Basics
Description
- Speech delay is delay in the acquisition of spoken language.
- Language is a system of symbols through which humans communicate thoughts, feelings, and ideas. It has 3 components " ”receptive, expressive, and visual language.
- Receptive language is the ability to process and understand language.
- Expressive language is the ability to communicate through speech, written, or formal sign language.
- Visual elements include eye contact, pointing, and gestures.
- Speech delay can be primary as in specific language impairment (SLI) or developmental language disorder (DLD), or secondary to another condition such as a syndrome or neurologic disorder. SLI is impaired speech/language in an otherwise normally developing child who lacks signs or stigmata of other conditions.
- Constitutional language delay, a retrospective diagnosis, is language delay associated with eventual achievement of normal speech and language milestones by school age. There are no subsequent difficulties with learning to read or write.
- Expressive language disorders include the following:
- Verbal dyspraxia: little speech produced with great effort, very dysfluent, single words most commonly
- Speech programming deficit disorder: poorly organized, difficult-to-understand speech
- Mixed receptive and expressive disorders
- Verbal auditory agnosia: impaired ability to decode speech, resulting in a severe expressive impairment. Can often learn language visually
- Phonologic/syntactic deficit disorder: most common type of DLD. Comprehension exceeds spoken ability. Speech is dysfluent, grammatically incorrect with short utterances.
- Most frequent causes of speech delay:
- Hearing loss
- SLI
- Autism spectrum disorder
- Intellectual disability (formerly mental retardation)
Epidemiology
- Up to 15% of 2-year-old have speech and language delays.
- 5% of school-aged children have speech and language delays.
- 3:1 male-to-female ratio in DLD
Risk Factors
- Family history of speech/language delay or disorder
- Male gender
- Low maternal education
- Maternal depression
- Prematurity
- Birth weight <1,000 g
Diagnosis
Differential Diagnosis
- Hearing loss
- Isolated genetic hearing loss
- Hearing loss secondary to in utero cytomegalovirus (CMV) infection: full syndrome at birth or asymptomatic infection with delayed onset of progressive hearing loss
- Acquired hearing loss: following head trauma, tumor-associated, complication of bacterial meningitis, end result of frequent acute otitis media or chronic otitis media with effusion
- Intellectual disability
- Autism spectrum disorder
- SLI
- Constitutional language delay
- Selective mutism
- Environmental
- Lack of stimulation and/or poor linguistic environment
- Child abuse or neglect
- Lead poisoning
- Congenital
- Cerebral palsy
- Hydrocephalus
- Down syndrome
- Fragile X syndrome
- 22q11 microdeletion syndrome
- Fetal alcohol syndrome
- Turner syndrome
- Klinefelter syndrome
- Prader-Willi syndrome
- Angelman syndrome
- Muscular dystrophy
- Tuberous sclerosis
- Neurofibromatosis
- Williams syndrome
- Branchio-oto-renal (BOR) syndrome
- Craniofacial anomalies such as Treacher Collins and Goldenhar syndromes
- Nutritional
- Malnutrition
- Iron deficiency
- Infectious
- HIV encephalopathy
- Other in utero viral infection
- Congenital toxoplasmosis
- Congenital syphilis
Alert
- Avoid late referral of congenital hearing loss: Amplification and therapy by 6 months of age can result in near-normal rate of speech/language acquisition.
- Constitutional language delay is a retrospective diagnosis. Do not miss a language disorder if assuming a delayed toddler is a "late bloomer. " ¯
- Avoid overlooking fine or gross motor delays.
- Avoid missing a genetic or neurologic diagnosis.
History
Does the family note a concern about speech delay or hearing impairment? ‚
- Question: Perinatal history?
- Significance: prenatal care, maternal illness, NICU admission, hyperbilirubinemia requiring exchange transfusion, treatment with ototoxic drugs such as gentamicin, newborn hearing screen results
- Question: Full developmental history?
- Significance: to determine if global delay or isolated speech and language delay
- Question: Parental concern about delayed expressive language?
- Significance: often the presentation of autism
- Question: History of feeding, swallowing difficulties, or poor acceptance of textured foods?
- Significance: signs of oromotor dysfunction which may indicate a neurologic problem
- Question: Family history of speech delay, hearing loss, neurologic disorder, or syndrome?
- Significance: may direct further evaluation
- Question: Any regression or loss of language milestones?
- Significance: should prompt a neurologic and metabolic workup
- Question: What is the social interaction of the child?
- Significance: Lack of interest in playing is a red flag for autism.
- Question: Any concern regarding child abuse or neglect or psychosocial deprivation?
- Significance: may have occurred as the result of a parental, genetic, or developmental disorder; drug or alcohol abuse; poverty; child malnutrition; or environmental toxins such as lead
- Question: History of frequent acute otitis media or otitis media with effusion and conductive hearing loss?
- Significance: may precede speech delay
- Question: Visual impairments?
- Significance: may impact speech development because interpretation of facial expressions and gestures is a component of infant receptive language development
- Question: History of traumatic brain injury?
- Significance: Speech delay may occur with a seizure disorder.
Physical Exam
Complete examination looking for signs that may be associated with speech delay. ‚
- Finding: Microcephaly?
- Significance: associated with intellectual disability, in utero CMV infection, or dysmorphic features
- Finding: Macrocephaly?
- Significance: associated with hydrocephalus, various syndromes
- Finding: Dysmorphic features?
- Significance: suggestive of a syndrome
- Finding: Excess drooling and open-mouth posture?
- Significance: signs of poor oral motor control of muscles used for speech production
- Finding: Craniofacial abnormalities?
- Significance: Articulation difficulty may be due to velopalatal insufficiency (VPI) seen with unrepaired cleft lip or palate.
- Finding: Scarred tympanic membranes or middle ear fluid?
- Significance: may be clue to acquired intermittent or chronic conductive hearing loss
- Finding: Macroorchidism?
- Significance: fragile X syndrome
- Finding: Neurologic exam " ”hypertonia or hypotonia, abnormal reflexes, other focal findings?
- Significance: suggestive of neurologic impairment
- Finding: Cafe au lait spots, hypopigmented macules, shagreen patch, axillary or inguinal freckling?
- Significance: skin findings suggestive of a neurocutaneous syndrome
Diagnostic Tests & Interpretation
- The American Academy of Pediatrics recommends a specific development screening tool be administered at the 9, 18, and 24 or 30-month well-child care visits and an autism-specific tool be administered at the 18- and 24-month visits.
- Office development screening tools
- Denver Developmental Assessment II
- Early Language Milestone Scale (ELMS)
- Clinical Linguistic and Auditory Milestone Scale (CLAMS)
- Hearing evaluation
- Most states have mandated Universal Newborn Hearing Screening Programs.
- Screening tests: automated auditory brainstem response (AABR) and transient evoked otoacoustic emissions (OAEs)
- Hearing should be tested in all speech-delayed children, even if the newborn hearing screen was normal.
- <6 months of age: The definitive test is brainstem auditory evoked response (BAER).
- >6 months of age in a neurologically normal child: The definitive test is behavioral audiometry, such as visual reinforcement audiometry (VRA), performed by a trained audiologist.
- Selected speech/language milestones
- 2 months: cooing, response to voice
- 6 months: babbling
- 4 " “9 months: turns to sound, responds to name
- 9 months: dada/mama nonspecific, begins to understand "no " ¯
- 9 " “12 months: jargon
- 12 months: dada, mama specific, 1 additional word, jargon is complex, points to gesture, follows 1-step command
- 18 months: 10 words, knows body parts
- 2 years: 50 words, 2-word phrases, 50% intelligible by strangers, pronouns, can point to specific objects in a picture, may know 1 color, follows 2-step commands
- 3 years: 300 " “500 words, tells stories, 75% intelligible by strangers
- 4 years: grammatically correct sentences, 100% intelligible by strangers
- Routine cranial imaging or screening tests for metabolic diseases are not recommended.
- Test: Full speech and language evaluation
- Significance: To delineate the disorder and determine therapy
- Test: Individuals with Disabilities Education Act (IDEA) mandates early intervention services from birth to 3 years.
- Significance: Children can get a full developmental evaluation and appropriate therapy if sufficient delays are demonstrated.
- Test: EEG
- Significance: Indicated if there is concern for seizures
- Test: Genetics evaluation
- Significance: Should be obtained for congenital hearing loss or if there is concern for a syndrome or genetic diagnosis
- Test: Prolonged sleep EEG
- Significance: Indicated with loss of language milestones (consider the diagnosis of Landau " “Kleffner syndrome)
Treatment
General Measures
- Congenital hearing loss is managed by a team consisting of an otolaryngologist, audiologist, and speech/language therapist who individualize management. Options are amplification, cochlear implant for the severely impaired, or use of sign language.
- Speech and language therapy can be provided through physician referral or parent-generated referral to early intervention programs.
- Sign language can be used as a bridge to promote communication while the child learns verbal skills. It will not preclude or delay the development of speech.
- Augmentative communication devices such as picture boards or programmed computers with voice synthesizers can be used by children with physical impairments such as cerebral palsy.
- Children with DLD usually speak adequately by school age. Some percentage will go on to have difficulty reading and writing.
- Children with constitutional language delay will achieve normal milestones by school entrance without reading disability or other learning problem.
Additional Reading
- Agin ‚ M. The "late talker " ¯ " ”when silence isn 't golden. Contemp Pediatr. 2004;21:22 " “32.
- Campbell ‚ T, Dollaghan ‚ C, Rockette ‚ H, et al. Risk factors for speech delay of unknown origin in 3-year old children. Child Dev. 2003;74(2):346 " “357. ‚ [View Abstract]
- Coplan ‚ J. Normal speech and language development: an overview. Pediatr Rev. 1995;16(3):91 " “100. ‚ [View Abstract]
- Feldman ‚ H. Evaluation and management of language and speech disorders in preschool children. Pediatr Rev. 2005;26(4):131 " “140. ‚ [View Abstract]
- Rapin ‚ I. Practitioner review: developmental language disorders: a clinical update. J Child Psychol Psychiatry. 1996;37(6):643 " “655. ‚ [View Abstract]
- Sokol ‚ J, Hyde ‚ M. Hearing screening. Pediatr Rev. 2002;23(5):155 " “162. ‚ [View Abstract]
Codes
ICD09
- 315.39 Other developmental speech disorder
- 315.34 Speech and language developmental delay due to hearing loss
- 315.31 Expressive language disorder
- 315.32 Mixed receptive-expressive language disorder
- 315.35 Childhood onset fluency disorder
- 784.59 Other speech disturbance
ICD10
- F80.9 Developmental disorder of speech and language, unspecified
- F80.4 Speech and language development delay due to hearing loss
- F80.1 Expressive language disorder
- F80.2 Mixed receptive-expressive language disorder
- F80.0 Phonological disorder
- R47.9 Unspecified speech disturbances
- F80.81 Childhood onset fluency disorder
- F80.89 Other developmental disorders of speech and language
SNOMED
- 229721007 speech delay (disorder)
- 441719005 Speech and language developmental delay due to hearing loss (disorder)
- 229734008 Expressive language delay (disorder)
- 702528003 Developmental delay in receptive-expressive language (disorder)
- 62221000119105 Severe expressive language delay (disorder)
- 62231000119108 Mild expressive language delay (disorder)
- 62415009 Delayed articulatory and language development (finding)
- 62211000119103 Moderate expressive language delay (disorder)
FAQ
- Q: Do 2nd- and 3rd-born children speak later than 1st-born children?
- A: No. The norms for expected speech/language development are the same regardless of birth order. 2nd- and 3rd-born children should have the same degree of motivation to speak as their 1st-born sibling.
- Q: When should I refer a child for speech/language evaluation?
- A: If the parents or physician have any concern for speech delay, then referral for evaluation is wise. Some speech-delayed children will eventually normalize and meet all milestones. It is difficult to distinguish who is constitutionally delayed from those who have another disorder. There are several indications for a prompt referral: no pointing or babbling by 1 year, no single words by 16 months, no 2-word spontaneous phrases by 2 years, no sentences by 3 years, poor intelligibility for age, child has behavioral "melt downs " ¯ or tantrums with efforts to communicate, or any regression in language skills.
- Q: Do children raised in bilingual households have expressive language delay?
- A: No. Living in a bilingual household is not a cause of expressive language delay. However, toddlers who are learning 2 languages may interchange words in both languages. Total vocabulary and phrase length are typically normal in these children by 2 " “3 years of age.