Speech Delay

Dear Lisa,

I am worried about my 2 year old son because he is not talking yet. He calls me “ma ma” when he wants me. The only other words he says is “da da” for his father and “ta ta” for his sister. Otherwise he doesn’t say anything else. If he wants something he just points to it. When he wants milk, he just walks into the kitchen and points to the refrigerator. I am starting to get worried. Should I get his hearing checked?

“Worried about my son not talking yet”

Dear “Worried about my son not talking yet”,

Speech and language development play a very important role in a child’s learning and development. Speech development is needed so that a child can communicate with the outside world. The most critical period for speech development is between the ages of 9 and 24 months. (1) It is important to pick up on cues that indicate a delay during this period. If a child demonstrates a lack of progression of speech and language development a comprehensive evaluation is necessary in order to identify and treat the problem.

Language development includes receptive milestones and expressive milestones. Receptive language includes the child’s ability to understand speech. Expressive language involves the child’s ability to express or speak verbally. A Speech Therapist evaluates a child’s receptive and expressive speech and language development. The evaluation includes obtaining information about a child’s ability to interact, communicate, socialize, play, identify pictures, and carry out simple commands.

When a child is found to have a speech delay, an assessment of other areas of childhood development should also be evaluated. A comprehensive evaluation is necessary because a Language delay in childhood can be a presenting symptom of another problem such as a global developmental disorder. (1) A child’s coordination, sensory skills, neurological status, perceptual-motor function, neurologic status and hearing should all be evaluated. This comprehensive assessment many times involves a team approach involving specialists in areas of speech, education, and psychology.

Many parents ask the question, “What should my child be saying at this age?” It is important to remember that Speech and Language development begins in infancy. The development of Speech and Language is a continuum that slowly develops over time. The first signs of speech and language development begin early in infancy when a baby responds to sounds. By four months old an infant turns its head in response to his mother’s voice and by 9 months old the infant understands the word “no”. These receptive language skills progress to the point where an infant can differentiate between different sounds. An infant’s communication skills are expected to develop at nine months old. A delay noted during this time should be referred to an early intervention program. (2)

Expressive language also begins in infancy. Signs of expressive language development in infancy include cooing sounds at 2 months of age and babbling at 6 months of age. By the time a child is 12 months old he should be able to express the words “ma ma” and “da da”. A one year old child should be able to express 3 additional words besides “ma ma” and “da da”. Jargoning develops between 12 and 18 months old. Jargoning sounds like the child is speaking a foreign language. (1,3) As a child speech progresses, they begin to slip a real word in between jargoning. This tends to occur between 15 and 18 months old.

A language burst is expected to occur between 20 and 24 months old. At this time a child develops a vocabulary of 50 words and new words are demonstrated on a daily basis. This language burst is following by two word combinations in which the child puts two words together while talking. By the time a child is two years old, he should be able to respond to simple commands such as “give me that”, “sit down” and “sit up”. The child should also be able to understand and point on command to mouth, nose, hair and ears.

A twenty-five month old child should be able to express up to 270 words with an average of 75 words spoken per hour during free play. At this age a child should use phrases in their speech by putting two words together such as, “want cookie”, “up daddy” or “all gone”.(3)

As with all areas of child development, some children progress through the stages of development quicker and some children progress through the stages slower. As long as a child shows progression in speech development it is okay if a child is not exactly on target. Close follow up and continued monitoring of speech development is the key. On the other hand, a marked delay, a regression in speech, loss of previously gained milestones or lack of speech development are all signs that a child’s condition needs to be investigated further .

It is understandable that you are concerned about your son’s speech since he did not reach the point of jargoning yet and he is two years old. Since he has not met the speech and language milestones that are expected for his age, it would be reasonable to have him evaluated by a Speech therapist. A developmental evaluation by your Primary Care Physician is also necessary in order to determine if there are delays in other areas of his development.

For those children who are speech delayed, a Speech Therapist can set up a program to improve a child’s expressive and receptive language skills. In addition to therapy received during a session, the Speech Therapist can give you and your child exercises to perform at home to help promote speech.

There are some measures that parents can take that can help promote speech development. These measures include; reading books to your child, feeding your child food which require a lot of chewing, having your child use a cup without a top, and blowing bubbles. Giving your child sandwiches made with soft bread also helps. When a child eats a sandwich, the bread gets stuck on the roof of their mouth and on their teeth. In order to remove the bread from these areas, the child needs to move their tongue in such a manner that requires strength and coordination. These types of mouth exercise help develop the muscles in the mouth and tongue that are needed for speech.

Reading picture books, slowly annunciating each sound and pointing to objects on the page can also promote speech. An important part of speech and language development involves the child’s ability to comprehend and identify words. By 2 years old a child should be able to identify pictures of objects such as a dog, ball, train, bed, doll, cup, chair, box, car and fork. By reading picture books with your child while pointing to these objects, it can help your child’s speech and language development.

Your question about having your son’s hearing tested is a very good one. The ability to hear is critical for the development of speech, language and learning. (3) Therefore children who develop a speech or language delay should have a hearing evaluation to determine if a hearing deficit is contributing to the problem.

Children at risk for hearing loss include those with a family history of hearing loss, a maternal history of infections with Rubella, Syphilis or Cytomegalovirus in the early months of pregnancy, an anatomical malformation of the head or neck (such as abnormalities of the external ear or cleft palate), a history of bacterial meningitis, a history of being exposed to chronic loud noise, treatment with ototoxic drugs in infancy (such as Streptomycin or Neomycin), chronic nasal obstruction and history of fluid accumulation in the ear.
Another good indicator that a child may have a hearing loss is a child who does not pay attention to parental requests. A hearing evaluation is recommended in children who don’t respond to their parent’s commands, in children who received drugs that may have affected their hearing and in children with repeated middle ear infections. (3)

It is essential that delays in any area of development be identified and treated early. Early intervention can prevent a child from developing emotional, social and cognitive deficits that can affect their relationships and future school performance. (2,4)

References:
(1)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:2074.
(2 )Council on Children with Disabilities, Section on Developmental Behavioral Pediatrics. Bright Futures Steering Committee and Medical Home Initiatives for Children with Special Needs Project Advisory Committee. Identifying infants and young children with developmental disorder in the medical home an algorithm for developmental surveillance and screening. Pediatrics. 2006. 118:405-420.
(3)Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984:933-955.
(4)Schwartz M, Charney E, Curry T, Ludwig S. Pediatric Primary Care. A Problem Oriented Approach. 2nd Ed. Littleton, Mass:Year Book Medical Publishers, Inc. 1990:696-697.

Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

Pediatric Advice About Keeping Babies Healthy