Is Your Child A Late Talker?

· Are they quiet? · Seem shy? · Not talking like their peers?

· Allow you or siblings to speak for them? · Do you wonder why?

Your baby’s babbling and toddlers first words can be music to your ears. When faced with a child who doesn’t speak or seems to have difficulty with words parents are often told that their child is “just a late-talker.” Unfortunately, all too often, that is not the case. The American Speech and Hearing Association (ASHA) estimates that 16 million Americans under the age of eighteen have a chronic speech-language disorder and that some 45 million Americans are affected by communication disorders of one kind or another which was announded by Congresswoman Carolyn McCarthy during the kick-off of the Better Hearing and Speech Month Health Fair in Washington, DC on May 8, 2002 .

Most parents, and even most pediatricians, are not concerned when faced with a two-year-old who passes all of his developmental milestones on time – except speech and language. However, they should be. It is vitally important to identify and treat speech and language challenges as early as possible in a child’s life, with a strong emphasis on the early intervention years of birth to three. At this age the brain is undergoing the most rapid development. No harm will come from therapeutic services. “Early intervention services are benign in their delivery but can be extremely beneficial. Don’t wait. Six months for a 2 year old is equivalent to a quarter of their lifetime developmentally” as Dr. Judy Flax says, who is a Research Coordinator of the Tallal Lab and a Senior Research Speech Pathologist for the Infancy Studies Laboratory at the Center for Molecular and Behavioral Neuroscience (CMBN) of Rutgers University, Newark, NJ

To find out about your nearest Early Intervention program you should call your local school district, they will be able to refer you to the program appropriate for your child’s age. Waiting to refer is a loss of precious time that may impact on the child’s learning ability and social-emotional well being in later years. Pediatricians and parents should insist on a speech and hearing evaluation as soon as there is a real concern about a child’s early language development. Early referral is endorsed by the American Academy of Pediatrics, and the American Academy of Neurology. In addition, “any child with a severe speech/language delay should have a comprehensive health and neurologic assessment to look for medical conditions that may be causing or contributing to the delay” as Dr.Marilyn Agin says, a developmental pediatrician who is the Medical Director for Early Intervention for NYC.

CHERAB is a non-profit foundation that focuses on raising awareness of Apraxia and other speech and language delays, and the importance of early intervention. Working with developmental pediatricians, speech pathologists, neuroscientists and major hospitals the CHERAB Foundation is working towards research on therapies which may help late talkers with Apraxia, Dysarthria, delayed language development, Autism and other speech and language impairments. A list-serv overseen by pediatricians, speech-language pathologists, and educational consultants is run by CHERAB and can be found at their web-site. Through the list you can connect to many other parents who have children who have speech or language delays, and find out what they have been able to do to help their child.

Some speech disorders can overlap, or be misdiagnosed. For example, “Verbal apraxia, a disorder of central nervous system (CNS) processing, and dysarthria, a disorder of output, are commonly confused”, says Dr. Andrew Morgan, chief of child development at the Chicago College of Medicine. “Experts are able to differentiate between these two disorders by listening carefully to a child’s speech and by identifying certain physical clues”, says Dr. Morgan, but adds, “These disorders are poorly understood by physicians and by a lot of speech therapists as well.” It is possible for phonological disorders, apraxia and dysarthria to all occur together in the same child. Speech Language Impairments, which is connected to language based learning difficulties may also be present. And the severity of each may vary.

Apraxia is perhaps the most misunderstood of all the speech disorders. So, what is apraxia? Verbal Apraxia is a neurological motor speech impairment that involves a breakdown in the transmission of messages from the brain to the muscles in the jaw, cheeks, lips, tongue and palate that facilitate speech. There is no obvious weakness in these muscles and the child may well be able to move them quite happily when not trying to speak. Apraxic children, who are usually seen as “just late talkers” when young, are able to comprehend language at an age appropriate level, however have difficulty expressing themselves using speech. With apraxia, a child knows what he wants to say but there is a road block obstructing the signal from the brain to the mouth. For any child with a speech disorder, but especially with apraxia, the earlier therapy is begun, the better the results for your child and their social-emotional development.

Your Child’s Language Development

So how do you know when your child is having problems with speaking? When is a good time to seek out help? Being aware of average speech milestones can also help you decide whether or not to speak to your doctor. Some guidelines are provided here for your information, but if you have concerns about your child’s speech or language development, or any other developmental issue, make an appointment with your pediatrician so you can discuss these issues. While the average milestones are a good way to measure development, every child develops at their own pace, and this overview should not be used to diagnose a specific problem.

Normal Language Milestones – Clues of a Possible Problem
Typically seen in first 6 months
· Responds to name by looking for voice · Can regularly find speaker or source of sound · Cooing, gurgling, chuckling, laughing ·Imitates sounds and actions · Enjoys social games (peek-a-boo, pat-a-cake) · Babbling (bababa, mamama)

Cause for concern in first 6 months
· Cannot focus, easily over-stimulated · Seems unaware of sound, Cannot find source of sound · Seems unaware of people and objects in environment · Does not seem to understand or enjoy imitating · Lack of connection (eye contact, vocal turn-taking)
· No babbling, or babbling with few consonants

Typically seen in first 9-12 months
· Attracts attention by vocalizing · Waves bye · Vocalizations that sound like first words (mama,dada) · Clearly indicates desire for objects · Imitates new sounds and actions

Cause for concern in first 9-12 months
· Easily upset by sounds that would not upset others · Lack of response indicating comprehension of words · Lack of consistent patterns of babbling · Does not clearly indicate desire for objects

Typically seen in first 12-18 months
· Single word production begins · Requests objects: points, vocalizes, word approximations · Gets attention vocally or physically (mommy) · Knows adult can do things for them (wind up a toy) · Uses “ritual” words (bye, hi, please, thank-you)
Protests: Says no, shakes head, moves away etc) · Comments: Points and vocalizes or uses word approximations) · Acknowledges: Eye contact, vocal response, repetition of word

Cause for concern in first 12-18 months
· Lack of communicative gestures · Does not attempt to imitate or produce single words
· Does not persist in communication (may hold hand up for help, but gives up if adult does not respond immediately) · Limited comprehension (understands less than 50 words) · Limited vocabulary (speaks less than 10 words) · Lack of new words between the age of 12-18 months

Typically seen in first 18-24 months
· Uses mostly words to communicate · Begins to use two word combinations (more cookie etc) · By 24 months has more than 50 words, or word approximations

Cause for concern in first 18-24 months
· Relies on gestures to communicate · Limited vocabulary (speaks less than 50 words)
· Does not use any two word combinations · Limited consonant production · Mostly unintelligible speech · Regresses in language development: Stops talking, repeats phrases inappropriately

Typically seen in first 24-36 months
· Engages in short dialogues · Expresses emotions · Begins using language in imaginative ways · Begins providing descriptive details when speaking · Begins to use articles and word endings (a, the, ing,) uses plurals (cats)

Cause for concern in first 24-36 months
· Words limited to single syllable and no final consonants · Few or no multiword utterances · Does not demand a response from a listener · Asks no questions · Speech difficult to understand · Tantrums when frustrated · Echoing of speech without communicative intent

Adapted from Clinical Practice Guidelines Communication Disorders III 22-25
In addition, the policy statement from the neurology journal Neurology, (August, 2000), states that Absolute Indications for Immediate Evaluation include,
· No babbling or pointing or other gestures by twelve months · No single words by sixteen months · No two-word spontaneous phrases by twenty-four months · Any loss of any language or social skills at any age.

Oral-Motor Problems

Early feeding problems could be a sign of later speech challenges. The same muscles that are used for eating are used for speaking. A baby that has trouble nursing could be a early sign that the baby has muscle weakness in the oral motor area for example. If oral-motor difficulties are present your child should have an evaluation by a pediatric medical and oral motor speech expert to determine the cause and best therapy to possibly prevent some future speech problems. A few possible signs of oral-motor problems are outlined next.

Does your child have difficulties with any of the following?
· Blowing (unable to blow out birthday candles, or blow bubbles by one year) · Kissing or making a kiss face · Licking his lips · Imitating facial expressions such as smiling · Chewing or transitioning to solid foods · Excessive drooling

When trying to speak does your child?
· Display groping behaviors, searching for proper mouth position, silent posturing, dysfluencies · Show expressive language disturbances: limited vocabulary, grammatical
errors, disordered syntax · Make up sign language, or show frustrations when not understood?

It is important to note that some children have no difficulty with oral-motor movements, and may also pronounce speech clearly, but still may have difficulty learning language. There are many different types of speech and language problems, which together represent the number one learning disabiltiy in schools today. That is why again it is important to seek an assessment if a child is not attaining the language milestones at the expected age. Early intervention is key to your child’s development. If you have any concerns about your child’s speech or language development be sure to express them to your child’s doctor. If you want to find out more about early speech and language development and CHERAB’s efforts to help children with speech and language delays you can contact the group or visit the web-site at:

Book: The Late Talker, What To Do When Your Child Isn’t Talking Yet Dr. Marilyn C. Agin, Lisa F. Geng, Malcolm Nicholl

CherabFoundation
Communication Help, Education, Research, Apraxia Base
Main Websites: Cherab.org CherabFoundation.org
Main Online Support Groups: Childrensapraxianet Apraxia.org
Twitter @TheLateTalker
PO Box 8524
PSL, Florida 34952
772-335-5135

To find a Speech Language Pathologist near you:

American Speech-Language-Hearing Association (ASHA)
10801 Rockville Pike
Rockville, MD 20852
Phone: 1-900-638-8255
301-897-8682 (Voice or TTY)
Web: asha.org

Acknowledgements:

Marilyn Agin MD
Medical Director NYC Early Intervention, Advisor Cherab Foundation, co author The Late Talker book

Lisa Geng
President and Co-Founder of Cherab Foundation, PursuitofResearch.org, co author The Late Talker book

Cheryl Bennett Johnson SLS/MA Educational Consultant
VP Cherab Foundation, NJ State Teacher Representative

Paula Tallal, Ph.D
Rutgers’s University, Board of Governor’s Professor of Neuroscience
Co-Founder, Scientific Learning Corporation, Advisor Cherab Foundation

Also See The Cherab Foundation Brochure

Experts state that oral apraxia can be diagnosed as young as 18 months, while most experts believe that it’s difficult to get a definite diagnosis of verbal apraxia until the age of 3. You say your son is 25 months with no signs of oral apraxia. This said, it’s suggested that if apraxia is suspected, to begin appropriate oral motor therapy right away, because it won’t hurt, and the earlier the better for therapy with apraxia. Even with early intervention, some children with apraxia may always need an alternative way of communicating (sign language, picture exchange communication, computer, etc.), but many will learn how to overcome the apraxia enough to talk and be understood.

Through Early Intervention (free through your state’s Birth to Three program and through your local school district from 3 up) or through private (ie provided for by insurance or out-of-pocket), an expert (SLP, OT, developmental pediatrician, neurologist, etc.) will evaluate your child’s ability to move his tongue on command and will assess his strength in various areas (physical, language, emotional, social, and intellectual development), all via fun ways using toys, so he’ll love it. I recommend that you be in the room with him. I was ALWAYS there with Tanner, for all of his evaluations, testing, and therapy, except when he started the preschool disabled program. (We now can watch from a two way mirror.) Some therapists want to be alone with the child and some parents feel their child behaves better without the parent in the room. I believe that since my husband and I are with our son most of the time, our observation is important so that we may provide “carry through” therapy. For us, this has worked well.

Your child may be a late talker for a number of reasons other than apraxia. Most often, it is due to a speech delay, but like I said, early intervention is a free, federal program your child is entitled to if he qualifies, for whatever the reason for the delay in speech. There is a lot of research into the benefits of brain stimulation during the birth to three stage, so the “play therapy” your child would receive from early intervention will most likely benefit him for whatever the reason for the delay of speech. If your child just starts talking perfectly a week or a year later…great! And then do you really care what the reason was for his being a late talker? Since no large scale research has been done yet on the neurologically based condition that is referred to as “apraxia of unknown origin,” all of us as parents of children with apraxia, have questions. But we may not have those questioned answered before our children are teenagers or adults. Our main goal at the Cherab Foundation is to help all children learn to talk, and we do know what works for teaching a child to communicate, overcome apraxia, and reduce frustrations for a “late talker”. A few of the late talkers do have apraxia, and the fact that you’re out there researching on the internet shows that you are the type of parent whose child is in good hands, for whatever the reason he is a “late talker.” Knowledge is so powerful in helping us to help the children.

2. How can you tell the difference between a child that’s not talking because he or she is shy, and one that has apraxia?

The diagnosis of apraxia, according to experts, is difficult to give until the age of 3. Oral apraxia, on the other hand, can be diagnosed as young as 18 months.

My son Tanner seemed shy because he was dependent on people he felt comfortable with to communicate for him and understand him, but that “shy” behavior disappeared as we provided alternative means of communication. I didn’t think of it as much as shy as I did dependency.

His speech disorder didn’t go away when his shyness did. In other words, shy or not shy, Tanner has a speech disorder. Does your child speak clearly in front of anyone? Like you or your husband? Does your child speak in clear sentences at home? If so, then perhaps it is just shyness. If not, to help with any shyness/dependency, you might try Picture Exchange Communication. That would be where your child points to a picture of a juice box vs. a cup when you ask him what he wants his juice in, for example. You can do this for breakfast choices, anything! Also, let him know that “everybody has to learn to talk.” It’s true, you’re just leaving out the details!

Even if your child is showing improvement, you should be concerned if a therapist believes that lack of speech and/or un-intelligibility is from shyness if there are signs of oral apraxia. Again, oral apraxia is something that could be diagnosed as young as 18 months. Apraxia is neurologically based, and it is not a psychological disorder. Even though children can develop low self esteem from communication challenges, most children are still too young to know for sure if his or her progress is normal. If he or she does have shyness issues that affect speech, then that’s an issue that can easily be dealt with through simple methods. So I would highly recommend that you seek a second opinion from an SLP that is knowledgeable about apraxia and other motor planning disorders.

In addition to oral apraxia, it’s not uncommon for apraxic children to have other issues. (Don’t freak out – they’re generally treatable ones) like low tone/hypotonia which looks like the cherub baby, or sensory integration issues. He’s at an age where you may start to notice these other added surprises and it’s good to know what they are so that you can help him if he has them. But while you’re getting second opinions on the “shy vs. apraxia” situation, these are other things to ask about.

This is something you could try:
Buy 2 blow horns. You blow into one and give the other to your child. Imitate (in a fun way) each other’s toots. Let him or her take the lead, then you take the lead. If your child can’t imitate 3 or 4 toots of a horn, he or she is not ready for 3 or 4 word sentences yet. It has to do with breath control.

3. Are all late talkers apraxic?

Many have noted that through my own personal story, both of my children were late talkers and apraxic. Sorry if our story is confusing, but I hope this explanation will clear things up.

The easy answer is no, a child can be a late talker and not have apraxia. But because you brought up my two “late talking” kids, we go to the tough question! The pediatric neurologist diagnosed our older son, Dakota, with oral apraxia at 2, but Dakota never had oral or verbal apraxia in the way our son Tanner does. Dakota’s “apraxia” was used as a symptom (like if you look up the word apraxia in the dictionary and use it as a definition to describe what is happening. Loss of ability to…) The word apraxia was used for Tanner as a diagnosis. Tanner has oral and verbal apraxia.

There are so many names for apraxia – the neurological based disorder we are talking about when we say “Children’s Apraxia Network” for example, names such as dyspraxia, verbal apraxia, oral apraxia,developmental apraxia, global apraxia, limb apraxia, oral motor disorder, etc. and because the speech and medical community are not always on the same page, names are used by professionals that are very confusing, or that even conflict, at times. Some neurologists are knowledgeable about apraxia, and some are not, some are knowledgeable about apraxia, but use other names to describe it. I’ll explain.

Tanner was diagnosed as havinig severe oral and verbal apraxia by various SLPs and by Dr. Marilyn Agin. However, the same pediatric neurologist who wrote in an evaluation that Dakota has “oral apraxia,” diagnosed Tanner as having a “phonological motor processing disorder which effects motor planning and speech.” You see, this neurologist used the term “apraxia” as a symptom rather than a diagnosis since in his medical opinion the diagnosis “apraxia” was not clear. “Apraxia of what? The limbs, the eyes, it’s to vague a term!” is what he said to me in a frustrated way. “I don’t like this name apraxia, it’s too vague!,” he also said. So even though this neurologist knew Tanner was diagnosed as having oral and verbal apraxia by many other speech professionals, and by a medical professional, and even though he understood what apraxia was, he still did not want to use the term “apraxia” to diagnose Tanner. He preferred the diagnosis “phonological motor processing disorder.” But if you run that past some SLPs, some will say that means something different than apraxia!

Since Dakota, our older son had “facial palsy” from crushed facial nerves, among other things, from a traumatic delivery, it created “oral apraxia” but this was describing the action of the nerve damage, not diagnosing him as being oral apraxic. It’s complicated, but yes, even though both our sons had oral apraxia, only Tanner has apraxia, the neurologically based speech disorder of unknown origin. So for all of you with one child with apraxia trying to explain this to family and friends, imagine us! Thank God that Dakota today is mainstreamed and getting top grades in school! We just can’t wait until Tanner makes it out of the woods, as well, at some point.

Once again though, our situation is unique and isn’t the best example of two typical “late talkers.” One was a late talker from birth trauma, and one was a late talker from apraxia, but they both were described as having apraxia. The average late talker does NOT have apraxia. Apraxia is not rare, but it’s not that common, either.

4. Is there an association between apraxia and mental retardation?

Children with apraxia have been MISdiagnosed as mentally retarded and autistic for far too long.

A child can have apraxia and have normal or brilliant intelligence; from what I’ve read, seen, and heard, most do. Just so you know however, a child COULD have apraxia and other issues, such as apraxia and mental retardation, or apraxia and autism, or apraxia and cerebral palsy, or apraxia and downs, etc. (Just like they could have a broken leg and autism.) This is why it’s so important to bring your child to developmental pediatricians and/or neurologists who are knowledgeable about apraxia as well as other issues. Don’t let anyone treat or educate your child as having cognitive challenges unless you know for a fact he does. And don’t leave it up to your child’s school to “find out” and classify him or her as mentally retarded. Find out by having your child privately evaluated by a medical authority (or two) that you respect, and who has experience and knowledge of apraxia and other issues.

Be careful of “receptive” language evaluations on written reports. Your child can have a severe expressive delay, but if they write a “severe expressive and receptive delay,” it means something different. That’s a red flag that there could be cognitive challenges going on. It translates (in parent language) to “You’re talking to this child, but there is nobody home.” If that’s the case, again, see a medical professional, but if that’s not the case, if your child does understand and can follow simple commands, these are the first baby steps to misclassifying apraxic children. Take it seriously and find out privately.

Don’t just depend on one diagnosis, especially since many apraxic children have been misclassified or misdiagnosed. This is one of the reasons we so highly recommend Dr. Marilyn Agin, because she has the background of an SLP, but is now a developmental pediatrician who specializes in autism and apraxia. She gives lectures to medical and other professional communities about these issues and others, and tries to raise awareness so that apraxic children will no longer be misdiagnosed, and will receive the appropriate therapy and early intervention. On top of that, Dr. Agin is the Medical Director for Early Intervention for New York City, the largest of it’s kind in the USA. Dr. Agin states that since so many apraxic children are intelligent and know they aren’t being understood, some tend to withdraw, and be misdiagnosed as autistic. Her information is at our website under Ask The Doctor.

Again, apraxic children can be brilliant and misdiagnosed or misclassified. What’s fortunate is that, because of the Internet, you can prove this point by speaking with the children who have grown up with apraxia or their parents.

The way apraxic children speak varies. You can listen to various apraxic children at The Talking Page. Our son Tanner used to sound deaf when he spoke, but what’s funny is that now that he goes to a school for the hearing impaired and deaf, he no longer sounds like he’s deaf, and he has many inflections when he talks or sings! Lori Roth, who has worked with both deaf and apraxic children, believes that they both may learn to speak in similar ways, which is why so many apraxic children have done well in schools for the deaf or hearing impaired. It’s something to look into anyway. Dr. Agin can explain why apraxic children sometimes sound deaf from a medical aspect as well.

As far as people looking at your son when he babbles, I know how you feel! Tanner is a big kid, so even when he was only 3 he looked 4, and now at 4 and a half he looks like he’s at least 5 or 6. At three he had only a few simple sounds or words. He went through the “babbling” stage after three too. His SLPs say that is typical, and a good thing, since it’s an important stage in language development that our apraxic children either miss, or don’t fully go through when younger. Apraxic children typically go through most of the “normal” stages of language development if they are getting appropriate therapy, but just LOTS slower and later than a typical “late talker” that is not apraxic. Today Tanner talks “like a baby” using 3 to 5 word sentences, and not only are we all proud of him, but he’s proud of himself! We don’t want to lose that healthy self confidence, so if he doesn’t notice any strange looks cast his way, I ignore them. But if these people say anything, or Tanner notices them staring at him, I use my now classic, “He’s learning to talk, and he’s doing great!” Works like a charm!

Lisa Geng, President of Cherab Foundation

Participating Pediatricians:

Marilyn Agin MD

Neurodevelopmental pediatrcian Marilyn Agin MD is the Medical Director for NYC Early Intervention -the largest of it’s kind in the USA. She is also the Co-Author with Lisa Geng and Malcolm NIcholl of The Late Talker book!

Dr. Agin was our dynamic (standing room only) speaker for many of our nonprofit’s meetings since 2000 and presented a paper on apraxia at The First Apraxia Conference Summer 2001. Since then Dr. Agin has been overwhelmed by the amount of calls and emails that she has received from all over the world. Dr. Agin has generously worked very closely with the Cherab Foundation as our Medical Advisor.

Larry Laveman MD

Dr. Laveman has generously volunteered his time to helping the Cherab Foundation and has also presented at a number of CHERAB meetings. He is a developmental pediatrician in New Jersey who diagnoses apraxia, and is looking forward to being involved in apraxia research through Cherab.