HEA LTH

1 8 A N DUN DER

WhentoWorryifaChildHasTooFew
Words
ByPERRIKLASS,M.D. FEB.8,2010

Thereisnothingsimpleaboutspeech,andthereisnothingsimpleaboutspeech
delaystartingwiththechallengeofdiagnosingit.
Everypediatricianknowsthefrustrationoftryingtoquantifythespeechand
languageskillsofascreamingtoddler.Howmanywordscanhesay?Cansheput
twoormorewordstogetherintoasentence?Canpeoplebesidesyouunderstand
himwhenhetalks?Questionslikethese,puttotheparents,arethequickand
somewhatcrudeyardsticksweoftenuse.
Crudeornot,theassessmentiscrucial:theearlieritismade,theearlierthe
speechdelayedchildcangetsomehelp,andtheearlierthehelp,thebetterthe
prospects.
Thephysicianwhounderstandsdelayedspeechunderstandschild
development,saidDr.JamesCoplan,aneurodevelopmentalpediatricianin
Rosemont,Pa.,whocreatedtheEarlyLanguageMilestoneScaletomeasure
childrenslanguagefrombirthtoage3.
GuidelinesbyagecanbefoundontheWebsiteoftheAmericanSpeech
LanguageHearingAssociation:asha.org/public/speech/development/chart.htm.

Childrenwithinthefirstyearstarttounderstandmuchofwhattheyhear
aroundthem,saidDianeR.Paul,thegroupsdirectorofclinicalissuesinspeech
languagepathology.Oneyearolds,shecontinued,starttousesinglewordsand
followsimpledirectionsandpointtobodypartsandlistentosimplestories.By
about2,theystartputtingwordstogetherby3,theyshouldbeusingsentencesof
threewordsattheveryminimum.
Theearlyutterancesmaybesimple,butwhatproducesthemisverycomplex.
Whenachildisnotmeetingthosemilestones,therecanbeamultitudeofreasons.
Dr.Coplan,whoisalsotheauthorofMakingSenseofAutisticSpectrum
Disorders(RandomHouse,2010),sayshelooksatspeechdelayinaverybroad
context,fromcognitiontocommunication.Isitpurelyaproblemwithspeechand
language,oristheresomemoreglobaldelay?Hassomethinggoneawryinthe
childssocialconnections?
Thefirstquestiontoaskiswhetherthechildcanhear.Nowadays,all
newbornshavetheirhearingscreenedbeforetheyleavethenursery,butlater
testingcanpickupprogressiveoracquiredhearingloss.
Nextquestion:Whatabouttherestofthechildsdevelopment?Speechand
languagedelaycanbeonewayparentsandpediatriciansfirstnoticemoreglobal
developmentaldelay.
Youllseedelayedreceptivelanguage,delayeduseofvisualskillslike
pointing,adaptiveskillslikeusingaspoonorusingacrayon,Dr.Coplansaid.An
18montholdnotfollowingcommands,notusingaspoontodigwith,nowyoure
lookingatglobaldelay.
Speechandlanguageissuescanalsobeearlycluestoneurodevelopmental
disorders,includingthevariousformsofautism.Notallchildrenwithautismwill
havedelayedspeech,thoughoftentheyarenotusingtheirwordstocommunicate
suchachildmayhavememorizedthealphabet,Dr.Coplansaid,butwithoutever
learningMamaorDada.
Ifthechildshearinganddevelopmentarefine,onemorequestiontoconsider
isenvironment.Isanyonetalkingtothisbaby?Issomethinggettingintheway

maybeanexceptionallychaotichousehold,maybeaseverelydepressedparent?
Speechandlanguagedevelopmentrequiresstimulation.
Pediatricianshavebeenfaultedinthepastfordraggingourfeetinmaking
speechdelaydiagnoses,buttimeshavechangedDr.Coplancreditedparent
advocacyandthefederallymandatedearlyinterventionprogram,whichmakesit
possibleforchildrenyoungerthan3togetafreeevaluation.
Ithinkphysicians,nowthattheyhavesomewheretheycansendchildren,are
muchmorepronetodoso,insteadofsaying,Wellwaitandsee,waitandsee,
hesaid.IdontencounterthehorrorstoriesIwouldhear20,30yearsago,when
parentswouldsay,Wecameoverourdoctorsobjections.
Still,asaprimarycarepediatrician,Ihavenotalwaysmanagedbrilliantly
withparents.IoncetookcareofalittleboyaboutwhomIworriedmoreandmore.
Intheexamroom,heseemedwithoutnormalcommunicationskillsIwas
increasinglysurethathewasontheautisticspectrum.
Ididntthinkhewasreallylearningwords,butIworriedmuchmorebecause
asfarasIcouldtell,henevermadeeyecontact,neverrespondedinanyclearway
toanythinghisparentssaidordid,becauseheseemeddisconnectedinsome
fundamentalway.
Hisparentsshruggedoffmyconcernsandrefusedallreferrals.Whenhewas
homewithhisgrandmother,theyinsisted,hewasabletocommunicateperfectly.
Hedidntneedanyhelp.
Inthatcase,Ihadthediagnosisright,butmyowncommunicationskillswere
notuptothechallenge.AndthenthereweretheparentsIreassured:shemaynot
betalkingasmuchashersisterdidatthatage,butsheissayingmuchmorethan
theminimumfora2yearold,sheunderstandseverythingyousaytoherandshe
canfollowcomplexcommands.Letswaitandwatch,letsgivehertime.DidIget
thatoneright?
Pediatriciansareremindedagainandagainnottobecasualaboutdelaysin
speechandlanguagenottoshrugandsayboysjusttalklaterthangirls,or

youngersiblingstalklaterthanoldersiblings.Suchfactorsmaycontributeto
normalvariation,buttheyshouldntbeusedtoexplainwhyachilddoesntmeet
essentialmilestones.
Andaseverypediatricianknows,therealstalwartsinthisstoryandthereal
expertsarethespeechandlanguagepathologists.
Dr.Paulofferedgeneraltipstoparentswhowanttoenhancetheirchildrens
speechandlanguageskills:Talktoyourchildaboutwhattheyrefocusedon.
Readtoyourchildoften.Iftheyreinabilingualhome,speaktothechildandread
tothechildinthelanguagethatyouremostcomfortablewith.Speakclearlyand
naturallyanduserealwords.Showexcitementwhenthechildspeaks.
Andlistentowhatyourchildistellingyou.
AversionofthisarticleappearsinprintonFebruary9,2010,onpageD5oftheNewYorkeditionwiththe
headline:WhentoWorryifaChildHasTooFewWords.

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