Just like other developmental milestones, there is a lot of variability in speech development from child to child. Some developmental milestones have more variability that others. For example, I’ve seen perfectly healthy children walk as early as 9 months and as late as 18 months. On the other hand, the range I might expect for sitting up on his own would be somewhere between 6-10 months (some chubby babies struggle a bit). In addition to considering the ranges of normal for any given developmental milestone, we also look at milestone categories. For example, when assessing a child’s fine motor skills, even if she doesn’t scribble on paper like I would expect at 15 months, I would be reassured by seeing her drop a raisin in a bottle or stack a couple blocks. Perhaps she simply hasn’t seen others scribble much to know what to do. On several occasions I have seen a child do in the office what her parents didn’t know she could do.
Speech is no different from other milestones in how I assess a child. I really like to think more in terms of communication than speech, because the word “communication” encompasses a broader exchange of information. When your newborn cries, he may be telling you he is hungry. When your 2 month-old reciprocates your smile, she is telling you that she acknowledges your presence and gets a good vibe from you. When your 2 month-old coos or your 6 month-old says “ga ga ga”, he’s revealing his feelings and emotions (simple as they may be). When your 10 month-old points at something and looks at you, she is telling you “I’ve seen something that grabs my interest and I want you to see it too!” When you put on a stern face and tell your 11 month-old “no”, her curled lips say “I understand the negativity and I’m ashamed”.
The actual formation of intelligible words is really a very small part of our language assessment. In fact, it is probably the least of my concerns when assessing a toddler. So what is my biggest concern? It is whether I see the building blocks for language development. If I see all the prerequisites there but the child simply isn’t saying real words in the language spoken at home, I usually can predict a good outcome. The prerequisites I want to see are as follows.
1. Does the child have an interest in social interaction? Without that interest language development will be a challenge. Let me give a couple of examples. Have you ever talked to a 2-4 month old baby and the baby waits for you to finish talking, then coos or babbles? You go on back and forth that way. Likewise, you play pat-a-cake with your 10 month-old and he laughs and tries to imitate your hand clapping. Sometimes interest in social interaction can manifest as pretend play. Your 11 month-old pretending to talk on the phone, for example. Similarly, your 16 month old scribbling on paper and bringing it to you in hope of receiving praise for her fine work. These examples might not be seen in a child who will be ultimately diagnosed with speech delay and autistic spectrum disorder.
2. Does the child use non-verbal forms of communication, like gesturing or sign language. Gesturing examples might include pointing to things of interest, clapping hands when happy, waving bye bye, shaking (“no”) or nodding (“yes”) the head, frowning, etc. Some children are taught sign language at a very young age and can communicate in this manner well before their verbal skills mature. I often recommend this in a late speaking child who gets frustrated (with resultant temper tantrums) by his inability to express himself.
3. Does the child babble or speak gibberish? While a toddler who speaks fluent gibberish is certainly amusing, the gibberish is an excellent indicator that he gets the gist of language. Always a reassuring sign.
4. Does the child seem to comprehend language. It could be comprehension of sign language or spoken language. If a 15 month-old goes and gets her shoes when asked, that is a good sign.
5. Is the child’s hearing OK? A hearing deficit always should be considered in a speech delayed child. We will typically send them to an audiologist to get specialized testing for young children (similar to the newborn hearing test they had). Deafness can either be congenital (present at birth) or develop later. Thus, a normal newborn hearing test does not exclude hearing loss as a potential cause of speech delay.
If all of these prerequisites are in place, then I will often take a conservative approach of either watchful waiting or referral to a speech therapist for a little extra help. The child will usually have a word “explosion” soon enough. If there is suspicion of autism or other general developmental delays, more intensive early intervention services are needed.
One final note on children in bilingual families. Two languages at home do not confuse children and do not cause speech delay. I expect the child in the bilingual home to have language skills as advanced as they would have in a monolingual home. If an 18 month-old child in a monolingual home speaks, say, 30 words, that same child in a bilingual home would probably speak 15 words in one language and 15 in the other.