5-Minute Pediatric Consult
4th Edition

Speech Delay
Nathaniel S. Beers
  • Speech delay is delay in the development of speech, the verbal expression of language.
  • Language, the symbolic system used to communicate, is made up of receptive and expressive language.
    • Receptive language is the ability of the person to process the language they are hearing or seeing.
    • Expressive language is the ability to produce language to express oneself through speech, sign, or another means of communication.
Types of expressive language delays (these differ from speech disorders in that the speech sounds are intact and well formed):
  • Verbal dyspraxia: little verbal output with very poor phonology
  • Speech programming deficit disorder: sounds as if something is said, but there are little to no actual words
Mixed receptive and expressive delays:
  • Verbal auditory agnosia: difficulty in understanding language as a result of the inability to hear parts of words, which leads to severe expressive delays.
  • Phonologic/syntactic deficit disorder: language understood is better than the language spoken. Speech has poor organization of individual words and phrases.
  • Approximately 20% of 2-year-olds have delayed speech.
  • At 5 years old, 19% have speech and language disorders (6.4% speech, 8% language, 4.6% both)
  • 85% of children with language delays are boys.
  • Articulation problems occur in 5% of school-age children and 10% of preschool-age children
  • Higher prevalence of speech and language delays in first-degree relatives of affected persons with up to 30% of affected children having a first-degree relative with a speech or language delay.
  • Twin concordance rates are 70% to 90% in monozygotic twins and 30% to 60% in dizygotic twins.
Differential Diagnosis
  • HIV encephalopathy
  • Lack of stimulation
  • Lead poisoning
  • Hearing impairment
  • Fragile X syndrome
  • Down syndrome
  • Muscular dystrophy
  • Fetal alcohol syndrome/effects
  • Malnutrition
  • Iron deficiency
  • Tuberous sclerosis
  • Neurofibromatosis
  • Constitutional language delay
  • Mental retardation
  • Autistic spectrum disorders
  • Dysarthria
  • Stuttering
  • Apraxia
  • Acquired hearing loss
Data Gathering
  • Focus on the concerns of the parents
  • Birth history including prenatal care and exposures
Question: Ask about details of the developmental history.
Significance: Will allow one to determine if this is an isolated speech delay or global delay.
Question: Ask about trouble with chewing or excessive drooling for age.
Significance: Signs of oromotor dysfunction can be important in thinking about cause of delays and treatment.
Question: Ask about hearing and frequency of ear infections.
Significance: Children with undetected hearing loss are at higher risk for speech and language delays.
Question: Ask about the social abilities of the child.
Significance: Will help differentiate speech delays from autistic spectrum disorders.
Question: Ask about family history of speech/language delays, mental retardation and hearing loss.
Significance: Family history will encourage further exploration for less common causes of speech delay.
Physical Examination
  • Complete evaluation to assess the child’s nutritional and physical health.
  • Particular attention to assess for any dysmorphic features, or hearing or neurologic abnormalities.
  • Finding: Excessive drooling
  • Significance: Poor oromotor control suggestive of hypotonicity of the muscles that are required for adequate speech development.
  • Finding: Dysmorphic features.
  • Significance: Syndromes such as Down syndrome, Williams syndrome, fetal alcohol syndrome, fragile X syndrome, Angelman syndrome.
  • Finding: Abnormal tympanic membranes.
  • Significance: Chronic ear infections or congenital abnormalities of the TM can lead to hearing impairment, which can cause speech delays.
  • Finding: Skin lesions.
  • Significance: Café-au-lait patches and fibroma suggestive of neurofibromatosis, Shagreen patches suggestive of tuberous sclerosis.

Laboratory Aids
  • Hearing evaluations—should be done in all children with speech delays; best if done by audiology. However, oto-acoustic emissions are being used by some providers to rule out hearing loss. Pure-tone audiometry has a significant false-negative rate, and should not be used to rule out hearing loss in children with speech delay.
  • Developmental testing—if clinical suspicion of delays in other developmental domains.
  • Screening tools for language delays
    • Denver Developmental Screening Tool Revision II—commonly used but not as sensitive for language delays as other tools.
    • Early Language Milestone Scale (2nd edition) (ELMS) sensitive for language screening.
    • Clinical Linguistic and Auditory Milestone Scale (CLAMS) sensitive for language screening.
General guidelines for language milestones to help determine if a delay exists
  • Four to 6 months   Babbling
  • Eight to 9 months   Mama/Dada
  • One year   Single word other than Mama/Dada; points to indicate wants
  • Eighteen months   5 to 10 words
  • Two years   2-word sentences, >50 words
  • Three years   Stories, prepositions, naming objects
  • Four years   Speech 100% understandable
  • Formal speech and language evaluation—to determine the type of disorder and to recommend the best intervention for the child
  • Genetic counseling and additional laboratory testing—should be considered based on history and physical findings.
  • Children with hearing loss should be referred to an otolaryngologist (Ear, Nose, and Throat [ENT] specialist)
  • Speech and language therapy—should be considered for all children with speech delays.
  • Sign language—can be a mechanism to decrease a child’s frustration as he or she is improving his or her verbal communication. This will not delay the onset of verbal language, but should help decrease frustration for the child.
  • Augmentative communication devices (picture boards) may be helpful for children unable to sign.
  • Children with isolated developmental language disorders will often improve and become normal with time. However, 20% to 60% of these children will have difficulties in the ability to learn to read and write later.
  • Children with constitutional language delay will normalize and should have no academic delays.
  • Inadequate evaluation of hearing.
  • Missing delays in other areas of development.
  • Delays in referral to speech and language evaluations.
  • Inadequate history and physical—missed seizure disorder, missed organic disease causing speech delays, missed genetic syndrome
Common Questions and Answers
Q: Why should I send the child for hearing testing when he or she appears to hear normally in the office?
A: Children are very adept at using visual cues to figure out what is being asked of them. In addition, people often use gestures to indicate instructions to children, or use visual demonstrations. The level of receptive language delay and hearing loss is very difficult to predict without formal assessments.
Q: At what age should I refer a child for formal speech and language evaluation?
A: Children certainly develop at different rates, and some normal children will not have completed certain speech tasks by the expected age. However, any child who continues to lag at a follow-up visit should be evaluated more formally. In addition, a child who is having any behavioral problems, such as tantrums or aggressive behavior, should be evaluated by a developmental specialist. Finally, children with language concerns and delayed social skills should also be evaluated for autism.
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