Article growth and development

Speech and Language Development:

Monitoring Process and Problems
Susan McQuiston, PhD,*
Objectives After completing this article, readers should be able to:
Nancy Kloczko, MD†
1. Describe the progression of normal speech-language development.
2. Recognize delayed and disordered speech-language development and indications for
Author Disclosure referral.
Drs McQuiston and 3. Understand possible biologic and environmental contributions to delayed language.
Kloczko have 4. Implement appropriate management strategies.
disclosed no financial
relationships relevant
to this article. This Case Study
You are seeing a 21⁄2-year-old boy for a routine health supervision visit. On a general
commentary does not
developmental screening questionnaire, his mother reports that he is not yet talking. She has not
contain a discussion been too concerned because the child’s father was a late talker and they live in a bilingual
of an unapproved/ household. Although the boy has had several episodes of otitis media, she feels strongly that there
investigative use of a is no question of hearing loss because he seems to understand what is said to him. Other domains
commercial product/ of development are reported as age-appropriate. His physical examination results are normal,
device. and he appears to be a socially engaging toddler. However, you have concerns about his
apparent low frustration tolerance and tendency to throw tantrums.

Introduction
It has been said that all typically developing children in all cultures master the basics of their
language by 4 years of age. (1) However, 5% to 8% of children experience speech-language
delays or disorders by the preschool years, which may be associated with later learning,
socioemotional, or behavioral problems. The primary clinician often is the first professional
to whom parents turn when a developmental problem is suspected, and in the course of
routine health supervision visits, the clinician may encounter any of the following
language-related questions or concerns:
● The parents of a 9 month old wonder what language and social skills should be present
at this age, and they have heightened concern because an older sibling has autism.
● The parents of a 12 month old wonder if their child is hearing impaired because he rarely
responds to his name.
● The parents of an 18 month old who has a history of recurrent ear infections ask if those
infections will affect their child’s language development.
● A 20 month old is reported to have lost the words he was using previously.
● The mother of a 2 year old reports that her child is not talking as much as her older
siblings did at the same age.
● The parents of a 3 year old report that their child’s speech is very hard to understand and
they wonder if this is normal.
● The father of a 31⁄2 year old expresses concern that his child has started stuttering.
● The parents of a 51⁄2 year old report that their son failed his kindergarten screening
because he did not recognize letters of the alphabet; they wonder if kindergarten entry
should be delayed a year.
This article provides a brief review of normal speech and language development from
the discrimination and production of speech sounds to the comprehension and use of
language for functional communication to the eventual development of reading and
written language. The clinical presentation, epidemiology, and prognosis of specific speech

*Pediatric Psychologist.
†
Developmental-Behavioral Pediatrician, Baystate Children’s Hospital, Springfield, MA.

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 growth and development speech and language

and language disorders is described, and the possible role their child understands more words than they can count.
of biologic and environmental influences on language Typically, children understand far more than they are
development are considered. Finally, the clinician’s role able to express in the early years of language acquisition.
in surveillance, screening, and management of language
delays or disorders is reviewed.
Early Speech Production, Communicative
Milestones in the Development of Normal Gestures, and the Emergence of
Speech and Language Expressive Language
Speech Discrimination and Receptive Language Early language development proceeds through predict-
Language development involves a complex interaction able stages from the early production of vowel sounds in
between biology and environmental experience. Typical the first few postnatal months (cooing) to the emergence
infants come into the world with many of the founda- of consonant-vowel sounds by 6 months (babbling),
tional skills necessary for learning language, including the production of long consonant-vowel strings between
the capacity to hear speech sounds, recognize speech 6 and 10 months (a skill known as canonical babbling),
contrasts, and prefer some sounds (human) over others the emergence of first words between 9 and 15 months,
(inanimate). Speech discrimination and the production and finally the combining of words in meaningful and
of early speech sounds form the basis of oral language intentionally communicative ways between 18 and
and communication. Although children are born with 24 months. Just as infants are born with the capacity to
the capacity to detect speech sound differences, their hear and discriminate speech sounds, they come into the
speech perception abilities become more specialized and world prepared to vocalize and eventually to form words
efficient over the first postnatal year. Their ability to and sentences.
discriminate sounds within their native language be- Oral expression is preceded by intentional, nonverbal
comes more refined, and they become less capable of communicative gestures such as pointing, showing, and
discriminating nonnative speech sounds that are not giving, which emerge at approximately 9 months and
relevant to the learning of their primary language. For have been shown to be predictive of receptive and expres-
example, infants raised in an English-speaking environ- sive language at age 2 years. Canonical babbling sets the
ment continue to discriminate the difference between stage for the formation of words and is a precursor to the
the /r/ and /l/ sounds, but the ability to hear this development of meaningful speech. Delays in the onset
distinction wanes in children who are learning Japanese. of canonical babbling have been associated with both
English contains 45 distinct speech sounds (phonemes); hearing impairment and delayed language development.
experience in hearing the language shapes and sensitizes (2) Clinicians should probe specifically for the onset of
the child’s speech discrimination skills to those specific canonical babbling when infants are between 6 and
sounds. 12 months of age.
By 8 months of age, infants begin to recognize the Jargon emerges as infants begin to combine a variety
boundaries around words embedded within utterance of consonant-vowel sounds with speechlike inflection.
streams; that is, they begin to extract and segment words As jargon matures, intelligible words are inserted within
from speech, a necessary prerequisite to single-word complex vocal strings. By the time a “critical mass” of
recognition, comprehension, and production. This ca- approximately 50 words has been achieved at around
pacity corresponds to the onset, between 8 to 10 months 18 months, most children experience a vocabulary
of age, of single-word comprehension. One of the earli- burst. Between 18 and 24 months, they begin to con-
est words the child recognizes is his or her name, a skill struct two-word utterances, and the content of their
that develops as early as 6 months. Shortly thereafter, the language expands to include not only nouns but verbs
infant responds appropriately to names for primary care- and adjectives.
givers. Contextually specific words that are part of famil- By age 3 years, children should be producing three-
iar routines are present by 9 months (eg, no, no; wave word utterances, their speech should be 75% intelligible,
bye-bye; play pat-a-cake). From there, single-word re- and vocabulary size should approach 1,000 words. At
ceptive vocabulary builds exponentially. this stage, children are still mastering production of
Parents (and pediatricians) often are surprised to learn specific speech sounds, some of which are not well-
of the size of the single-word receptive vocabulary ex- articulated until 6 to 8 years of age (eg, /l/, /r/, /s/,
pected of the average 15-month-old child (150 to /z/, /th/). However, speech should be fully intelligible
200 words). By 18 months, most parents report that by age 4 years, when children typically are speaking in

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growth and development speech and language

sentences, relating experiences, and participating in re- support early literacy and language development (www.
ciprocal conversations. reachoutandread.org). A series of studies has demon-
The age of acquisition of many receptive and expres- strated that families participating in ROR report that
sive language milestones varies (Table 1). For example, they are more likely to read to their children and describe
in one study, the average word production of 2-year-old reading aloud as a preferred parenting activity. Exposure
children was 312 words, but the range was 7 to 668 to ROR has been associated with higher receptive and
words. (3) One factor that has been shown to account for expressive language scores in toddlers. (5) More research
this variability is the amount of language to which chil- is needed to assess long-term efficacy in promoting lan-
dren are exposed in the early years of language learning. guage skills and literacy in later school years.
In an often-cited study of the early language experience
of children from different socioeconomic backgrounds, Delayed Versus Disordered Language
children in economically disadvantaged homes were Development
found to have far less exposure to language and less Determining whether a developmental difference is sig-
varied verbal interactions with others in the home than nificant and warrants further evaluation and intervention
children from advantaged homes. (4) On average, chil- is one of the clinician’s greatest challenges. There is no
dren in advantaged homes were exposed to 215,000 generally agreed-upon standard for what constitutes a
words over the course of 1 week versus 62,000 words in developmental language delay, and clinicians should
the disadvantaged group. consider data from multiple sources (history, screening
The content of the language directed to the children tools, and clinical judgment) in determining which chil-
also differed significantly between the two groups, such dren are delayed or at risk. Parental concern should be
that children in economically advantaged homes heard acknowledged and is, in itself, sufficient reason for closer
many more approving than disapproving statements over examination of the child’s status. Parental worry about
the course of an hour, while the pattern was reversed for language status in the toddler and preschool-age child
children in disadvantaged homes. The more parents has been associated with delayed expressive language
talked to their children, the more rapid was the child’s development.
vocabulary growth. By age 3 years, children from ad- The term “language disorder” refers to a deficit in the
vantaged homes had a vocabulary of 1,100 words com- comprehension or production of language that causes
pared with an average of 525 words for children from clinically significant impairment in functioning relative to
disadvantaged families. developmental norms and cultural expectations. A child
who has a developmental language delay may or may not
Early Literacy Skills and the Emergence of develop a speech-language disorder, depending on the
Reading and Written Language severity of the delay and whether it causes significant
The process of reading symbols and connecting those impairment in functioning. The clinician may identify a
symbols to sounds, sounds to words, and words to child at risk or one who is presenting with delayed
meaning is the product of thousands of years of human language development, but the speech-language clini-
evolution and brain development. By kindergarten age, cian usually determines whether a delay is clinically sig-
typically developing children have acquired the “alpha- nificant or constitutes a disorder.
betic principle”: the understanding that written symbols Prevalence studies suggest that 13% to 18% of 11⁄2- to
(letters) correspond to speech sounds. The process re- 3-year-old children present with late talking or expressive
quires an ability to attend to the sounds of language, language delays. (6) At 4 years, approximately 50% of
segment sounds within words, and connect individual late talkers still present with language difficulties. Cur-
sounds with their corresponding visual symbols. rent screening measures do not predict reliably persistent
Just as the richness of the child’s language environ- language delay versus maturational lag followed by re-
ment is associated with vocabulary development, the covery. Factors that have been associated with early
amount of time spent reading aloud to children has been delays in expressive language include family history of
linked to later reading proficiency. Reach Out and Read language delay, low socioeconomic status, and the rich-
(ROR), a pediatrics-based intervention in which children ness of the language environment. (6)
are given an age-appropriate book at each health super- Of those who continue to manifest speech-language
vision visit and parents receive anticipatory guidance delays, many require specific intervention. Early inter-
about the importance of reading to young children, has vention programs often set a percent delay standard to
proved to be one of the most effective strategies to determine eligibility, which typically is 20% to 30% below

232 Pediatrics in Review Vol.32 No.6 June 2011

 growth and development speech and language

Table 1. Language Milestones

Age Receptive Expressive
Birth to 3 Months • Attends to voices/sounds (may quiet, vary • Has differential cries
suck pattern) • Vocalizes (coos, gurgles)
• Shows preference for parental voice • Reciprocally vocalizes
• May orient to voice by turning eyes or
head
• Startles/blinks/cries to loud sounds
3 to 6 Months • Works to localize voices/sounds • Exhibits vocal play with emotional content
• Responds to change in tone/emotion • Babbles, single syllables (/p/, /b/, /d/, /m/)
• Enjoys rattles/ toys that make noise
• Responds to own name (6 months)
6 to 9 Months • Looks to family member when named • Babbles, strings of syllables with
• Begins to understand words and picture intonation (canonical babbling)
names • Uses “mama,” “dada” nonspecifically
• Understands basic concepts such as “no,”
“all gone,” “bye-bye”
9 to 12 Months • Understands verbal cues for practiced • Uses “mama,” “dada” specifically
routines (eg, “peek-a-boo”) • Points with index finger
• Recognizes words for common items • Gestures to communicate (reaches to be
• Responds to simple requests (“come picked up, waves bye)
here,” “give me”) • Imitates speech sounds
• Looks when name is called • Uses 1 or 2 true words
• Receptive vocabulary by 12 months:
⬃70 words
12 to 15 Months • Follows one-step direction • Jargoning with tone and rhythm of speech
• Shakes or nods head appropriately • Shaking or nodding head appropriately
• Points to body part when named (15 • Use of 3 to 6 words
months)
• Rapidly increases receptive vocabulary
15 to 18 Months • Understands simple pronouns (“you,” • Repeats words
“me”) • Says “no”
• Points to objects/pictures (18 months) • Uses 5 to 50 words mixed with jargon
• Recognizes common objects by name • Uses words for wants/needs
• Learns new words weekly
18 to 24 Months • Follows two-step directions • Experiences a language “explosion,”
• Enjoys simple stories, being read to learning new words daily
• Uses two-word phrases/telegraphic speech
• Begins to use simple pronouns
• Has an average vocabulary of 200ⴙ words
by 2 years
• Speech ⬃50% intelligible by 2 years
24 to 30 Months • Understands pronouns (“you,” “me,” “my,” • Has decreased jargon and repeating
“mine”) • Commonly uses 2- to 3-word sentences
• Understands some prepositions (eg, in, • Increasingly uses pronouns; some
on, under) adjectives, adverbs, prepositions
• Identifies objects by use • Asks simple questions
• Joins songs/nursery rhymes
30 to 36 Months • Follows 2- to 3-step directions • Answers questions
• Understands most common objects and • Helps to tell simple story
pictures • Average vocabulary: 900 to 1,000 words
• Able to point to different actions in • Uses 4- to 5-word sentences by 3 years
pictures • Speech ⬃75% intelligible by 3 years
• Identifies several colors
36 to 48 Months • Listens with interest to conversations, • Uses 5- to 6-word sentences by 4 years
longer stories • Can state name, age, sex
• Points to object by category • Talks about experiences
• Understands concepts of relative amount/ • Has fully intelligible speech by 4 years
size
• Understands past tense
48 to 60 Months • Uses complex sentence structure and
includes much detail
• Uses irregular past tense, future tense
• Tells longer stories, staying on topic
• Can rhyme words and use some letters and
numbers

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growth and development speech and language

chronologic age in one or more domains of develop- Phonologic Disorder

ment. Many speech-language pathologists use a criterion Phonologic disorder refers to impaired ability to articu-
of 1.25 standard deviations below the mean on standard- late the speech sounds expected for age and develop-
ized measures or below the 10th percentile as a clinical mental level to a degree that negatively affects com-
cutoff for identifying a child in need of therapeutic municative functioning. The speech production deficit
services. These criteria identify a delay or lag in skill may involve errors of omission (eg, failing to produce
mastery relative to some agreed-upon norm. beginning or ending consonant sounds: banana⫽
There are various classification systems for speech and “nana”), errors of commission (substituting one sound
language disorders. The Diagnostic and Statistical for another: thumb⫽“fum”), or errors in the sequencing
Manual of Mental Health Disorders-Fourth Edition of sounds (spaghetti⫽“pasghetti”). As described earlier,
(DSM-IV) distinguishes among expressive language, mastery of all speech sounds in English does not occur
mixed receptive-expressive language, and speech pro- until about 8 years of age, but speech should be fully
duction problems (phonologic disorder and stuttering) intelligible by 4 years. Moderate-to-severe phonologic
that interfere with social, academic, or occupational problems occur in approximately 2% to 3% of young
functioning and are not solely the result of environmen- school-age children. (10)
tal deprivation or another disorder (eg, pervasive devel-
opmental disorder, intellectual disability, sensory defi- Childhood Apraxia of Speech
cit). (7) Speech-language professionals expand the Childhood apraxia of speech (CAS) refers to a severe and
classification system. persistent speech intelligibility disorder marked by an
impaired ability to imitate and spontaneously produce
speech sounds in isolation or sequentially. The problem
Specific Language Impairment is believed to stem from central nervous system-based
Specific language impairment (SLI) refers to a disorder of mechanisms that control the planning, sequencing, and
oral language acquisition in the absence of environmen- coordination of oral-motor movements for speech. The
tal deprivation, deficits in nonverbal cognitive ability, cause is unknown, but genetic transmission is suspected.
hearing loss, autism, or other identified neurologic con- Prevalence estimates range from 0.1% to 1%. (11) The
ditions. Recent research suggests, however, that children typically affected child is a quiet baby who has delayed
in whom SLI is diagnosed often have other, more subtle, babbling and limited jargoning. Unlike the child who
deficits in nonlanguage areas of functioning relative to has phonologic disorder, whose articulation errors often
normal controls. (8) Children who have SLI have diffi- are predictable and consistent, CAS is characterized by
culty understanding and using syntax and grammar, irregular and inconsistent speech production patterns.
such as tense markings, plurals, and possessives. Prob- The diagnosis is difficult and should be made by a qual-
lems comprehending and formulating responses to ified speech-language pathologist after review of the
open-ended questions (eg, why, what, and how) com- child’s history; careful examination of oral-motor func-
promise their ability to participate in sustained conver- tions; and thorough assessment of receptive, expressive,
sation. Many children who have SLI eventually have and speech production skills. Intensive individual treat-
trouble comprehending what they read. ment usually is required, and most children improve,
Although its cause is unknown, SLI is presumed to be although many continue to have some difficulty with
a biologically based neurodevelopmental disorder. Early higher-level language function.
signs of SLI include late onset of first words and phrases,
immature or delayed mastery of the rules of grammar, Stuttering and Developmental Dysfluency
and short utterance length relative to peers. Symptoms of A period of developmental dysfluency is not uncommon
SLI usually present in the preschool years, and by kinder- among 2 and 3 year olds in which they repeat a phrase
garten age, an estimated 7% of children have SLI. Inter- (“I want, I want, I want some juice”), a word (“I, I,
estingly, in a prevalence study, only 29% of the parents I want some juice”), or even a part of a word (“Wa, wa,
of kindergartners in whom SLI was diagnosed had ever want some juice”). This tendency is associated with the
been told that their child had a significant speech- rapid increase in speech production around this age and
language problem. (9) The clinician’s role in early detec- usually resolves by age 4 years. Clinicians should reassure
tion and timely referral is underscored by the significant parents of toddlers and preschoolers that this is a normal
morbidity associated with persistent speech-language developmental pattern that typically resolves without
disorders and the efficacy of appropriate treatment. treatment. Parents should be cautioned against inter-

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 growth and development speech and language

rupting, filling in, or offering prompts to the child (eg, Special Conditions
“Slow down,” “Take your time” ) or placing children in Hearing Impairment
situations in which they are pressured to speak. Auditory input is critical for organizing the neural
In contrast, stuttering refers to a clinically significant pathways associated with speech. This development
impairment in speech fluency and timing that involves requires both an intact mechanism for sound percep-
speech sound repetitions, prolongations, and pauses, tion (intact auditory sensory system) and a language-
sometimes accompanied by interruptions in air flow and rich environment. Vocalizations in the first 6 postnatal
face or body clenching. The individual may actively avoid months are similar in infants who have intact or impaired
certain words and substitute others that are less problem- hearing. Canonical babbling should emerge between 6
atic. Stuttering occurs in approximately 1% of school-age and 10 months, and if it does not, hearing impairment
children and is three times more common in boys than must be a primary diagnostic consideration. Infants who
girls, with a strong family influence. (7) Onset is usually have mild-to-profound sensorineural hearing deficits
around 4 to 5 years and almost always before age 10 identified early in life and receive appropriate treatment
years. Treatment is effective and involves targeting not have significantly better language than those identified
only the speech production problem itself but the asso- later in life. (13)
ciated attitudinal and emotional issues that accompany Currently, all states have programs for universal new-
the disorder. Like CAS, remediation of stuttering re- born hearing screening, with the goal being to complete
quires direct speech therapy. diagnostic audiologic testing and appropriate medical
evaluation by 3 months of age and to assure access to
Dysarthria early intervention services not later than 6 months of age.
Dysarthria is a disorder involving motor control of mus- Amplification, if indicated, should occur within 1 month
cles required for speech production. Seen in disorders of diagnosis and consideration for cochlear implantation,
such as cerebral palsy, muscle disorders, and acquired if appropriate, by 12 to 24 months, depending on the
brain injury, this disorder is characterized by abnormali- degree of hearing loss.
ties of tone, strength, or coordination of facial, oral- Otitis media with effusion (OME) is common in
motor, and respiratory muscles, resulting in speech that is young children, with most children experiencing this
labored and disordered. Speech therapy is indicated, and disorder before school years. OME usually results in
if the disorder is severe, augmentative communication minimal-to-mild conductive hearing loss, and studies
may be appropriate. indicate that this level of mild and probably fluctuating
deficit does not significantly impair long-term language
Dyslexia development for children who are otherwise healthy and
Dyslexia refers to a significant deficit in the ability to not at risk for developmental problems. (14) Hearing
recognize words in print and to spell at the age-expected assessment as well as speech-language evaluation should
level in spite of adequate cognitive ability, motivation, be undertaken if the child has OME in the setting of risk
and appropriate reading instruction. The core deficit factors for communication or academic problems. In
most often is impairment in phonologic processing, in- addition, because a small proportion of children may
cluding difficulty recognizing sounds within words, fail- have a hearing loss in the moderate range, hearing testing
ure to master sound-symbol relationships, inability to should be performed if effusions persist for 3 months or
remember and repeat sound sequences, and slow naming longer or at any time if delays or hearing impairment is
of letters and objects. Poor phonemic awareness (the suspected.
ability to recognize the discrete sounds or phonemes
within words) and slow naming of letters are two of the Bilingual Language Development
best predictors of later reading problems. A child biologically prepared for normal acquisition of
Approximately 8% of second graders have a reading one language is capable of learning a second. Exposure to
disability. (12) Genes are implicated, and children who two languages can occur simultaneously or sequentially,
have a family history of reading disorder are significantly and the learning processes associated with these are
more likely to have reading problems relative to the somewhat different. With simultaneous exposure to two
general population. Early recognition of reading prob- languages, a child follows the same developmental sched-
lems is essential because failure to acquire literacy skills ule as a monolingual learner but incorporates elements
in the primary grades is associated with persistent reading from both languages. First words may emerge slightly
problems and school dropout. later but still occur within the normal range. Some

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growth and development speech and language

mixing of words or grammatical rules may occur until Many general screening tools have been identified that
the languages are differentiated, often not until ages 3 or vary in age applicability, administration time, and psy-
4 years. With sequential learning, mastery of the primary chometric properties. (16)
language is important because it provides the foundation Because language development provides the best early
for learning the second language. The amount of expo- correlate to cognitive development and because commu-
sure and the child’s motivation and temperament affect nication delays can result in significant comorbid dys-
how rapidly the second language is learned. function, a child’s speech and language functioning
There is consensus among many researchers in the should be a major consideration in surveillance and
field that bilingualism in the context of normal language screening. A mnemonic to aid the pediatric clinician in
learning potential does not cause language delay. Evalu- monitoring speech and language development is offered
ation of the bilingual child who has delayed speech- in Table 2. The anticipatory guidance that clinicians
language milestones should use the same criteria as for provide at health supervision visits should include infor-
monolingual children. When a child has weak primary lan- mation regarding normal language development and
guage skills or recognized delay, the family should be en- expected milestones so that parents can be informed
couraged to use the child’s dominant language at home. historians who participate in the developmental surveil-
lance process.
Autism and Genetic Syndromes The United States Preventive Services Task Force
The language skills of children who have autism spec- recently reviewed data and found insufficient evidence at
trum disorders vary widely from those who are nonverbal this time to recommend either for or against the routine
and require augmentative and alternative communica- use of specific speech and language screening tools for
tion to those who are very verbal but have difficulty using preschool-age children in the primary care setting. (17)
language for social communication. Most children who Evidence was insufficient, in part, because a “gold stan-
have autism spectrum disorder have some level of speech- dard” for screening is difficult to define in light of in-
language delay, and approximately 25% to 30% have a consistent measures and terminology. Some frequently
history of language regression, which occurs usually be- occurring risk factors were noted and included positive
tween 15 and 24 months of age. (15) Developmental family history, perinatal indices (eg, prematurity, low
regression at any age is an automatic indication for referral. birthweight), and male sex, but findings were inconsis-
The cognitive phenotypes in many genetic syndromes tent. Children who have obvious risk factors, such as
(eg, William, Turner, velocardiofacial) include impair- hearing impairment, craniofacial abnormalities, and syn-
ments in the social or pragmatic use of language, even in dromes associated with known language impairment,
the face of normal acquisition of early language mile- warrant direct referral for evaluation and intervention.
stones. Klinefelter syndrome is associated with deficits in
language processing and language-based academic skills.
Individuals who have primary intellectual disabilities (eg, Referral and Treatment
Down syndrome) present with speech-language delays When a speech-language problem is suspected, the clini-
commensurate with their cognitive functioning. cian should make simultaneous referrals for audiologic
and speech-language evaluations. If the child is younger
Identification and Management of Delayed or than age 3 years, a referral should be made to the local
Disordered Language early intervention program; if 3 years or older, referral
Surveillance and Screening should be to the public school early childhood program.
The primary care clinician may be the only professional If a speech-language problem occurs in the context of
who has regular contact with children before school global developmental delay or there are concerns about
entry and, therefore, has responsibility for collaborating the quality of the child’s social interaction suggesting an
with parents to enhance their child’s development and to autism spectrum disorder, further diagnostic evaluation
identify the early indications of problems. The American is indicated.
Academy of Pediatrics recommends that surveillance, the The clinician should educate parents about the impor-
ongoing process of assessing the child’s development tance of a language-rich environment, which includes
and behavior, be performed at all health supervision child-directed conversation, early reading, vocabulary
visits. In addition, a formal screening instrument should building, and responding contingently to the child’s
be administered at the 9-, 18-, and 30-month visits or at emerging use of language for communication. Parents
24 months if patients will not be seen at 30 months. should be guided in understanding the importance of

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 growth and development speech and language

their active role in collaborating with clinicians and sup-

Speech and Language
Table 2. porting their child’s development at home.
Development Mnemonic* Case Study Discussion
This 21⁄2-year-old boy clearly has delayed expressive lan-
⁄ Year
1 2
guage development that requires further evaluation. It is
• Parts of words (babbling) important to explain to his mother that his failure to talk
1 Year cannot be assumed to be due to the history of familial late
• 1 word
talking, otitis media, or bilingual exposure. Although his
• Follows 1-step direction mother is confident that her son’s hearing is normal, his
• Index finger pointing delayed language suggests the need for formal audiologic
11⁄2 Years evaluation. A speech-language evaluation should be con-
ducted either through his local early intervention program
• “Between words and sentences”
– Jargons with words included or by an independent speech-language pathologist. The
– Lots of gestural communication early intervention program will also conduct a full devel-
(nods, shakes head, points, uses facial opmental evaluation to rule out other problems and to
expressions) design an individualized family service plan. The clinician
2 Years can help the family understand the problem, make appro-
• 2-word sentences priate referrals, advocate for services, and guide the care-
• Follows 2-step directions givers in supporting language development in the home
• ⬃200 words environment.
• Speech 1⁄2 intelligible
3 Years
• 3- to 5-word sentences
• Follows 3-step directions
Summary
• Speech 3⁄4 intelligible • There is consensus regarding the developmental
• Knows these 3 pieces of information: sequencing of receptive, expressive, and phonologic
– First name skills in early childhood and the role of exposure to
– Age speech sounds in language development. Strong
– Sex research evidence implicates genetic and
environmental factors in the causes of speech-
4 Years language disorders. (18)
• Converses • Strong evidence suggests that speech-language
• Speech fully intelligible disorders are prevalent and are associated with
• Proficient in the 4 Ps: increased risk for learning and behavioral problems.
– Pronouns, all (18)
– Prepositions • Based on strong evidence regarding the impact of
– Plurals the environment on language development, clinicians
– Past tense, regular should guide parents in providing a language-rich
• Names 4 colors environment, which includes talking to, reading to,
and encouraging reciprocal communication with
5 Years their children from infancy onward. (4)
• Extended narrative • Scientific evidence is mixed concerning the efficacy of
• Future tense early intervention and treatment of speech-language
• Knows these 5 pieces of information: disorders, and more controlled studies are needed.
– Some letters • There is consensus that the pediatric clinician is in a
– Some numbers unique position to identify delays early through a
– Shapes continuous process of surveillance and screening. A
– Full name “gold standard” for screening is difficult to find
– Address because of inconsistent measures and terminology. At
this time, evidence is insufficient that a specific speech
Recognize that there is wide variability in the range of normal mile-
stone acquisition and that the complexity of grammar is learned as a
and language screening instrument is more effective
process spanning many years. than clinical observation and parental concerns to
*Mnemonic clues that correspond to age are italicized. identify children who require further evaluation.

Pediatrics in Review Vol.32 No.6 June 2011 237

growth and development speech and language

References reading disability in boys and girls: results of the Connecticut

1. Bates E, Thal D, Janowsky J. Early language development longitudinal study. JAMA. 1990;264:998 –1002
and its neural correlates. Handbook of Neuropsychology: Child Neuro- 13. Moeller MP. Early intervention and language development
psychology. 1992;7:69 –110 in children who are deaf and hard of hearing. Pediatrics. 2000;
106:e43
2. Eilers RE, Oller DK. Infant vocalizations and the early diagnosis
14. Roberts JE, Rosenfeld RM, Zeisel SA. Otitis media and speech
of severe hearing impairment. J Pediatr. 1994;124:199 –203
and language: a meta-analysis of prospective studies. Pediatrics.
3. Fenson L, Dale P, Reznick JS, Bates E, Thal D, Pethick S.
2004;113:e238 – e248
Variability in early communicative development. SRCD Mono-
15. Tuchman RF, Rapin I. Regression in pervasive developmental
graphs #242. 1994;19(5)
disorders: seizures and epileptiform electroencephalogram corre-
4. Hart B, Risley TR. Meaningful Difference in the Everyday Ex- lates. Pediatrics. 1997;99:560 –566
perience of Young American Children. Baltimore, MD: Paul H 16. Council on Children with Disabilities, Section on Develop-
Brookes; 1995 mental Behavioral Pediatrics, Bright Futures Steering Committee,
5. High PC, LaGasse L, Becker S, Ahlgren I, Gardner A. Literacy and Medical Home Initiatives for Children With Special Needs
promotion in primary care pediatrics: can we make a difference? Project Advisory Committee. Identifying infants and young chil-
Pediatrics. 2000;105:927–934 dren with developmental disorders in the medical home: an algo-
6. Horwitz SM, Irwin JR, Briggs-Gowan MJ, Bosson Heenan JM, rithm for developmental surveillance and screening. Pediatrics.
Mendoza J, Carter AS. Language delay in a community cohort 2006;118:405– 420
of young children. J Am Acad Child Adolesc Psychiatry. 2003;42: 17. US Preventive Services Task Force. Screening for speech and
932–940 language delay in preschool children: recommendation statement.
7. American Psychiatric Association. Diagnostic and Statistical Pediatrics. 2006;117:497–501
Manual of Mental Disorders. 4th ed. Washington, DC: American 18. Simms MD. Language disorders in children: classification and
Psychiatric Association; 1994 clinical syndromes. Pediatr Clin North Am. 2007;54:437– 467
8. Marton K. Visuo-spatial processing and executive functions in
children with specific language impairment. Int J Lang Comm Dis.
2008;43:181–200 Suggested Reading
9. Tomblin JB, Records NL, Buckwater P, Zhang X, Smith E, Paul R. Language Disorders From Infancy Through Adolescence:
O’Brien M. Prevalence of specific language impairment in kinder- Assessment and Intervention. 3rd ed. St. Louis, MO: Mosby
garten children. J Speech Lang Hearing Res. 1997;40:1245–1260 Elsevier; 2007
10. Shriberg L, Kwiatkowski J. Developmental phonological Russell RL, Simms MD. Language, communication, and literacy:
disorders. I. A clinical profile. J Speech Hearing Res. 1994;37: pathologies and treatments. Pediatr Clin North Am. 2007;54(3)
1100 –1126 Wolf M. Proust and the Squid: The Story and Science of the Reading
11. Shriberg LD, Aram DM, Kwiatkowski J. Developmental Brain. New York, NY: Harper Perennial; 2007
apraxia of speech. I. Descriptive and theoretical perspectives. Wolraich ML, Drotar DD, Dworkin PH, Perrin EC. Devel-
J Speech Lang Hearing Res. 1997;40:273–285 opmental-Behavioral Pediatrics: Evidence and Practice. Phila-
12. Shaywitz SE, Shaywitz B, Fletcher J, Escobar M. Prevalence of delphia, PA: Mosby Elsevier; 2008

238 Pediatrics in Review Vol.32 No.6 June 2011

 growth and development speech and language

PIR Quiz
Quiz also is available online at http://www.pedsinreview.aappublications.org.

5. Which of the following statements regarding normal speech development in children is true?
A. Canonical babbling is the first stage of language development.
B. Children can usually understand speech before they can express words.
C. Infants are not born with the ability to detect speech differences, but they develop it later.
D. Most children who have normal speech say their first word at 18 months of age.
E. Socioeconomic status has no effect on language development.

6. At a health supervision visit, the mother of a 9-month-old girl asks you if her daughter’s language
development is normal. Which of the following language milestones is most appropriate for this girl’s age?
A. Localizing of voices and sounds.
B. Reciprocal vocalizing.
C. Saying three words, including “mama” and “dada.”
D. Startling to loud sounds.
E. Understanding “bye-bye” and “no.”

7. You are evaluating a 2-year-old boy at a health supervision visit. His mother says that he does not talk as
much as her other two children did at his age, and she asks you for a referral for a speech evaluation.
Which of the following is the most appropriate indication for this referral?
A. Failure to point to pictures when requested.
B. Failure to recognize four colors.
C. Failure to use pronouns appropriately.
D. Failure to use two-word sentences.
E. Speech that is not fully articulate.

8. You are evaluating a 6-year-old girl at a health supervision visit. Her mother is concerned about her speech
because she usually only says portions of words and consistently substitutes consonant sounds for others.
Her teachers have complained that they often cannot understand what she says. A look at your records
reveals that she babbled and jargoned appropriately in infancy. Which of the following is the most likely
diagnosis?
A. Childhood apraxia of speech.
B. Developmental dysfluency.
C. Dyslexia.
D. Phonologic disorder.
E. Specific language impairment.

HealthyChildren.org Parent Resources from AAP

The reader is likely to find material to share with parents that is relevant to this article by
visiting this link: http://www.healthychildren.org/English/ages-stages/baby/pages/
Language-Development-4-to-7-Months.aspx.
Also, the reader can find additional articles on speech development and problems by
typing “speech problems” in the search function box on the Healthy Children website.

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