Speech Delays in Children with Kelly Wilber, CCC-SLP

Podcast Transcript

Molly Shroades:

Hi, and thanks for joining us for this episode of the Health Essentials podcast. My name is Molly Shroades and I'll be your host. The first word, it's something parents look forward to with excitement as your baby turns into a toddler and goes through each of their milestones. But what happens if their speech doesn't take off naturally? Today, we're joined by speech language pathologist, Kelly Wilber, to talk about speech delays, signs of a delay, and treatment options to get your child back on track. Thank you so much for joining us today.

Kelly Wilber:

Hi, Molly. Thanks for having me. I'm glad to be here.

Molly Shroades:

So just starting off, can you give us a basic definition of what a speech delay is?

Kelly Wilber:

Yes. A speech delay for short, or a speech and language delay is a term we used to describe children who are not developing their communication skills or hitting those milestones at the expected times. And that looks different at the different ages and stages of early childhood. So I'd love to go over some of those milestones with you if you'd like.

Molly Shroades:

Absolutely.

Kelly Wilber:

Okay. So from infancy, babies are learning to communicate. And we know from research that babies prefer human speech over synthesized speech. And they prefer to look at things with lines and angles and contrasts and light and darkness. So that makes your face and your facial expression of utmost importance to your baby. And you should see your very young babies start to attend to, imitate and react to, and maybe start to interpret your facial expression. So that's in infancy.

And then, as we hit the age of one, there are some milestones we're looking for. We want kids to have a few true words by age one. We want them to establish and direct your attention. So even if they're not using a lot of words, can they point over in a distance and get you to look over with them at what they want you to see? Joint attention is a big one by age one. I think of this like a communication triangle between you and the child and whatever you're looking at. Let's say it's a book. You want that one-year-old to be actively looking back and forth between you and the book to establish joint attention.

So between the age of one and two, this child closer to two should have maybe 50 words in his vocabulary. A big one by the age of two, we want kids to start to put two words together at a time. So "No, mom" or "My ball" would be great ones to hear from your two-year-old. These kids should be understanding what the word no means, so they don't always follow through with that. And they should be able to bring you a toy from another room when you ask them to.

So moving on up between the ages of two and three, we want this child to be able to ask a simple question like "What's that?" or "Where's my?" Maybe 450 words in their vocabulary by age three. We're listening for some word endings at this point, like the ING. So jumping, running, crying. Some plurals, cars, trucks. These kids like to hear the same story over and over again. It's how they learn. They should be solving problems at this age by using their words and fewer tantrums. They should be matching and understanding maybe big versus little.

So between three and four, the vocabulary expectation jumps up to maybe 1,000 words. These kids have a sentence length of maybe four to five words at a time. They're starting to understand spatial concepts like under versus inside or on the top. They can tell you their name, maybe the street that they live on. Looking at between four and five, wow, maybe 1,500 words in their vocabulary. A sentence length of four to five words or more at a time. They're understanding time concepts like next or lunchtime or yesterday or last night. They ask many, many questions like who and why. And I have one more age group for you between ages five and six. They have a sentence length of greater than six words. They have a vocabulary, maybe around 2,000 words. They're using all types of different sentences, not just simple but compound and complex.

So that's looking at the language expectation. If we look at their speech expectation, one metric we use is intelligibility or how much children are understood by unfamiliar listeners. Unfamiliar might be a relative you don't see very often or a new teacher or daycare provider. At the age of two, we want your child to be approximately 50% intelligible to an unfamiliar listener. At the age of three, that expectation jumps up to around 75% understandable to an unfamiliar listener. And by the age of four, we want that child to be nearly 100%, in the high 90s, intelligible to an unfamiliar listener. So when your child isn't reaching a handful of those milestones, it's something we want to look at and consider intervening.

Molly Shroades:

Wow, it's wild.

Kelly Wilber:

Yeah.

Molly Shroades:

That's so wild how many like words they jump up by in each stage there.

Kelly Wilber:

It is. And it's by no means an exhaustive list, but it's just some things that you can refer to when you're wondering if your child does have a speech delay.

Molly Shroades:

Awesome. Now, let's talk a little bit about why these delays might happen. What are some of the causes of a possible speech delay?

Kelly Wilber:

So just like the presentation of a speech delay is so different in every child, so to is the etiology or the causes. Sometimes the cause is clear. Sometimes different disorders and disabilities are associated with communication delays. But other times we work under the assumption that the cause is a combination of genetic, environmental, and child-based factors. Sometimes kids come to us with a speech delay and they go on to receive a different diagnosis once we get started and get more information. Sometimes they start with a speech delay and they end with the speech delay and remediation is helpful and we just kind of move on. So the cause sometimes is not very clear.

Molly Shroades:

Awesome. Yeah, it definitely every child is unique, right?

Kelly Wilber:

Absolutely.

Molly Shroades:

So let's talk a little bit about some things that parents might be worried about could cause a speech delay. Like pacifiers, I've heard being something. Are there things at home that could lead to this?

Kelly Wilber:

Yes. Let's talk about pacifiers. My disclaimer is that depending on what professional you ask, you might get a slightly different response. So if you talk to a speech language pathologist versus a dentist, an orthodontist, a lactation consultant, an occupational therapist, an ear, nose, and throat doctor, they all have a slightly different perspective on pacifier use.

In my practice, I like to promote a moderate and mindful use of pacifiers. We know that in infancy pacifiers do have benefit in terms of helping the baby to establish a suck-swallow-breathe reflex, and also to provide a means to calm and comfort. But as children get older, if that pacifier use is misused or overused, then we know it can lead to difficulties with articulation, dentition, oral motor structures and functions. So what we don't want to see is a toddler walking around with a pacifier when he could or should be communicating. But if your baby needs a pacifier to go to sleep, I think that's a more mindful use.

Molly Shroades:

Got you, got you. Now, I know a lot of parents get really nervous around milestones, especially when they're thinking, "Oh man, I want to check this box and make sure that we are on track." What are a few signs of parents should watch out for when it comes to speech development?

Kelly Wilber:

Great question. So yes, those milestones are helpful. But we do have what I would consider maybe red flags or predictors of continued language delay. So if a young child is exhibiting some of these factors, we know that likely it could lead into more difficulties as they age, so we want to intervene. And I'll go over those red flags with you.

Some of them are a small vocabulary for his age. We talked about how quickly and rapidly the vocabulary develops. So if there is a small vocabulary, we know that that gap is only going to get larger. We want to intervene as soon as we can. Also, if there's a less diverse vocabulary. Some kids will be really good at talking about transportation or dinosaurs, but they don't have many verbs or modifiers in their lexicon. So we want to make sure the vocabulary is diverse.

If there's a delay in comprehension. So as language is developing, sometimes comprehension edges out oral expression just slightly. But if there's a delay in what the child is understanding, we want to intervene and see what's going on. Likewise, if there's a large gap between what the child's understanding and what the child's using, regardless of what that gap looks like, whether expression is higher or comprehension is higher, those two should be developing somewhat neck and neck. So if there is a large gap, we do want to intervene. And we do consider that a red flag.

If your child is using very few pre-linguistic vocalizations, this is babbling. We want your baby to be babbling early, often, and in different ways. So, how are they babbling? Is it just vowels? Are they using consonants and vowels? And about those vowels, how do they sound? Are they trying to imitate the vowels that you're using? We think of vowels as maybe a little bit easier to produce. So when children are struggling to imitate vowels, we want more information on that.

Few spontaneous imitations. Kids should be really good imitators. Before they're imitating your words, they should be imitating your play, imitating your gestures. And if they're not doing that, we want to see why. And at the same time we want them to be initiators. We don't want them to just be responding to their environment. We want them to seek out opportunities to communicate as well.

What does their play look like? We want to see some symbolic play in toddlers. Are they pretending to feed a baby doll? Are they pretending to feed you? Or are they just kind of grouping and manipulating toys? We want to see a lot of symbolic play. What about middle ear infections? We know that if a child has a lot of ear infections, it could dampen the auditory signal going in and they might not be able to hear, understand and interpret all of the words at that time. And finally, if there's a family history of persistent problems in language learning, we might consider that a red flag too.

Molly Shroades:

Got you, great. Now, once you've kind of identified some of these red flags and you want to do something and take action. What are some of the first steps that a parent will go through as their child starts to get treatment for a speech delay?

Kelly Wilber:

Okay. So I wanted to mention just the referral process, because you have some options there. So if your insurance requires that you can certainly ask your pediatrician for a script for speech and language evaluation and treatment. Also, if your child is less than three, you can contact your county's birth to three provider. Might be called Help Me Grow or Bright Beginnings to have access to some home-based services. If your child is over three, you can also contact the school district. And you can do more than one of those things at a time. So I think the important part is just to get started.

Molly Shroades:

Yeah, definitely starting the conversation with your healthcare provider or someone else is a good way to kick it off if you're concerned.

Kelly Wilber:

It is.

Molly Shroades:

Great. So let's talk a little bit about the treatment itself. What happens for a toddler or young child with a speech delay during this treatment?

Kelly Wilber:

That's the big question and so much. But how we treat a child with a speech delay is with a lot of joy, with a lot of flexibility, with a lot of creativity, and a lot of play with a purpose. There are very specific techniques that we use for children with specific needs. But there are also dozens and dozens of language enhancing strategies that we embed into our play that parents can feel empowered to use at home as well. So I would love to go over with you some of those like language enhancing strategies.

Molly Shroades:

Awesome. Yes, please.

Kelly Wilber:

Okay. So the first three are the basics. So expansion, repetition and recasting. So if a child is saying "Ball," we might spit back just one more. We might expand and stretch what he's saying and say, "Ooh, red ball." If a child is saying "Me turn," we might recast in a correct way and say, "My turn." And then, add one more and say, "My turn, please." So throughout the play, you are repeating, you are expanding, and you are recasting what that child is using.

We also use parallel talk, and it's similar to parallel play. It's where you kind of reduce the expectation for the child to repeat after me. Not every child likes to do this, say this. So you're simply talking about what you're doing beside the child. "Oh, the horse is hungry." "Mmm, that's delicious." And you're talking beside him and that has a powerful effect on the interaction.

Child-directed speech is a huge one. This is also known as motherese or parentese. It's different from baby talk though. It's not baby talk. But there is so much research behind child-directed speech. Basically, it's a way of talking to your toddler that has a slower rate, exaggerated intonation patterns and pitch changes, and more simplified grammar and vocabulary choices.

We have researched to show that children as young as three years old intuitively use this with their younger siblings. And for some of us, it comes naturally to use this child-directed speech, but sometimes it doesn't. And in those cases, I don't mean to single out dads, but sometimes it's with dads that they just feel weird or silly in a speech session, engaging in child-directed speech. So I will share with them the research behind it and how it really helps their toddlers because it'll gives them extra time to tune in to the important parts of the message. It gives them extra time to process all the important items that are coming in through the message. So we definitely use that one.

Feedback is big. Of course, we're giving positive feedback, good job, high five, great work. But we also want to give specific feedback so that the child is learning. So if we're working on ending sounds, I might say, "Oh, you used your ending sound well.  And we'll get some blocks and we'll put them together. Let's try it together." And I'm telling them very specifically what I'm praising or "Wow, I heard two words. Let's try it again. My turn, one, two." And they really kind of tune into what you're happy with and they try to emulate that.

So another good one is sabotage. That sounds mean, but it's not. Sabotage is when you intentionally create a problem for your child to solve and to communicate. And something beautiful happens with sabotage. It takes a child who maybe has just been a passive responder in the conversation and it helps them become the initiator. And kids, just in general, love it when parents are wrong and we just do something wrong and they have to fix it.

So you might be reading a book about horses and you turn to a page with a horse and you say, "Pig." And if the child knows the difference between a horse and a pig, he's going to either look at you funny. So establish that joint attention. He's going to say, "No." He's going to say, "Horse." And then, whatever he says, you can, of course, expand on and repeat and recast right back to him. So that's powerful.

Language temptations are huge. At the clinic, we have a lot of our toys in clear plastic bins or bags. So the child can see and get excited about what the toy is or the activity is. But they can't necessarily independently access it without using their communication. So in the home setting, you can put your child in the highchair and give him a spoon and a bowl, but you forget to give him the yogurt. But it's over right there on the counter. So, he can see it on the counter. And you just look at him expectantly like, "Go ahead, enjoy your yogurt." And he'll do something to let you know that you forgot. So maybe he'll point. Maybe he'll give you a word. Maybe he'll make a noise. And you can certainly expand on that too. So another powerful one.

Pause time or wait time is huge. And sometimes as parents, we want to fill those pauses. We don't want our child to struggle. We know what they want. We just want to give in. But pause time is so powerful. If you are playing with cars on a ramp, I'll do, "Ready, set, go." And we're zooming and we're having so much fun and the child is attending. And by the 10th time, I might say, "Ready, set..." And then, I just stop. And even right now, the pause time is uncomfortable. But I hold onto it because inevitably that child is going to do something to get me to continue the interaction because I've already established engagement and excitement. So that's a big one.

I would be remiss if I didn't mention augmentative and alternative communication. Sometimes we say AAC, and this is just a way to supplement communication, with some children will use gesturing like more or eat or my turn. Some kids will use pictures to show us what they want. Some children will use a device with a voice output. And parents often express a concern, "But I want my child to be verbal, why would I teach them this other method to communicate?" And I try to reassure them that teaching them another method is a bridge that helps them get over this hurdle. And the research will show us that it does not hinder their verbal language development at all. If anything, it supports their verbal language development to add an augmentative piece there.

I just have a few more. We can imitate the child. So, often in that caregiver-child dyad, the caregiver is the one saying, and then the child is the one being asked to imitate or repeat. But if we can flip the script a little bit and let the child start the interaction and imitate the child, really amazing things can happen. I was building a tower and I was trying to take all the blue ones and then all the red ones and he wanted nothing to do with it, so he just started banging the blocks and I thought, "Okay." So I started banging the blocks with him. And next thing you know, we have a whole drum situation going on and he was just so engaged. I heard lots of good language. And so, imitation is powerful as well.

Visual cues, giving your child access to your face, giving your child access to the visual supports. If you're talking about dogs, maybe having a puppet of a dog or a manipulative of a dog, just to allow them to rely on more than just their auditory system. So I think that was a lot of them right there.

Molly Shroades:

That's fantastic though. And it does sound like you're trying to kind of give these kids tools to figure it out and ease some frustration too, because I imagine they can get quite frustrated.

Kelly Wilber:

They do. And when we see some of the frustration, because you can tell, oftentimes I will pull back on what I call imperative language, which is tell me, show me, repeat, do this. And I will use more declarative language. It's like we're just going to talk about it like, "Oh, the car goes down the hill," "Oh, I see snow falling," instead of saying, "What do you need to put on? Where's your coat?" So, yes, you can pull back a little bit without increasing the frustration by using more declarative language sometimes.

Molly Shroades:

That's awesome. So I am wondering, as you were talking through this, I'm wondering about the best time to start therapy for a child. Is there an ideal time to start treatment?

Kelly Wilber:

So my previous answer was really long. So, this one will be short. The answer is the sooner, the better, but it's never too late.

Molly Shroades:

Got you, great. Great. Now, how long are kids typically in treatment for speech delays? I imagine this is not a one size fits all kind of answer.

Kelly Wilber:

You're right. So sometimes a few months. Sometimes a few years. Sometimes we take more of an episodic care approach where we will provide intensive services upfront, so for a few weeks or months. And then, we'll take a break to let these skills generalize before coming back to the therapy table. But it does look different for every child. And your therapist will work with you to customize and individualize a good treatment plan.

Molly Shroades:

Yeah. And this is probably something that involves homework on the parents part, right? This doesn't just stop in the doctor's office. It's not something that you can just do and then go on with your merry way. Parents need to be involved, right?

Kelly Wilber:

A hundred percent. And I like to use the visual of a bowl of M&M's. If you have a bowl of red M&M's and one green one on top, that green one represents the amount of time your therapist spends with your child and that red bowl just represents the amount of time you're spending with your child. So yes, home practice and home work is essential. And I have elementary age kids and sometimes I get intimidated when they come home with homework, so I know the feeling. But with this really young, early childhood age group, you can embed your learning and your strategies into their everyday experiences. So mealtime, bath time, getting dress time, car time, you can use all these strategies then.

Molly Shroades:

Yeah. As you were talking about the different strategies for developing speech that you use during therapy, I was thinking about how those could fit into your everyday life as a parent talking to your kid.

Kelly Wilber:

Absolutely. There are lots of opportunities throughout your day.

Molly Shroades:

Awesome. So I am wondering, should parents be doing a lot of these strategies right out of the gate, even before a speech delay ever happens?

Kelly Wilber:

You sure can. And we know these strategies can support all early language learners, whether there's a delay or a suspected delay or not. So yes, they can.

Molly Shroades:

Got you. Probably not going to prevent a speech delay, correct?

Kelly Wilber:

Right. You can support your child's language development. But if she still requires speech and language therapy, it doesn't mean you failed. It just means she requires a higher level of care right now.

Molly Shroades:

Great. And I definitely think that's a good thing to remind parents of because it's so hard when your kid doesn't meet a milestone. But it's not... It's just something you work through, right?

Kelly Wilber:

Yes. And it is more of a marathon than it is a sprint. And so, helping parents to understand that can be helpful too.

Molly Shroades:

So one thing I'm curious about, after this experience we've all had where we had a long stretch of isolation, does isolation play a role in speech development and any possible delays?

Kelly Wilber:

Yes. The short answer is yes. We don't want children to be isolated. We all have had to live through COVID and the mitigation procedures. And the truth is that I believe we are still in the process of fully characterizing the impact of those mitigation practices, whether it's the isolation or the distancing or the masking. I think we are still in the process of characterizing those things. But what we can feel comfortable in is that it's the quality of the interaction between the child and whoever he's communicating with. It's not the quantity. So, if you've pulled back on the amount of activities you're doing with your toddler, or the amount of large groups that you're involved with, I think that's okay as long as you have a high-quality relationships surrounding that.

Molly Shroades:

Got you. So that one-on-one time and story time and spending good time together is really important here.

Kelly Wilber:

Very much. And to have more than one communication partner, to have a diverse range of communication experiences.

Molly Shroades:

Got you, great. Now, can a toddler catch up after a speech delay?

Kelly Wilber:

So, yes and oftentimes they do. We have many, many success stories of toddlers catching up and then being discharged from therapy and going on to be very successful students. And oftentimes we will kind of start off in speech therapy and then realize that we need to take a break for a while and then come back to the table. But yes, the answer is a child can catch up, but different children catch up at different rates.

Molly Shroades:

Got you. So the long term is different for each child?

Kelly Wilber:

It is. And if there's a long-term involvement, then it usually involves more than just a speech delay. But sometimes we are in the process of getting more information during the treatment phase as well. So it's highly individualized.

Molly Shroades:

Got you, wonderful. So as we wrap up today, I'm just wondering if you can give a few words of wisdom for parents out there that are worried about a possible speech delay. What would you want those parents to know about a possible speech delay with their child?

Kelly Wilber:

Sure. Well, number one is don't wait and use what we talked about today to advocate to your pediatrician, for example, because sometimes doctors don't see what you're seeing at home when they spend a few minutes with your child. So let them know the specific concerns that you have. So don't wait.

Number two is I think we need to celebrate the small successes along the way. Just like we wouldn't teach your child algebra before we teach him his math facts, we really need to celebrate some of the steps that we are making and achieving before we get to being very successful, verbal, conversational communicators. So whether that means playing together or responding to you or saying those first words, all of those steps are important.

So I'd also like to mention some of my favorite toys to promote speech and language development. So in a nutshell, my favorite toys for kids would be toys that do nothing. So the fewer the bells and whistles and lights the better. And the reason being is because you want your child to be playing with you and with the toys. The toys should be a tool, not a substitute for the interaction.

So things like Mr. Potato Head, I know we have them in every room at the clinic. They're so valuable, not just for body parts, but you can turn Mr. Potato Head around. And there's a hole in the back of his head and you can put his eyes there and then open up his back, and you can pretend to see them and you can put the wrong body parts in and just be silly and create a lot of language opportunities that way.

I really like pretend play with pretend food. Sensory play is great with Play-Doh and bubbles. Parents laugh that kids tend to like the wrapping paper or the boxes more than they like the present sometimes. And this is real and true, so let's use that. Let's take those wrapping paper tubes and zoom some Hot Wheels cars down there. So the less things that the toys do, the better because the stronger the interaction can be.

Molly Shroades:

That's awesome. And definitely good to keep in mind when you have little ones that you're trying to plan for.

Kelly Wilber:

Yes.

Molly Shroades:

Well, thank you so much for joining us today and sharing your insights.

Kelly Wilber:

My pleasure, Molly. Thank you.

Molly Shroades:

To learn more about speech therapy, visit clevelandclinicchildrens.org/therapy.

Speaker 1:

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