Expressive language delay ("late talking") in young children

INTRODUCTION — An overview of expressive language delay ("late talking") in young children is presented below. The etiology, evaluation, and treatment of speech and language disorders in children are discussed separately. (See "Etiology of speech and language disorders in children" and "Evaluation and treatment of speech and language disorders in children".)

OVERVIEW — The development of communication and language skills is one of the most important tasks of early childhood. It is the key to early learning and social skills, and to helping young children regulate their own behavior.

Primary care providers will see many infants and preschool-age children whose early expressive language development and communication skills do not appear to be progressing as expected ("late talkers"). Receptive language delays often coexist with expressive delays but may not be suspected by the clinician or caregivers until the child is older. (See 'Prevalence' below and 'Cautions' below.)

Some children with expressive language delay "catch up" during the preschool years ("late bloomers"), whereas others have persistent delay (see 'Natural history' below). Early evaluation can help to correctly identify late-talking children who will benefit from intervention and/or additional evaluation. The developmental, psychosocial, and family histories are particularly important. Most children with language delays have no associated medical or physical findings, but the absence of such findings should not delay referral for functional evaluation of suspected delay. (See 'Primary care evaluation' below.)

There is no universally accepted definition of "delay" in developmental conditions, and different definitions may be used for research and treatment purposes (see 'Definitions' below). Specific program eligibility requirements should not discourage clinicians from identifying children with delays, although they may affect how information about such conditions is communicated to caregivers. Even if the child does not qualify for services, awareness of a delay can lead to closer monitoring and provision of information to caregivers about ways to promote early language skills (see 'Prevention' below). All caregivers of late-talking children benefit from guidance and close monitoring of their child's early communication development. The provision of appropriate supportive services and accommodations can help children with language delay achieve their full developmental and academic potential. (See 'Management' below and 'Prognosis' below.)

DEFINITIONS

●Speech – The ability to produce vocal sounds.

●Expressive language – The ability to produce or use language.

●Receptive language – The ability to understand language.

●Gestural communication – The ability to communicate nonverbally (eg, by pointing; nodding or shaking the head; using and interpreting facial expressions; using and coordinating eye contact). Gestural communication is necessary for successful interpersonal interactions.

There is growing awareness of the importance of the development of nonverbal communication in the language and social development of young children. Absence of or delay in the development of nonverbal communication skills impacts the quality of overall communication development and can be a marker for more global delays and or atypical development, such as autism spectrum disorder [1]. (See "Autism spectrum disorder in children and adolescents: Clinical features", section on 'Impaired social communication and interaction'.)

●Language delay – There is no universally accepted definition of "delay" in developmental conditions. For research purposes, children often are considered delayed if their performance on a standardized assessment of language is at least one standard deviation (SD) below the mean for age.

The clinical threshold for concern (ie, "red flag") generally is the age at which 90 percent of typically developing children have attained a clinically predictive skill (eg, 12 months for the use of "mama," "dada," or "papa" to call a parent). Red flags for language delay are listed in the table (table 1).

Treatment programs, such as early intervention (for children birth to 36 months), and early childhood special education provided through the public school system (for children ≥3 years), may have more stringent eligibility criteria for children to qualify for services. The absence of a universal standard means that children may have a developmental condition without qualifying for services in some or even many communities or settings.

Examples of criteria that may be used in different states, communities, or treatment programs include [2,3]:

•Scores of 1, 1.5, or even 2 SD below the mean for age.

•A certain percentage (eg, 25 percent, 40 percent) of delay compared with chronologic age. The percentage delay = (1 - [DA/CA]) x 100 percent, where DA is the developmental age equivalent and CA is the chronologic age. As an example, an 18-month-old child who has language skills at a 12-month level is 33 percent delayed: [1 - (12/18)] x 100 percent.

•A specific amount of delay (eg, skills that are ≥1 year behind those expected for age).

EPIDEMIOLOGY

Prevalence — Approximately 10 to 15 percent of two-year-old children have language delay, but only 4 to 5 percent remain delayed after three years [4,5]. Approximately 6 to 8 percent of school-age children have specific language impairments (SLIs) [6,7].

These statistics indicate that a certain proportion of young children with language delay catch up during the preschool years but also that a certain proportion of school-age children with SLI were not identified before school entry.

Risk factors — Knowledge of risk factors for expressive language delay may improve surveillance and screening.

Risk factors for expressive language delay include [5,8-17]:

●Poverty

●Low parental educational attainment (ie, parent did not graduate from high school)

●Low birth weight or prematurity, including late-preterm (ie, 34 to 36 weeks) and early term gestations (ie, 37 to 38 weeks)

●Family history of language delays, language disorders, or language-based learning disabilities (eg, dyslexia)

●Screen time during first year of life

●Maternal depression

●Male sex

Males are somewhat more likely than females to have SLI at kindergarten entry (8 versus 6 percent of children, respectively) [6]. In addition, conditions that are associated with language delay (eg, autism spectrum disorder [ASD], global developmental delay/intellectual disability) are more common in males than females [18-20]. (See "Autism spectrum disorder (ASD) in children and adolescents: Terminology, epidemiology, and pathogenesis", section on 'Epidemiology' and "Intellectual disability in children: Evaluation for a cause", section on 'Epidemiology'.)

The identification of risk factors such as poverty, low parental educational attainment, and/or maternal depression may be helpful in addressing the global needs of the child and family, as well as the need for enrichment of the early learning environment (eg, through early intervention services). (See 'Referral options' below.)

ETIOLOGY — There are two core aspects of diagnosis for children with expressive language delay: the functional level and the cause/etiology. It is important to consider both aspects because they may have implications for treatment and eligibility for services. Community and educational programs, such as early intervention or early childhood special education, provide services based upon a child's developmental level or degree of delay (see 'Definitions' above). They also provide services to children who have certain diagnoses (eg, Down syndrome, ASD).

Developmental and behavioral conditions — Developmental and behavioral conditions that involve expressive language delay are listed in the table (table 2). These diagnoses are made on the basis of patterns of delay or behavior.

Other diagnoses and contributing factors — A large number of medical, neurologic, metabolic, genetic, and environmental conditions can cause or contribute to early language delays, particularly in the context of a more global developmental condition. Selected conditions that may cause or contribute to early expressive language delay are listed in the table (table 3). For most children with isolated expressive language delays, a specific etiology beyond socioeconomic risk factors, maturational issues, or family history may not be found.

Invalid explanations — Clinicians should be wary of the rationalizations listed below as explanations for language delay in a young child [4,21,22]. Further evaluation or referral should not be delayed on the basis of these rationalizations.

●"He's a boy, and boys talk later than girls." A variant of this rationalization is: "His father and uncle didn't talk until they turned three, and they turned out fine."

This rationalization is invalid because speech and language milestones develop at a similar rate in males and females before three years of age. Males actually are at increased risk for developmental conditions associated with language delays compared with females, given the higher prevalence of ASD and global delays/cognitive impairments in males. Male family members with early language delays might have benefited from evaluation and intervention if they had been available at the time.

●"She is growing up in a bilingual home."

Bilingual exposure and confusion about language generally does not explain a frank delay in language development in early childhood. When assessing the language skills of children who are exposed to two languages, clinicians should ask about the child's most complex skills in both languages. The amount and quality of exposure to each language may affect the rate of skill acquisition [21,23,24]. Additional information about language development in bilingual children is available through the American Speech-Language-Hearing Association and the Foundation for Child Development.

●"His older brother talks for him." A variant of this rationalization is: "I meet all of his needs as his parent; he doesn't need to talk to get what he wants."

This rationalization is invalid because young children are naturally driven to communicate, not merely to get their needs met, but for social interaction, which typically developing children seek from the time they are infants. The absence of a drive to communicate and engage others is a red flag for developmental delays and/or conditions involving impairment in reciprocal social interaction (eg, ASD). (See "Autism spectrum disorder in children and adolescents: Clinical features", section on 'Impaired social communication and interaction'.)

●"He is not saying much, but he understands everything."

While this may indeed be the case, clinicians should have a high index of suspicion for a receptive language delay in young children with expressive language delays. (See 'Cautions' below.)

●"He talks fine at home, but his teacher at child care says he doesn't talk at all there, even though he doesn't mind going and has been going there for six months."

Before this explanation is accepted, selective mutism, an anxiety disorder, must be considered. Children with selective mutism speak only in familiar settings, often only with a few close family members. Although overall language development may be normal, children with selective mutism are difficult to assess. They require intervention/therapy to address anxiety, which impacts their social-emotional and overall development. (See "Anxiety disorders in children and adolescents: Epidemiology, pathogenesis, clinical manifestations, and course", section on 'Selective mutism' and "Anxiety disorders in children and adolescents: Assessment and diagnosis" and "Psychotherapy for anxiety disorders in children and adolescents".)

If a child with selective mutism is spending a significant part of the day not speaking (eg, in a child care program or in school), the child may also be at risk for developing an expressive language delay due to limited language practice.

CLINICAL PRESENTATION — Children with expressive language delay may present with delayed language milestones or behavioral problems.

Normal language milestones are provided in the table (table 4). Although there is no universally accepted definition for language delay, the clinical threshold for concern (ie, "red flag") generally is the age at which 90 percent of typically developing children have attained a clinically predictive skill (eg, 12 months for the use of "mama," "dada," or "papa" to call a parent). Red flags for language delay are listed in the table (table 1). Additional evaluation and/or referral may be warranted for children with red flags for language delay. (See 'Primary care evaluation' below and 'Approach to referral' below.)

Children with language delays may present with behavioral issues [25,26]. Caregivers may not recognize their child's language delay but generally are keenly aware of temper tantrums and other behavioral self-regulation difficulties. For this reason, the language development of toddlers and preschool children whose caregivers raise behavioral concerns should be monitored closely.

Children with speech delays may present with associated concerns about feeding, chewing/swallowing, or prolonged drooling beyond infancy. Children with dysarthria associated with cerebral palsy or apraxia of speech may also have expressive language delays, but it may be difficult to assess their expressive language abilities due to difficulty understanding their speech articulation. (See "Etiology of speech and language disorders in children", section on 'Apraxia' and "Cerebral palsy: Classification and clinical features", section on 'Speech impairment'.)

NATURAL HISTORY — A significant percentage (as many as 60 percent) of children with isolated early expressive language delays appear to spontaneously "catch up" in their language milestones between age two and three years [27]. However, early language delays may be an important marker for future language-based learning differences and difficulties, which may be accompanied by neuropsychiatric difficulties [28-34]. (See "Reading difficulty in children: Normal reading development and etiology of reading difficulty", section on 'Risk factors'.)

Cautions — It is not possible to accurately predict, at the time of identification, which children with isolated expressive language delays will catch up without special services and which will have persistent language problems [4,21,27]. Historically, the majority of children with language delays and disorders have not been identified before school entry [35-37].

Accurate prediction of persistent language difficulties is hampered by the difficulty in identifying coexistent receptive language delay, which is associated with increased risk of persistent language problems (see 'Prognosis' below). Receptive language delay may not be suspected by the clinician (or caregiver). Primary care clinicians may not objectively screen for receptive language skills, which are difficult to assess subjectively. Caregivers may report that the child responds to directions in the context of daily routines, but the child actually may be responding to the routine or caregiver gestures or eye gaze.

PRIMARY CARE EVALUATION

Surveillance — Developmental surveillance consists of ongoing, longitudinal attention to young children's development, including the eliciting of caregiver concerns, taking a developmental history of milestone acquisition, knowledge of the family and caregiving environment, observations of the child, and information from the physical examination [38]. (See "Developmental-behavioral surveillance and screening in primary care", section on 'Approach to surveillance'.)

Routine developmental surveillance may identify risk factors for or caregiver concerns about language delay. Concerns raised during routine surveillance should prompt further action, which might include:

●Developmental screening within the primary care practice using a validated screening tool, or

●Referral for further evaluation through community-based organizations (eg, early intervention if the child is <3 years of age [in the United States]), evaluation within the medical system (eg, developmental-behavioral pediatrics, neurodevelopmental disabilities, neurology), or evaluation by a specific therapist (eg, speech and language pathologist). (See 'Referral options' below.)

The specific action that is taken may depend on the availability of resources in the clinician's community.

Screening — Language screening is suggested for preschool age children in the context of formal developmental screening and autism screening as recommended by the American Academy of Pediatrics (AAP). Language-specific screening is indicated if general developmental or autism screening raises concerns for language delay or disorder or if the caregiver or clinician has concerns about the child's language development.

A 2015 systematic review found the following caregiver-report language-specific screens to be appropriate for use in primary care [39]:

●Infant-Toddler Checklist – Sensitivity 89 percent (95% CI 80-97) and specificity 74 percent (95% CI 66-83) at 12 to 17 months; sensitivity 86 percent (95% CI 75-96) and specificity 77 percent (95% CI 64-90) at 18 to 24 months [40]

●Language Development Survey – Median sensitivity 91 percent and specificity 86 percent at 24 to 34 months of age (based on three studies) [41-43]

●MacArthur-Bates Communicative Development Inventory – Median sensitivity 82 percent and median specificity 86 percent at 18 to 62 months based on five studies (four assessed the toddler version [18 to 36 months], one assessed the preschool version [36 to 62 months]) [44-48]

Language-specific evaluation measures that require direct observation or direct observation in addition to caregiver-report and can be used in the primary care setting (but were not assessed in the 2015 systematic review) include [21]:

●The Early Language Milestone, second edition (for children from birth to three years) [49]

●The Clinical Adaptive Test/Clinical Linguistic and Auditory Milestone Scale, for children 3 to 36 months of age [50,51]

The AAP recommends formal general developmental screening using a validated screening tool at 9, 18, and 24 or 30 months and autism-specific screening at the 18- and 24-month visits as part of routine well-child care [52,53]. Formal screening is also recommended whenever the caregiver or clinician has a developmental concern about the child. (See "Autism spectrum disorder in children and adolescents: Surveillance and screening in primary care", section on 'Approach to ASD surveillance and screening' and "Developmental-behavioral surveillance and screening in primary care", section on 'Approach to screening'.)

The United States Preventive Services Task Force determined that there is insufficient evidence to recommend for or against the routine use of brief, formal screening tools to detect speech and language delays in asymptomatic children up to five years of age [54].

History — Important aspects of the history in the child with an expressive language delay include [4,22]:

●Caregiver concerns about hearing, speech and/or language development, or social development.

●Risk factors for hearing loss.

●Prenatal exposures and prenatal or perinatal complications.

●Developmental and adaptive skills, including loss of developmental skills.

●Parents' and siblings' level of educational attainment.

●Parental symptoms of depression or diagnosed depression, as well as parent or family isolation, particularly during the COVID-19 pandemic.

●Play and social interaction skills.

●Family history of language delays, learning issues, childhood hearing loss, or school failure.

●The linguistic environment (ie, the quantity and quality of exposure to language in the home and other settings in which the child spends significant time).

●The child's use of language: It is important to elicit information from the caregivers on the ways in which language is used (eg, to communicate needs, share enjoyment, express ideas, or mainly to label objects; use of language mainly to label objects may be a feature of autism spectrum disorder).

Physical examination — The physical examination may disclose clues to the underlying etiology of expressive language delay. Particular attention should be paid to:

●Weight, length, and head circumference (and growth trajectories) – Abnormal growth parameters may be clues to a genetic or global condition (eg, acquired microcephaly in Rett syndrome or tall stature in Klinefelter syndrome) or socioeconomic concerns (eg, poverty). (See "Normal growth patterns in infants and prepubertal children", section on 'Abnormal patterns of growth' and "Microcephaly in infants and children: Etiology and evaluation" and "Macrocephaly in infants and children: Etiology and evaluation".)

●General appearance, looking for dysmorphic features and minor malformations (eg, transverse palmar crease, clinodactyly) that may suggest a genetic syndrome or intrauterine infection. (See "Congenital anomalies: Epidemiology, types, and patterns", section on 'Patterns'.)

●Social interaction (eg, eye contact, pointing to objects, use of joint attention [looking back and forth between another person and an object, to share enjoyment]). (See "Autism spectrum disorder in children and adolescents: Clinical features".)

●The ear – Abnormalities of the external ear may be a clue to hearing loss; tympanic membrane scarring (picture 1) may indicate chronic or persistent otitis media (with associated conductive hearing loss). (See "Congenital anomalies of the ear", section on 'Outer ear malformations' and "Hearing loss in children: Etiology" and "Otitis media with effusion (serous otitis media) in children: Clinical features and diagnosis", section on 'Hearing loss'.)

●The mouth and oral motor examination – Is the palate intact or could there be a submucous cleft? Is the uvula bifid? Does the tongue have normal mobility? What is the condition of the teeth? Is there drooling? Can the child purse and smack the lips? Thrust, click, extend, and wiggle the tongue? Puff the cheeks? Shout and whisper [55]? Asking the child to repeat sounds like "pa, ta, ka" will help to identify children with abnormal speech and dyspraxic oral motor function.

●The neurologic examination – Abnormal muscle tone, strength, or reflexes may be a clue to a neurologic condition. (See "Detailed neurologic assessment of infants and children", section on 'Neurologic examination'.)

●The skin examination – Abnormal pigmentation may indicate a neurocutaneous disorder (eg, café-au-lait macules in neurofibromatosis or hypopigmented macules in tuberous sclerosis complex). Specific patterns or locations of bruising or scars may suggest physical abuse. (See "The genodermatoses: An overview", section on 'Neurocutaneous syndromes' and "Physical child abuse: Recognition", section on 'Inflicted bruises'.)

Hearing test — All children with suspected language delay should be referred for a hearing test by an audiologist. Children younger than three or four years typically cannot be adequately screened for hearing impairment in the primary care office in cases where a language delay is suspected [4]. (See "Hearing loss in children: Screening and evaluation", section on 'Formal audiology'.)

Formal audiologic evaluation should be performed even if the child passed their newborn hearing screen or a hearing screen in the primary care office [56]. Newborn hearing screening does not identify hearing loss that was acquired after the newborn period (eg, secondary to ototoxic medications). Office hearing screening may not identify complex patterns of hearing loss (eg, at specific frequencies that are necessary for normal speech and language development). (See "Screening the newborn for hearing loss" and "Screening tests in children and adolescents", section on 'Infants and children' and "Hearing loss in children: Screening and evaluation", section on 'Screening for hearing loss in children'.)

Laboratory tests — Depending upon the findings from the history and examination, laboratory tests that may be warranted in a child with expressive language delay include:

●A complete blood count to exclude anemia (this may already have been performed as part of routine care). Iron deficiency is associated with impaired development in young children. (See "Iron deficiency in infants and children <12 years: Screening, prevention, clinical manifestations, and diagnosis", section on 'Associated disorders and effects of treatment'.)

●Venous blood lead level, particularly if child mouths objects or lives in older housing (this may already have been performed as part of routine care). (See "Childhood lead poisoning: Clinical manifestations and diagnosis", section on 'Neurologic'.)

●Genetic tests (eg, chromosomal microarray analysis, DNA test for fragile X syndrome, and others) generally are not ordered by primary care clinicians without guidance from a specialist. However, they often are recommended for children with language delays that are part of a more generalized condition, such as a global developmental delay or autism spectrum disorder. (See "Intellectual disability in children: Evaluation for a cause", section on 'Approach to diagnostic testing' and "Autism spectrum disorder in children and adolescents: Evaluation and diagnosis", section on 'Genetic testing'.)

DIFFERENTIAL DIAGNOSIS — Depending on the child's presentation and other areas of delay or concern (eg, social interaction, fine motor), the major considerations in the differential diagnosis of expressive language delay are isolated language delay, language delay as part of a more general developmental condition, hearing impairment, and poor linguistic environment. These conditions usually can be distinguished through developmental and behavioral history and physical examination, as described above [4,21]. (See 'Primary care evaluation' above.)

●Isolated language delay – Isolated language delay encompasses expressive language delay with or without receptive language delay. There are two main categories:

•Delayed language developmental milestones (expressive, receptive, or mixed) – Delayed developmental language milestones is a diagnosis made in younger children who are in the early developmental period. These delayed milestones may resolve in some children; in other children they may progress to a more specific diagnosis at the age of school entry. Some see this as a diagnosis that can only be made definitively in retrospect [4]. However, making the functional diagnosis allows children to receive treatment services while other causes of language delay are being evaluated.

•Specific language impairment (expressive, receptive, or mixed; also called primary language impairment or language disorder [before school age]) – Specific language impairment occurs without other developmental abnormalities (delays or disorders) [22]. Clinical manifestations of specific language impairment are variable and may include a combination of impairments in producing sounds, using words or understanding what words mean, sentence structure, and using language for social interaction [22]. Specific language impairment should be considered when language skills are delayed more than other abilities. Failure to meet language milestones at or after age two years is associated with specific language impairment [57].

●Expressive language delay as part of a more general developmental condition – Examples include:

•Globally delayed developmental milestones/intellectual disability; in addition to language delay, children with globally delayed developmental milestones/intellectual disability have abnormalities in other streams of development (eg, visual-motor problem solving, adaptive skills) and may have abnormalities in nonverbal communication (eg, lack of eye contact); normal receptive language skills help to exclude global developmental delay [4,22] (see "Intellectual disability (ID) in children: Clinical features, evaluation, and diagnosis", section on 'Clinical features')

•Autism spectrum disorder (ASD); in addition to possible language delay, children with ASD have abnormalities in social communication (eg, lack of eye contact, lack of pointing) and restricted and repetitive behaviors [22] (see "Autism spectrum disorder in children and adolescents: Clinical features", section on 'Terminology')

•Selective mutism/anxiety; children with selective mutism speak normally in familiar settings with close individuals

•Speech sound disorder or phonologic disorder, in which children have difficulty producing developmentally appropriate sounds of speech (figure 1) (see "Etiology of speech and language disorders in children", section on 'Speech disorders')

•Apraxia of speech (impairment in the ability to program the speech musculature to select, plan, organize, and initiate a motor pattern) (see "Etiology of speech and language disorders in children", section on 'Apraxia')

•Dysarthria in association with cerebral palsy; abnormal function of oropharyngeal muscles may contribute to speech problems in children with cerebral palsy; normal gross and fine motor skills are helpful in excluding cerebral palsy [4] (see "Cerebral palsy: Classification and clinical features", section on 'Speech impairment')

•Stuttering (see "Etiology of speech and language disorders in children", section on 'Fluency disorders')

●Hearing impairment – Hearing impairment may be suspected based upon the pattern of the child's understanding and production of speech. Children with moderate or severe hearing loss typically have difficulty hearing and producing sounds with high frequency and low energy (eg, "f," "s," "th") [21]. Children with hearing impairment usually have normal visual language development (eg, eye contact) and social interaction skills. Normal receptive language skills generally exclude significant hearing loss but cannot exclude subtle hearing impairment. Children with language delay should undergo objective hearing evaluation by an audiologist. (See "Hearing loss in children: Screening and evaluation", section on 'Formal audiology'.)

●Poor linguistic environment – The size of a child's vocabulary and the maturity of their grammar are associated with the quality and quantity of caregiver input [21]. A number of factors may contribute to a poor linguistic environment (eg, low parental educational attainment, child neglect or abuse, maternal depression). A thorough social history generally identifies factors that may contribute to a poor linguistic environment.

MANAGEMENT — The management for language delays is multimodal and depends upon:

●The child's age

●Child and family risk factors

●Findings from the physical examination and hearing test

●The availability of treatment resources in a given community

●The eligibility criteria of different services and agencies

Referral options — Referral options for young children with expressive language delay may include:

●Early intervention services (for children from birth through 36 months of age)

●Early childhood special education services (for children ≥36 months of age) and special education services (for children beginning in kindergarten)

●Speech and language therapy

●Medical specialist (developmental-behavioral pediatrician, neurodevelopmental disabilities, or neurologist)

●General support services

In the United States, the early intervention (EI) program is mandated to provide an initial evaluation for children younger than 36 months of age who are referred for developmental concerns. Ongoing EI services are provided for children who meet eligibility criteria (through Part C of the Individuals with Disabilities Education Act). The percentage of children who are served by EI varies widely by state (range 1.3 to 7.5; mean 2.4) [2,58]. (See "Definitions of specific learning disorder and laws pertaining to learning disorders in the United States", section on 'Individuals with Disabilities Education Act'.)

Children 36 months of age or older who require evaluation and/or who have diagnosed delayed language developmental milestones or language disorder may be referred for early childhood special education or special education evaluation and services through the local public school district. These services are provided through Part B of the Individuals with Disabilities Education Act [3]. (See "Definitions of specific learning disorder and laws pertaining to learning disorders in the United States", section on 'Individuals with Disabilities Education Act'.)

Children of any age who are suspected of having a significant language delay or who have been diagnosed with delayed language developmental milestones or language disorder may be referred for speech and language therapy. Speech and language therapy services may be provided independently and/or within the context of an EI or special education program. Speech and language therapy services may be covered by the child's medical insurance. Meta-analyses of randomized controlled trials indicate that compared with no therapy, speech therapy is effective for children with phonologic difficulties (standardized mean difference [SMD] 0.44, 95% CI 0.01-0.86) or expressive vocabulary difficulties (SMD 0.89, 95% CI 0.21-1.56) [59,60]. Longer duration of therapy (>8 weeks) was associated with greater improvement.

Referral to a medical specialist (eg, developmental-behavioral pediatrics, neurodevelopmental disabilities, child neurology, medical genetics) may be warranted if the child has clinical findings compatible with a specific disorder (eg, specific language impairment, autism spectrum disorder, verbal apraxia) (table 2 and table 3).

General types of services for low-income families and/or families that would benefit from parenting support include:

●Parent training activities through community-based parenting centers.

●High-quality child care (eg, licensed group child care or preschool program, rather than home child care or kinship care).

●Head Start and Early Head Start. Head Start programs serve families based on low family income. However, Head Start programs also are mandated to serve children with developmental delays, who must account for 10 percent of the children served.

Approach to referral — The indications for referral to an EI program, speech and language therapist, or medical specialist depend to some extent upon the mode of identification and the level of concern of the clinician and/or caregivers.

It is not possible to distinguish, at the time of identification, the child who will continue to have language difficulties and for whom intervention would be beneficial from the child with a maturational delay for whom treatment might be unnecessary [4]. Thus, the clinician must balance the provision of reassurance with the provision of information about expected language milestones and the availability of evaluation and treatment services, if needed.

●We recommend that children with expressive language delay that is part of a more general developmental condition (eg, autism, Down syndrome) be referred to the appropriate medical specialist for additional evaluation and management.

●We recommend that children with suspected language delay who are identified through surveillance or screening (ie, children who have red flags for language delay (table 1)) be promptly referred for intervention. Referral options are discussed above (see 'Referral options' above). Such children also should be referred for additional evaluation as indicated by the initial evaluation (eg, neurologist, geneticist).

The "watch and wait" approach, which has traditionally been adopted by some primary care providers for children with isolated early language delay, contributes to delayed identification and intervention for children with persistently delayed language developmental milestones [61]. Given the critical importance of early brain development and benefits of early (as opposed to later) intervention in affecting neural pathways [4,62], providing early referral to families of young children with suspected developmental delays is strongly recommended.

●When the caregiver is concerned about language delay, we suggest that the child be referred for further screening and/or evaluation of the child's language development, even if the clinician is not concerned. Caregiver concerns are a reliable source of information about the child's development, and reassurance should not be provided without additional screening or evaluation [44,63]. Referral options are discussed above. (See 'Referral options' above.)

●When the clinician is concerned about language delay, but the caregiver is not, communication skills and general development should be closely monitored. The child should return for developmental screening sooner than the next scheduled routine well-child visit. This is particularly important for children who are older than two years; waiting until the three-year-old well-child visit may lead to missed opportunities for early intervention.

●Communication skills and general development also should be closely monitored when the clinician is uncertain of whether the child has a language delay.

Role of primary care provider — Primary care providers and the medical home play a critical role for families of children undergoing evaluation and/or treatment for expressive language delay.

The primary care provider's review of reports of diagnostic assessments (from medical specialists, early intervention, speech-language pathologist) can help to reinforce the family's understanding of the diagnosis or level of delays and treatment options.

The primary care provider also provides follow-up and care coordination, which are crucial to the success of treatment intervention [4]. In addition, the primary care provider can monitor for potential long-term sequelae of early language delay (eg, academic failure or underachievement, neuropsychiatric disorders). (See 'Natural history' above.)

PROGNOSIS — The prognosis for expressive language delay depends upon the underlying etiology. Children with speech and language problems that persist beyond five years of age may continue to have difficulty into adulthood [34]. Being born very low birth weight (<1500 g) or very preterm (gestational age <32 weeks) is associated with persistent language delay. In a meta-analysis of observational studies, children born very low birth weight and very preterm had lower expressive language, receptive language, and total language scores at age five to nine years than peers who were born full-term [15].

It is not possible to predict the course of early language delay at the time of identification in an individual child [4,21,27,64]. However, in longitudinal studies, factors that have been associated with resolution during the preschool years include [65-70]:

●Isolated speech/language problem (ie, normal developmental milestones in other domains)

●Average to above-average intelligence

●No receptive language difficulties

●Normal nonverbal skills and gestural communication

●Capacity for symbolic thinking (eg, playing with dolls)

Isolated expressive language delay does not appear to be a risk for behavioral and emotional disturbances during school-age or adolescence [71].

PREVENTION — Caregivers can enhance or promote their child's language development by providing "language nutrition" [72], specifically a "language-rich" environment that includes caregiver warmth and responsiveness to children's communication signals, increasing the quantity and quality of language spoken to the child, and caregiver-child interactions and/or routines that promote engagement with symbols, words, and books [73,74]. Examples include [5,22]:

●Reading aloud to the child (increases the amount and diversity of language) [75-78]

●Providing exposure to advanced or unusual words; this is readily done by sharing books

●Engaging in dialogic reading, a style of book-sharing in which caregivers encourage toddlers and preschool-age children to comment on pictures and the story to engage the child and promote conversation [79]

●Narrating daily activities, in which the caregiver talks aloud to the child as they are going through the day, explaining what they are doing and commenting to the child (eg, "Now I'm washing the dishes. I'll start with your bowl.")

●Listening to the child and responding to the child's conversational lead, repeating and expanding on the child's conversational output [4,80-82]

●Limiting or reducing media exposure (including play with electronic toys) [83-86]

●Asking questions and having the child indicate a choice in response

●Accompanying words with gestures to make them more understandable

In a systematic review of 59 randomized and 17 nonrandomized clinical trials in 5848 children <6 years of age who had or were at risk for language impairment, caregiver-implemented interventions (eg, naturalistic responding to child communication, asking questions and having discussions while reading with the child) were moderately associated with improved child communication, engagement, and language outcomes [87].

RESOURCES — A list of resources for caregivers and clinicians related to language delay or language disorders is provided in the table (table 5).

SUMMARY AND RECOMMENDATIONS

●Language development is the key to early learning and social skills. Early and appropriate intervention for expressive language delay can help children achieve their full developmental and academic potential. (See 'Overview' above.)

●There is no universally accepted definition of "delay" in developmental conditions. The clinical threshold for concern generally is the age at which 90 percent of typically developing children have attained a clinically predictive skill (table 1). (See 'Definitions' above.)

●Risk factors for expressive language delay include poverty; parents who did not graduate from high school; prematurity or low birth weight, including late-preterm (ie, 34 to 36 weeks) and early term gestations (ie, 37 to 38 weeks); family history of language delays, language disorders, or language-based learning disabilities; maternal depression; and male sex. (See 'Risk factors' above.)

●Expressive language delay has a wide range of causes and contributing factors (table 2 and table 3). (See 'Developmental and behavioral conditions' above and 'Other diagnoses and contributing factors' above.)

●Explanations for expressive language delay that should not allay concern or delay evaluation/intervention include male sex; bilingual household; older siblings; apparent normal receptive language skills; or use of expressive language in the home, but not at child care. (See 'Invalid explanations' above.)

●As many as 60 percent of children with isolated early expressive language delays appear to spontaneously "catch up" in their language milestones between age two and three years. However, early language delays may be an important marker for future language-based learning differences and difficulties. It is not possible to accurately predict, at the time of identification, which children will catch up without special services and which will have persistent language problems. (See 'Natural history' above and 'Cautions' above.)

●Surveillance and screening for language delay should occur as part of routine well-child care. (See 'Surveillance' above and 'Screening' above.)

●The history and physical examination of the child with suspected language delay should focus on identification of risk factors, contributing factors, and disorders that are associated with language delay (table 2 and table 3). (See 'History' above and 'Physical examination' above.)

●Young children with expressive language delay should be referred to an audiologist for a comprehensive hearing evaluation. The laboratory evaluation should include a complete blood count and blood lead level. Genetic testing may be warranted in children who have language delay as part of a more general neurodevelopmental condition. (See 'Hearing test' above and 'Laboratory tests' above.)

●The differential diagnosis of expressive language delay includes isolated language delay; language delay as part of a more general developmental condition; hearing impairment; and a poor linguistic environment. These disorders usually can be distinguished through developmental and behavioral history and physical examination. (See 'Differential diagnosis' above.)

●The indications for referral to an early intervention program, speech and language therapist, medical specialist, or general support services depend upon the mode of identification and the level of concern of the clinician and/or caregivers. Children with suspected language delay who are identified through surveillance or screening should be promptly referred for evaluation and intervention. Referral for further screening and/or evaluation of language development is also warranted if the caregiver is concerned about language delay (even if the clinician is not). Communication skills and general development should be closely monitored if the clinician is uncertain of whether the child has an expressive language delay or if the clinician is concerned about language delay but the caregiver is not. (See 'Approach to referral' above.)

●Caregivers can enhance or promote their child's language development by reading aloud to the child and encouraging the child to comment on pictures or the story; narrating daily activities; listening to the child and responding to their conversational lead; limiting television and media exposure; asking a lot of questions; and accompanying words with gestures to make them more understandable. (See 'Prevention' above.)