[lg policy] When to Worry if a Child Has Too Few Words
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Tue Feb 9 16:39:22 UTC 2010
When to Worry if a Child Has Too Few Words
By PERRI KLASS, M.D.
Published: February 8, 2010
There is nothing simple about speech, and there is nothing simple
about speech delay — starting with the challenge of diagnosing it.
Every pediatrician knows the frustration of trying to quantify the
speech and language skills of a screaming toddler. How many words can
he say? Can she put two or more words together into a sentence? Can
people besides you understand him when he talks? Questions like these,
put to the parents, are the quick and somewhat crude yardsticks we
often use. Crude or not, the assessment is crucial: the earlier it is
made, the earlier the speech-delayed child can get some help, and the
earlier the help, the better the prospects.
“The physician who understands delayed speech understands child
development,” said Dr. James Coplan, a neurodevelopmental pediatrician
in Rosemont, Pa., who created the Early Language Milestone Scale to
measure children’s language from birth to age 3.
Guidelines by age can be found on the Web site of the American
“Children within the first year start to understand much of what they
hear around them,” said Diane R. Paul, the group’s director of
clinical issues in speech-language pathology. One-year-olds, she
continued, “start to use single words and follow simple directions and
point to body parts and listen to simple stories.” By about 2, they
start putting words together; by 3, they should be using sentences of
three words at the very minimum.
The early utterances may be simple, but what produces them is very
complex. When a child is not meeting those milestones, there can be a
multitude of reasons. Dr. Coplan, who is also the author of “Making
Sense of Autistic Spectrum Disorders” (Random House, 2010), says he
looks at speech delay in a very broad context, from cognition to
communication. Is it purely a problem with speech and language, or is
there some more global delay? Has something gone awry in the child’s
The first question to ask is whether the child can hear. Nowadays, all
newborns have their hearing screened before they leave the nursery,
but later testing can pick up progressive or acquired hearing loss.
Next question: What about the rest of the child’s development? Speech
and language delay can be one way parents and pediatricians first
notice more global developmental delay. “You’ll see delayed receptive
language, delayed use of visual skills like pointing, adaptive skills
like using a spoon or using a crayon,” Dr. Coplan said. “An
18-month-old not following commands, not using a spoon to dig with,
now you’re looking at global delay.”
Speech and language issues can also be early clues to
neurodevelopmental disorders, including the various forms of autism.
Not all children with autism will have delayed speech, though often
they are not using their words to communicate; such a child may have
memorized the alphabet, Dr. Coplan said, but without ever learning
Mama or Dada.
If the child’s hearing and development are fine, one more question to
consider is environment. Is anyone talking to this baby? Is something
getting in the way — maybe an exceptionally chaotic household, maybe a
severely depressed parent? Speech and language development requires
Pediatricians have been faulted in the past for dragging our feet in
making speech-delay diagnoses, but times have changed; Dr. Coplan
credited parent advocacy and the federally mandated early intervention
program, which makes it possible for children younger than 3 to get a
free evaluation. “I think physicians, now that they have somewhere
they can send children, are much more prone to do so, instead of
saying, ‘We’ll wait and see, wait and see,’ ” he said. “I don’t
encounter the horror stories I would hear 20, 30 years ago, when
parents would say, ‘We came over our doctor’s objections.’ ”
Still, as a primary care pediatrician, I have not always managed
brilliantly with parents. I once took care of a little boy about whom
I worried more and more. In the exam room, he seemed without normal
communication skills; I was increasingly sure that he was on the
I didn’t think he was really learning words, but I worried much more
because as far as I could tell, he never made eye contact, never
responded in any clear way to anything his parents said or did,
because he seemed disconnected in some fundamental way.
His parents shrugged off my concerns and refused all referrals. When
he was home with his grandmother, they insisted, he was able to
communicate perfectly. He didn’t need any help.
In that case, I had the diagnosis right, but my own communication
skills were not up to the challenge. And then there were the parents I
reassured: she may not be talking as much as her sister did at that
age, but she is saying much more than the minimum for a 2-year-old,
she understands everything you say to her and she can follow complex
commands. Let’s wait and watch, let’s give her time. Did I get that
Pediatricians are reminded again and again not to be casual about
delays in speech and language — not to shrug and say boys just talk
later than girls, or younger siblings talk later than older siblings.
Such factors may contribute to normal variation, but they shouldn’t be
used to explain why a child doesn’t meet essential milestones.
And as every pediatrician knows, the real stalwarts in this story —
and the real experts — are the speech and language pathologists.
Dr. Paul offered general tips to parents who want to enhance their
children’s speech and language skills: “Talk to your child about what
they’re focused on. Read to your child often. If they’re in a
bilingual home, speak to the child and read to the child in the
language that you’re most comfortable with. Speak clearly and
naturally and use real words. Show excitement when the child speaks.”
And listen to what your child is telling you.
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