Speech delay.

Remi is 27 months old and lives in a bilingual household. He is an active toddler, likes to play with kids and is very social. But when he is in his play group, his mother notices that he hardly speaks a word while other kids of his age chatter away happily. Also sometimes he is aggressive and pushes or bites other kids. His mother is not very concerned about his speech delay, at least not as much as the onlookers. The reason she says is that Remi is well up to mark in all other areas of development, he is also improving in his speech ( he has started to say caa for car). She thinks that the delay is only because of his bilingual environment and is certain that he will catch up soon. Nevertheless she has decided to bring this issue up to the Paediatrician during his 'well baby' visit.
Does Remi have a speech delay?
If yes, what could be the cause?
Is the mother right in not being too concerned?
Does the child need intervention?
To understand and answer these questions, one need to know about the basics of speech and language development and the possible causes for delay.

Speech and Language:
Speech and language are two interlinked concepts that need to be understood before discussing about speech or language delay. Speech is the actual act of communicating by articulating verbal expression. In simple words, speech is the sound that comes out of our mouths. But language in the other hand is the knowledge of a symbol system that is used for communication, which includes understanding the meaning of words, ability to coin words and put them together to make meaningful sentences . Generally language delay is more serious than speech delay, but speech problems like stuttering can be equally frustrating.
Why is it important to recognise a delay in talking?
No other mile stone in a child's life brings so much change in parental relationship, as beginning to talk does. No more confusion, no more trying to figure out what the child needs, no more groping in the dark. Speech helps kids to express their needs precisely and parents to understand them.
Delay in talking concerns most parents and doctors and rightly so ,because speech delay has a significant impact on a child's personal , social and academic life and intervention at any age can help the children immensely and improve the outcome. Also many developmental problems can accompany speech delay , so early screening can help a lot in diagnosing them. Inability to communicate effectively can lead on to frustration and thechild may resort to physical aggression or bullying.
Normal speech development:
It is important to understand what is expected of the child in terms of speech and hearing , so as to be concerned if there is a deviance or delay. Speech development begins in the womb and most children develop at his or her own pace.
Birth to 3 months:
Cries,
startles at a loud sound,
Quietens and smiles when talked to,
soothened and pacified at gentle voice,
Cries, grunts and gurgles,
From around 2 months, cries differently for different reasons
smiles at your face.
Warning sign: No response to sound?
3 to 6 months:
intently looks at your face and coos when you talk,
vocalises excitement and displeasure,
Gurgles and babbles,
Notices musical or sound producing toys and pays attention to them.
Warning signs: Any of the above behaviour absent?
7 months to one year:
Turns and looks at the source of sound,
Enjoys playing pat-a-cake, peek-a-boo games,
Laughs and imitates a cough,
Responds to his name,
Understands commonly used words and names,
Begins to respond to requests like 'Give me' or ' Come here'.
Babbles- the babble is more of an imitation of normal speech,
Varies the pitch and uses different consonants during babble (m, p, b, g etc) .
Warning sign: Is babbling absent?
Is baby not responding to name, understand simple commands, shows interest in musical toys?
Does your child have recurrent ear infections?
1 to 2 years:
Jargon speech develops, the child appears to chat away in his own lingo,
At around this age, child begins to point at objects.
Words begin to appear , the acquisition of first few words of his vocabulary is often slow and they usually include nouns- names of persons and objects, and those needed to express their needs (more milk) ,
Make gestures that indicate his comprehension (puts phone to ear) ,
Makes sounds of familiar animals (cat – meow) ,
Starts speaking 1 or 2 words at around 1 year, increases to about 5 to 20 words at around 18 months while only 20% is understandable by strangers at this age. Says about 50 words at around 2 year of age, 60% of which is understood by strangers.
Some echolalia is present- the child repeats the words and sentences he hears.
Begins to say 2 words together,
Often generalises – all men are daddy or restricts - only family cat is a cat. Both these are normal stages in development of a child's speech.
Understands simple directions (Bring your shoes), questions like 'where is daddy?'. Asks many 'What is that ?' questions.
Enjoys and likes to dance to music.
Warning sign: Not a single word at 18 months?
Is child sociable and friendly or seem to be dwelling in his own world?
Does he use more gestures than words to indicate his needs?
2 to 3 years:
Sudden explosion of speech that begins at around 18 to 24 months continues with vocabulary increasing by leaps and bounds every day.
Speaks about 400 words, 75% of which is understood by strangers.
Starts using 'me' instead of name for self.
Echolalia diminishes.
Use sentences with two to three words or more.
By around 21/2 to 3 years, the child can have a conversation by putting together2 or 3 simple sentences by combining noun and verbs. Carries on conversation with self and dolls.
Uses plurals and past tense.
Understand prepositions (on the table, under the chair, next to the book etc), understands big/ little.
Likes to hear stories.
Names one or more colors by the beginning of 3rd year.
Warning sign: Does not follow instructions?
How many words does he speak?
No sentences yet?
Can not follow what he says most of the time?
After 3 years the child's language continues to develop in terms of complexity and logic.
3 to 4 years:
Child uses longer sentences, narrate incidents and tell stories,
Often understands time, color and number related concepts,
Ask many questions.
4 to 5 years:
Understands more complicated language,
Speaks well formed sentences.

These mile stones are general guidelines indicating a need to watch out when there is a delay. Children develop at their own pace and a child may still be developing normally even if he/ she does not meet every expected milestone at the corresponding age.

Why is my child not talking yet?
Before discussing the causes, it is important to determine if the child has a speech delay. Parents have the chance to observe their kid in different situations- alone, with parent, with friends or playmates and they are in the best position to recognise and report any delay. It is generally advised not to 'wait and watch' as it is noted that earlier the intervention, better is the outcome. So whenever there is a doubt, it is advisable to discuss with the Paediatrician as soon as possible.
The most common causes for speech and language delay are developmental language disorders, hearing loss or mental retardation.

Developmental language disorders:
Some children fail to speak at the expected age, but seem to have normal hearing, interpersonal relationships, articulation skills but have difficulty putting their ideas across in spoken words. Comprehension is usually normal, most kids can understand when they are signalled by gestures or what they are told , but some kids may also have a delay in receptive comprehension.

These children often use gestures to communicate their needs.With due intervention, these kids catch up with their peers by the time they enter school.
Some kids with such expressive language disorder have a constitutional delay in speech
(otherwise called maturational delay or late bloomers). As the name indicates, these kids develop normally but at a delayed pace. But this group of kids have an excellent prognosis, with all of them catching up with their peers at school age even without any intervention. It is difficult to differentiate this group from the earlier group who need intervention. Some factors like using plenty of gestures and attaining age appropriate receptive language development may help in differentiating the two groups. Nevertheless it is important to screen both groups as early as possible, since it is not always possible to differentiate them beforehand.

Mental retardation:
Language delay sometime accompanies a global developmental delay. It is associated with a delay in other fields of development.

Hearing impairment:
Intact hearing in early years is crucial for speech development. It is very important not to overlook hearing impairment just because the child responds to a loud noise (door bell) as hearing loss can occur over a range of frequencies. The cause of hearing loss can be repeated middle ear infections (leading to accumulation of fluid in the ear) or other causes that are unrelated to infections (like malformation of middle ear or neural hearing loss). Hence, it is critical to identify hearing impairment as early as possible.

Other less common causes of language delay:
Autism:: Most children with Autism have difficulty using language effectively. Persistent echolalia, poor attention duration, absence of eye contact, absence of gestures like pointing, inability to engage in interactive conversation can help in diagnosis.
Prematurity: can lead to delay in different areas including speech and language.
Psychosocial deprivation: Absence of a reliable primary care giver, poor stimulation, neglect can all lead to language delay.
Bilingualism:
Although statistically bilingual children start to talk a little later than their monolingual counterparts, the emergence of language skills in these children are still well within the normal range.
Selective mutism:
Children who have the ability to speak normally fail ( not refuse) to do so in certain social settings like school for more than 1 month. It can be very disabling for the child at school.The causes are not clear but supposed to be extreme shyness ,social anxiety and a genetic vulnerability. Previously selective mutism was thought to be due to poor adjustment and parental relationships but these assumptions are unproven. Some children are found to have additional disabilities.
Other causes of speech delay include Cerebral palsy, cleft palate, Developmental apraxia of speech, Receptive aphasia (where the child hears but does not listen), and intellectual disability.
Tongue tie, although per se does not cause a language delay , may cause speech problems.

What should I do if I think that my child has language delay?
Parents are often first to notice if a child has any problem with his language development or hearing.
As it is important to recognise speech or hearing problems as early as possible (even before the child starts talking), such concerns should be immediately discussed with the Paediatrician.
The Paediatrician will enquire about the child's functioning in other ares of development,the possibility of presence of risk factors ( prematurity, low birthweight, jaundice in newborn period etc) handedness, his school and family environment and if any other members in the family have similar problems.He then conducts a thorough physical examination and a detailed developmental assessment. Hearing assessment is also usually included .
Hearing evaluation helps to diagnose the type of hearing loss, the degree of hearing loss and if one or both ears are involved. There are various audiological procedures from which the audiologist selects the tests the child may have to be subjected to, depending on the child's age and the clinical scenario.

Management of a child with speech delay is individualised. The team includes his Paediatrician, audiologist, speech language pathologist (who is a health professional trained to evaluate and treat people with language and speech problems), psychologist, vocational therapist and social worker. The goal is to make the child understand what is spoken to him and to communicate his ideas effectively.
Treatment for children with hearing loss include placing tubes for middle ear effusions, using hearing aids , and employing other complex surgical procedures when required. These children are given speech therapy, auditory training and taught lip reading. Babies who are at risk for hearing loss, can be helped by subjecting them to frequent screening tests.
Speech language pathologists can help parents learn ways to encourage and enhance child's communicative skills, teach activities to improve their communication and when necessary teach them augmentative and alternative communication. Behaviour therapy can help children with selective mutism.


How can I help my child with language development?
Here are some tips to help your kid with his/her language development.
1.Start talking with your baby right from birth. Babies love to hear the sound of the language.
2.Move closely to your baby when you talk to him so he watch your eyes, face and lips.
3.Smile a lot and make eye contact with your baby. Talk with your baby as you give him bath, change diaper or carry him around.
4.Speak in Parentese -Parentese is the sing song tune that most people automatically use when talking to baby , often with exaggerated facial expressions, with short simple sentences which are repeated over and over again. It is found that 'Parentese' not only delights the babies but also help them acquire language skills. (Parentese is different from baby talk which uses meaningless words and sounds. Experts discourage parents from using baby talk to babies)
5.Encourage baby to localise sounds by ringing the rattle on either side and praising the baby when he turns.
6.Imitate your baby which encourages his vocalisation.
7.Play 'peek-a-boo' and 'pat-a-cake' with your baby.
8.Introduce your baby to variety of sounds like humming,buzzing, whistling and animal sounds.
9.Play music to your child, sing songs and encourage your kid to sing along.
10.Read age appropriate books to the kid. When young, read books with short sentences and simple illustrations. Babies enjoy reading picture books with parents.
11.Teach kids the concept of prepositions- in, out, over, under etc by using a box and small toys.
12.Teach him and encourage him to point and name body parts.
13.Talk a lot to your kid. Teach him the names of objects and persons. Ask him lot of questions. Encourage him to participate in simple conversation. Narrate stories and experiences.
Reinforce your conversations with plenty of gestures.
14.When your child begins to speak words, expand what he says (For example, if your kid points a car, explain him about the car, its color etc). This will help him learn more words.
15.When your kid starts asking questions, listen to him and patiently answer him.Wait for him to complete sentences, neither hurry him nor finish it for him.
16.Do not force your kid. Do not withhold objects and demand that he asks for it, to have it.
17.When your child makes mistakes, repeat the sentence with correct grammar.
18.Play with your child one to one. Talk about his toys and games.Watch his TV programmes with him and discuss the plot and story characters with him.
19.Encourage him to play with other kids who talk well and let him pick up words from them during play.


Stuttering:
Stuttering or stammering is an interuption of the flow of speech by repetition or prolongation of words, often accompanied by struggling behaviours like tremors of lips or eye blinking. Developmental stuttering occurs in young children who are yet to master the language.Children stutter when they are excited or when they are hurried to answer. Most kids outgrow their stuttering. Treatment is considered when the child has been stuttering for 3 to 6 months or display struggling behaviours.
Tips for the parents:
1. Do not react negatively when your child stutters.
2. Present a relaxed enironment at home.Do not be too demanding on the child's performance.
3. Talk about his stuttering problem in an accepting manner.
4. Talk a lot to your child and while talking maintain a relaxed tone.
5. Seek professional help if you find that stuttering is affecting his quality of life and inhibiting him socially.