Autism. Apraxia. Developmentally delayed.
These are just a few of the devastating diagnoses clinicians can mistakenly hand down to parents of late-talking children.
These diagnoses can shift children out of mainstream and into special-needs classrooms, set them up with an IEP that outlines unnecessary and unhelpful interventions, and prevent them from reaching their early potential.
So what does it mean if a child is late-talking, and how is this different from the many diagnoses that late-talking might be confused for?
Symptom or Stage?
Late-talking is usually defined as a child between the ages of 18 and 30 months who isn’t meeting standard milestones for speech. ASHA points out that one of the most commonly used markers is a child that, at two years of age, uses fewer than 50 words and doesn’t use any two-word combinations.
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While children with developmental delays are generally late-talkers, not all late-talkers are developmentally delayed, explains Dr. Stephen Camarata, a speech pathologist and researcher with more than 30 years experience diagnosing and treating late-talkers.
“Children are late in beginning to talk for all sorts of reasons, so there is not a one size fits all explanation or any one size fits all treatment,” he writes in his landmark book Late-Talking Children: A Symptom or a Stage?
As the name of the book suggests, late-talking is sometimes a symptom of a wider developmental problem, but for a larger percentage of children it is simply a stage they will go through. Here is a look at late-talking by the numbers:
- 10% of children won’t have spoken their first words at 12 months; a lack of language at this point does not yet indicate late-talking or developmental delay.
- 60-70% of those who go on to be “late-talkers” (not meeting milestones during 18-30 month window) will ultimately develop normal speech by their 5th
- 30-40% of late-talkers do have a physical or developmental delay or disorder.
- Less than 20% of late-talkers are on the autism spectrum. Some reports suggest the number is as low as 9%.
Key Observations Regarding Late-Talkers
Researchers aren’t completely certain why some children begin speaking later than others, but one theory is that these children have a different learning style.
It appears that the brains of late talkers spend their early years focusing on analytical development instead of verbal development. Once this development slows down, the verbal development has a chance to catch up. Even into adulthood, late-talkers tend to flourish in analytical fields but at times lag behind in language-focused careers.
In addition, brain scans show that a majority of late-talkers who are otherwise neurotypical actually use the right side of their brain for speech, instead of the more typical left side.
Some often-noted observations of late-talkers (tendencies, not absolutes) include that they:
- Excel in the “3M’s”: Music, math, and memory
- Have a close relative working in music or analytical fields
- Are late potty trainers
- Excel at puzzles and are curious about how things are put together
- Demonstrate more behavioral issues as toddlers
- Tend to be strong-willed
- Are more likely to be left-handed
Some late-talkers struggle in school with reading, spelling, and grammar, even when their speaking skills have already caught up. On the other hand, some are early readers and comprehend well above their grade level.
Some risk factors for late-talking include:
- Being male
- Family history of language delay
- Being born at less than 85% of optimal birth weight
- Were born preterm (prior to 37 weeks)
- Demonstrate delayed motor development
What Steps Should Parents Take When a Child Isn’t Talking When Expected?
We all know that early intervention in speech disorders is key to long-term success. But if more than 3 out of 5 children will be speaking normally by their 5th birthday, how do you decide who to treat and how?
- Don’t Wait it Out
Some parents hear that late-talking can be a stage and find comfort in the above mentioned statistics, deciding to “wait and see”. Unfortunately, if their child is one of the 30-40% facing developmental delays or other serious diagnoses they may miss out on therapy during an ideal window.
If a child isn’t speaking at 18 months parents should go to their pediatrician for a hearing exam and to rule out any physical causes. From here, the child needs to be evaluated by a speech-language pathologist.
- Get a Differential Diagnosis, Not a Confirmation of Suspicions
As an SLP, you want to see the child receive a differential diagnosis, not a confirmatory diagnosis. What does this mean?
Camarata explains: “all too many clinicians seem to assume that there must be something wrong when a child talks late, and end up conducting an evaluation that confirms this assumption…”
Some key things to ask regarding a diagnosis include:
- Was the evaluation designed to provide a differential diagnosis for the various conditions that late talking can be a symptom of, or was it focused on making the child eligible for public services, early intervention, or special education?
- Was the IQ portion of the evaluation reliant on verbal factors? If so, the child should be given a non-verbal IQ test instead.
- Would this child be considered X (autistic, developmentally delayed, etc.,) if they were not late-talking? If late-talking is removed from the equation and they are otherwise normal, it is fair to hold off on settling with a specific diagnosis until a later time.
In recent years as many as 2 out of 4 children diagnosed with autism no longer fit that diagnosis at age 4, in part because of this issue with “confirmatory” diagnoses.
For the 30-40% of children for whom late-talking truly is a symptom of a larger problem, possible diagnoses include:
- Some form of expressive language disorder (most common reason)
- Speech disorder related to pronunciation
- Fragile X Syndrome
- Specific intellectual disability
- Hearing problem
- Hold Any Early Diagnoses With an Open Hand
Diagnosing late-talkers can be difficult.
Why are they failing to comply with the evaluator’s instructions? Is it because they don’t have the intellectual ability to do so, or because they don’t want to?
Because late-talkers are notorious for refusing to do things that don’t interest them, experts recommend re-evaluating regularly to discover the child’s actual ability.
Some signs that a late-talker will go on to speak normally include:
- Regular use of a wide array of communicative gestures.
- Ability to comprehend on par with their peers, even if they can’t respond verbally to the instructions of parents and teachers.
- Absence of significant delay in other developmental markers.
Even these encouraging markers can be slippery guideposts, however, it can take an agonizing few years for some parents to find a clear diagnosis for their child.
Experts in late-talking agree, though, that it’s worth taking the road to diagnosis slowly; a false diagnosis can be worse than no diagnosis.
Why? Because some of the tactics used for addressing other issues, like autism, can backfire with late-talkers.
For example, in working with children with autism therapists often use repetition and offer rewards when the child says the correct word. With late-talkers this has resulted in children who echo others in hopes of a reward instead of developing actual conversational skills.
- Get Therapy
Dr. Leslie Rescorla, developer of the Language Development Survey, says that although most late-talkers catch up to their peers by age 5 or 6, even neurotypical children with no evidence of other delays or disorders should take part in speech therapy.
She explains that while the group that catches up goes on to perform in normal academic ranges these children “were significantly less advanced in their language skills than comparison children who came from the same social class background and had the same level of non-verbal ability when they were toddlers.”
This proved to be true even up to the age of 17, when her study ended.
In particular, late-talkers seem to struggle with grammar, spelling, narrative ability, classroom discussion, and at times with reading comprehension.
By working with late-talkers early on, you can improve their language foundation and long-term language-based outcomes.
Treatment Options for Late-Talkers
It’s impossible to overstress the reality that there is no one form of therapy or intervention that is best for all late-talkers. In fact, experts disagree on when exactly intervention should start for late-talkers. Following are some of the more common therapy responses to late-talking:
- General Language Stimulation
With this form of treatment, you don’t target specific words or forms of communication. Instead, your provide a linguistically-rich environment for the child where you encourage and model accurate language. Your method will look something like this:
- Observe what the child is seeing, feeling and doing. Is the child feeling happy? Playing with blocks? Seeing a car?
- Respond and Model with language a step or two ahead of where the child is at. If the child is playing with blocks, they may say “blocks!” You as a clinician respond, “Yes! Play with blocks!” If the child gets excited about something they see out of the window, you respond by naming that thing. “Car! You saw a car.” You can see a video of General Language Stimulation in practice here.
You’ll want to consider this form of therapy for late-talking children who don’t present with other significant developmental delays. While it’s a solid, evidence-based method to use with these children, it might not be ideal for children who have autism or intellectual disabilities.
- Focused Language Stimulation
This form of therapy targets specific words, grammatical patterns, and communication skills. With this approach, you choose a specific language element you want to work on and then provide a multitude of opportunities to practice it. It usually follows a pattern that looks something like this:
- Introduction of the new word (i.e., block)
- Repetition of the new word in various contexts multiple times. For example: “Here’s the block!”, “I have a block and you have a block!”, “I’m putting my block here.” “Where is your block?” “Here’s your block!”
- Transference of the new word. Find opportunities to use the new word/language element in other situations throughout the day. Some clinicians recommend circling back to the same element up to 200 times in a day, although this will vary depending on the child’s intellectual abilities and learning style.
You’ll want to consider this form of therapy especially for children with specific language impairment, cognitive delays, autism spectrum disorders, and other developmental delays.
- Milieu Teaching
On the surface, this form of therapy looks a bit like Focused Language Stimulation: Milieu Teaching (also called Milieu Therapy) focuses on integrating language learning with the child’s natural play and life environment, and you’ll start off with the same steps outlined under Focused Language Stimulation.
The primary difference between the two is that with Milieu Teaching, the child is prompted to specifically reproduce the language form.
So, for example, during the “repetition” phase the clinician might say: “Do you want to play with the block? Ok, first, say ‘block’”, encouraging the child to accurately repeat the clinician. You can find a video of the method here. (The specific difference found in Milieu Teaching can be seen at the 4:11 point minute mark.)
Experts disagree on the wisdom of using the request for accurate speech (“Say X”). Some experts feel this puts undue pressure on the child, while others point to studies suggesting long-term benefits. This is an area where it will be important to pay close attention to the child’s body language and emotional responses to the therapy method.
Attempting to force or push a child with a therapy method that doesn’t match their learning style can slow down the process and leave both you and the child frustrated.
In addition, research clearly demonstrates that involving the parents in the process and encouraging them to actively repeat the therapy methods at home improves overall outcomes for the child.
Focus on the Big Rocks
Your time with a child can be limited by many things: family availability, finances, school district regulations, and even your own case load.
You may have heard the phrase “focus on the big rocks”; that is, focus on the most important elements first and let the lesser elements fill in the gaps.
There are some increasingly popular forms of therapy that may be applicable for certain issues but don’t appear to enhance a late-talking child’s ability to speak.
- Oral Motor Exercises
- Flashcards with rote repetition
- Sensory Integration Therapy
- Rewards as used for children with autism (appropriate for these children, but not other late-talkers…tends to result in parroting and non-conversational speech)
When considering the reality of limited time, researchers in the field of late-talking strongly recommend that you spend your resources on therapy methods that are directly related to speech and show clear evidence of improving speech outcomes. These researchers point to cases where children spent 1-2 years in therapy with minimal language improvement, but improve significantly once all “extras” were removed and the therapists focused only on speech-related therapy.
Additional Resources for Parents and SLPs Working with Late-Talkers
Currently there aren’t any industry-recognized standard certifications for treating late-talkers. If you want to specialize in late-talking or are treating a late-talking child, you may find the following resources helpful:
- Late-Talking Children: A Symptom or a Stage? Stephen Camarata
- Play To Talk: A Practical Guide to Help Your Late-Talking Child Join the Conversation, James MacDonald Ph.D., Pam Stoika Ph.D.
- The Late Talker: What to Do if Your Child Isn’t Talking Yet, by Dr. Marilyn C. Agin, Lisa F. Geng, Malcolm Nicholl
- The Einstein Syndrome: Bright Children Who Talk Late, Thomas Sowell
- Specific Language Impairment in Special Populations, ASHA
- Target Word ™ Advanced Workshop for Speech-Language Pathologists, The Hanen Centre
- Periodic workshops offered by Dr. James Macdonald