:afpserv@aafp.org)forcopyrightquestionsand/orpermissionrequests.
Wanttousethisarticleelsewhere?GetPermissions(http://www.aafp.org/journals/afp/permissions/requests.html)

EvaluationandManagementoftheChildwithSpeechDelayAmericanFamilyPhysician
http://www.aafp.org/afp/1999/0601/p3121.html
Copyright2016AmericanAcademyofFamilyPhysicians.Allrightsreserved.
11400TomahawkCreekParkwayLeawood,KS662112680
800.274.2237913.906.6000Fax:913.906.6075contactcenter@aafp.org