When should we consider speech production onset delayed?

[Snow, Laura]

Fatima,
I'm a pediatric SLP with a private practice, and also teach graduate students at a university hospital clinic where I work on an interdisciplinary team that does developmental assessments. A few things to consider:

-Make sure her hearing has been checked recently (not just at birth). Even a mild hearing loss can impact speech/language development.

-I agree with what another responder said about the possibility that this child is producing word approximations that no one is recognizing as such due to her very limited repertoire of speech sounds, or maybe even some error inconsistencies.

-I would lean towards referring her for a speech/language evaluation closer to 18 months than 24 months.  This child's limited use of consonants at 16 months brings up the possibility of a motor speech disorder like childhood apraxia of speech. If that's the case, the sooner she gets help, the better. Most state early intervention programs first asses speech/language around 18 months, and can assess other areas of development like fine and gross motor, social, etc. 

--What you described of this child's social interest and communicative intent makes autism unlikely, but I would not rule out a general language delay based on parent perception of what she understands. (Too many parents tell me their child "understands everything" but then report on the CDI or CSBS or Rossetti in a way that confirms the delay in skills revealed by my direct evaluation results)

--You didn't mention whether this child has begun walking yet or not, but the OTs and PTs I work with do not consider walking to be "delayed" until 18 months, so no major concern there if she is still not walking at 16 months.  Walking is considered a gross motor skill, whereas navigating an iPad would be fine motor (a child can have difficulties in just FM or just GM or both).  Interestingly, I've yet to see a child with fine motor deficits who could not navigate an iPad!  I think conceptual, Visio-spatial, and motivational factors might be more important than motor skills...but I also think children are just born hard-wired to use i-devices these days:)

--When in doubt, refer! Developmental evaluations and therapies are generally fun for kids--we have lots of cool toys and don't give shots! The family will get one of three answers:1) there's no need for concern, 2) Minor concerns and here are some suggestions about how to help your child (e.g., "It takes two to talk" from Hanen.org, ; use of signs or picture symbols to communicate) and come back in 6 months, or 3) she qualifies for some early intervention (more toys!). 

-Even if she is walking by 18 months but still not talking, I would have both communication and motor skills evaluated. Some kids who walked on the later end of the normal range may have clear delays in other gross motor skill acquisition.  Also, some but not all kids with motor speech impairments also have more global motor difficulties, a sort of motor apraxia. This can make it as difficult for them to use manual signs as it is to use speech (some basic signs are often taught to children with expressive speech and/or language delays to help alleviate the frustration of not being able to communicate better in those 2nd and third years of life, but for kids with motor as well as verbal apraxia, picture symbol communication would be more appropriate).

--The fact that this child is exposed to two languages should be always be considered in any communication assessments,  but would not explain the limited repertoire of speech sounds.  Also, tell the family that there is no reason for them to stop using Arabic with their child and to not let anyone tell them that she'd be better off hearing and learning to speak only English (unfortunately there are some "old school" SLPs out there who still give that misguided advice. Those
Arabic consonants may be hard for this little girl to produce if she does end up having some degree of motor speech impairment, but the gift of bilingualism is just too great. My own niece, who had a severe language delay as well as dysarthria and apraxia of speech as a youngster, now pronounces both Arabic and English perfectly).

--Finally, If the family does end up pursuing a speech/language eval, I would recommend finding a SLP who has experience with motor speech disorders. If the local early intervention program does not have someone with this specific expertise, you could look for someone in a private clinic. 

Let me know if I can answer any other questions, or help the family find a clinic in their area.  Hope this helps.

Laura Snow, PhD, CCC-SLP 
in private practice, and
Center on Human Development and Disability
University of Washington
Seattle, WA

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