I get so many questions from parents who want to know if their child should be evaluated by a speech-language pathologist or other professional. On my October 23 show “Teach Me To Talk with Laura and Kate” we discussed “red flags” that we note in toddlers and preschoolers that warrant a referral to an early intervention program (if your child is not yet 3) or therapy services through your local school system (if your child has turned 3 but is not yet in kindergarten).
If you want to hear the complete discussion, please listen to the show #13 by clicking the blogtalkradio link from this page or the home page.
For those of you who would like to review the entire list we found at www.sensory-processing-disorders.com here goes:
Gross Motor
If a child is…
Not rolling by 7 months of age
Not pushing up on straight arms, lifting his head and shoulders, by 8 months of age
Not sitting independently by 10 months of age
Not crawling (”commando” crawling–moving across the floor on his belly) by 10 months of age
Not creeping (on all fours, what is typically called “crawling”) by 12 months of age
Not sitting upright in a child-sized chair by 12 months of age
Not pulling to stand by 12 months of age
Not standing alone by 14 months of age
Not walking by 18 months of age
Not jumping by 30 months of age
Not independent on stairs (up and down) by 30 months of age…an early intervention/developmental therapy referral may be appropriate.Here are some other gross motor “red flags”:
“walking” their hands up their bodies to achieve a standing position
only walking on their toes, not the soles of their feet
frequently falling/tripping, for no apparent reason
still “toeing in” at two years of age
unusual creeping patterns
any known medical diagnosis can be considered a “red flag”: Down’s syndrome, cerebral palsy, congenital heart condition etc.
Fine Motor
If a child is…
Frequently in a fisted position with both hands after 6 months of age
Not bringing both hands to midline (center of body) by 10 months of age
Not banging objects together by 10 months of age
Not clapping their hands by 12 months of age
Not deliberately and immediately releasing objects by 12 months of age
Not able to tip and hold their bottle by themselves and keep it up, without lying down, by 12 months of age
Still using a fisted grasp to hold a crayon at 18 months of age
Not using a mature pincer grasp (thumb and index finger, pad to pad) by 18 months of age
Not imitating a drawing of a vertical line by 24 months of age
Not able to snip with scissors by 30 months…an early childhood intervention/development therapy referral may be appropriateHere are some other fine motor “red flags”:
Using only one hand to complete tasks
Not being able to move/open one hand/arm
Drooling during small tasks that require intense concentration
Displaying uncoordinated or jerky movements when doing activities
Crayon strokes are either too heavy or too light to see
Any know medical diagnosis can be considered a “red flag”: Down’s Syndrome, cerebral palsy etc.
Cognition/Problem Solving
If a child is…
Not imitating body action on a doll by 15 months of age (ie, kiss the baby, feed the baby)
Not able to match two sets of objects by item by 27 months of age (ie, blocks in one container and people in another)
Not able to imitate a model from memory by 27 months (ie, show me how you brush your teeth)
Not able to match two sets of objects by color by 31 months of age
Having difficulty problem solving during activities in comparison to his/her peers
Unaware of changes in his/her environment and routine…an early intervention/developmental therapy referral may be appropriate
Sensory
If a child is…
Very busy, always on the go, and has a very short attention to task
Often lethargic or low arousal (appears to be tired/slow to respond, all the time, even after a nap)
A picky eater
Not aware of when they get hurt (no crying, startle, or reaction to injury)
Afraid of swinging/movement activities; does not like to be picked up or be upside down
Showing difficulty learning new activities (motor planning)
Having a hard time calming themselves down appropriately
Appearing to be constantly moving around, even while sitting
Showing poor or no eye contact
Frequently jumping and/or purposely falling to the floor/crashing into things
Seeking opportunities to fall without regard to his/her safety or that of others
Constantly touching everything they see, including other children
Hypotonic (floppy body, like a wet noodle)
Having a difficult time with transitions between activity or location
Overly upset with change in routine
Hates bath time or grooming activities such as; tooth brushing, hair brushing, hair cuts, having nails cut, etc.
Afraid of/aversive to/avoids being messy, or touching different textures such as grass, sand, carpet, paint, playdoh, etc.…an early childhood intervention/developmental therapy referral may be appropriate.NOTE: sensory integration/sensory processing issues should only be diagnosed by a qualified professional (primarily, occupational therapists and physical therapists). Some behaviors that appear to be related to sensory issues are actually behavioral issues independent of sensory needs.
Possible visual problems may exist if the child…
Does not make eye contact with others or holds objects closer than 3-4 inches from one or both eyes
Does not reach for an object close byPossible hearing problems may exist if the child…
Does not respond to sounds or to the voices of familiar people
Does not attend to bells or other sound-producing objects
Does not respond appropriately to different levels of sound
Does not babble
Self-Care
If a child is…
Having difficulty biting or chewing food during mealtime
Needing a prolonged period of time to chew and/or swallow
Coughing/choking during or after eating on a regular basis
Demonstrating a change in vocal quality during/after eating (i.e. they sound gurgled or hoarse when speaking/making sounds)
Having significant difficulty transitioning between different food stages
Not feeding him/herself finger foods by 14 months of age
Not attempting to use a spoon by 15 months of age
Not picking up and drinking from a regular open cup by 15 months of age
Not able to pull off hat, socks or mittens on request by 15 months of age
Not attempting to wash own hands or face by 19 months
Not assisting with dressing tasks (excluding clothes fasteners) by 22 months
Not able to deliberately undo large buttons, snaps and shoelaces by 34 months…an early intervention/developmental therapy and referral may be appropriate.
Social/Emotional/Play Skills
If a child is…
Not smiling by 4 months
Not making eye contact during activities and interacting with peers and/or adults
Not performing for social attention by 12 months
Not imitating actions and movements by the age of 24 months
Not engaging in pretend play by the age of 24 months
Not demonstrating appropriate play with an object (i.e. instead of trying to put objects into a container, the child leaves the objects in the container and keeps flicking them with his fingers)
Fixating on objects that spin or turn (i.e. See ‘n Say, toy cars, etc.); also children who are trying to spin things that are not normally spun
Having significant difficulty attending to tasks
Getting overly upset with change or transitions from activity to activity…an early intervention program referral may be appropriate
THESE ARE THE FOLLOWING LANGUAGE MILESTONES THAT A CHILD SHOULD HAVE MASTERED BY THESE AGES FROM THE ARTICLE ON THIS SITE TITLED “WHEN TO WORRY”
· Difficulty making and maintaining eye contact with an adult by 6 months
· No big smiles or other warm, joyful expressions during interaction with another person by 6 months
· No back-and-forth sharing of sounds, smiles, or other facial expressions by 9 months
· No babbling by 12 months
· No back-and-forth gestures, such as pointing, showing, reaching, or waving by 12 months
· No consistent responding to their names by 12 months
· No words by 16 months
· No following simple and familiar directions by 18 months
· No two-word meaningful phrases without imitating or repeating & says at least 50 words by 24 months
· No back-and-forth conversational turn-taking by 30 months
· Any loss of speech or babbling or social skills (like eye contact) at any age
The presence of any of these concerns warrants an immediate discussion with your pediatrician and insistence for a referral to an early intervention program and/or speech-language pathologist for a complete evaluation of your child’s communication skills.
Let me also add that babies who are doing well with development exceed these milestones by leaps and bounds. These are very, very low thresholds for all the skills listed. If your child is not meeting these basic guidelines, please don’t dismiss your feelings. There is in all likelihood a true developmental delay or disorder present. Seek professional help from your pediatrician, your local school system, an early intervention agency, a children’s clinic, a university evaluation team, or a therapist in private practice.
Comment by Tara Ling on 27 October 2008:
I have a 4 years old daughter who doesnot talk like the other 4 years old do. i have braught her for speech pathologist evaluation and they diagnosed her with language disorder. but during the evalutaion i discovered that i didnot teach her about this or about that the questions which the pathologist were asking her.she is very good in learning, if i tell her anything once she won’t forget it and also she started writing down her Alphabets all by herself.i also want to mention that she stayed home for 4 years.and we donot have any family around,i myself didnot make any friends so that i can spend more time with her whenever i had off from work but my problem was i was so quiet which now gives me a guilt that probably due to which she cannot speak like she should be.now all the time i am trying to get different ideas so that i can help her. she just started going to daycare. she is doing well over there but still not talking due to kids not being friendly with her probably due to that language barrier which hurts me a lot. i want to help but donot want anybody to misjudge her because she doesnot have any development issues its only the speech part.please help me with the advice
Comment by Laura on 27 October 2008:
Tara - This website is full of ways you can help your daughter with expressive language. Click the category “expressive language” and read the articles, beginning with ones from last January, and then read forward to the more recent ones. Expressive language issues can be overcome with speech therapy and lots of hard work on your part at home. Read - read - read! Then play- play - play. Ask your SLP for specific ideas to work on at home. Let me know if you have any other questions! Laura
Comment by Karen on 31 October 2008:
Hi, can you further explain what is unusual “creeping” patterns and walking their hands up to their body to achieve a standing position? Also, my son tends to cruise along the furniture on his tip toes, but I also find him standing flat on his feet too. How do I stop him from standing on his toes when cruising? Thanks.
Comment by Laura on 31 October 2008:
Karen - Unusual creeping(traditionally referred to as crawling) patterns would mean anything other than a baby using his hands and knees to crawl. Commando crawling, or pulling your body with your arms while your tummy and legs stay flat on the floor, is common, but not necessarily typical. Other unusual patterns could be a child sitting on his bottom and propelling himself with his legs and feet, using both hands but with one knee down on the floor and the other foot on the floor, etc… This could indicate coordination problems.
Walking hands up to the body to achieve standing means a kid who gets up by placing his hands flat on the floor way in front of him who then “walks” his hands on the floor back toward his body to push himself up from the floor.
My PT friends tell me that kids are less likely to walk on their toes when they are wearing shoes.
Hope this answered your questions! Laura
Comment by Rebekah on 26 March 2009:
Hi Laura. I conratulate you on your site. It is fantastic. I have a question. I am a native English speaker and my husband is a native Spanish speaker. Caroline is 30 months and has a very limited vocabulary. She uses about 30 words spontaneously, however none are more than 2 syllables. However, when she hears me speak English (not that frequently) she is quick to repeat 2 and 3 words together. She is receiving speech therapy in Spanish 3 times a week since the last week of December and I have seen moderate improvement but not not like I would have hoped. She sings 3 different songs rather effortlessly in English. Is it possible that she has a tendency toward English and we are stunting her ability to speak buy insisting she learn Spanish first? Should we switch gears? If so, then after she masters English, when do we begin teaching her Spanish?
Comment by Laura on 26 March 2009:
Rebekah - This is an interesting question. I’d recommend that you stick to Spanish if that’s the predominant language she’ll need for school and to interact with the little friends she’ll make. I don’t think she’s “hard-wired” for one language over another, or that English is any easier to learn than Spanish. You didn’t mention how she’s understanding Spanish. I’m also curious to know what her SLP thinks the issue/s is/are. Studies tell us that children who are raised in bilingual homes do speak a little later than children learning just one language. Since she’s exhibiting delays, and especially if there are delays in comprehension too, I’d stick to one predominant language for the time being, and it sounds like you’re already doing this.
Glad you’re liking the site! Hope you pick up some new ideas! I love hearing from readers around the world!!!! Laura
Comment by GarykPatton on 16 June 2009:
I think I will try to recommend this post to my friends and family, cuz it’s really helpful.
Comment by Elena on 16 July 2009:
Hi Laura -
We have a 33 month old daughter. Our native language is Russian, but she has been in an English-speaking day care/preschool full-time since she was 26 month old. We have followed “one place - one language” model, so we only speak Russian to her at home, and only English is spoken at the preschool. The school has, however, some French, Spanish and Portugese speaking kids.
Her teachers report that they “are working on communication” with her. Basically, after almost a year there, she is still not understanding or speaking English well enough. At home we have problems communicating with her as well. We would like of course to help her overcome any language/communication issues before they might turn into learning disabilities. However, we feel that our situation (because of the bilingual environment) is somewhat different from other similar cases, and have a hard time finding resources that we can use to make any progress. Can you recommend what might be helpful here?
I apologize for such a long post, was only trying to describe the situation.
Comment by Laura on 21 July 2009:
Elena - I’d go ahead and try to find a pediatric SLP who can evaluate her and help you know whether she’s learning language later since she’s being raised in a bilingual environment, or whether it’s a more serious language delay or disorder. Since you’re having problems at home too, I’d think it’s likely the latter.
When I assess children who are having great difficulty with more than one language, I always recommmend that parents pick one primary language and use this one until she’s “caught up” and understanding and using at least one language at an age-appropriate level. Are you planning on doing an English school forever? Do most of her friends speak English? If that’s the case, I’d stick to English. If not, then you should decide which language is going to be her primary language for her education and predominantly use this one of her, even at home. I hope that you can find a good SLP to help you sort all of this out and give you a better idea for recommendations that will be helpful to you! Thanks for your question! Laura
Comment by Elena on 12 August 2009:
Thank you, Laura. I will follow your advise and keep you posted on the progress.
Comment by Marsha on 21 November 2009:
I have a 28 month old son who is only using vowel sounds, occansionly he will use a consonant. Only for such words as bubba, papa, dada, mama, wolf wolf. He uses the words ool, for cool or full. At for cat, hat. Ahh, and Eee, are commonly used for his “language”. He is trying to tell us stories, but gets frustrated with us, because we lack understanding on what he is trying to tell us. I have him in Speech Therapy once a week, but I would love some tips on how to move him forward. Thank you
Comment by Laura on 23 November 2009:
Marsha - Read ideas in the apraxia section since it will give you strategies for targeting new language while working on more specific speech development (new consonants). I also have a DVD that targets this difficulty called Teach Me To Talk with Apraxia and Phonological Disorders. It includes very basic language techniques as well as more specific recommendations for working on speech sounds. Laura
Comment by Anne on 20 December 2009:
Hi Laura,
My 11 month old son is not babbling, he is very social (lots of eye contact, laughing etc). We have the full array of vowel sounds, and he’ll make “mmm” sounds back and forth with his dad and me. We’ll hear consonants within his vocal play, but none of the ma-ma-ma, ga-ga that we keep expecting. He is on the slow side of development in general (just like his dad was), sitting at 8 months, still just creeping, and so on. Is there something we could be doing to encourage him?
Thanks!
Anne
Comment by Laura on 22 December 2009:
Anne - The website is FULL of ideas for you to use with him in play, but the important thing is to keep modeling those sounds and words so he can learn to imitate. You didn’t mention his developing receptive language skills and that’s probably even more important than developing expressive language at this point. Read the articles in that section for ideas too. You’ll also want to make sure he’s using gestures - pointing to what he notices and then later wants to ask you to get for and even waving bye-bye. Gestures are a very important pre-cursor to words and sounds because then you know he’s developing communicative intent. I love that his social skills are a strength for him!! Keep playing those fun games with him! It sounds like you’re doing a great job with him and that he may be following Dad’s later pattern of development. It really doesn’t matter when he walks or talks - just that he does!! Keep trying - he’ll get there! Laura
Comment by Jen on 11 January 2010:
Hi Laura,
I have a question/concern regarding my daughter’s language development and would love your opinion.
She is exactly 14.5 months. Repetitive babbling began at approximately 5.5 months with lots of dada, mama, baba, nana, and yaya. This type of babble was frequent during her infancy, along with other types of vocal play (raspberries, yells, etc.) However, I am still waiting for the “jargon” babble to emerge. While she does have a couple of “stock” nonsense phrases which can be transcribed as “yabeedabeedabee” and “abeeabeeabee“, there is not much variety. Actually, if I ask her to “talk” to me, she breaks out with one of these phrases. There is other vocal play, just not really any of that “foreign” language type that I keep reading about.
That said, she has about 25 words/approximations and an additional 5 animal sounds, all of which are used spontaneously and consistently. She probably uses her entire set of words and sounds 2-3 times in a day, by pointing out and labeling things she knows. There is some inflection in words as well. She has a handful of two syllable words in her vocabulary that are said rather well if not perfectly such as Mommy, apple, Elmo, doodle (as in cheese), bottle (although she says baboo), so I know that she CAN sequence at least SOME different sounds. She has several “basic” words like, “up,” “more,” “no,” “down” and she has found a way to use those thorough the day to tell me what she needs/wants. Basically, instead of a lot of nonsense, most of what she “says” during the day makes sense (at least to a familiar listener like myself.)
By the way, receptive language is excellent.
So, here are my questions:
1. Is there still time for “jargon” to emerge for her?
2. Is it a “red flag” if jargon does not emerge for her?
Comment by Laura on 14 January 2010:
Jen - There’s still time for jargon to emerge, and in my opinion, not a red flag if it doesn’t. She has an excellent spontaneous vocabulary for her age, so I wouldn’t worry about her at all!
Things you can do to make sure sequencing emerges are singing and doing little rhymes with her. Ring Around the Rosies is a favorite for this age. You can usually get “Ashes, Ashes” or “fall down” pretty quickly with this game. Now these aren’t the most functional phrases, but it does let you know she can sequence some new sounds.
Again, I wouldn’t worry about her at all. It sounds like she (and you!) are doing a great job!! Relax Mom!! Laura
Comment by Jennifer on 27 January 2010:
Thank you so much for your opinion/advice. I think this site is amazing and I have learned so much from you.
One last question. You mention sequencing. When I say to her “all done” she says “ah duh” back. If I say “no no” she will repeat me and say “no no.” If I line up two objects like an “apple” and a “banana” and point to each, she’ll name them one after the other. If she falls, she says “boo boo.” I realize that these are not phrases, but is this what you mean by “sequencing some new sounds?”
She is not yet imitating phrases like “more apple,” even though she has both words in her vocabulary. If say to her “more apple?” she says “apple.” Does this concern you at all? (She’s 15 months now.)
Thank you again!
Comment by Laura on 27 January 2010:
Jennifer - Most children begin combining words into phrases when their spontaneous vocabulary (or words they say completely on their own unprompted by you) reaches 35-50 words. She should be able to repeat multisyllabic words and even phrases before then, but I would not be concerned AT ALL that she’s not doing this yet. Most of the time, this begins at 18 months.
To answer your question, your examples of sequencing sounds above were right on target.
Based on what you’ve said about her, I think she’s right on track and you’re doing a great job!! Laura
Comment by Caroline on 5 February 2010:
This is auch a wonderful site, thank you so much.
I am concerned about my son: he is 27 months old and has a significant speech delay. He was evaulated at 18 months and was diagnosed being at a 9 month old level. He has never called me Mama/Mommy but he can say Mama. He has been seeing a speech therapist for about 6 months now but can only say about 30 words but uses babbling words the majority of the time. When he does use words, half the time he uses them incorrectly. For example, he can say ball but if a ball is out of reach he will look at me, point to the ball and say “aaaaaaa.” His eating has slowly deteriorated and there are days when he’ll eat oatmeal for breakfast and milk for the rest of the day. And he won’t ask me for milk, he will go to the fridge and pull the jug out and hand it to me with his cup. He has wonderful eye contact, laughs/smiles/cries appropriatley and follows directions nicely. His favorite is peek-a-boo and cracks up everytime we play it. He will line up objects, but only a few times and moves on. Plus he will not get upset if I mess up this line. A couple of times he has waved bye bye or said hi to me but hasn’t for a while. I read your article “Could My Toddler Be Autistic” and there were a few items that jumped out at me. Should I be worried?
Comment by Laura on 7 February 2010:
Caroline - Since I can’t see him, you’re going to have to rely on his SLP and your other team members. What do they think? Have they given you a specific diagnosis other than delay? One of the responsibilities of an SLP is to discuss a parent’s concerns, and discussing this with you is a very valid way to spend treatment time. I’d also recommend that you not wait until she’s on her way out the door to ask her what she thinks. You can call her or shoot her an email to let her know that you’re going to want to talk about this so she has a “heads up” and you don’t catch her off guard. I hope it goes well for you. Good luck! Laura
Comment by Tiffany on 8 February 2010:
Hi-
My son is 24 months and he says no words yet. He makes this weird noise and pushed his tongue down to the bottom of his mouth. Once and a while he will babble dada, but that is it. He has been in speech for 4 months and I have seen no improvement. He has been to a developmental pediatricaina and he is not Autistic. His face tenses up so much when he tries to talk. How do I help him to talk an is there a possibility that he will NEVER talk!!! Please help!!!
Comment by Laura on 10 February 2010:
Tiffany - I’m so glad your son is in speech therapy. Since I can’t SEE him myself, I really don’t know what’s going on with him, so I can’t help you with a diagnosis. What does his SLP say? Does she have a specific reason he’s not talking yet? Children with apraxia often display facial grimmaces or other oral groping behaviors when learning how to talk. Ask your SLP about that possibility. I also have a DVD for ideas for parents for how to work with these kids at home. It’s called Teach Me To Talk with Apraxia and Phonological Disorders, and you can find information about it by clicking the blue oval in the right hand column at the top of the page.
Although there are some children who don’t learn how to talk, the percentage is very low compared to those who still aren’t talking at 2. You’re doing everything you can, by having him in therapy AND more importantly, by working with him yourself at home (that is the case, right?), so try not to worry so much yet.
Read the articles here on the site for ideas and check out the DVDs so you can see strategies to help him at home. Thanks for your question and try not to worry!!! Laura