More Than Words: Does My Toddler Need Speech Therapy?
Every week I hear from parents with a specific set of concerns. Almost predictably the tots in question are 15-17 months old. The parents are looking forward to the epic 18-month well visit and wondering whether their child is on target. This happens even more with parents of multiples who are anticipating all the possible challenges of sharing a womb, being born early, and being made to suffer parents with divided attention (Gasp! For those of you that don't know, I have twins myself and I'm fairly certain they will make it to adulthood unscathed despite sometimes being ignored in lieu of my other two children).
It’s nearly always fine. But the story goes something like this:
“Hi. I am worried about my twins and was hoping you could help me. My daughter has a few words but maybe only 4 or 5. She says mama for sure. And probably dog, daddy (those are hard to distinguish) and ball. My son says mama sometimes but isn’t interested in repeating anything I say. They just turned 15 months. They also use a few signs. Is that going to stop them from learning spoken words? I’d appreciate any advice you have.”
Sound familiar? If you have a toddler this age I bet you’ve been stealthily counting words. Or perhaps you are open about your paranoia and have a list on the refrigerator. Mine was in a note file on my phone. Either way, there are few things that raise a parent’s heart rate like the fear that their child may not be talking on time. Nowadays most states have programs in place for young children who need a little extra help and research shows that early intervention is very effective. But how do you know if your child is behind?
There is great variability in the rate of vocabulary development before the age of two. Most children experience a vocabulary burst around 16-18 months that takes them from the handful of early words to a much larger set quite rapidly. But how many should we see in general? Research tells us that on average:
- 12 month olds have 2-6 words (other than mama and dada)
- 15 month olds have 10
- 18 month olds have 50
- 24 month olds have 200-300 words.
While its helpful to have that data, those averages can cause parents to worry unnecessarily. If half of children have at least 50 words at 18 months that means half do not. We want to get children into therapy as early as possible but without providing therapy to kids who are just late bloomers. So what we really need to figure out is the cut-off at which kids are more likely to need support. This cut-off varies quite a lot depending on who you ask but in my experience many doctors take a more relaxed view than is recommended by the literature. It makes me cranky to hear pediatricians using 5-10 words as an indicator of good communication development at 18 months (this is the most common range I hear from parents). First, that is significantly below the average. Second, there are more accurate predictors of robust communication development which are not always addressed in the doctor’s office. Third, we know that early intervention is key. If we take a “wait and see” approach for children with 5 words at 18 months we may not get some of them into therapy until well after their second birthday – registration and evaluation processes for early intervention take time. That is all to say that I think it’s much safer to have a more stringent vocabulary expectation to prevent kids from slipping through the cracks. An evaluation may show that a child is doing just fine. But in my opinion it’s much better to be safe than sorry.
If a child has fewer than 20 words at 18 months (adjusted if needed for prematurity), I want to know why. It's not a certain indicator of a speech and language delay, but its a signal that we need to explore other markers of communication to determine if that child’s overall speech and language skills are progressing normally. That means asking questions about family history, play skills, and how well the child understands his or her world. I’ll list some useful ones below. If you are on the fence about whether your toddler needs speech therapy or is just a late talker, ask yourself these questions:
Does it feel like your toddler is connected with you and likes to share experiences with you?
Does he make frequent and sustained eye contact with you?
Does your child look between you and an object pointedly as if to say, “Hey mom! It’s a ball!”?
Does your child look at you when something surprising or startling happens to check your reaction?
Can you recognize a range of emotions on your child’s face? Sad, mad, surprised, happy, puzzled? Does he or she seem to recognize those emotions on your face?
Can you play games with your toddler where he anticipates what you are going to do next and gets excited about it? Think tickle monster, peek-a-boo, here comes mommy…
Does your child respond to her name, the word no, and look at the speaker when spoken to?
Does your child follow familiar single-step directions? Go get your shoes. Throw it in the trash. Go find daddy.
Does your child understand the use of household items? Holding your phone to her ear, pretending to stir or scoop with a spoon, stacking blocks, rolling a car?
Does your child seem to understand familiar routines? For instance, if you always read a book after bath does he automatically go to the bookshelf to get one without being told?
Does your child clap, point, wave bye-bye, and hand you items?
Does your child babble with a variety of consonants and use jargon that sounds like conversation even though it’s mostly nonsense?
When your child is upset do you know how to help her calm down?
Can you usually tell what your child wants or needs?
Is there a history of ear infections or a family history of speech or language disorders?
If after thinking about those questions you feel more confident that your child is developing good foundations for communication, it’s likely words will be on their way soon. However, if these left you more concerned about your child’s communication development then it’s a good idea to follow up with a speech-language pathologist. Words are just the tip of the iceberg when it comes to communication and relying on vocabulary counts as the main marker of communicative competence can be extremely misleading. Follow your gut and know that there are people to support you and your child should the need arise!
References:
Lanza, J.R. & Flahive, L.K. (2008). Linguisystems Guide to Communication Milestones. Moline, IL: Linguisystems.
Paul, R. (2012). Language Disorders from Infancy Through Adolescence (4th edition). St. Louis: Elsevier Health.
