Understanding Speech And Language Delays In Toddlers

Dr. Richard So, MD:

Welcome to Little Health, a Cleveland Clinic Children's podcast that helps navigate the complexities of child health one chapter at a time.

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It's hard not to worry when every other child seems to be hitting language milestones that yours hasn't reached yet. I'm Dr. Richard So, a pediatrician at Cleveland Clinic Children's. And on this special episode of Little Health, we're talking about speech and language delays. We'll discuss how to spot the earliest warning signs and what to expect during a speech evaluation. My guest today is Kellie Wingerter. She's a speech language pathologist at Cleveland Clinic Children's. Welcome to Little Health, Kellie.

Kellie Wingerter:

Hi, Dr. So.

Dr. Richard So, MD:

Please tell us a little bit about yourself.

Kellie Wingerter:

Uh, it's so great to be here. My name's Kellie Wingerter. I'm a speech therapist, like you mentioned over at Cleveland Clinic Therapy Services. I work out of the Middleburg Heights office. Um, I've been practicing speech therapy for about 10 years now, at Cleveland Clinic for about eight. Um, and I just have a really high interest, passion working with kids with language speech delays that are struggling in their families.

Dr. Richard So, MD:

Yeah. As a primary care pediatrician, every visit, we're monitoring the development of children, whether it's gross motor or fine motor, but it comes down to speech. We know that the baby's coo at two, they laugh and giggle at four months. And every child develops at their own pace. But when do you think slow start becomes delay?

Kellie Wingerter:

Mm-hmm. I think the slow start inkling for parents needs to be trusted. You know, parents are gonna know right away, or most parents, I should say, will know, and kinda have that intrinsic feeling of something's a little bit different, and I want parents always to trust their gut and lean into that. As a speech therapist, when families come in and they're concerned about this, I really am looking at, you know, them globally. Like you said, it comes down to the speech, that's always the tip of the iceberg. But for me, when these kids come in, it's a lot of other things that are happening beforehand. We're looking at their comprehension. We're looking at their medical history. And oftentimes, if kiddos come in and they have this quote unquote slow start, it's my job to weed out, is this just a slow start or is there something more?

And that something more will come into play when we're looking at the family history. Was there a NICU stay? Or is there other medical things going on?

Dr. Richard So, MD:

Were they on antibiotics?

Kellie Wingerter:

Yeah, there's a lot of other things that go into play. Um, and again, if they're having a, a hard time with their comprehension, um, maybe their play skills are behind, maybe their attention is a little bit lower, things like that.

Dr. Richard So, MD:

Yeah. So there's a lot more to speech than just talking.

Kellie Wingerter:

Oh, yeah.

Dr. Richard So, MD:

So let's get into that a little bit. What's the difference between, like, a speech delay versus a language delay?

Kellie Wingerter:

Yeah, good question. And I think that lingo is kind of interesting because speech and language to me go hand in hand, but language really is more about the communication side of things and speech is more about the pronunciation.

Dr. Richard So, MD:

So the production of sound- [Yeah.] ... and understanding.

Kellie Wingerter:

Yeah. So articulation is that pronunciation. How clearly are they making their sounds? And languages, what are they understanding of that language or, you know, what are they expressing in that language? Grammar, vocabulary, syntax, that type of stuff.

Dr. Richard So, MD:

That makes sense.

Kellie Wingerter:

Mm-hmm.

Dr. Richard So, MD:

When I'm in my office and I'm doing my well child physicals, you know, I'm always covering developmental milestones. [Mm-hmm.] You know, and you get to that 18 months to two and a half year old, [Yeah.] you know? Can you talk about, like, late talkers?

When is someone a late talker versus, yeah, there might be something wrong and I don't wanna miss it? What do you recommend for, like, the pediatricians out there or even the parents?

Kellie Wingerter:

I think when you first are, you mentioned that 18 month mark, that's a huge point in a child's development. As you know, you know, birth to three is really that highest neuroplasticity. So our children's brains are growing exponentially. So for a typically developing 18 month old, you're really gonna be seeing an increase in communication more than just words, but, you know, gestures, we're gonna be wanting to see them pointing, identifying their body parts, following directions and being a participant in their daily routines. You know, we really want them to be an active participant in these things.

Dr. Richard So, MD:

I, I think that's where we get into, like, speech versus language. Language could be the part where it's like receptive language. Do you know your body parts? Can you follow the one step command by 15 to 18 months?

Kellie Wingerter:

Mm-hmm.

Dr. Richard So, MD:

You know, but when is it too late?

Kellie Wingerter:

I will say my job does get harder for these late talkers when they're older, only because at that point, the child is starting to have some of these behaviors that then we have to kind of work around to. They've learned that, oh, I can just grunt or reach to get what I want instead of these single words.

Dr. Richard So, MD:

And those are poor social interactions.

Kellie Wingerter:

Yeah. And I think, I mean, it's never too late to start, but it does make the job harder when we miss that neuroplasticity window. And so I think, again, I'm always just encouraging my families, "Get in here as soon as you can. " If there's that teeny tiny inkling of something going on, there is a very low risk by coming in for assistance.

Dr. Richard So, MD:

Is there a early that's too early? Like how, what, what, what do you think- [Mm-hmm.] Like how young do you see your patients?

Kellie Wingerter:

Mm-hmm. I would say for late talkers specifically, you know, maybe without other medical conditions going on, I have parents that come in at 12 months. Yeah, they're not babbling yet. Maybe they're not using any gestures yet. They're not necessarily, like, identifying some of their familiar things in their environment, like, "Where's your bottle? Get your blankie." You know, those are types of things that we really want those kids to be able to do. And at that point, I would probably see them more on, like, a biweekly or a monthly basis as a check-in with the family and just do intervention more targeted towards the parents and the caregivers so that they feel equipped to support the development and just kind of know what to look out for.

Dr. Richard So, MD:

So when, when we get to these young, young, younger kids, you know, like 15 months, you know, and under, when do you suspect a hearing problem that, that comes out of speech?

Kellie Wingerter:

Mm-hmm. I don't necessarily always suspect hearing as the primary concern. If there-

Dr. Richard So, MD:

But it's a rule out.

Kellie Wingerter:

It is a rule out. I always want my kiddos to be seen by audiology first. I tell my, my parents all the time, you know, go to the audiologist-

Dr. Richard So, MD:

So if there's a speech referral, you should go get a hearing check at the same time. I agree 100%.

Kellie Wingerter:

That's my recommendation. Yeah. My background, I had educational training and coursework in kiddos with hearing loss, and my fellowship was on a cochlear implant team. So I have a high interest in kiddos with hearing loss and just understanding the impact of even, like, a unilateral or a mild loss has on speech and language development.

Dr. Richard So, MD:

So a lot of speech language pathologists have, like, that spidey instinct of- [Yeah.] ... of something else is going on.

Kellie Wingerter:

Yeah, I think so.

Dr. Richard So, MD:

When we get to the kids and, you know, it's late talk or speech delay or you're concerned, like, how often do you suspect that, like, phones or screens are a part of it?

Kellie Wingerter:

Mm-hmm. I think phones and screens are a part of everything right now in child development. I can't really put a percentage on how often I think it's at play, but it is a conversation that I have with every single parent that comes into the door. You know, the American Academy of Pediatrics says two and under, no screen time.

Dr. Richard So, MD:

Yeah. I think they get hypnotized, you know, and it's very passive. You know, I'll tell the parents, like, "Okay, if your kid's that young and you're busy, we get it, that you have a lot, you know, but just use it so you can do your chores, but it's not a substitute for educating your child because I think it can lead to that passive learning, you know, that's not interactive that can cause the late talker."

Kellie Wingerter:

Yeah. The talking, it takes two, you know, just like a dance, it takes two to tango. Kids are gonna be reinforced and wanna communicate more when somebody's interacting with them back and forth. Screens don't have that. You know, communication is that I serve you something and you return it to me and it's a volley back and forth. And like you said, they get hypnotized. They're just a passive consumer of what's on the TV. And if we are, you know, having screen time out for our kids, it's better to kind of co-watch with them. Kids are gonna wanna look towards their caregiver and be like, "Did you see that? " And you're like, laugh with the caregiver when something funny happens and they're gonna have still that social reference.

Dr. Richard So, MD:

I, I, I agree with you 100%. [Mm-hmm.] You know, that's like reading with all the voices and using all the characters- [Yeah.] ... and doing that. But say the parent, you're just so busy, is there anything that you could use technology, you know, that could help?

Kellie Wingerter:

Hmm. You know, I get this question a lot. And honestly, you know, I'll see my kids on their screens on, on their parents' phones out in the waiting room and they're playing with this app that's supposedly educational. And I think there is a time and a place for that. [Yes.] But, you know, I don't think that, like you had mentioned, it should not substitute social interaction, it should not substitute physical activity, it should not substitute homework time or family time or meal time. I think if you use it in the right dosage, it can be a tool for the family. And we live in a world that is technology driven. These kids are gonna go to school on tablets. They're, you know, courses are online and everything like that. So I think kind of having that no screen time rule isn't necessarily the route to go where it's like, let's teach boundaries, let's teach responsible consumption, especially beyond the age of five.

Dr. Richard So, MD:

Yeah. I, I could see where, you know, from a parent's perspective that, yes, if they're in your office, they can see the phone. But I think at home, there's other ways to stimulate the child. [Yeah.] You know, if it's a preschooler, some sensory things- [Mm-hmm.] ... that might also help facilitate language- [Mm-hmm.] ... where, you know, between two and a half and three developmentally, you're, you're teaching the kid feelings- [Mm-hmm.] ... you know, whether that's emotional, but also touch. [Mm-hmm.] You know, it could be play-doh, a stuff toy and playing pretend. [Yeah.] Hey, what do you... like the doctor's kit is one of my favorites. [Yeah. Yeah.] You know? [Mm-hmm.] Just give them their doctor's kit instead of the screens would be- [Yeah.] ... like a good alternative.

Kellie Wingerter:

Mm-hmm. And again, I think even maybe creating like screen-free zones where it's like, you know, we have a dedicated space in our house that no screens allowed. You know, this is where we sit, this is where we play. Maybe it's a little table with crafts or like a little shelf with a few toys out because you also don't wanna overwhelm them with too many choices. You, you know, at two and a half to three, like you mentioned, you kind of have to facilitate what they're learning and what their play looks like to some extent by offering some age appropriate, developmentally appropriate toys.

Dr. Richard So, MD:

Yeah. I think the screens, it really changes their attention span.

Kellie Wingerter:

Mm-hmm.

Dr. Richard So, MD:

You know, and that, that's a really hard part. If they're just focused on the screen, they're not learning how to talk.

Kellie Wingerter:

No, they're not. You know, that's not the place to learn communication. It might be a, a decent place to learn a song or learn about their letters, colors, shapes, et cetera, but that back and forth communication exchange isn't gonna happen in front of a screen.

Dr. Richard So, MD:

Gotcha. So I'm gonna make a shift a little bit. So when we get the kid with the speech problem, or communication problems-

Kellie Wingerter:

Yeah.

Dr. Richard So, MD:

... the number one thing that parents are worried about in my office- [Mm-hmm.] ... when we talk about, "Hey, does my kid have autism?" Yeah. What are some of the things that you see when you get a referral from a early kid and you think some, your gut instinct says, "Hey, this is something more than just speech."

Kellie Wingerter:

Yeah.

Dr. Richard So, MD:

There's like total communication issues.

Kellie Wingerter:

Yeah. Yeah, that's fair. Again, communication for me is always the tip of the iceberg. And honestly, a lot of kids that are autistic have trouble with motor planning, so speech will be hard for them. So I'm looking at other ways that they're communicating. I'm looking at their behavior, I'm looking at their attention. You know, there's kind of this symphony of pre-linguistic skills that go into play with a child before their first words even emerge, and that's what I'm looking at.

Can they imitate? Are they using gestures? What's their eye contact like? What's their joint attention like? Are they socially referencing their caregiver? What's their affect? Are they happy? Their emotional regulation. There's a lot of things that I look at. And when you talk about red flags earlier, I try, I, I do try to steer away from the language of a red flag only because, especially when a child first comes in, because then it almost indicates to the family, red alert, red alert, there's something wrong versus let's look at the way that their brain is processing this information.

Let's see, you know, the, their preferences, let's look at what they can do. And I think that's a huge thing right now in the medical field specifically. When we evaluate a kid, we're looking for these deficits, we're seeing what they can't do, but part of my job is also to identify what they can do.

Dr. Richard So, MD:

So talk about what is neurodiversity affirming therapy. Y- you know, how's it differ than traditional?

Kellie Wingerter:

Yeah. It is so dependent on the child and that neurodiversity, neuro-affirming care is a big topic right now, only because as I mentioned, I've been out of school now for about 10 years and those words weren't even in-

Dr. Richard So, MD:

Yes, these are brand new.

Kellie Wingerter:

Yeah.

Dr. Richard So, MD:

This is new to me when, when I saw it on the sheet.

Kellie Wingerter:

I mean, it's just not something that we were taught, but as we are seeing the prevalence just kind of increase and we're learning more as we're going, we want to be trauma informed, especially as autistic individuals are coming out as adults saying like, "This is how I processed. I spent my whole life masking my more or less characteristics."

Dr. Richard So, MD:

I think it's a, it's a positive term.

Kellie Wingerter:

100%. Mm-hmm.

Dr. Richard So, MD:

Instead of having the deficit- [Yeah.] ... that it's just, "Hey, this is your normal rather than a deficit."

Kellie Wingerter:

Yes, 100%. Yeah. We do, um, autistic screenings at our clinic. We do like a level one basic screening, just like a parent questionnaire similar to like what you would get at the pedi-

Dr. Richard So, MD:

Like, m chat.

Kellie Wingerter:

Mm-hmm. Yeah. And then, you know, depended on their response, then we do more of a behavioral screener for the patient and we're looking at, you know, their social referencing cues is like the first and foremost thing. And so one of the things in the screener is showing this like magic scarf and it's supposed to be like a magic trick. And a neurotypical child would respond with a smile, a giggle, like a 'wow.' They may be looking at their caregiver saying like, "Mom, did you see that? " You know, things like that. And, you know, it's discouraging for parents, I think, when I say, "This is what I would expect their response to be and this is how they responded." So before I even do this screener, I kind of tell my families, this assessment was built upon neurotypical responses to these things and anything that deviates from that would be a neurodivergent response and it's just a difference of how their brain is processing this information.

Dr. Richard So, MD:

So on the spectrum, you know-

Kellie Wingerter:

Mm-hmm.

Dr. Richard So, MD:

... there's some kids that can talk, you know-

Kellie Wingerter:

Yeah.

Dr. Richard So, MD:

... where they fall through the loops and the diagnosis and you almost get a, a later diagnosis than some of the ones who are clear cut.

Kellie Wingerter:

Yeah.

Dr. Richard So, MD:

Versus, yeah, my kid can talk. [Mm-hmm.] He knows every jingle off the TV. He knows every commercial. He puts two words together, he puts three words together, he's singing the songs.

Kellie Wingerter:

Mm-hmm.

Dr. Richard So, MD:

What's the approach on that child?

Kellie Wingerter:

Right. And so kind of what you're explaining right there is almost understanding what Gestalt language processing looks like. And just for the listeners, Gestalt language processing is a type of language processing that we see oftentimes in autistic individuals that just learn language more so from the top down. So they're learning language in, in chunks, which the word Gestalt is German for chunk. And so instead of learning analytically word by word-

Dr. Richard So, MD:

Like from syllables, ma, then mama, then specific ba, ba, ma.

Kellie Wingerter:

Yeah. Yeah. So like an analytic learner would be somebody who learns the word 'go' and then down the road they learn 'go car' or 'car go' or let's go to the car. They then are able to understand that each word is a unit and you can combine and use each word to make a novel phrase. But for an autistic individual, like you said, that's reciting jingles, you hear them maybe saying scripts or their ex-

Dr. Richard So, MD:

Songs.

Kellie Wingerter:

Yeah. They just know every song by heart, they're processing the information as a whole chunk, you know, and so they have this extreme rote memory, almost like an episodic memory for these things.

Dr. Richard So, MD:

So they say the words, but they don't know the meaning or the context?

Kellie Wingerter:

The context and the meaning is there, but not necessarily per unit of the word. So for example, if let's say a child is getting in the car with their mom, they're getting ready to go somewhere and the mom said, "Time to go. " The child now associates that whole intonation, everything like that, time to go, I'm getting in the car and going somewhere.

Dr. Richard So, MD:

That could be like get, with 15 months you say, "Go get your shoes." They know they're leaving.

Kellie Wingerter:

Yeah. And an analytic processor might just say shoes, but your Gestalt processor's gonna say, "Let's go get your shoes." Before understanding that shoes is this object here. They associate-

Dr. Richard So, MD:

Gotcha. That chunk with, with shoes.

Kellie Wingerter:

Yeah, with shoes.

Dr. Richard So, MD:

Makes sense now.

Kellie Wingerter:

Mm-hmm. Yep.

Dr. Richard So, MD:

Wow, great, what a great explanation.

Kellie Wingerter:

Thanks. <laugh> Yeah. So I think it, it's, it's very challenging at times to quote unquote find that process I just explained.

Dr. Richard So, MD:

Yeah, we could have a whole conversation- [Oh, easy.] ... about that one, a whole 'nother podcast.

Kellie Wingerter:

Yeah. Yeah.

Dr. Richard So, MD:

Let's, let's move on a little bit.

Kellie Wingerter:

Okay.

Dr. Richard So, MD:

In Cleveland, I grew up born and raised here, and now in my practice, my Spanglish is pretty good. So we have Spanish speaking populations, we have Arabic. I learn a little bit of every language to be culturally sensitive to all my patients and parents and they love it.

Kellie Wingerter:

I love that. [Okay.] Yeah.

Dr. Richard So, MD:

When there's a speech delay and you're speaking more than one language in the house, you know, like in Europe, that's normal.

Kellie Wingerter:

Mm-hmm.

Dr. Richard So, MD:

You know? But here in the United States, we're worried about school, we're about education, we're about getting there, what do you do to those parents who think their child is behind?

Kellie Wingerter:

So it's so hard when you're looking at ... I will say, when we have a family come in and they think that their child is behind in language and, and they're bilingual or multilingual, my first inkling is, what are you talking at home? You know, you may claim yourself as multilingual or bilingual, but what are you really speaking to the child at home? And they may say Spanish and English, but then with further digging, we find, okay, well, most of the time it is Spanish, you know, and you're coming here because your child is quote unquote not talking yet. But what we need to do is really look at what all of their languages have.

Dr. Richard So, MD:

The total number of words.

Kellie Wingerter:

Yeah.

Dr. Richard So, MD:

In both languages.

Kellie Wingerter:

Yes. So that takes a very dynamic type of assessment to understand, okay, do they not have pronouns or do pronouns just not exist in their language? You know, what's their tense like? Okay, well, do they have tenses in their language? What's the word order look like? And kind of weeding out, is this a delay? Is this a difference? Is it lack of exposure? And I think if you're doing an assessment well, it's going to take more than an hour to really figure all of that out.

Dr. Richard So, MD:

Oh, yes. And to complicate you, what if you have that child and you suspect they're on the spectrum?

Kellie Wingerter:

Again, we are speech language pathologists, but I think the better word are communication specialists. We're really looking at how we can get this child- [So good.] ... communicating the best way that we can. And that's gonna be in conjunction with their parents and the school and us and what supports are we offering.

Dr. Richard So, MD:

And I think when we get in those types of situations is that the parents are very open to, okay, let's just learn one language and the default is English.

Kellie Wingerter:

In my experience-

Dr. Richard So, MD:

Yeah. ...

Kellie Wingerter:

And even in the research, that's not necessarily the best route to go.

Dr. Richard So, MD:

Wow.

Kellie Wingerter:

Yeah. So-

Dr. Richard So, MD:

But even if you're schooling here in English-

Kellie Wingerter:

Mm-hmm.

Dr. Richard So, MD:

... if the parents are fluent.

Kellie Wingerter:

If the parents are fluent in English <laugh>-

Dr. Richard So, MD:

Tough question.

Kellie Wingerter:

It's a tough question only because it depends on what the family wants for that child. If they want-

Dr. Richard So, MD:

They want the best.

Kellie Wingerter:

Yeah. And if their long-term goal is, I want them to be able to communicate and immerse themself in my culture. We travel back to Puerto Rico or they ha- their grandparents only speak Spanish, there's no benefit of them only learning English at that point.

Dr. Richard So, MD:

But would we be going like, which language do you learn first then?

Kellie Wingerter:

I would say do both. [Okay.] At the same time. [Okay.] Yeah, we do both at the same time.

Dr. Richard So, MD:

Wow. I like it.

Kellie Wingerter:

Yeah.

Dr. Richard So, MD:

That's, that's very, very, very interesting topic on that part. [Mm-hmm.] So yeah, I, I, I was, my parents came here in '66 with like $200. Actually my dad first and like one suitcase.

Kellie Wingerter:

Oh my.

Dr. Richard So, MD:

You know? [Yeah.] And a lot of families are, okay, we're only speaking our native language Tagalog, which is the Filipino language at home.

Kellie Wingerter:

Uh-huh <affirmative>.

Dr. Richard So, MD:

And I was really good at home, but then like when you turn eight, I told my parents, I go, "I am not speaking Tagalog anymore." [Okay.] 'Cause I wanna fit in like everybody else. [Oh, yeah.] I don't know whether if it was shame, embarrassment- [Yeah.] ... you know, or, or something like that because that goes through it- [Yeah.] ... through a lot of kids. I tell my parents now, "Nope, whatever they say they're not gonna talk to you, keep on speaking in your native language because I lost it. "

Kellie Wingerter:

Oh, okay. <laugh> Yeah. I mean, that's what happens with our aging brains. All those synapses kind of just get pruned away and we use what we need.

Dr. Richard So, MD:

So let's get under the hood. Let's see what you do. You know, walk us through a typical evaluation. What goes on, you know, we've done the hearing check, how long does it take- [Mm-hmm.] ... for an anxious kid to talk to you, how many visits, you know- [Yeah.] ... before you really connect. I know it's kid dependent, but- [Yeah.] ... I just want parents out there to have realistic expectations, "Oh, they're, my kid won't even sit in the doctor's office. How are they gonna talk to the speech language pathologist?"

Kellie Wingerter:

Mm-hmm. So the way that I approach treatment evaluations in general is that first and foremost, we have to have a relationship with the child, you know, and it is child dependent upon how long that will take, but in my treatment sessions, I prioritize connection over compliance. I don't necessarily want to be pestering them to communicate. Communication is a free will. It's so intrinsically motivated and as much as, you know, parents think about speech therapy and, oh, it's flashcards or I'm gonna sit here and we're gonna drill words or maybe they have this presumption of what it could look like where it's really child led, it's play based, it's their interest driven, kids are gonna talk about what is interesting to them, there's a learning curve on the child's and, and on my end about what their interests are.

Dr. Richard So, MD:

So the, like- [Mm-hmm.] ... for toddlers, a lot of it is diversion and distraction. So say you get like the anxious toddler who doesn't even wanna take their coat off- [Yeah.] ... you know?

Kellie Wingerter:

Yeah.

Dr. Richard So, MD:

What are your tricks that you get to get the information that you would get- [Mm-hmm.] ... without overtly like saying to the parent, "Yeah, um, this is learning."

Kellie Wingerter:

Yes. And I think a lot of parents have this conception of like, what is what? Yeah, because, because they're

Dr. Richard So, MD:

Expecting flashcards-

Kellie Wingerter:

Yeah. ...

Dr. Richard So, MD:

Like videos-

Kellie Wingerter:

Yeah. ... of

Dr. Richard So, MD:

Everything on that part.

Kellie Wingerter:

Yeah.

Dr. Richard So, MD:

But I wanna get like down to that part, like in the beginning to get the buy-in.

Kellie Wingerter:

Yeah, the buy-in from the family. Honestly, I love those 'aha' moments when they do happen because it's like now you see the benefit of this strategy and that's what it really comes down to is the strategies that we use to facilitate this communication from the child. And when we prompt them or when we cue them into this and then it happens, that's really when the buy-in. But when it comes to tricks, it, it is- It,

Dr. Richard So, MD:

It's not a trick to you. [Yeah]. But it's like just like what your in- depth training is for that anxious toddler who doesn't even wanna be there.

Kellie Wingerter:

Yeah.

Dr. Richard So, MD:

And you could, you could say, "Hey, we're gonna do, hey, we're, we, it's rewards, it's stickers," but just to get the kid to take a coat off- [Yeah.] ...that was language.

Kellie Wingerter:

Yeah.

Dr. Richard So, MD:

And then how do you, and then you explain that to the parent, "Wow, they listened."

Kellie Wingerter:

Yeah.

Dr. Richard So, MD:

"I know she's in there."

Kellie Wingerter:

Mm-hmm. Mm-hmm. Yeah, I'm always trying to point out those little wins to families too. Yeah. Like, listen, you sat down and you said, "Okay, Bobby, look at Ms. Kellie." And he turned and shifted and I'm like, "Ooh, I really loved mom, the way that you just got his attention before you gave the direction. You tapped his shoulder. That was a really good strategy you used to gain his attention beforehand. And because you did that, he attended." So maybe I'll try that and I'll be like, "Here, Bobby, here's a car."

Dr. Richard So, MD:

I, I can't imagine how much ... Like I'm getting goosebumps right now thinking about what you feel when that kid says the first word. [Mm-hmm.] And the parent hears it for the first word. I mean, I've seen the ones, you know, where the kids with the cochlear implants- [Yeah.] Here's the parent's voice, but tell us about that. Where, where the kids say is the first word- [Yeah.] ... that the parents have heard.

Kellie Wingerter:

You know what, this is an interesting question for me personally, only because I think the way that I felt about that shifted when I had my own children. And initially, like it was almost prior to kids, "Oh, this strategy really worked. This is a very strong strategy. Like I'm gonna keep using this language thing," but now that I have my own kids, the second that I hear the child say the word, my shift goes to the parents because I can relate to the parent in that way. It's like the amount of pride that you feel for your child that like this clicked and that child is going to be empowered now to use it more. I mean, it's just like this feeling of we've got this, you're in there, let's connect, let's, let's keep it going. It's just pride in the child.

Dr. Richard So, MD:

Yeah. From, from my own personal experience, like on that part is that I take care of speech pathologist children and when we know the development, you know, where linguistically baba is before dada and before mama, which takes a lot more muscles on that part. But I had the speech pathologist kid saying, "Mama, it's six months."

Kellie Wingerter:

Mm-hmm.

Dr. Richard So, MD:

And I go, "How did you do that? I'm not expecting that till nine months."

Kellie Wingerter:

Yeah.

Dr. Richard So, MD:

And they said they learn language visually where whenever they babble, you echo everything back and they look right at your lips and you go, "Ma, mama, mama." [Mm-hmm.] And I did that-

Kellie Wingerter:

Mm-hmm.

Dr. Richard So, MD:

... for my own kids.

Kellie Wingerter:

Yeah.

Dr. Richard So, MD:

Okay. When my kids were six months-

Kellie Wingerter:

Yeah. ...

Dr. Richard So, MD:

In the middle of the night, they would say, "Ma, mama." Yeah,

Kellie Wingerter:

Yeah.

Dr. Richard So, MD:

But it was always in the middle of the night. I'd look over to my wife-

Kellie Wingerter:

Your turn.

Dr. Richard So, MD:

She's calling you.

Kellie Wingerter:

Uh-huh. Of course.

Dr. Richard So, MD:

To be called, finally be called mama.

Kellie Wingerter:

Yeah.

Dr. Richard So, MD:

Even though it was very nonspecific.

Kellie Wingerter:

But as she responded, she inadvertently was reinforcing that mama.

Dr. Richard So, MD:

And, I got to sleep. <laugh>

Kellie Wingerter:

Well, that's, that's a win-win right there.

Dr. Richard So, MD:

So language development starts in infancy.

Kellie Wingerter:

Mm-hmm. Yeah. And you, you hit the nail on the head. Language isn't necessarily, I'm using gestures yet, I'm shaking my head, I'm using even mama. I mean, yes, it was a word, it's a meaningful phrase, but that communication, that giggle, that shared like smile, you know, and the, the prolonged gaze and shifting gaze, that's all communication that happens in infancy.

Dr. Richard So, MD:

So what do you do for homework?

Kellie Wingerter:

Depends on the child, you know?

Dr. Richard So, MD:

Okay- [Totally.] ...just basic.

Kellie Wingerter:

Basic for speech would just be more, more words to practice, you know. So say if the kiddo comes-

Dr. Richard So, MD:

So common blends like Spider-Man.

Kellie Wingerter:

Oh yeah.

Dr. Richard So, MD:

You Know? <laugh> Or I, they say the color wed.

Kellie Wingerter:

Oh yeah.

Dr. Richard So, MD:

Like, like some of those are normal, right?

Kellie Wingerter:

Yeah. The way that you just said Spider-Man would be an atypical pattern. [Okay.] So what you did with your tongue there is you stuck it between your teeth and it sounded more lispy. That would be like an A typical- [Yes.] ... speech sound air versus like if they were to say Biderman, they dropped off the S. That's kind of like a typical developmental thing that happens. And yeah, we talk to parents about that. Say they have a three-year-old that comes in and they're worried about their Rs. Well, that's pretty normal, you know.

Dr. Richard So, MD:

When do you expect perfect speech?

Kellie Wingerter:

Perfect speech.

Dr. Richard So, MD:

At what age? [Yeah.] Kinder- [Yeah.] I know kindergarten, I like it because kids are mean. [Mm-hmm.] They'll tease you. [Yeah.] So if your speech isn't there, it affects like your self-esteem, your social interactions.

Kellie Wingerter:

Mm-hmm. Most of the sounds are developed by the age of five. There are gonna be some lingering ones, like that TH sound can be tricky for some kids, the Rs, the Ls. Those might linger five, six, maybe seven sometimes.

Dr. Richard So, MD:

I try to get kids into speech. I, I like it by five by kindergarten, otherwise you're missing art and music class and they're throwing you into speech.

Kellie Wingerter:

Yeah.

Dr. Richard So, MD:

So I have kids that are in school in speech, but they don't do it during the summer. [Mm-hmm.] And then they lose it.

Kellie Wingerter:

Yeah. Yeah.

Dr. Richard So, MD:

So you recommend it to go sometimes get private year round?

Kellie Wingerter:

Mm-hmm. Yeah. And honestly, that's something that we, maybe not necessarily even year round because as I'm, you know, working with kids of older ages with speech sound disorders, they are getting speech in school, maybe they're in sports, they're in school all day, they come to me at 5:30 and their participation buy-in is like not great. And so almost even sometimes with those kids that just have a few lingering sounds, like I mentioned, TH, R or something like that, I'll just tell the families, "Come back in the summer, we'll do an intensive speech therapy burst twice a week if you can manage it for six to eight weeks and we'll hammer out these sounds and then hopefully we'll be on our way after that. " If the family elects to keep coming, great, but if they don't, that's fine if they're getting support in school.

Dr. Richard So, MD:

That's great.

Kellie Wingerter:

Mm-hmm.

Dr. Richard So, MD:

What a wonderful conversation today. How can can, how can our parents get ahold of you?

Kellie Wingerter:

So first and foremost, bring it up with the pediatrician. You know, let your pediatrician know what the concerns are. They can put in a referral for speech therapy. Once that order gets in place, our front end will reach out or you can contact us, um, directly. I don't know the phone number off the top of my head. <laugh>

Dr. Richard So, MD:

I do. It's 216.636.KIDS or 216.636.5437. That's how we can get ahold of our Cleveland Clinic Children's speech therapists.

If you're concerned about your child's development, don't hesitate to bring it up with your pediatrician. They're your best resource for taking those first steps. If you would like to schedule an appointment with a pediatrician at Cleveland Clinic Children's, please call 216.444.KIDS. That's K-I-D-S, or that's 216.444.5437.

Kellie Wingerter:

Thanks for listening to Little Health. We hope you enjoyed this episode. To keep the little health tips coming, subscribe wherever you get your podcasts, or visit clevelandclinicchildrens.org/littlehealth.