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: 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.

Guidelines by age can be found on the Web site of the American Speech-Language-Hearing Association: asha.org/public/speech/development/chart.htm.

“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.” 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?

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.

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.”

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.

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,
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.

Dr.
Paul offered general tips to parents who want to enhance their
children’s speech and language skills: “Talk to your child about what
they’re focused on. 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. Speak clearly and naturally and use real
words. Show excitement when the child speaks.”

And listen to what your child is telling you.

 

Source: New York Times – http://tinyurl.com/ydx86b2