There are between 3 and 6 million children in the United States with speech or language disorders. As a pediatric speech-language pathologist specializing in early intervention , I work with children between birth and 3 years of age. When I evaluate a child, after confirming parents’ suspicions that there is a definitive problem, the next question is usually some version of, “Why?” Sometimes we don’t know exactly why a child isn’t talking yet at 2 or 3. Many professionals err on the side of caution and label all children they evaluate as “delayed” when in fact they aren’t yet sure what the exact problem is. It is often difficult to pinpoint an exact diagnosis during the first visit or two (or 10!) with a toddler, but there are many common communication difficulties in this age group.
Below is a list of the most common diagnoses associated with pediatric speech-language problems with a basic explanation for each one. Please remember that this is a listing of specific speech-language diagnoses and not necessarily a medical or educational label. For example, a child diagnosed with autism may exhibit characteristics of apraxia, a child with Down Syndrome may have dysarthria, a child with dyslexia may also have an auditory processing disorder, etc…
The speech-language diagnosis may be just a part of a condition that affects a child’s overall developmental picture, or it could be the only issue a child faces. I have often evaluated children whose parents referred them for what they thought was a speech or language delay, when in fact their children were exhibiting delays in other developmental domains as well. This also happens with other disciplines too. My colleagues who are physical and occupational therapists often end up referring children for communication assessments when parents initially sought their help for what they assumed was just “late walking” or “difficulty with feeding” not realizing that their child was behind in other areas too. Many children with developmental difficulties have issues that overlap the motor, social, cognitive, adaptive, and communication domains.
When in doubt, get an evaluation. Be sure to ask the professional if there are other developmental concerns as well. You’d rather know, and the sooner, the better. All of the current research tells us that early intervention gives a child the best chance of minimizing long-term difficulties. Waiting until your child is school age to see if he will “outgrow” a problem puts him at a serious disadvantage, especially when it comes to communication difficulties.
Apraxia is a neurological speech disorder that affects a child’s ability to plan, execute, and sequence the movements of the mouth necessary for intelligible speech. Apraxia can also be referred to as developmental verbal apraxia, childhood apraxia of speech, or verbal dyspraxia. Most SLPs use the terms interchangeably. Characteristics of apraxia include:
- Limited babbling is present in infancy. These are quiet babies.
- Few or no words when other babies are talking by age 2
- Poor ability to imitate sounds and words
- Child substitutes and/or omits vowel and consonant sounds in words. Errors with vowel sounds are not common with other speech disorders.
- His word attempts are “off-target” and may not be understood even by parents.
- He may use a sound such as “da” for everything.
- Often his errors are inconsistent, or he may be able to say a word once and then never again. The child understands much more than he can say.
- There is sometimes (but not always) a family history of communication difficulty. (i.e. “All the boys in our family talk late,” or “My husband’s grandfather still has trouble pronouncing some hard words.”)
There has been controversy in the field of speech-language pathology in giving this diagnosis to children under 3. However, the kinds of therapy useful for children with apraxia are often not introduced if the clinician does not suspect this as the root cause for a child’s communication difficulty. If you suspect this as your child’s problem, initiate a conversation with your child’s pediatrician and begin speech therapy with a clinician who has experience treating children with apraxia. If your therapist says that he/she does not believe that this can be diagnosed before age 3, look for a new therapist!
An excellent resource for parents and professionals working with children with apraxia is www.apraxia-kids.org. Another comprehensive resource for an explanation of apraxia is http://www.kidspeech.com/index.php?page=56.
Many children with apraxia also have difficulty with sensory integration, or how he processes information from all his senses including visual, auditory, tactile, and proprioceptive. (For more information about sensory issues, go to http://www.kid-power.org/sid.html .)
Feeding issues are sometimes present because of the sensory issues a child exhibits such as poor awareness in his mouth so that he overstuffs to “feel” the food, or to the other extreme, he is so sensitive that he gags when new textures are introduced.
For more answers to a parent’s questions about apraxia on this site look under Amy’s question in the comments section under Ask the SLP or go to this link http://teachmetotalk.com/2008/01/31/ask-the-slp/#comment-24.
A phonological disorder is difficulty with the “rules” or “patterns” for combining sounds intelligibly in speech in English. For example, phonological process patterns include prevocalic consonant deletion (leaving off consonant sounds that precede a vowel such as “at” for hat), syllable reduction (producing only one syllable in a multisyllabic word such as “bay” for baby), or reduplication (simplifying a multisyllabic word to a duplicated pattern such as saying “bubu” for bubble or even “dog dog” for doggie).
There are many patterns for analyzing a child’s speech according to a phonological processes model. All of these processes are common in typically developing children as well. It becomes a problem when most children are maturing in their patterns of production, and a child is not. For example, final consonant deletion (leaving off ending consonant sounds in words) typically disappears between 2 1/2 to 3 years of age. If a child is not including final consonants by this age, it would be considered “disordered” or “atypical” since most of his same-age peers are now using a more mature pattern.
A child with only a phonological disorder exhibits typically developing language, meaning that his vocabulary and utterance length are the same as his peers, but he continues to exhibit patterns that are consistent with a younger child’s speech errors. A child with phonological disorder needs speech therapy to learn new patterns. The most popular approach for therapy for this disorder is the Hodson cycles approach. A pattern is targeted in therapy for a certain number of sessions, then a new pattern is initiated. Once all of the patterns are addressed, the cycle starts over. Your child’s speech sounds begin to improve, even if it’s not “perfect” through the first few cycles. This approach has lots of research to support it. It’s generally used for highly unintelligible kids over 3. For more information on this approach, ask your child’s SLP if it’s right for your child because even the veterans know and use this technique.
An articulation disorder is difficulty with the production or pronunciation of speech sounds. This difficulty may be present with an isolated sound such as substituting /w/ for /r/, difficulty with blends such as “st,” or with distortion of sounds such as a lisp. Sometimes clinicians speak of phonological disorders and articulation disorders interchangeably. I use the term phonological disorder when there seems to be difficulty with attaining a “pattern” of sounds and the term articulation disorder when a child has difficulty with only a couple of sounds rather than an identifiable pattern. If a child is still exhibiting errors with even a few sounds after most of his peers can correctly use the sound, he needs therapy to help him. For a list of ages when children acquire certain sounds, try http://www.talkingchild.com/speechchart.aspx.
For a good discussion of articulation and phonological disorders go to http://www.psllcnj.com/articulation_disorders.htm .
Auditory Processing Disorder
An auditory processing disorder is difficulty with listening to, receiving, analyzing, organizing, storing, and retrieving information. It can also be called central auditory processing disorder (CAPD). In young children this often looks like the child cannot understand what’s been said to him, even when his hearing and language comprehension skills are within normal limits. A child may have difficulty paying attention to what someone is saying to him or difficulty following directions in the presence of background noise or when he’s more focused on something else. This might be the kid that won’t look away from his favorite TV program when a bomb goes off, much less when you’re calling his name.
This is commonly included as a receptive language disorder in children under 3, with an official diagnosis of auditory processing disorder coming later in the preschool or early school-age years since there’s no tests for this condition with younger children. Children with sensory integration differences also exhibit auditory processing disorders. It’s very common for children with autism and other learning disabilities such as dyslexia and attention deficit disorder to exhibit these characteristics as well. I could not find a site for information for very young children with auditory processing disorder, but this is receiving lots of attention in the field of early intervention right now, so maybe we should have a good resource soon.
Dysarthria is a neurological speech disorder that affects a child’s muscle tone. Weakness is noted in the muscles used for speech including his lips, tongue, soft palate, and cheeks so that his speech sounds slurred. Dysarthria is present in kids with Down Syndrome, cerebral palsy, or any other condition that causes “low tone.” Dysarthria may also affect a child’s vocal and respiratory quality so that he sounds hoarse or breathy.
A child may also have feeding problems due to muscle tone issues such as difficulty sucking from a bottle because his tongue isn’t strong enough, keeping foods or liquids in his mouth because his lips aren’t strong, or chewing because of overall weakness in his jaws and cheeks. A child may also drool because she can’t close her mouth consistently.
A child with muscle tone issues may also have difficulty with gross and fine motor skills. Physical and occupational therapy may be necessary to help meet milestones. Low muscle tone never truly “goes away,” and there’s a difference between strength and tone. All of us have varying degrees of muscle tone ranging from high to low, and kids with even very low muscle tone can learn to walk and talk.
For more information visit http://www.stronghealth.com/services/childrens/conditions/Dysarthria.cfm.
You might also try http://www.kidspeech.com/index.php?page=75.
Dysfluency is the more professional term for stuttering. It is the repetition of individual speech sounds usually at the beginning of words or phrases. Many children with typically developing language “stutter” when they move from using single words and short phrases to longer sentences and/or when they are under pressure to speak and can’t encode their words quickly enough. Typical dysfluency can occur anywhere from age 2-4. If it lasts for more than 6 months, seek a professional evaluation.
Many times there’s a family history of stuttering if this is going to be a chronic challenge. Kids who repeat individual sounds at the beginnings of words with facial grimaces or tremors, tense their muscles, blink their eyes repeatedly, or tap their feet are at greater risk for true difficulty with fluency than those who repeat whole words and who don’t seem to be phased physically by this.
The best advice for parents when your child starts to stutter is to ignore it. Do not tell him to slow down, stop and think, or any other comment that you feel might be helpful. Relax his environment and do not put pressure on him to “perform” verbally including asking too many questions in a row, demanding that he answer silly questions such as, “Did you hit your sister?” when you know he did, or insist that he sing his new song from preschool for grandma, grandpa, and all of your long-lost relatives at Thanksgiving. Don’t interrupt him when he’s talking, even when he’s struggling. This is hard!
Our oldest son had a terrible several month bout with stuttering while I was in grad school taking the class on dysfluency. It was horrible for me!! My professor’s advice was simple - ”Ignore it and it will (probably) go away.” Another piece of advice is to make sure his teachers at preschool, sitters, or even family members are on board with the “ignore it” method so that no one calls attention to this issue. The unnecessary pressure will make it worse, not better, so tell all of your well-meaning friends and family that you are doing this one your way.
Expressive Language Disorder
Expressive language disorder is present when a child is not meeting milestones in the area of language usually involving vocabulary, combining words into phrases, and beginning to use the early markings of grammar. A child with only an expressive language disorder doesn’t have difficulty pronouncing the words per se, but he has difficulty learning or retrieving new words and putting sentences together. A child may rely on non-specific words such as “that” and “there” rather than learning specific names for objects. She may have difficulty learning verb tenses (such as the “ing” for walking and “ed” for jumped) or have difficulty learning word classes such as prepositions or pronouns.
An expressive language disorder can and often co-exists with a speech disorder such as apraxia. I have treated kids like this with only expressive language delays/disorders, but more often than not, late talkers exhibit a speech AND a language disorder. Sometimes children exhibit receptive language disorders as well, so it’s not uncommon to have several speech-language diagnoses at the same time.
An expressive language delay would be a child who is acquiring vocabulary, combing words, and learning early grammar with the same sequence as his peers, but at a slower rate. If there are atypical characteristics present such as your child has some skills at a higher age level but is still missing many lower age-range skills, it’s called a disorder. Delays are typically easier to overcome, and most kids with delays eventually catch up. A disorder is generally something a child will struggle with for a while, perhaps his entire life.
Receptive Language Disorder
A receptive language disorder is difficulty understanding language. This is also called an auditory comprehension disorder. Kids who have receptive language disorders don’t follow directions and not because they’re being disobedient, but because they don’t understand what’s being said. They seem to ignore language because words don’t mean anything to them yet. They often hate reading books unless mommy lets them flip through the pictures because it’s all about listening to words which may not make very much sense.
When a kid gets a little better and understands a little more, signs of a receptive language disorder may be that he repeats a question rather than answering it or gives an incorrect response. For example, if you ask a child with a receptive language disorder who has been learning his colors, “What are you drinking,” he’s likely to respond “red” because that’s the color of his cup. Or if you ask a question such as, “Do you want milk,” she might answer ”no,” but then she still gets upset when you don’t give her the cup because she doesn’t understand that answering “no” means she doesn’t want it.
I have seen many kids whose parents or daycare teachers label as “difficult” or a behavior problem when really there’s a major receptive language delay that no one recognizes. Parents often overestimate what their language delayed/disordered child truly understands. This is so sad to me because when everyone decides to work on teaching and helping him understand language BEFORE we expect him to talk and BEFORE we expect him to “obey,” then everyone benefits; especially the kid who doesn’t understand why in the world he’s in trouble in the first place, even when his mother “told him not to do it!”
Make sure your child’s receptive language skills are addressed, or the other speech-language problems are not going to significantly improve. A child who doesn’t understand much really shouldn’t be saying much either. To expect more is simply wrong and well above what he’s able to realistically accomplish. Most SLPs think of working on receptive language hand-in-hand with expressive language, and this is absolutely the right way to go. When parents get on board with this approach, wonderful things happen.
For more information on improving receptive language, see the post titled, “Help Your Toddler Listen and Obey.”