Dr Kirsty Donald Division of Developmental Paediatrics Red Cross ...

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Dr Kirsty Donald
Division of Developmental Paediatrics
Red Cross Children’s Hospital
and UCT

• Normal language development in early
childhood
• Risk factors for speech and language delay
• Assessment
• Referral guidelines

• Speech—verbal production of language
• Language (the conceptual processing of
communication)—refers to 4 domains
– Semantics—rules that assign meaning to words and
strings of words
– Syntax—rules for combining words into phrases and
sentences
– Phonology—rules for combining sounds of
language/sound production
– Pragmatics—rules for social use of language

• Language skills include both
– Reception—ability to understand an incoming
message
– Expression—ability to formulate and express an
– Expression—ability to formulate and express an
outgoing message

Development occurs with sequential acquisition of
skills in four different areas
• Gross Motor
• Fine Motor
• Language
• Psychosocial
Language development most approximates cognition

EXPRESSIVE LANGUAGE
• 4-6 wks : cooing
• 4 months : bilabial sounds
• 6-8 months: polysyllabic babbling “lalala”, “mamama”
• 9 months : “mama”, “dada” nonspecific
• 12 months: “mama”, “dada” specific
• 18-20 mos: additional 1-2 words 20 words
• 24 months: 1+words/day new, 50 words, 2-word phrases
50% intelligible speech
• 24-30 mos:3-5 word sentences; pronouns “Me want
cookie.”
• 36 months: grammatically correct sentences in present
tense 75% intelligible speech; several new words/day
•
4 years : completely intelligible speech; 5-6 word
sentences
RECEPTIVE LANGUAGE
• respond to vocal stimuli by eye widening/sucking
• watch and listen to adult speak (2-3 mo old); turn
head to locate voice
• attentive to name
comprehend “no”; gestures
• respond to 1-step commands; point
• follows 1-step command without gestures; names
pictures of common objects
• follow 2-step commands; point to objects on
command by name

Delay
normal progress
rapid progress needed to catch up

• Speech and language delays occur at
prevalence rates of 2-19% depending on how
they are defined.

• Delayed and disordered language can occur as
a primary condition or as a secondary
condition of other physical and developmental
problems
– Hearing loss
– Intellectual disability
– Autistic spectrum disorders
– Learning disabilities
– Neurological conditions

• Speech problems can signal a specific physical
disorder:
– Speech apraxia—a coordination disorder of
speech articulators
– Dysarthria—impaired muscular function in speech
production
– Other neuromuscular disorders that affect speech
production (cerebral palsy)
– Phonological disorder—unable to process speech
sounds

• Speech production problems can occur
independently of language problems, but can
also co-occur with language difficulties.

• Family history of speech/language delay
(siblings, parents, grandparents as late talkers,
with learning disabilities, dyslexia, special
educations services, history of speech therapy,
or stuttering)
• Male gender
• Perinatal factors (preterm, low birth weight,
birth difficulties, poor sucking)

• Hearing loss
• Developmental language disorder
• Intellectual disability
• Autism spectrum disorders
• Neurological conditions
• Maturational delay (“late starter”)

• Hearing loss severe enough to affect language
development and learning occurs in 1-6/1000
children
• Hearing loss usually causes a delay in
language.
– Children with partial hearing loss may be slower in
vocabulary development, syntax and may have
distorted speech sounds.
• No mandatory neonatal screening in SA

• Children will usually show a language delay.
• Children who have mild cognitive impairment
will use speech as preschoolers, but those
who are more severe may be completely nonverbal

Estimates suggest that there are 1 in 100 people
with an ASD and many of these also have a learning
disability
Four times as many boys as girls have an ASD in the
group with LD and there may be ten times as many
boys as girls in the high–ability group
Baird, G. et al. Prevalence of disorders of the autistic spectrum in a population
cohort of children in South Thames: The Special Needs and Autism Project (SNAP),
Lancet: 2006. 368: 210 –215.

• Triad of impairment:
Social
Repetitive
behaviours/rest
ricted interests
Language

Social communication
Repetitive
behaviours and
restricted
interests

http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=94

• Age dependent unfolding of its characteristic
symptoms until full-blown at age 3.
• Non-progressive essentially.
• “progression” related to maturation of the
CNS /individual.
• Associated regulatory problems such as sleep
disorders common: delayed sleep onset,
awakening during sleep.
• Sensory integration issues

• At 2 years
– Child’s attention to voice/name
– Spontaneous direction of other’s attention
(pointing)
– Understanding words out of context
Lord, Risi, DiLavore et al, 2006

• Elevated frequency of repetitive behaviours
• A typical visuo-motor exploration of objects
• Extremes of temperament
• Decreased flexibility in disengaging visual
attention
Elsabbagh & Johnson, 2009

• Exclude a medical cause
– Hearing impairment
– Severe medical illness (especially chronic)
– Neurological disorder (central and peripheral)
• Congenital syndromes
• Prenatal exposure to drugs/alcohol
• TBI
• CP
• Neuromuscular disorders

• Determine that the language delay is
significant
– Parental concern is important
– Can use checklists
– Get formal Speech and Language
therapy assessment
• Don’t forget emotional causes
– Neglect can have a profound influence on
language development

Many parents, practitioners excuse
language delay < 2 yrs
Overestimate receptive skills
Expressive language difficult to assess in
infants
Problem of multilingual environments

Not vocalising by 6 months
Not following simple commands by 18-24 months
No words by 18 months
No communicative gestures
No joining of words by 2 years
Unintelligible speech, echolalia at 3 years
Absence of imitation and symbolic play at 2-3 years

How can I tell if my child has a
language problem or is just "late-
Very difficult!
starter”?
May use more alternative strategies for
communication
Other development should be normal
Worth taking seriously
If they turn out to be a late starter, the extra
attention to their speech will not have hurt in
any way

• Long-term
• Children who have had early language delay
may “catch up” by 5 years
– BUT many have later ongoing learning difficulties
in the school environment
– Those who are still delayed by 5 are likely to have
significant long term problems

• Hear parental concerns
• Always do a hearing test!
• Look at the child in context
– Environmental
– Medical
• Get more formal assessment if concerned
• Know local services