This document provides an overview of late talking in young children. It defines key terms related to language and discusses the epidemiology of language delays. Red flags for language delays are outlined for different age groups. Risk factors, potential causes, and the clinical presentation of language delays are reviewed. The natural history, screening recommendations, differential diagnosis, management approaches, and prevention strategies for language delays in young children are summarized.

1. Late Talking In Young
Children
Dr. Bashar Ibrahim
Pediatrician
2022

2. Review
• DEFINITIONS
• EPIDEMIOLOGY
• Language malestones
• Red flags for language delay
• Management
• prevention

3. 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)

4. 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

5. 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).
Examplesof 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.

6. Red flags for language delay
Age Red flag
Birth or any
age
Does not respond to sounds, particularly parent's voice
6 to 9 months Does not babble
12 months Does not use "mama," "dada," or "papa" to call parent
15 months
Does not use specific single word or word approximation
other than "mama," "dada," or "papa" to request or comment
Does not use a point to request something out of reach
18 months
Does not follow familiar one-step direction without gesture
24 months
Uses fewer than 50 words
Does not combine two words together to create new meaning
Stock
phraces

7. 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

8. Selected causes of expressive language delay
Cause/Contributing factor Examples
Maturational languagedelay(constitutionallanguage
delay)
Is a diagnosismade in younger children who are in
the early developmental period.These delaysmay
resolve or progress to a more specific diagnosisby the
age of school entry
Hearing impairment
Prematurity and/orlow birth weight
Infectious diseases Intrauterineinfection, meningitis, HIV/AIDS
Neurologicconditions Seizures, cerebral palsy…etc
Metabolicconditions Hypothyroidism,phenylketonuria,etc
Toxicologicconditions Lead poisoning, fetal alcoholspectrum disorders
Genetic conditions
Down syndrome, fragile X syndrome, Williams
syndrome, neurofibromatosis,tuberoussclerosis, etc
Family history
Language delay, learning problems, cognitive
disability,etc
Socioeconomicfactors Poverty, low parentaleducationalattainment

9. 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

10. 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

11. • 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.
CLINICAL PRESENTATION

12. 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).

13. 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.

14. Infant-Toddler Checklist

15. 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

16. History
●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).
Important aspects of the history in the child with an
expressive language delay include:

17. 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

18. 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.

19. 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.

20. 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

21. 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).
DDx..

22. 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

23. 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

24. 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)

25. 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)

26. 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

27. 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.

28. Thanks