Speech and language development in children

Key learning points

• Children develop language at hugely differing rates
• Language ability at school entry is predictive of later academic success and life chances, so it is important to identify and address delays in the pre-school years 
• Although some language difficulties are due to problems such as hearing impairments or developmental disorders, language delay can result from the lack of a supportive learning environment

Language difficulties can affect the child’s ability to produce the sounds for speech, to understand language or to produce words and sentences. Language delay may be the main difficulty facing the child, or be part of a broader atypical profile. When language is primarily affected, this is referred to as primary language delay. Language delay with sensory impairment or cognitive delay is referred to as secondary (eg in autism).

With extensive variation between children in the speed of language learning, it can be difficult to identify when a child has difficulties that require attention. This is further complicated because children’s language profiles can change; while approximately 70% of children identified as having a language delay during the pre-school years appear to improve, others start out well but later fall behind.¹ Children who have problems understanding (receptive language) generally fare worse than those who have good understanding but struggle to produce words and sentences (expressive language).² Although children from disadvantaged backgrounds are more likely to show delay, many will have good language, while some children from wealthier backgrounds face significant difficulties.

Similarly, children learning English as an additional language (EAL) may appear delayed, but those with good skills in their home language will generally catch up with their monolingual peers.³ This variation means it is important to know what to look out for at different ages, and to observe children who may have difficulties to see how their skills develop over time.

The prognosis for children with ongoing language difficulties depends on the nature of their delay and the support they receive. Developmental language disorder (DLD) is diagnosed typically after three or four years. These children have marked difficulty with language skills such as forming sentences, understanding spoken instructions, learning word meanings and telling simple stories.
Two children in every UK year one class will have a significant DLD. Children with DLD will require therapy and special education throughout childhood and adolescence, and are likely to have long-term literacy and social/behavioural problems.⁴

Language delay is always observed in children with autism, although the level of language attained by autistic individuals varies widely. Compared to language delay or DLD, children with autism show significant limitations in social interaction and non-verbal skills (pointing for interest) at two years or earlier⁵ and at three years will have limited play and expressive/receptive language. Differential diagnosis between language delay and disorder and autism must be carried out by a specialist multidisciplinary team.

Children typically all have immature speech patterns in the early years. Speech problems are identified at two to three years and can be divided into three main categories:

• Developmental phonological delay or disorder – the child is slow to acquire the range of speech sounds so that an immature pattern of speech persists. Speech sounds are omitted or substituted with simpler sounds.⁶ The problem is likely to persist if the child is unintelligible to adults outside of the family by 38 months and should be referred to speech and language therapy (SLT) services. Phonological delay or disorder frequently occur alongside DLD and can be associated with negative longer-term outcomes on socialisation and self-esteem.
• Speech errors – the child produces a limited number of speech sounds in an unusual manner (eg lisping on the sound ‘s’ or making the sound ‘r’ as ‘w’). Speech errors typically resolve without intervention and are not generally associated with negative social outcomes. However, speech errors that persist to school age may require intervention.
• Non-fluency – this is frequently observed in pre-school children in the third year of life and is characterised by speech repetitions. Most children pass through this phase quickly. Developmental stammering may be indicated when the non-fluent phase persists or if anxiety is associated with speech. Around 70% of developmental stammering cases will resolve within 18 months to three years.⁷ Referral and advice can prevent stammering becoming worse.

How caregivers can support language learning

Some families struggle to provide a language-rich environment for their child. Healthcare professionals can support families by promoting positive behaviours based on what we know from language and communication research.

For instance, babies produce more speech-like babble, practising for later language, when caregivers smile and look at them.⁸ Even though the baby isn’t yet talking, she is already learning important information about language. Talking to her, then waiting for a responsive gurgle or sound, helps her learn about the sounds of her language and taking turns in conversation. Later, babies will hold up objects towards their caregiver, or point to another person or object. These early gestures provide important clues about what interests the baby. The more time caregivers spend talking about something the baby is interested in, the more the baby gestures and the more words she learns.^9,10 Children who know more words begin to put words together into sentences earlier.¹¹

The quality of the language children hear matters, as well as the amount.¹² Children need lots of opportunities to remember new words and learn their meanings. Talking about objects in different contexts (eg food at dinnertime and in the supermarket) provides more opportunities to learn. Reading books with young children, even very simple ones, is particularly beneficial. Reading the same book repeatedly helps children to extract new information.¹³ It can be tempting to use simplified language when talking to children, but children benefit from hearing many different words used in full sentences.¹⁴

As children get older and produce sentences themselves, they are helped by caregivers who expand on what the child has said,¹⁵ leaving time for them to respond. This helps children learn how to put sentences together while carrying on with the conversation and keeping them engaged. Connecting what children say to meaningful contexts in their daily life, referring to things and events not physically present, and using more complex kinds of sentences (eg ‘Before we have dinner, we need to wash our hands’) helps children develop more complex language skills.¹⁶

What to do if you suspect a language problem

• Referral routes – children can be referred directly to an SLT by their health visitor, or by parents, guardians and nurseries. Details of SLT services, contact information and assessment policies will be available on the relevant trust websites. 
• Process after referral – SLT service procedures vary across the country. In most cases, the child will be seen by the SLT for an assessment of communication skills. The SLT will make a recommendation about further action that needs to be taken. Options vary according to individual need but will include: 

– For children with early language delay – individual or group parent training/advice in stimulation techniques. 

– Language delay at three to four years – increased support for parents and individual or group direct therapy; advice for nursery or children’s centre staff. 

– DLD – long-term and specialist SLT supervision; direct intervention with advisory programmes for school support staff; additional support from a specialist teacher; education and healthcare plan required for children with special educational needs.

– Children with speech problems need to be referred to SLT services as they require specialist therapy. 

In some parts of the UK, demand for SLT paediatric services is high. Parents can ask the SLT for advice on how to support their children while on a waiting list. Various websites provide helpful information (see ‘Resources’).

References

1. Reilly S, McKean C, Levickis P. Late talking: can it predict later language difficulties? Research Snapshot 2014 2
2. Snowling M, Bishop D, Stothard S et al. Psychosocial outcomes at 15 years of children with a preschool history of speech-language impairment. J Child Psychology & Psychiatry 2006;47:759-65
3. Law J, Todd L, Clark J et al. Early language delays in the UK. Save the Children; 2013
4. St Clair M, Pickles A, Durkin K et al. A longitudinal study of behavioral, emotional and social difficulties in individuals with a history of specific language impairment. J Communication Disorders 2011:44:186-99
5. Constantino J, Charman T. Diagnosis of autism spectrum disorder: reconciling the syndrome, its diverse origins and variation in expression. The Lancet Neurology 2016;15:279-91
6. Dodd B. Differential diagnosis and treatment of children with speech disorder. John Wiley & Sons; 2013
7. Yairi E. Ambrose N. Early childhood stuttering for clinicians by clinicians. Pro Ed; 2005
8. Hsu H, Fogel A, Messinger D. Infant non-distress vocalization during mother-infant face-to-face interaction: Factors associated with quantitative and qualitative differences. Infant Beh & Dev 2001;24:107-28
9. Cameron-Faulkner T, Theakston A, Lieven E et al. The relationship between infant holdout and gives and pointing. Infancy 2015 20:576-86
10. McGillion M, Herbert J, Pine J et al. Supporting early vocabulary development: What sort of responsiveness matters. IEEE Transactions on Autonomous Mental Development 2013;5:240-48
11. Bates E, Bretheron I, Snyder L. From first words to grammar: Individual differences and dissociable mechanisms. New York: Cambridge University Press; 1988
12. Rowe M. A longitudinal investigation of the role of quantity and quality of child-directed speech in vocabulary development. Child Development 2012;83:1762-74
13. Horst J, Parsons K, Bryan N. Get the story straight: contextual repetition promotes word learning from storybooks. Front Psychol 2011;2:10.3389/fpsyg.2011.00017
14. Hoff E, Naigles L. How children use input to acquire a lexicon. Child Dev 2002;73:418-33
15. Taumeopeau M. Maternal expansions of child language relate to growth in children’s vocabulary. Language Learning & Dev 2016;12:429-46
16. Huttenlocher J, Vasilyeva M, Cymerman E et al. Language input at home and at school: Relation to child syntax. Cognitive Psychology 2002;45:337-74

Resources