L A N G U A G E D E L AY

A MEDICAL APPROACH TO LANGUAGE

DELAY

Communication is central to the personal development, social interaction and learning

of a child.

Speech, writing, art and body and sign language are all methods of communica-
tion. Because communication is central to the development of a child, failure of
a child to speak by the age of 2 years should be taken seriously. Language prob-
lems interfere with a child’s ability to communicate effectively, both in the expres-
sion and understanding of ideas. The outcome of such a delay may have wide-
spread results ranging from academic to social problems.

The evaluation of speech development in a child requires a range of skills

embodied in different specialists, making a team approach appropriate. Doctors
need to understand the terminology used by speech therapists in order to facili-
tate communication between team members. As language delay may be associat-
ed with a wide variety of medical conditions and developmental problems the
L JACKLIN
doctor plays an important role in the team.
MB ChB, MMed (Paed), FCP (Paed), MSc

Child Health (Neurodevelopment) Boys are more likely to suffer from language problems. As there is also a strong
Principal Specialist (Paediatrician) genetic predisposition, the presence of a family history is a useful indicator of the
Department of Paediatrics course the delay will follow. The prevalence of language delay is 7 - 10% and it
is the most common developmental problem in preschool children. Although the
Johannesburg Hospital and
speech problem may decrease with age, language delay frequently persists as
Memorial Institute for Child Health and
an educational or social problem.1
Development

Johannesburg

NORMAL LANGUAGE DEVELOPMENT

Lorna Jacklin is a registered neurodevelop-

mental paediatrician. Her interest in child The doctor needs to understand normal communication milestones and language
development extends into childhood dis- patterns (Table I). This will assist in detecting deviant language and in assessing
abilities, particularly the child with a visual the seriousness of the problem. Parents, on the other hand, usually compare the
child to a peer or sibling as a guide to normal language development. Fig. 1
impairment, and the interaction between
shows the normal speech and language pathway as described by Reynell in
child abuse and developmental delay.
1969.1

Experience of Opportunity for

language Feedback
verbal
expression

Hearing of speech Articulated speech

Verbal comprehension/ Expressive language

receptive language

Comprehension Concept formed Expression

Fig. 1. Pathway for normal speech and language development.

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Table I. Linguistic and auditory milestones

Language milestone Age (months) Language milestone Age (months)

Alerting 1 Two words 12

Social smile 1 1/ 2 Three words 14
Cooing 3 One-step command (without gestures) 15
Orient to voice 4 Four to six words 15
Orient to bell (I) 5 Immature jargoning 15
‘Ah-goo’ 5 Seven to 20 words 18
Razzing 5 Mature jargoning 18
Babbling 6 One body part 18
Orient to bell (II) 7 Three body parts 21
‘Dada/mama’ (inappropriately) 8 Two-word combinations 21
Gesture 9 Five body parts 23
Orient to bell (III) 10 50 words 24
‘Dada/mama’ (appropriately) 10 Two-word sentences (noun-pronoun 24
One word 11 inappropriately and verb)
One-step command (with gesture) 12 Pronouns (I, me, you, inappropriately) 24
Source: Capute AJ, Accardo PJ. Linguistic and auditory milestones during the first two years of life. Clin Pediatr 1978; 17: 847.

Table II. Landmarks in the development of communicative skills during the first 15 months of
life1 (Extract)

Month Sound production Auditory perception Communication

0-1 Reflexive sound production: Responses to instrumental Infant links mother's voice
cry, discomfort sounds, music and speech are with her face and is
vegetative sounds. These differentiated. Responses comforted when crying by
sounds are either vocalic or show preference for human her voice. Infant responds
consonantal. Pain and speech. Ability to turn differently to infant crying
hunger cries are head in horizontal plane to and to adult speech. Infant
differentiated in first week sound source in immediate stares intently at faces
vicinity is present
2-3 Consonantal sounds are Sucking and heart rate Social smiling and cooing
produced at the back of the responses indicate vocalisations appear.
mouth. Brief consonantal discrimination of different Infant is attentive to
elements are superimposed CV syllables (ba v. da; da nodding, smiling adult and
upon vocalic sounds v. ta) is likely to vocalise in
response to adult. Turn-
taking is managed chiefly
by adults; mother and infant
may vocalise in chorus

The speech of 5-year-old children is environmental factors and the ability infant to the information. This is a
usually fluent; they are able to express to hear. Significant language delay in social interaction. The development of
themselves adequately and understand a child with normal hearing is a pre- communication can therefore be divid-
what is said in the everyday context. dictor of a learning disability, and ed into 3 areas, namely production,
From this age speech will increase in such children should be referred to a understanding and communication
complexity until adulthood. The rate speech and language therapist for (Table II). Delayed production but
and extent of speech development is evaluation and intervention (Table I). good understanding and communica-
widely variable. Some children with tion would have a better prognosis
delayed speech will catch up while Language milestones in than a delay in all areas.1
others require intervention. The chal- infancy
lenge is to decide when to intervene. In the infant language is the interac- Sound production is dependent on
Factors to consider when a child has a tion between information received by motor control of the oral structures
developmental delay are the familial a variety of means, e.g. vision, hear- such as the tongue, palate and jaw.
pattern of language development, ing and touch, and the response of the Movement of the oral muscles has to

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Because communication is
central to the development Processing of Processing of outgoing information
incoming
of a child, failure of a auditory
child to speak by the age input Expressive Speech
of 2 years should be taken (sounds, words, speech production
grammar)
seriously. — interpretation
— discrimination Grammar Vocabulary Articulation
— memory (syntax) (semantics) discrimination
The prevalence of lan- — sequencing
guage delay is 7 - 10% — retrieval
— understanding
and it is the most common — attention
Conversation Spelling
developmental problem in — closure
(pragmatics)
— analysis/synthesis
preschool children. — comprehension

The speech of 5-year-old Fig. 2. Areas where problems may arise in children with severe speech/language
children is usually fluent; impairment.
they are able to express
ing a delay in all areas will have a The use of speech to communicate in
themselves adequately and worse prognosis than one with a the social context is termed pragmat-
understand what is said in delay in one area only. ics. The child learns how to use
the everyday context. speech to establish and maintain
Language acquisition in the
social interest. This is done by linking
second year
utterances to the needs of the partner.
Children with language dif- In the second year language starts The child is aware of the need to sus-
ficulties may demonstrate with sounds, later replaced with real tain a topic. This is achieved by turn
problems in self-regulation words, accompanied by gestures.
taking. Language is modified to the
There is a rapid growth in vocabulary
and are easily frustrated, context, e.g. more or less formal
to about 50 words. Speech starts as
impulsive and inattentive single-word utterances, progressing to
depending on the social context. The
when activities related to child shows an awareness that lan-
multi-word phrases with a single mean-
language are involved. guage can be used to influence others.
ing (‘out the door’ meaning ‘out’) or
In summary the child learns to have a
multi-word with multi-function, e.g. ‘me
conversation.
— go — bye-bye’. Sentences will con-
be co-ordinated with breathing and sist of a content word, e.g. baby, and
a function word which expresses rela- The requirements for language acquisi-
the larynx. The resulting pitch, hard-
tions, e.g. go, sleep, my, etc. The tion are the following:
ness and timing of speech are referred
method of production and the use of • Normal hearing, necessary to
to as prosody.
gesture vary from child to child. develop the ability to perceive the
The understanding of speech develops Language can be described by its elements of speech and to discrimi-
from an awareness of the rhythm, form, content and use. Increasing com- nate between sounds.
pitch, intensity and content of adult plexity occurs with the development of • Normal speech motor abilities and
speech and the ability to discriminate grammatical form. The form of the sen- normal hearing, necessary for the
sounds. An infant will respond to this tence is referred to as syntax, i.e. child to monitor the production of
aspect of speech long before under- grammar. This is the structure of the sounds.
standing develops. sentence, which in English is depend-
• An environment where a child is
ent on word order, and the endings of
exposed to speech and is encour-
Communication behaviour in the infant words (pleural, possessives, tenses).
aged to express him/herself will
is seen as responsiveness to others The early understanding of speech is
support the learning of speech.
and awareness of the response of oth- situational, e.g. ‘give me the cup?’
Language and cognitive develop-
ers, as shown in vocal play behaviour when the child is sitting at the meal
ment are closely related.
between mothers and their babies. table. This request is usually accompa-
nied by gesture to assist understand- • Language must be learnt in an envi-
Infants soon learn that they are able to
ing. Parents naturally accommodate ronment that allows speech to
influence interaction and to make
the communication needs of a child by develop as a means of social inter-
demands on the adult. Observation of
these three aspects of communication simplifying and slowing their speech. action.
will give an indication of the serious- The meaning attached to a word is See Table III for referral guidelines.
ness of the problem. An infant show- referred to as semantics.2

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Table III. Guidelines for referral of an infant for audiology, speech-language or psychological
evaluation

Interaction-communication Expression-production
Excessive crying after 3 months of age Failure to produce any consonantal sounds (raspberries,
Lack of crying, or crying perceived as abnormal in nasals, and stops) in the first year of life
infancy Failure to produce consonantal sounds towards front of
Lack of eye contact or smiling after 3 months of age mouth in second 6 months of life
Lack of cooing vocalisations or response to smiling at Failure to produce high front /v/, back /a/, and rounded
adults from 3 to 6 months of age vowels /u/ by 15 months of age
Expressions of dislike at being held (squirming, crying, Failure to produce prolonged vocalic or consonantal
consistent tenseness relieved by placing child in infant sounds, to combine primitive consonantal and vocalic ele-
seat) in first 6 months ments in a single segment, or to produce series of segments
Failure of appearance of laughter or lack of laughter in or syllables in non-cry in the first 12 months of life
interactive situations by 6 months of age Failure to produce reduplicated babbling by 9 - 10 months
Failure to respond in interactive peek-a-boo and patty of age
cake games by 1 year of age Lack or use of an excessive amount of expressive jargon
Failure to indicate communicative intention non-verbally after 18 months of age
by 1 year of age Failure to produce recognisable words by age 2
Failure to use several recognisable two-word combinations
Reception-comprehension that combine two ideas by age 2 years, e.g. ‘more juice’
Failure to respond to environmental sounds Lack of multi-word utterances (phrases, sentences) by age 3
Failure to quiet to mother’s voice when infant is fussing or Lack of intelligible speech by age 3
crying and when mother is out of immediate line of sight Many initial consonants omitted at age 3. Lack of final con-
and not in contact with infant sonants by age 4
Difficulty in localising a sound source correctly after 9 - 12 Continuing substitution of easy sounds for more difficult
months sounds after age 5
Failure to respond to voices of family members in the sec- Persisting faults of speech articulation after age 7
ond 6 months of life when they return after an absence and Decrease in amount of speech produced, instead of steady
are still out of immediate line of sight and not in contact increase, at any age from 3 to 7 years
with infant Sentences that are poorly formed, confused, marked by
Failure to understand common words or commands by age word reversals or telegraphic style by age 4 (dialectal varia-
18 months tions not to be considered in this category)
Failure to indicate 1 or 2 familiar objects or people when Noticeable stuttering or other types of abnormality of rhythm
these are named with gesture in the second year of life or rate (rapid speech, cluttering) after age 4
Failure to indicate 1 or 2 familiar objects or people when Monotonous, unusually loud, hoarse, harsh, or inaudible
these are named (without accompanying gesture towards or voice
gaze at object-person) early in the third year of life Pitch that is not appropriate to child’s age and sex
Failure to understand simple discussions of past or future Noticeable hypernasality or lack of normal resonance
events by age 3 years Embarrassment or disturbed feelings about speech on the
Report that a child does not understand what is said, ‘takes part of the child at any age
no notice’ of what is said, or ‘takes a long time to catch on’
to what is said in the third year of life

DISORDERS OF abnormality of the palate, velum or the management. Referral to an ENT

COMMUNICATION pharynx, resulting in hyponasal or specialist, speech therapist, neurologist
hypernasal speech. Referral to an ENT and/or psychologist may be necessary.
Disorders of communication can be due specialist, speech pathologist, or dentist
to abnormalities in expressive speech, is recommended. Disorders of fluency
receptive speech or both together (Fig. Fluency is dependent on the rate and
2). Voice disorder rhythm of speech. Dysfluency is common
The voice may be abnormal in quality, between 2 and 4 years and may
DISORDERS OF EXPRESSIVE pitch or loudness. This may be caused progress into later life. Early referral is
SPEECH by damage to the vocal cords or by needed to determine the nature of the
allergy, or it may be neurogenic or psy- problem and underlying factors. It is
Disorders of resonance chogenic in origin. In most cases, inde- important to provide the parents with
There are due to interrupted oronasal pendent of the aetiology, voice training guidance on how to handle the problem
sound balance, caused by anatomical will be necessary as part of and to monitor progress.

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Disorders of articulation • words and relationship expressed appropriate strategies to facilitate the
This is a disorder in sound production, by a word, e.g. his, hers production of language consistent with
i.e. consonants and vowels. Sound • sentences with different grammati- age, and academic and social needs.
production is a learnt auditory motor cal structures and lengths
• social conversations, idioms, PSYCHOLOGICAL ASPECTS OF
act, which requires both hearing and
humour, explanations LANGUAGE
production. It requires intact oral,
nasal and laryngeal co-ordination. • stories and lectures.
Specific language impairment refers to
Sounds are refined into grammatical
Evaluation by a speech therapist a child who has normal hearing, nor-
forms. Speech sounds are complete by
would involve an assessment of all mal cognitive function in certain
8 years. There is a variable rate of
these areas of difficulty measured areas, normal social interaction and
acquisition. Articulation errors include
against the age expectations for the no emotional cause for language
substitution, omission, distortion or
child. Children who have difficulties in delay. The diagnosis of a specific lan-
addition. Causes of poor articulation
comprehension may also have expres- guage disability is based on the
are heterogeneous and include:
sive language difficulties. Expressive assumption of normal intelligence.
• hearing impairment
language is the means of representing Most of the intelligence tests rely on
• structural abnormalities of the oral
thoughts and self in a social context. language to determine intellectual
cavity, jaw, palate
Deficits are manifest by difficulties in functioning. This places language-
• neurological problems — central or
age-appropriate syntax, morphology, disabled children at a disadvantage.
peripheral, e.g. difficulties with co-
word-finding and ability to comment in These children will do better in the
ordination, weakness or paralysis
story-form or conversation. non-verbal scales of such tests. It is
of the vocal cords
therefore recommended that tests
• central nervous system problems —
To assess expressive language the fol- which rely less heavily on language,
may cause an abnormality of voli-
lowing are looked at: such as the CASS or Hisky-Nebraska
tion. These children have a normal
• analysis of the topic Test of Learning Aptitude, be used.
capacity for movement but lack the
capacity to sequence the sounds • context of communication
• intent of the child Children with language difficulties
into speech.
• principal means of communication may demonstrate problems in self-regu-
Management of expressive • relationships expressed by the child lation and are easily frustrated, impul-
speech disorders • sentence-building skills sive and inattentive when activities
Children with a mild or moderate dis- • word-finding abilities related to language are involved.
order respond to traditional speech • appropriateness of the sentence These children struggle with aggres-
therapy. Severe disorders of communi- • organisation of narrative in conver- sion. This and poor communication
cation require augmentative communi- sation. lead to difficulty with peer relation-
cation techniques such as boards (Bliss ships. These children are therefore at
Board), charts, sign language Parents complain that their children risk for psychiatric disorders including
(Makaton), and computer-assisted com- have difficulty expressing ideas in anxiety and behavioural problems.
munication systems. A thorough evalu- words or that they are unable to fol- Such problems frequently persist as
ation of the child, environment and low the child’s conversation. The child self-regulation and academic prob-
financial constraints is needed before does not speak like other children and lems.2 Referral is recommended for a
a decision on the form of assistance becomes frustrated if not understood, hearing test, to a speech therapist,
can be made. and refuses to repeat. These children and to a psychologist.
do not speak much and prefer to do
LANGUAGE DISABILITY things for themselves, or will use ges-
WHAT ROLE COULD A
tures to communicate. They frequently
DOCTOR PLAY IN
This is a heterogeneous group of disor- exhibit tantrums or difficulty in control.
PROMOTING LANGUAGE
ders characterised by deficits in com-
Management of language DEVELOPMENT IN THE
prehension, production and use of lan-
delay COMMUNITY?
guage. The aetiologies range from
hearing impairment, mental retarda- Therapy includes programmes that
tion, to pervasive developmental disor- improve the cognitive forms represent- There is a strong association between
der. All children who present with a ed in language. A modified teaching early language skills and academic
language delay should have a hearing environment may be necessary which performance. It is therefore important
assessment. Problems in comprehen- provides for organisation and lan- not only that early language delays be
sion of language refer to difficulty in guage modification. Individual therapy identified and remediated, but that
understanding the spoken language. will begin with what the child knows there is active prevention of language
These children present with difficulty in and proceed developmentally, assist- delay. Factors that have been associat-
understanding: ing the child in acquiring new and ed with good language development

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and subsequent good academic out-

IN A NUTSHELL
comes are good parent-child interac-
tion and a good language environ- Communication is central to the per- A doctor must have some idea of
ment.3-5 It is therefore the responsibility sonal development, social interaction normal communication milestones
of the medical practitioner to encour- and learning ability of a child. and language patterns.
age parents to spend time talking to
Development of communication can There is wide variability in the rate
their children. The traditional bedtime
therefore be divided into 3 areas, and extent of speech development.
story does much to encourage both
namely production, understanding Factors to consider when a child has
bonding and an opportunity for lan-
and communication. a developmental delay are the famil-
guage development. The ‘television
culture’ does little to encourage good A team should do the evaluation of a ial pattern of language development,
language. Retaining the tradition of child who fails to communicate. environmental factors and ability to
eating around the dinner table has To play a meaningful role in the hear.
many elements that encourage both team it is important that the doctor Significant language delay in a child
good communication and emotional understands the terminology used by who has normal hearing is a predic-
stability. speech therapists. tor of a learning disability and such
Language delay may be associated children should be referred to a
References available on request. speech and language therapist for
with a wide variety of medical condi-
tions and developmental problems. evaluation and intervention.

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