Applied Evidence

Speech, language, hearing delays: Time for early intervention?

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A wait-and-see approach may not be best for the child exhibiting delayed development. This review—complete with extensive resource lists—can facilitate an expeditious referral.




› Consider using age-specific published milestones, such as those found online at the American Speech-Language-Hearing Association’s site, to evaluate children’s developmental progress. C
› Consult your state’s early intervention agency (cited in this article) for assistance in referring children for further evaluation and possible treatment. C

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

A young mother in your practice arrives with her 2-year-old son for a well-child visit. She remarks that, although her son uses a few single words to indicate hunger and other needs, her sister’s child at the same age had begun using multiple words to ask questions and express her wishes. She’s concerned about whether her son’s behavior is normal. As you start to engage the child, you note that he responds only after you repeat his name a few times. Are these observations indicative of a typical delay in development, or are they clues to a serious medical issue or communication disability? Given the absence of any known medical problem or evident physical or intellectual disability, how would you proceed in this case and in counseling the mother?

Developmental screening minimizes adverse long-term consequences

Speech, language, and hearing delays and disorders in children can lead to learning and socialization problems that may persist into adulthood. Health care providers who monitor speech, language, and hearing development in children can guide parents, as needed, to appropriate services for further assessment or treatment1 and direct them to advocacy programs such as the Center for Parent Information and Resources (formerly the National Dissemination Center for Children with Disabilities).2

A useful tool at well-child visits is the Denver II, a quick developmental screening test to help identify a variety of disorders of intelligence, language, mental health, and motor and self-help skills.3

Suspicion of a developmental delay not likely due to a medical issue or congenital abnormality requiring examination by an otorhinolaryngologist could warrant referral of the child for early intervention (EI).

Communication disorders and their manifestations

Communication—the ability to receive, process, comprehend, and transmit information—is essential for a successful life.4 Speech, language, and hearing impairments affect a child’s ability to send (speak, write, or gesture) and receive (hear, interpret, or decipher) messages.

Speech impairments

Beginning at birth, we systematically develop speech sounds and an ability to use these sounds to convey meaning by forming words and using language.5 Speech and language pathologists make a distinction between speech and language impairments.6

Speech disorders may involve problems of articulation, fluency, voice, or resonance. About 8% to 9% of preschool children have speech disorders, and approximately 5% of school-age children have speech or language impairments.7

Problems of articulation are heard in such instances as substituting a “w” for an “r” (“wabbit” for “rabbit”) or in distorting or omitting sounds or syllables (“tato” for “potato”). Considering that articulation involves the precise coordination of about 70 muscles (tongue, lips, velum, vocal folds, etc), development of this skill normally goes through phases of inaccurate sound productions. Concerns arise when these phases persist or are atypical.

Speech fluency/stuttering is the uncontrollable blocking of speech, sound prolongation (“wwwwater”), or repetition of a sound, syllable, or word during speaking (“pu-pu-pu-puppy”).

Problems of voice include symptoms such as hoarseness, an exceptionally weak voice or one that is too high or too low, or abnormal resonance (hyper- or hyponasality, which gives the impression the child is talking “through the nose” or is constantly congested).

Using common milestones as reference points. The American Speech-Language-Hearing Association (ASHA)8 lists the milestones for speech development (English and Spanish) at For example, between 12 and 24 months of age, a child should be learning vocabulary (“doggie, nana”), combining 2 words (“mommy car”), asking 2-word questions (“where daddy?”), and producing a variety of speech sounds. These milestones represent an average and some children may not master all the items in a category until they reach the upper limit of the age range (TABLE 1).8 Roth et al9 found that intervention benefited preschoolers with speech and language disabilities when applied earlier than previously recommended. In other words, avoid the “wait-and-see” option. Busari and Weggelaar,10 studying referral recommendations for children who are “slow to speak,” concluded that EI may diminish further consequences later in the child’s life.

ASHA launched a campaign to increase awareness of communication disorders across the lifespan and to encourage early identification ( The site has basic lists of signs of common speech and language disorders and hearing loss in children from birth to 4 years of age. This period in a child’s life is “an important stage in early detection of communication disorders.”


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