Randall Neustaedter OMD
Holistic Pediatric Association
Parents whose children talk late are justifiably concerned. They may worry when their children’s language development does not conform to expected timetables of language skills (e.g. 4-6 words by 16 months and multiple word statements by 24 months). Their children’s health care providers may also have concerns. When other developmental milestones are normal (comprehension, crawling and walking, social skills), then concerns about global development are usually allayed. Some children begin talking later than others and their development is normal. However, talking late may be one of the first indications of a developmental or other health problem. Parents need to have their concerns or fears allayed and clinicians need to ensure that children are developing normally or receiving appropriate interventions for developmental problems.
The age of language acquisition has historically been a subject of some debate, since many children who talk late develop perfectly normal language skills as they get older. Other children who do not speak may indeed have problems that will not resolve on their own. What are parents and clinicians to do when confronted with a child who is slow in learning to talk? This paper will examine the evidence from the relevant clinical studies and the commonly applied assumptions of clinical practice in an effort to reach a consensus opinion about the holistic pediatric approach to early language delays.
A study published in the April 2005 issue of Pediatric Neurology found that isolated delays in language development in children under five years of age without apparent other impairments are often followed by significant wide-ranging developmental difficulties by age 7-8 years (Shevell, 2005). This finding contradicts previous studies suggesting that early language delay is followed by eventual age-appropriate language outcome for a large percentage of children, a process identified as maturational lag. Others have identified a “syndrome” of highly gifted children who also display early delays in language acquisition.
Acquiring normal language skills
Several studies in the past have offered reassurance that children with an isolated delay in preschool language development where other cognitive functions appear normal would later catch up and develop normal language skills. In one study only 16 percent of children with expressive language delay at age 2 had language impairment by age 7 (Paul, 2000). In another study, 44 percent of language-impaired children assessed at age 4 who had normal nonverbal ability developed normal language skills by age 5 ½ years. Their scores were then indistinguishable from the control group (Bishop, 1987b). It should be noted that these two studies suggest that children with language delays at age 2 are more likely to acquire normal skills than children identified with language problems at age 4. Whitehurst and Fischel specifically addressed the issue of age at diagnosis. They suggested that “poorer long-term outcomes are much more likely if language delay persists until the later preschool years, and if the delay is not specific to language and/or includes problems in understanding.” In other words, a delay in talking in the early preschool years is also less worrisome if it is accompanied by normal receptive language skills (understanding) and normal development of other skills (motor, self-help, and social abilities). They go so far as to state that “most children with specific language delay recover to the normal range by five years of age (Whitehurst, 1994).” A more detailed analysis by Fischel determined that the size of a child’s vocabulary at age 2 was a good indicator of the speed at which normal language would be achieved. A child with a large vocabulary was more likely to develop normal language during the third year than a child with poor vocabulary (Fischel, 1989).
Persistent language disorders
Some studies have revealed a much higher percentage of persistent language problems in children diagnosed with expressive language delays in the preschool years. One study followed 20 preschool children with isolated language disorders for 10 years and found that 80 percent continued to show evidence of moderate to profound language impairment in adolescence (Aram, 1984). A recent study by Shevell and his team arrived at similar conclusions and discovered that these children also display other developmental problems later in life. They conclude that specific language delay is not merely a risk factor followed by many of these children recovering to normal range, but rather “a harbinger of the heightened possibility of long-term, wide-ranging developmental difficulties.” Their study published in Pediatric Neurology found that not only did children’s language problems tend to persist beyond the preschool years, but only 10 percent of the children in that study had no evidence of any developmental impairment (Shevell, 2005).
This study examined a total of 70 children who were initially assessed and diagnosed with an isolated delay in speech and language skills (without other impairments) at a mean age of 3.6. Of that initial group 43 were reassessed at a mean age of 7.4. The remainder of the children were lost to follow-up or refused follow-up, but no difference was found in the type or severity of language delay in the two groups (those children reassessed and those not reassessed).
All children were assessed with the Battelle Developmental Inventory that examines 6 realms of development attainment (personal, adaptive, gross motor, fine motor, communication, and cognitive). Of the children reassessed, 83 percent continued to show considerable ongoing language impairment. In addition, two thirds of the children fell below the cutoff level indicating meaningful overall developmental concerns on the total Battelle Developmental Inventory score. And finally, despite an initial diagnosis of an isolated language impairment, 74 percent of children tested were impaired in two or more domains on the Inventory at follow-up, meeting the criteria for global developmental delay.
A second test, the Vineland Adaptive Behavior Scale, that measures functional/adaptation domains (communication, socialization, daily living) similarly showed that nearly half of the children fell below the cutoff level on the overall score, and 48 percent had persistent communication impairments.
The authors argue that the data “support the concept of early specific language delay as a marker for a later increased risk of more wide-ranging neruodevelopmental difficulties and not merely reflecting a maturational lag.” They do acknowledge that the initial assessment may have been insufficiently sensitive to impairments in realms other than language. They suggest that children with language impairment identified in the preschool years be periodically reassessed at key transition points such as school entry (Shevell, 2005).
The Einstein syndrome
A third possible outcome has also been identified for children with significant delays in expressive language development. Some children display unusually precocious intellectual development but are very late in learning to talk. Professor Thomas Sowell has coined the term the Einstein Syndrome to identify these children because Albert Einstein displayed these characteristics as a child, as did other physicists (Edward Teller, Richard Feynman) and musicians (Arthur Rubinstein and Clara Schumann). In an earlier age these children were often diagnosed as retarded (Einstein), and in our own age as developmentally impaired.
Two studies have examined late-talking children who in other respects seem exceptionally bright. The first was conducted by Thomas Sowell of Stanford University (1997) and included 46 children. The second was conducted by Stephen Camarata of Vanderbilt University (2000) and included 239 children. The results of both studies are reported and discussed in Professor Sowell’s book The Einstein Syndrome (Sowell, 2001).
These children developed language at a significantly late age, but display many other remarkable talents. In both studies more than half the children were three and a half years-old before they made their first multi-word statement. In one study most children were four before they completed a sentence. In the other study complete sentences came for most of the children by age five.
Some characteristics of these children were remarkably consistent. Boys represented 87 and 89 percent of the children in the two studies. Both studies showed a high level of analytical abilities in these children. Most excel in putting puzzles together as toddlers. Parents rated these children as unusually good at solving puzzles (67 percent in the first and 46 percent in the second study). Similarly parents rated the children as having an extremely good memory (56 and 52 percent of children). Some parents described their children’s memory as “truly unbelievable.” These children were also particularly attracted to computers and music. In the larger study 86 percent of the preschoolers liked computers and 97 percent liked music.
Family patterns also emerged in the two studies. The vast majority of biological children had a close family member in an analytical occupation (engineer, scientist, or mathematician). Musicians were also prominent in the families of these children. At least one close relative played a musical instrument in 75 percent and 78 percent of the biological families in the two studies. Only 4 and 7 percent of the children respectively in the two studies did not have a close relative who either had an analytical occupation or was a musician. Parents of these children also tended to have a high level of education. Nearly 60 percent of parents in one study and 71 percent of parents in the other had completed at least 4 years of college.
Professor Sowell cautions parents about labeling these late-talking children and the tendency of professionals to misdiagnose them based on their refusal to perform tasks, their disinterest in tests, and their low scores on language assessment instruments. These children may have specific intense interests, and a lack of concern about other topics such as talking. Einstein for example had tremendous talent in mathematics, but nearly failed out of school because of his disinterest in other subjects. Rubinstein began playing the piano at age three, but would not say a single word. By age four he could play complicated pieces on the piano after hearing them played once, evidence of the unusually proficient memory of these late-talking, gifted children.
The holistic perspective
Exceptionally bright children who talk late represent only one of the individualizing situations that should be taken into account from a holistic perspective when considering language delays. Developmental pediatrician Stephen Cowan considers language delay within the context of many other issues that affect children, including their innate individual styles. Understanding the motivation and underlying reasons for a language delay may not only lead to a more accurate diagnosis, but also reveal the best means of addressing the needs of the individual child. For example, the Chinese medicine view of children’s types (Fire, Earth, Wood, Metal and Water) can not only lead to a greater understanding and awareness but also to the best approach to intervention and remediation.
“The holistic view takes into account the full spectrum of causes and conditions, (from dietary influences to family, friends, toxic exposures, etc.) in the unique context of each child. My experience has been that there are kids who have language delays that are “type specific.” For example, some “metal-type” children will often wait until the age of two before speaking because their language is not “perfect.” When he/she does speak it comes out amazingly well in full blown sentences, and later problems, if there are any, may be more directly related to his/her temperament than specifically to the language delay. There are certainly some kids who do exhibit language delays who will go on to have later developmental problems, particularly auditory processing problems. This is most notable in some “water type children” who grow up in rather “Fiery” households. But it is important to remember that the flip side of this is that these are the same kids who may be superb visual learners. In a holistic model, the creative child who is identified as having a verbal deficit early on may be found to perceive the world best through visual or tactile or social input and would benefit from a customized school environment that addresses his/her strengths as well as his so called weaknesses.”
Language delays may be due to a host of factors, including temperament (shy, cautious children who are reluctant to express themselves), physical problems such as hearing impairment or tongue deformities, or more serious developmental disorders such as autism or genetic .
How to screen children
Children’s language skills (receptive and expressive language) should be assessed with an appropriate questionnaire or parent interview. Several charts for assessing language at various ages exist for clinicians. The Early Language Milestone Scale (www.proedinc.com) is an easy to use analog scale of expressive, receptive, and visual response skills. The Receptive-Expressive Emergent Language Test is an excellent expressive/receptive language analysis tool that pinpoints emerging language skills from birth to age 3 (www.proedinc.com).
There are a number of general developmental screening tools that have some sensitivity in picking up children with developmental problems. These include: The Ages and Stages Questionnaire (www.brookespublishing.com), the BRIGANCE screens (www.curriculumassociates.com), the Child Development Inventory (www.agsnet.com).and the Parents’ Evaluations of Developmental Status (www.pedstest.com).
Screening from a holistic perspective should also include a more global assessment of psychological factors, family interactions, and an individualized portrait of the child’s behaviors, learning style, talents, interests, temperament, and understanding of how the child manifests the seven types of intelligence (linguistic, logical-mathematical, musical, spatial, bodily-kinesthetic, interpersonal, intrapersonal). This holistic understanding of the child will place the language assessment into a context of the child as a whole. It will also provide a guide to the best sort of parenting style, learning environment, and holistic treatment
Any child with language delays should be assessed for hearing impairment. Clinicians can do an informal hearing test of cooperative preschoolers by arranging a set of small toys and asking in a normal tone of voice and then in a whisper to point to one toy at a time. Once children reach the age of four they will usually comply with an office audiometric exam. Impedance testing (tympanometry) is a simple clinical tool to assess the presence of fluid in the middle ear (effusion) associated with conductive hearing loss. Formal hearing tests can be arranged for any child with questionable hearing abilities.
When to worry
Speech and language may develop late and then achieve normal or even advanced levels later, often by the age of five or six. Any child with significant delays in language should be followed and reassessed periodically (every 6 to 12 months) so that continuing problems are not neglected. Any significant loss of language or social skills should be properly assessed. If certain milestones are not achieved, then referral to an audiologist and speech and language specialist is prudent. These milestones are listed in the following table.
Indications for Referral to Audiology and Speech/Language Specialists
0-1 month No response to pleasing sound when alert
2-4 months No response to pleasing sounds: does not attend to voices
5-8 months Decrease or absence of vocalizations
9-12 months No babbling with consonant sounds; no response to music
13-18 months No comprehension of words; does not understand simple requests
18-24 months Vowel sounds but no consonants
24-36 months No words; does not follow simple directions
30-36 months Speech largely unintelligible to strangers; dropout of initial sonants; no sentences
3-4 years Speech not comprehended by strangers; still dependent upon gestures; consistently holds hands over ears; speech without modulation
4-5 years Stuttering; consistently avoids loud places
(Adapted from Dixon SD and Stein MT. Encounters with Children: Pediatric Behavior and Development. Mosby, 2000)
Aram DM, et al. Preschoolers with language disorders: 10 years later. J Speech Lang Hear Res 1984; 27:232-44.
Bishop DVM, Edmundson A. Specific language impairment as a maturational lag: Evidence from longitudinal data on language and motor development. Developmental Medicine and Child Neurology 1987 (a); 29:442-59.
Bishop DVM, Edmundson A. Language-impaired 4-year-olds: distinguishing transient from persistent impairment Journal of Speech and Hearing Disorders 1987 (b) May; 52(2):156-73.
Fischel JE et al. Language growth in children with expressive language delay, Pediatrics 1982; 82:218-27.
Paul R. Predicting outcomes of early expressive language delay: ethical implications. In: Bishop DVM, Leonard LB, eds. Speech and language impairments in children: causes, characteristics, intervention and outcome. Philadelphia: phychology Press, 2000:195-209.
Shevell MI, et al. Outcomes at school age of preschool children with developmental language impairment. Pediatric Neurology 2005; 32(4):264-69.
Sowell, Thomas. The Einstein Syndrome: Bright Children Who Talk Late. Basic Books (New York) 2001.
Whitehurst GJ, Fischel JE. Practitioner review: early developmental language delay: what if anything should the clinician do about it? J Child Psychol Psychiatry 1994 May; 35(4):613-48.