Distinguishing Delay from Disorder: How long will my child need speech therapy?

How long will he need speech therapy? Will he have a language disorder forever? Will his delay resolve with time?

These questions may sound familiar. As a parent of a toddler experiencing speech and language delays, it is only natural to ask these questions.

Research shows that approximately 15% of toddlers exhibit delayed language skills whereas only 3% of preschoolers present with a language delay (Paul, 1996). This means that many toddlers with language delays will catch up to their typically-developing peers with speech therapy and/or time.

I don’t have a crystal ball to predict whether a child’s language delay will persist or resolve. However, research on language delays and disorders have identified factors that help us determine whether a child is at an increased risk of a language disorder, or language deficits that persist into school-age years and/or beyond:

Biological Factors:

• Language delays are more common in boys than in girls. Research shows that boys account for 70% of children with expressive language delays (Kovačević, Kraljevic, and Cepanec, 2007).

• A family history of speech and language delays increase a child’s risk of a persistent language disorder. There is an increased risk for persistent language disorder if the child’s sibling(s) or parent(s) have a history of language difficulties (Olswang, Rodriguez, & Timler, 1998)

Receptive Language Factors:

• Receptive language refers to a child’s understanding of language. Children who exhibit more than a 6 month delay in receptive language skills are more likely to present with persistent language delays (Olswang, Rodriguez, & Timler, 1998).

• From a clinical standpoint, a significant gap between receptive and expressive language skills on standardized testing is a reason to be concerned for a language disorder. Receptive language skills are expected to be at least commensurate with expressive language skills (use of language). When children’s expressive language skills far exceed their receptive language skills on standardized testing, this is considered an atypical language pattern. This may indicate decreased attention to a communication partner and/or use of scripted and stereotyped language, which is often associated with language disorders or larger developmental concerns (e.g., autism spectrum disorder).

Social Factors: It should be noted that many of the social factors listed below are also signs that a child’s language disorder is a part of a larger developmental concern. It is important to consult a developmental and behavioral pediatrician in addition to a speech-language pathologist should you have concerns for social use of language.

• Reduced initiation of communication attempts: Long before children begin talking, they initiate interactions with parents and other family members using sounds (e.g., cooing, babbling), eye contact, joint attention (e.g., shifting their eye gaze between a parent and an object of interest), and gestures (e.g., pointing, showing, etc.). Children who show reduced communication attempts are at greater risk for a language disorder as compared to a language delay that resolves with speech therapy (Paul, 2019).

• Reduced use of gestures to support communication attempts: Many children who exhibit disordered language skills struggle to supplement communication attempts with a variety of gestures, such as pointing to an object that is out reach, clapping their hands, nodding their head ‘yes’/shaking their head ‘no’, blowing kisses, etc. (Thal and Tobias, 1992).

Cognitive Factors:

• Reduced imitation: Children who demonstrate limited spontaneous verbal imitation (Olswang & Bain, 1996) are at a higher risk of a persistent language disorder.

• Difficulty with play: Children with reduced play skills are more likely to present with a language disorder. Remember that play skills are a good indicator of overall cognitive development and are necessary for continued language development. Play is the foundation for language learning. Children with language delays that eventually resolve engage in more relational and symbolic play (Bates et al., 1979; Casby & Ruder, 1983; Mundy, Sigman, & Kasari, 1990; Mundy, Sigman, Kasari, & Yirmiya, 1988). On the contrary, children with persistent language difficulties tend to engage with objects by grouping or manipulating them rather than using more complex play schemas (Rescorla & Goossens, 1992).

Phonological Factors: The frequency and type of vocalizations (e.g., babbling, cooing, etc.) a child produces also predicts the likelihood of a delay persisting into a language disorder. Children with increased risk of a persistent language disorder have the following characteristics associated with their early speech sound production:

• Few vocalizations

• Few consonants, including fewer than 50% consonants by 30 months (Paul, 2019)

• Limited babbling

• Vowel errors

If you are clinician, I would highly recommend Dr. Rhea Paul’s Distinguishing Language Delays from Chronic Language Disorders presentation on the ASHA Learning Pass. It’s a great review!

Research references:

Adani, S., & Cepanec, M. (2019). Sex differences in early communication development: behavioral and neurobiological indicators of more vulnerable communication system development in boys. Croatian medical journal, 60(2), 141–149. https://doi.org/10.3325/cmj.2019.60.141

Bates, E., Benigni, L., Bretherton, I., Camaioni, L., & Volterra, V. (1979). In E. Bates, L. Benigni, I. Bretherton, L. Camaioni, & V. Volterra (Eds.), The emergence of symbols: Cognition and communication in infancy (pp. 69–140). New York: Academic Press.

Casby, M., & Ruder, K. (1983). Symbolic play and early language development in normal and mentally retarded children. Journal of Speech and Hearing Research, 26, 404–411.

Kovačević M, Kraljevic K, Cepanec M. Sex differences in lexical and grammatical development in Croatian. Proceedings from the First European Network Meeting on the Communicative Development Inventories; 2006 May 24-28; Dubrovnik, Croatia. Gävle: University of Gävle; 2007.

Mundy, P., Sigman, M., & Kasari, C. (1990). A longitudinal study of joint attention and language development in autistic children. Journal of Autism and Developmental Disorders, 20, 115–128.

Mundy, P., Sigman, M., Kasari, C., & Yirmiya, N. (1988). Nonverbal communication skills in Down syndrome children. Child Development, 59, 235–249.

Olswang, L., & Bain, B. (1996). Assessment information for predicting upcoming change in language production. Journal of Speech and Hearing Research, 39, 414–423.

Olswang, L. & Rodriguez, B. & Timler, G. (1998). Recommending Intervention for Toddlers With Specific Language Learning Difficulties We May Not Have All the Answers, But We Know a Lot. American Journal of Speech-Language Pathology. 7. 23. 10.1044/1058-0360.0701.23.

Paul, R. & Fountain, R. (1999). Predicting Outcomes of Early Expressive Language Delay. Infant-Toddler Intervention: The Transdisciplinary Journal. 9.

Paul, R. (February 20, 2019). Distinguishing Delay from Chronic Language Disorder. ASHA. https://learningcenter.asha.org/diweb/catalog/item/id/4876758

Paul, R. (2012). Language disorders from infancy through adolescence : listening, speaking, reading, writing, and communicating. St. Louis, Mo. :Elsevier.

Thal, D., & Tobias, S. (1992). Communicative gestures in children with delayed onset of oral expressive vocabulary. Journal of Speech and Hearing Research, 35, 1281–1289.

Tomblin JB, Records NL, Buckwalter P, Zhang X, Smith E, O’Brien M. Prevalence of specific language impairment in kindergarten children. J Speech Lang Hear Res. 1997;40:1245–60. doi: 10.1044/jslhr.4006.1245.

Ukoumunne, O & Wake, Melissa & Carlin, J & Bavin, Edith & Lum, Jarrad & Skeat, Jemma & Williams, Joanne & Conway, Laura & Cini, E & Reilly, Sheena. (2011). Profiles of language development in pre-school children: A longitudinal latent class analysis of data from the Early Language in Victoria Study. Child: care, health and development. 38. 341-9. 10.1111/j.1365-2214.2011.01234.x.