Information on Speech and Language Delays/Disorders
The present document was created by members of the department of Speech-Language Pathology at the Montreal Children’s Hospital. Its purpose is to provide medical staff with concise, accurate information about speech and language delays or disorders: definitions, possible consequences, and precise indicators of when to refer.
A Few Facts
The prevalence of speech and language disorders has been estimated to be approximately 13% of children between the ages of 2 and 5 years, with a 2 to 1 male to female ratio.
Speech and language disorders can be found in isolation in a patient, coexisting with another condition (example: attention deficit disorder), or as part of a global developmental delay. Also, speech-language disorders can result from certain primary conditions (example: a head injury, epilepsy, or multiple sclerosis).
Lack of stimulation, neglect, and abuse can also have a negative impact on language acquisition. In all of these cases it is important that the child be referred to a Speech-Language Pathologist for a full assessment of his speech and language abilities.
The Speech-Language Pathologist will then recommend appropriate interventions and follow-up (monitoring, periodic consultation with home programming, or intensive speech-language therapy). Speech-language services are provided in most hospitals, rehabilitation centres, schools, as well as in certain CLSCs and in private clinics. Children can be referred to a Speech-Language Pathologist as early as 1 year of age.
A child with significant language difficulties (comprehension and/or expression) generally has difficulty interacting with his peers and family, developing independence and socialization skills, and is at risk for serious academic difficulties.
The latter difficulties are often associated with behavioral problems resulting from daily frustration with understanding others and/or expressing oneself. As health professionals, you can contribute enormously through the early detection of speech and language delays and disorders.
Difficulty with receptive language: Difficulty with the comprehension of language (words, sentences, ideas expressed).
Difficulty with expressive language: Difficulty with the expression of language (production of sounds, words, and sentences, as well as formulation of ideas).
Difficulty with morphosyntax/grammar: Difficulty using adequate grammatical structures or understanding elements of grammar.
Difficulty with vocabulary: Difficulty naming objects or identifying objects when named.
Difficulty with phonology: Difficulty producing sounds (examples: sÜt, fÜp, rÜy, vÜb, or omitting sounds or syllables).
Articulation difficulties: Sound distortions (ex.: lisp) or faulty production of sounds caused by central and /or peripheral nervous system damage (i.e. dysarthria).
Voice difficulties: Abnormal voice quality (examples: hoarseness, breathiness) caused by an impairment in respiration and/or in the movement of the vocal folds, mass-size changes in the vocal folds (example: nodules), or misuse of the vocal mechanism (i.e. vocal abuse).
Fluency difficulties (stuttering): Disruptions in the normal flow of speech (i.e. repetitions, prolongations, inordinate pauses).
Resonance difficulties: Aberrations in the oral-nasal acoustic output during speech (examples: hyponasal or hypernasal resonance).
DYSPRAXIA (or Childhood Apraxia of Speech):
Difficulty with the voluntary production and correct ordering of speech sounds in the absence of a muscular deficit.
Developmental Language Disorder (formerly known as specific/primary language impairment)
Developmental Language Disorder is the result of a cerebral dysfunction which causes significant and persistent difficulty with the comprehension and/or expression of language, to the extent that the child is rendered unable to communicate normally or participate in age-appropriate activities.
A variety of profiles have been observed in children with developmental language disorder. The difficulties may be present in different areas of language development and at varying degrees. The heterogeneity of this population renders it challenging to identify.
More boys than girls are afflicted with this condition. In addition to the language difficulties (comprehension and verbal expression), problems with auditory perception, abstraction, generalization, and time perception are often also present. Other problems may also be associated (example: fine motor problems).
Normal Language Development and When to Refer
By 1 year of age a child…
- starts to recognize names of objects and body parts (ex.: blanket, nose, toes);
- starts to look at an object when asked where it is (ex.: “Where are your toes?”, “Where’s the cat?”);
- likes people he knows - may move away from an unfamiliar person ;
- points and makes a sound to ask for something;
- may start to use a few simple words;
- imitates simple sounds;
- waves “bye”;
- shakes his head to say “no”;
- does things to see how others will react (ex.: putting a blanket over his face);
- tugs at parent or holds up his arms to be picked up.
At 1 year of age, a child should be referred to speech-language pathology if he…
- produces only a few sounds (ex.: vocalizations, babbling).
By 1 ½ year of age a child…
- responds to requests to say words;
- looks at pictures;
- responds to “give me” command;
- may point to one or a few body parts;
- says three to ten words spontaneously;
- mixes words with jargon;
- may imitate animal sounds;
- may imitate other children but prefers to play alone;
- takes turns speaking;
- demonstrates functional use of objects (ex.: rolling a ball, placing telephone to ear).
At 1 ½ year of age, a child should be referred to speech-language pathology if one of the following is present…
·does not respond to his name;
·does not understand simple routine messages (ex.: “Say bye-bye”);
· produces only vowel sounds, communicates through gesture;
· little variety of sounds produced in syllable strings (i.e. little jargon);
· says no words, not even “Mommy” or “Daddy”;
· does not attempt to repeat what he hears (i.e. no learning echolalia).
By 2 years of age a child…
·understands simple instructions (ex.: “Drink your juice”);
·can show body parts on himself;
·learns the meaning of new words;
·listens to simple stories from a picture book;
·says the names of things, actions, and people;
·starts to put two words together (ex.: “more milk”, “car go”);
·asks questions (ex.: “What’(s) that?”, “Where’(s) Daddy?”);
·likes to pretend (ex.: imitates housework);
·is beginning to interact more with children his age (ex.: takes turns in familiar activities).
At 2 years of age, a child should be referred to speech-language pathology if one of the following is present…
·only understands few if any words (ex.: “bath”, “night-night”, “juice”, “outside”);
·does not imitate sounds (ex.: animal sounds, sound of car, etc..) or words;
·has few intelligible words.
By 2 ½ years of age a child…
·chooses one object from a group of five upon verbal request;
·follows a two-step related command (ex.: take your coat off and put it on the chair);
·identifies pictures when named;
·makes two-word phrases frequently;
·makes three-word phrases occasionally;
·uses simple pronouns (i.e.: “me”, “you”);
·stacks or assembles toys and objects;
·likes to pretend;
·interacts with children his age.
At 2 ½ years of age, a child should be referred to speech-language pathology if one of the following is present…
·does not understand choice questions (ex.: “Do you want milk or juice?”);
·does not understand the question “What’s that?”;
·is unable to follow simple instructions in context (ex.: “Go get your coat” when the parents are ready to go out);
·is not understood by his parents;
·rarely makes two-word phrases.
By 3 years of age a child…
·understands many words, including those for actions (ex.: “run”, “jump”, “sit down”), location of an object (ex.: “in”, “under”), pronouns (ex.: “I”, “you”), and simple opposites (ex.: “big”, “little”);
·will listen to a whole story for up to 15 minutes;
·uses short sentences (ex.: “Me do it”);
·pronounces words clearly but not perfectly;
·asks for things by name;
·asks simple questions (ex.: “What’s that?”);
·starts to tell simple stories;
·carries on a conversation with toys or animals;
·plays with other children;
·likes to pretend.
At 3 years of age, a child should be referred to speech-language pathology if one of the following is present…
·does not seem to recognize the name of familiar objects;
·does not understand simple questions (ex.: “who”, “where” questions);
·does not understand simple instructions which are not accompanied by natural gesture (ex.: “Put your coat on the chair”);
·does not understand basic concepts (ex.: “up/down”, “big/small”);
·communicates non-verbally (i.e. uses gestures) or combines single words with gestures to express most of his ideas, as if producing words was too difficult;
·still unintelligible to parents;
·rarely makes three-word phrases.
By 4 years of age a child…
·understands most of what is said to him;
·understands words that express concepts of size, space, and quantity;
·understands directions that have two or three actions (ex.: “Look on the table and find a story book that you would like to read”);
·can identify colours when they are named;
·is intelligible to most people;
·uses sentences that have 4 to 5 words;
·asks different questions (ex.: “how”, “why”, and “when”);
·can have long conversations with others;
·uses language to joke, tease and pretend;
·plays well with other children.
At 4 years of age, a child should be referred to speech-language pathology if one of the following is present…
·repeats the question asked instead of answering it;
·does not understand questions which refer to past events (ex.:“How did you hurt yourself ?”);
·seems to understand the object of the question but answers inappropriately (ex.: Question : “Where is the cat?” Answer: “The cat is black”);
·has difficulty differentiating prepositions related to spatial location (ex.: “on”, “in”, “under”, etc…) as well as naming and recognizing colours;
·expresses himself using telegraphic phrases (ex.: “Mommy, want water”);
·is always searching for his words;
·often makes off-topic remarks.
By 5 years of age a child…
·understands complex directions (example: “Please pick up your toys and wash your hands before dinner”);
·understands many questions, including questions that begin with “How”;
·understands the difference between “full” and “empty”, “loud” and “soft”;
·listens to stories, conversations, and movies;
·remembers a long story that has been read ;
·is readily intelligible;
·uses complete sentences that have 4 to 8 words;
·asks many questions including, questions that begin with “How” ;
·can have long conversations with others;
·can talk about a long story that has been read or makes up his own stories;
·likes to play with others.
At 5 years of age, a child should be referred to speech-language pathology if one of the following is present…
·has difficulty answering open-ended questions (ex.: “Why is the boy crying?”);
·has difficulty understanding two-part instructions (ex.: “Take off your coat and put it in the closet ”);
·has difficulty grasping abstract concepts (ex.: number concept, “first/next/last”);
·is often off-topic, lack of coherence in discourse;
· does not produce complex (two-part) sentences (ex.: “The boy is crying because he hurt himself ”).
Beyond age 5…
Some children are not identified before age 5. When parents and teachers report difficulty following instructions, producing grammatically correct sentences, expressing ideas, and finding words in children beyond 5 years of age, these children should be referred to their school
Speech Problems Warranting a Referral
If a child presents with a fluency problem (stuttering), he should be referred to a speech-language pathologist. However, many children go through a phase of normal hesitations when developing their language skills, particularly between the ages of 2 ½ and 3 ½ years. This phase could last from a few days to a few months. If it lasts more than 4 to 6 months, refer to a speech-language pathologist.
If a child presents with a mild articulation problem (i.e. such as a lisp after age 6), he should be referred to a speech-language pathologist. If the articulation problem has a dysarthric quality, a referral to a neurologist and a speech-language pathologist should be considered.
In the case of a voice problem (hoarseness, inappropriate pitch, pitch breaks, phonation breaks), a referral to an ENT is warranted in order to examine the vocal cords. Subsequently, a referral should be made to a speech-language pathologist.
br>In the case of resonance problems, a referral to a Cleft Palate Team should be considered for a child presenting with hypernasality and a referral to ENT for a child presenting with hyponasality.
·If, at any age, a child ...
1. is referred to a speech-language pathologist for a language evaluation, a referral to audiology should also be made if the child’s hearing has never been tested.
2. chokes easily when eating, consider a referral to the Swallowing Disorder Clinic.
3. has poor eye-contact, poor socialization skills, atypical behavior, and may also have difficulty adapting to change (physical environment, people, daily routine), consider a referral to the Child Development Program (Developmental Progress Clinic or Autism Spectrum Disorders Clinic).
4. has a rigidity and/or flaccidity of the facial muscles, often associated with drooling, consider a referral to a neurologist.
5. confounds similar sounds (ring of telephone and of doorbell), consider a referral to an audiologist.
6. presents with severe language regression or with stagnation, consider a referral to a speech-language pathologist, a neurologist, and a psychologist.
·Past 2 ½ years of age, consider referring to the Child Development Program (Developmental Progress Clinic or Autism Spectrum Disorders Clinic) any child who is fascinated with or scared of certain auditory stimuli (wind, noise of motor), visual stimuli (colours, shapes), or tactile stimuli (texture of wet or rough objects), and has poor socialization skills and atypical behavior.
·Past 3 years of age, consider referring to a speech-language pathologist and an audiologist any child who seems to learn more when watching others than by listening to verbal instructions.
Frequently Asked Questions
·In the case of the bilingual/multilingual child, a language delay or disorder only exists when it is present in the child’s best language (a speech-language pathologist should always conduct the assessment in the child’s best language, directly or using an interpreter if necessary).
·Exposure to more than one language does not cause a language delay or disorder.
·Parents will find useful information about speech and language delays and disorders on the internet using the key words CASLPA (site of the Canadian Association of Speech-Language Pathologists and Audiologists) or OOAQ (site of the Ordre des orthophonistes et audiologistes du Québec).
About our Profession
To become a Speech-Language Pathologist, one must successfully complete a master’s degree in speech-language pathology. All Speech-Language Pathologists practising in Quebec should be registered with the Ordre des orthophonistes et audiologistes du Québec. Parents looking to consult privately should call the Ordre (tel.: 514-282-9123).
Department of Speech-Language Pathology
Montreal Children’s Hospital
McGill University Health Centre