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: 1.
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.
2.
Guidelines by age can be found on the Web site of the American Speech-Language-Hearing Association:
asha.org/public/speech/development/chart.htm.
3 .“
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.” 4.
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 social connections?
5. 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.
6. 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.”
7. 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.
8. 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 stimulation.
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, (早期療育) 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 autistic spectrum.
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 one right?
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.
9. Dr. Paul offered general tips to parents who want to enhance their children’s speech and language skills: “(1)Talk to your child about what they’re focused on. (2)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. (3)Speak clearly and naturally and use real words. (4) Show excitement when the child speaks.”And listen to what your child is telling you.
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