Late Talking In Young

Children
Dr. Bashar Ibrahim
Pediatrician
2022
 Review
• DEFINITIONS
• EPIDEMIOLOGY
• Language malestones
• Red flags for language delay
• Management
• prevention
DEFINITIONS
●Speech –Refers to verbal production of language
● Language - It refers to conceptual processing of
communication
●Expressive language – The ability to produce or use language
"late talking".
●Receptive language – The ability to understand language.
●Gestural communication – The ability to communicate
nonverbally (eg, by pointing; nodding or shaking the head..etc)
EPIDEMIOLOGY
• Prevalence — Approximately 10 to 15% of two-year-old
children have language delay, but only 4 to 5% remain delayed
after three years. Approximately 6 to 8% of school-age children
have specific language impairments 
Language delay 
• No universally accepted definition of "delay“
• children often are considered delayed if their performance on a standardized
assessment of language is at least one standard deviation (SD) below the mean
for age.
• Red flag generally is the age at which 90%of typically developing children have
attained a clinically predictive skill (eg, 12 months for the use of "mama," "dada,"
or "papa" to call a parent).
Examples of criteria that may be used
• Scores of 1, 1.5, or even 2 SD below the mean for age.
• Percentage (eg, 25%, 40%) of delay compared with chronologic age. The percentage
delay = (1 - [DA/CA]) x 100 percent,
As an example, an 18-month-old child who has language skills at a 12-month level is 33%
delayed: [1 - (12/18)] x 100 percent.
Red flags for language delay
Age Red flag
Birth or (any
"let's
gDoes
age o," not
" respond to sounds, particularly parent's voice
all do
coun ne," "
6 to 9 months Doest asnot babble
nove good
12 months Does not use l"mama,"
two- "dada,"
word
jobor")"papa" to call parent
Thes
comor word eapproximation
Does not use specific single word do n
bi na otcomment
15 months other than "mama," "dada," or "papa" totrequest
ions or
.
Does not use a point to request something out of reach
Stock
Does not follow familiar one-step direction without gesture
18 months phraces

Uses fewer than 50 words

24 months Does not combine two words together to create new meaning
Risk factors 
Knowledge of risk factors for expressive language delay may improve
surveillance and screening.
●Poverty
●Low parental educational attainment (ie, parent did not graduate from high
school)
●Low birth weight or prematurity, including late-preterm (ie, 34 to 36 weeks)
●Family history of language delays, language disorders
●Maternal depression
●Male sex
 Selected causes of expressive language delay
Cause/Contributing factor Examples
Is a diagnosis made in younger children who are in
Maturational language delay (constitutional language the early developmental period. These delays may
delay) resolve or progress to a more specific diagnosis by the
age of school entry
Hearing impairment  
Prematurity and/or low birth weight  
Infectious diseases Intrauterine infection, meningitis, HIV/AIDS
Neurologic conditions Seizures, cerebral palsy…etc
Metabolic conditions Hypothyroidism, phenylketonuria, etc
Toxicologic conditions Lead poisoning, fetal alcohol spectrum disorders
Down syndrome, fragile X syndrome, Williams
Genetic conditions
syndrome, neurofibromatosis, tuberous sclerosis, etc
Language delay, learning problems, cognitive
Family history
disability, etc
Socioeconomic factors Poverty, low parental educational attainment
Invalid explanations
"He's a boy, and boys talk later than girls." 
"His father and uncle didn't talk until they turned three
"She's growing up in a bilingual home.“
"He's not saying much, but he understands everything.“
"He talks fine at home, but his teacher at child care says he doesn't
talk at all there
Selective Mutism
• An anxiety disorder must be considered. Children with selective
mutism speak only in familiar settings, often only with a few
close family members. Although overall language development
may be normal, children with selective mutism are difficult to
assess.
• They require intervention/therapy to address anxiety, which
impacts their social-emotional and overall development
CLINICAL PRESENTATION
• Children with language delays may present with behavioral
issues. For this reason, the language development of toddlers
and preschool children whose caregivers raise behavioral
concerns should be monitored closely.
• May present with associated concerns about feeding,
chewing/swallowing, or prolonged drooling beyond infancy.
• May be associated with cerebral palsy.
NATURAL HISTORY
• A significant percentage (as many as 60%) of children with isolated early
expressive language delays appear to spontaneously "catch up" in their
language milestones between age 2-3years. However, early language
delays may be an important marker for future language-based learning
difficulties, which may be accompanied by neuropsychiatric difficulties
• Accurate prediction of persistent language difficulties is hampered by the
difficulty in identifying coexistent receptive language delay, which is
associated with increased risk of persistent language problems.
• Receptive language delay may not be suspected by the clinician (or
parent).
Screening 
• Language screening is suggested for preschool age children in the context
of formal developmental screening and autism screening as recommended
by the AAP.
• A 2015 systematic review found the following parent-report language-
specific screens to be appropriate for use in primary care
• Infant-Toddler Checklist – Sensitivity 89%(95% CI 80-97) and specificity
74%(95% CI 66-83) at 12 to 17 months; sensitivity 86%(95% CI 75-96)
and specificity 77%(95% CI 64-90) at 18 to 24 months
• Language Development Survey – Median sensitivity 91% and specificity
86% at 24 to 34 months of age (based on three studies)
• MacArthur-Bates Communicative Development Inventory – Median
sensitivity 82%and median specificity 86% at 18 to 62 months.
Infant-Toddler Checklist
The AAP recommends
• Formal general developmental screening tool at 9, 18,
and 24 or 30 months and autism-specific screening at
the 18- and 24-month visits as part of routine well-child
care
History
Important aspects of the history in the child with an
expressive language delay include:
●Parental concerns about hearing,
speech and/or language development,
or social development.
●Risk factors for hearing loss.
●Prenatal exposures and prenatal or
perinatal complications.
●loss of developmental skills.
●Parents' level of educational
attainment.
●Parental symptoms of depression or
diagnosed depression.
●Play and social interaction skills.
●Family history of language delays,
learning issues, childhood hearing loss,
or school failure.
●The linguistic environment (ie, the
quantity and quality of exposure to
language in the home and other
settings in which the child spends
significant time).
Physical examination 
● Growth parameters – Abnormalities may be clues to a genetic or global condition (eg,
acquired microcephaly in Rett syndrome or tall stature in Klinefelter syndrome) or
socioeconomic concerns (eg, poverty)
●Social interaction (eg, eye contact, pointing to objects)
●The ear – Abnormalities of the external ear may be a clue to hearing loss; tympanic
membrane scarring may indicate chronic or persistent otitis media.
●The mouth and oral motor examination – Is the palate intact, submucous cleft? Is the
uvula bifid? Does the tongue have normal mobility? Is there drooling?
●The neurologic examination – Abnormal muscle tone, strength, or reflexes may be a
clue to a neurologic condition.
●The skin examination – (eg, café-au-lait macules in neurofibromatosis or
hypopigmented macules in tuberous sclerosis complex). Specific patterns or locations of
bruising or scars may suggest physical abuse.
● Hearing test — All children with suspected language delay should be referred for a
hearing test by an audiologist
Laboratory tests 
●A CBC to exclude anemia. Iron deficiency is associated with
impaired development in young children.
●Genetic tests (eg, chromosomal microarray analysis, DNA test
for fragile X syndrome, and others) recommended for children
with language delays that are part of a more generalized
condition, such as a global developmental delay or autism
spectrum disorder.
DIFFERENTIAL DIAGNOSIS
1. Isolated language delay – Isolated language delay encompasses
expressive language delay with or without receptive language delay.
There are two main categories:
a. Delayed language developmental milestones (expressive,
receptive, or mixed) 
b. Specific language impairment (expressive, receptive, or mixed;
also called primary language. Specific language impairment occurs
without other developmental abnormalities. Clinical manifestations
may include a combination of impairments in producing sounds,
using words or understanding what words mean, sentence structure.
It considered when language skills are delayed more than other
abilities.
DDx..
2. Expressive language delay as part of a more general developmental
condition – Examples include:
•Globally delayed developmental milestones/intellectual disability;
•Autism spectrum disorder
•Selective mutism/anxiety;
•Phonologic disorder, in which children have difficulty producing
developmentally appropriate sounds of speech
•Dysarthria in association with cerebral palsy; abnormal function of
oropharyngeal muscles may contribute to speech problems in children
with cerebral palsy; normal gross and fine motor skills are helpful in
excluding cerebral palsy
•Stuttering
DDx..

3. Hearing impairment
4. Poor linguistic environment – The size of a child's
vocabulary and the maturity of his or her grammar are associated
with the quality and quantity of parental input.
A number of factors may contribute to a poor linguistic
environment (eg, low parental educational attainment, child
neglect or abuse, maternal depression).
MANAGEMENT
The management is multimodal and depends upon:
●The child's age
●Child and family risk factors
●Findings from the physical examination and hearing test
●The availability of treatment resources in a given community

Models of intervention
• auditory integration training (AIT),
• sensory integration (SI) therapy, and
• Fast ForWord are examples of controversial practices
• intensive smooth speech therapy,
• caregiver-home smooth speech therapy, or
• intensive electromyography 
Specific interventions 
Management of speech and language impairment may include one or more
of the following:
Enrollment in individual or group speech and language therapy
Therapy through a private facility or the public school system
Attendance at a specialized school for children with speech, language,
and learning differences
Further assessment in specific areas (eg, oral motor function, general
motor function, psychological)
Application of assistive technology
Predictors of success and risk factors to consider
when initiating speech-language intervention
Predictors of success
Language production
Language comprehension
Phonologic improvement
Imitation
Play skills
Use of gestures
Social skills
Risk factors for speech-language impairment
Otitis media
Family history of language and learning problems
Caregiver characteristics (eg, low socioeconomic status)
PROGNOSIS
Depends upon the underlying etiology.
• Children with speech and language problems that persist beyond 5 years
of age may continue to have difficulty into adulthood.
• Being born very low birth weight (<1500 g) or very preterm (gestational
age <32 weeks) is associated with persistent language delay.
factors that have been associated with resolution during the preschool
years include:
●Isolated speech/language problem
●Average to above-average intelligence
●No receptive language difficulties
●Normal nonverbal skills and gestural communication
●Capacity for symbolic thinking (eg, playing with dolls)
PREVENTION
Parents can enhance or promote their child's language development by
providing "language nutrition" increasing the quantity and quality of
language spoken to the child, Examples include
●Reading aloud to the child (increases the amount and diversity of language)
●Providing exposure to advanced or unusual words; this is readily done by
sharing books
●Engaging in dialogic reading, a style of book-sharing in which parents
encourage children to comment on pictures and the story
●Listening to the child and responding to the child's conversation, repeating
and expanding on the child's conversational output
PREVENTION…cont.
●Reducing media exposure (including play with electronic toys)
●Asking questions and having the child indicate a choice in response
●Accompanying words with gestures to make them more
understandable
In a systematic review of 5848 children <6 years of age who had or
were at risk for language impairment, parent-implemented
interventions. There were moderately associated with improved child
communication, engagement, and language outcomes.
Thanks