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Age-Appropriate Speech and Language Milestones

The ability to hear is essential for proper speech and language development. Hearing problems may be suspected in children who are not responding to sounds or who are not developing their language skills appropriately. The following are some age-related guidelines that may help to decide if your child is experiencing hearing problems.

It's important to remember that not every child is the same. Children reach milestones at different ages. Talk your child's healthcare provider if you are suspicious that your child is not developing speech and language skills correctly. The National Institute on Deafness and Other Communication Disorders and other experts list the following age-appropriate speech and language milestones for babies and young children.

Milestones related to speech and language

Related links.

• Speech-Language Pathology
• Voice and Swallow Program
• Pediatric Otolaryngology/Head and Neck Surgery (ENT)
• What Is Airway Reconstruction?
• Stanford Medicine Children’s Health Pediatrics – Monterey
• Bass Center for Childhood Cancer and Blood Diseases
• Children's Orthopedic and Sports Medicine Center

Related Topics

Age-Appropriate Speech and Hearing Milestones

Hearing Problems and Speech and Language Milestones

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What Is Speech Therapy?

If your child needs speech therapy, you're not alone. Here's everything you need to know about speech therapy for kids and toddlers.

How Does Speech Therapy Work?

What does speech therapy treat, signs a child may need speech therapy.

• What is Early Intervention Speech Therapy?
• Speech Therapy for Toddlers

Speech Therapy for Elementary-Aged Kids

What about private speech therapy, what age is best to start speech therapy, how parents can refer their child for speech therapy, does insurance cover speech therapy, how long will my child be in speech therapy, how effective is speech therapy.

Prostock-Studio / Getty Images

If your child is currently in speech therapy or you're wondering if they might be a candidate for it, you're not alone. According to the American Speech-Language Hearing Association (ASHA), almost 8% of children in the United States have a communication or swallowing disorder. It doesn't mean you've done anything wrong, but it can be tough for families. The good news is speech therapy can make a difference.

So, what is speech therapy and how can it help? Here’s everything you need to know. 

Speech therapy is the treatment of communication, voice, and feeding/swallowing disorders by a trained professional.

Speech-language pathologists (SLPs) have a master's degree in speech-language pathology and specialize in evaluating, diagnosing, treating, and preventing these disorders. SLPs hold a license to practice in their state. 

You may also come across ASHA-certified SLPs. They have taken an additional step to pass a national exam and complete an ASHA-accredited supervised clinical fellowship.

There are various reasons a child may need speech therapy. Common ones include:  

1. Speech sound disorders. This means a child has difficulty with the production of speech sounds and how we combine them into words.

2. Language disorders. A child will have difficulty understanding and/or using language to communicate. Language disorders may impact vocabulary development, grammar, as well as the ability to tell a story, follow directions, answer questions, and more.

3. Social communication disorder/pragmatic language disorder . In this case, a child will have difficulty using language to socialize. This may include difficulty understanding social cues, taking turns during conversation, initiating or maintaining a conversation, and understanding personal space. A social communication disorder often leads to difficulty forming friendships. Children with these language barriers may have a concurrent diagnosis of autism spectrum disorder .

4. Cognitive - communication disorder . This includes difficulty with memory, reasoning, problem solving, and organization, impacting the ability to communicate.

5. Voice disorder . Children will have differences in voice quality (e.g., being too hoarse or too nasal).

6. Fluency disorder/stuttering . Kids will have difficulty maintaining a smooth flow of speech. A fluency disorder may include repetitions of sounds within words, prolongations of parts of words, and/or pauses in speech.

7. Feeding/swallowing disorder . This presents as a difficulty with sucking, chewing, and/or swallowing food or liquid.

Children may need speech therapy when they have not acquired speech/language milestones by an expected age. While milestones can vary from child to child, parents should refer their child for an evaluation if they have any concerns. Evaluation, which may include both standardized and non-standardized testing as well as observation, can help diagnose a speech/language disorder.

Some signs that may indicate a need for speech therapy include:

• A child isn't babbling by 6-7 months
• The child is having difficulty with feeding and/or swallowing
• A child beyond the age of 1 has no words
• A child beyond the age of 2 is not combining words into phrases
• The child's speech is difficult to understand
• The child is omitting syllables or sounds in words
• Speech errors are noticed during conversation
• The child has difficulty following directions or understanding spoken language
• The child has difficulty answering questions
• The child has a smaller vocabulary than what is expected for their age
• The child is stuttering
• The child's voice quality has changed or is noticeably hoarse or nasal
• The child has difficulty communicating with others socially
• The child has hearing loss
• The child has a cleft lip or palate

What is Early Intervention Speech Therapy? 

Early intervention refers to state-funded evaluations and interventions—including speech therapy—for children, ages birth to 3, and their families. In some states, early intervention continues until the age of 5. While professionals may refer a child to early intervention, parents can also refer their child on their own.

Speech Therapy for Toddlers 

Speech therapy for toddlers usually resembles play where toys are used to elicit target skills, says Dominica Lumb, M.S., CCC-SLP, who has over 30 years of experience conducting speech therapy with children in various settings. 

Children are given choices during play to encourage the need to communicate. While working on language skills, toddlers are encouraged to request objects, ask questions, answer questions, and use appropriate vocabulary.

Parents may be included in therapy sessions at this age. They may be taught to model speech sounds or how to label objects and actions during everyday routines to enhance vocabulary development.

Speech therapy can also work differently depending on a child’s needs. For example, one may require a mode of communication that differs from speaking. That’s referred to as augmentative and alternative communication (AAC) and may include picture boards or computers/iPads for communicating through text or voice synthesizer. This can begin in early intervention and beyond.

Speech therapy at this stage is typically more structured. Games are often used for motivation, but goals are targeted through practice and repetition. Children practice new skills throughout a continuum until they're able to use these skills naturally in all environments.

After early intervention, children may continue receiving services in elementary school through an individualized education plan (IEP). The IEP is written by all specialists who will be working with the child. It states the child's goals and documents any accommodations the child may need to meet them.

Therapy at this age may follow a “pull-out” model where a child receives support in a separate classroom or a “push-in” model where an SLP provides services within the regular classroom. This model can change throughout the duration of therapy. For example, a child working on the correct production of a sound will typically begin with pull-out therapy and, when ready, will be observed in their classroom to assess for carryover of this skill.

SLPs in the school setting also consult with teachers to provide the support children need to communicate effectively in the classroom.

While children must qualify for speech therapy through early intervention and in public schools, private practices can provide services beyond these standards.

Speech therapy in the private practice setting typically occurs one-on-one with the child receiving the SLP's undivided attention. But group therapy may occur when beneficial to the child.

"Therapy in the private practice setting is very child and family focused," explains Shanna Klump, M.S., CCC-SLP, CEO of Kid Connections Therapy in Severna Park, Maryland. "The family's goals for their child are often at the forefront of the work we do. In addition, parents and other family members often participate in the sessions to learn strategies that can be implemented at home to encourage generalization of skills."

Parents should refer their child for a speech/language evaluation when they first notice their child is falling behind in any area of speech/language or is no longer meeting speech/language milestones . It is never too late or too early to start therapy but, in general, earlier intervention leads to a better outcome. If you're unsure if your child requires speech therapy, a referral to an SLP is always recommended.

A parent can contact their local early intervention office to learn about speech therapy options. The Centers for Disease Control and Prevention (CDC) provides early intervention contacts by state. Parents can also reach out to their child's health care provider to determine where their local early intervention office is located.

A school-aged child can be referred for a speech/language evaluation by reaching out to the child's teacher or the school's SLP.

An evaluation by a private SLP is an option at any age, but evaluations through early intervention or a public school district are provided at no cost. ASHA ProFind connects parents to SLPs who have indicated they are accepting referrals.

While public school therapy is free, private outpatient speech/language therapy is often covered by health plans, but with limitations.

According to Klump, insurance coverage for speech therapy varies by state, insurance plan, and diagnosis. She explains that while some states require habilitative service coverage for children, others do not.

Often, private practices, including Klump's Kid Connections, complete a benefits verification before initiating speech evaluation or therapy. In her experience, therapy sessions without insurance coverage may cost between $100-150, depending on location.

As each health plan has its own coverage, it is important to reach out to your insurance company to determine your out-of-pocket costs.

Insurance and Speech Therapy Coverage

If you're looking to see what insurance covers, Shanna Klump, M.S., CCC-SLP, CEO of Kid Connections Therapy, suggests parents obtain the following information from their insurance carrier:

• Visit limit. This may be a hard or soft limit which refers to whether an extension of services could be granted if deemed medically necessary
• Whether the visit limit is combined with other services. For example, occupational therapy and physical therapy are sometimes grouped with speech therapy in the number of sessions covered
• Whether there are exclusions to coverage for different diagnoses
• If a deductible must be met
• The co-pay amount per session

Speech therapy can take anywhere from months to years. Each child makes progress at their own rate and has individualized goals based on their communication needs. Just as children develop and meet milestones individually, the time it takes them to master new skills will vary.

Speech therapy has been found to be effective for children. One study of more than 700 children with speech or language disorders up to 16 years old, found an average of six hours of speech therapy over six months significantly improved communication performance. Speech therapy was shown to be much more effective than no treatment over the same period.

Children of all ages typically find speech therapy engaging, fun, and rewarding. They're able to see their progress and use their newly learned skills proudly. Speech therapy is an effective way to enhance a child's ability to communicate and through these communication skills, a child will have better access to the world.

Is speech and language therapy effective for children with primary speech and language impairment? Report of a randomized control trial . International Journal of Language & Communication Disorders . 2011

Related Articles

5-Year-Old Speech Milestones

During the early elementary school years, children’s language and speech skills develop at an exponential rate. At this age, children are becoming more skilled at combining and playing with words in new and different ways. They also have an increasing awareness of how speech sounds are formed and how sounds come together to make words. It is common and normal for parents to worry about their child’s speech and language skills and to wonder if their child is where they should be in this area. It is important to remember that there is a very wide range of normal, and milestones are meant to serve only as a guideline and not as a tool for identifying or diagnosing a speech or language delay. Some children may have mastered none, several, half, or all of these skills by their sixth birthday. Children develop at different rates and acquire skills in varying order and frequency. If you have any questions or concerns about your child’s development, scheduling your free introductory call today with one of our speech therapists is a great step towards identifying any challenges or deficits and benefiting from early intervention. 

What is Normal Speech for a 5-year Old? Should a 5-year-old Speak Clearly? 

Language Sound Production 

By age 5, most children understand how speech should sound and how to produce every speech sound, with the possibility of some mistakes or imperfections. They can identify rhyming words and may engage in rhyming games or songs or listing off words that rhyme (hat, cat, bat, etc.) Children at the age of 5 should be widely understood by strangers when speaking. 

At this age, children are also learning about or already have learned which sounds are made by which letter. This information becomes the building block of reading skills. They are also learning how individual letter sounds combine to form a word, for example, “m” “o” and “p” form together to make “mop.” 

At age 5 most children are able to use the correct form of verbs when speaking about events of the past. That being said, it will take many years for a child to learn and understand the many exceptions that exist within the English language. 

By their 6th birthday, most children have an understanding that some words can have two or more different meanings. This teaches them to begin to rely on context to understand the meaning of the word. Children at this age are also learning about phrases or instances when the words are not meant to be taken literally (I was blown away! For example.) 

At this age, children are learning about combining two existing words to form another word. ‘Firetruck’ is a great example of the kind of compound words that children of this age are becoming more comfortable with. Learning that plurals don’t always include an s at the end is also a concept that children this age are beginning to learn about. 

Forming Sentences 

5-year-olds are also learning a great deal about sentence structure, and understanding and producing both passive and active sentences. Some children of this age may struggle to understand passive sentences, but these comprehension skills improve with age. They are also becoming more readily able to identify when a sentence doesn’t make sense, and even pinpoint where it goes wrong. At this age, children are forming complete sentences with as many as 8 or more words. 

Conversation and Storytelling Skills 

Children of this age are using increasingly descriptive and specific language. They are also learning to identify the parts of a story, the setting, characters, beginning, middle and end, etc. They are then learning to employ the use of these literary elements in their own storytelling. 

Descriptive language is really developing at this age, and many children are able to use adjectives to accurately describe the appearance of an animal or object. They may enjoy guessing games such as “What am I?” where you describe the object without saying what it is and have the other person try to guess. I Spy is also a popular game with this age group, as most children this age have mastered the identification of colors. 

The majority of children of this age are able to carry on a simple conversation with a peer or adult and can make requests using the future tense. “Let’s go to the beach tomorrow!” 

How can I Support my 5-year-old’s Speech and Language Development?

At this age, children are able to listen to stories being read aloud to them, even without pictures. In fact, this is a great age to introduce reading aloud of age-appropriate novels. This is a great way to continuously expose them to new and advancing vocabulary. Instilling a love of reading in your child is one of the most powerful things we can teach our children. If you want to learn more about how to engage with your child and support their learning and development, connect with one of our specialized speech therapists and schedule your free introductory call today!

Engaging children in conversation and listening attentively when they speak is one of the best and simplest ways to promote and support speech and language skill development. Ask your child open-ended questions (Not yes or no questions) like “Tell me about your day at school..” and make sure you are focused and distraction-free as you listen to their answer. Enjoy your time together and be intentional, the simple act of engaging in conversation teaches children a wide variety of skills. 

How can Speech Therapy help?

Speech therapy can be an incredibly valuable resource for children, even for those who are developing as they should. Speech and language pathologists are experts at interacting with and supporting children, and they dedicate their time to making sure your child’s appointments are fun and fruitful. Bringing speech therapy online is also highly beneficial, as it eliminates waiting room and travel time and can take place from anywhere with a quiet space and a wifi connection. Children are naturally attracted to technology and so the added element of online appointments can help make your child excited and enthusiastic about attending their appointments. If you are worried about your child’s speech and language development or are just seeking some extra support and guidance for your child as they learn and grow, connect with one of our highly experienced and qualified speech and language pathologists. Support is just a click away, schedule your free introductory call today!

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Age-Appropriate Speech and Language Milestones

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While not every child develops speech and language on the same timetable, the National Institute on Deafness and Other Communication Disorders does provide a list of age-appropriate speech and language milestones for babies and young children.

If you suspect your child is failing behind his peers, consult your child’s doctor or schedule a speech and language evaluation for your child.

Milestones related to speech and language

Birth to 3 months.

• Seems to know your voice and quiets down if crying
• ​Reacts to loud sounds with a startle reflex
• Is awakened by loud voices and sounds
• Vocalizes pleasure and displeasure sounds differently (laughs, giggles, coos, cries, or fusses
• Makes noise and smiles when spoken to
• Responds to sound of rattle

4 to 6 months

• Looks or turns toward a new sound
• Responds to “no” and changes in tone of voice
• Enjoys rattles and other toys that make sounds
• Vocalizes back when talked to
• Begins to repeat sounds (such as, “ooh,” “aah,” and “ba-ba”)

7 to 11 months

• Responds to his or her own name, telephone ringing, or someone’s voice even when not loud
• Knows words for common things (such as, “cup” or “shoe”) and sayings (such as, “bye-bye”)
• Babbles (says "ba-ba-ba," "ma-ma" or "da-da")
• Tries to communicate by actions or gestures
• Looks at things or pictures when someone talks about them
• Starts to respond to requests (such as, “come here”)
• Enjoys games like peek-a-boo and pat-a-cake
• Makes babbling sounds, even when alone
• Imitates simple words and sounds; may use a few single words or baby signs meaningfully

12 to 17 months

• Understands simple phrases (such as, “put the ball in the box” or “put the car on the table”)
• Enjoys being read to
• Follows one-step commands when shown by a gesture
• Answers simple questions by shaking his/her head or going to get an item when asked
• Says two to three words to label a person or object (pronunciation may not be clear)
• Tries to imitate simple words
• Vocabulary includes four to six words or more
• Says more words as each month passes

18 to 23 months

• Understands the meaning of action words (such as clap, sit or jump)
• Points to some body parts when asked
• Understands and answers simple “yes-no” questions (such as, “Are you hungry?”)
• Understands “not now” and “no more”
• Chooses things by size (such as, “big” or “little”)
• Uses a vocabulary of 50 words, pronunciation is often unclear
• Asks for common foods by name
• Makes animal sounds (such as, "moo")
• Starts to combine words into 2- to 3-word phrases to talk about and ask for things (such as, "more milk")
• Begins to use pronouns (such as, "mine")

2 to 3 years

• Knows some spatial concepts (such as "in" or "on")
• Understands and uses more pronouns (such as, "you," "me" or "her")
• Knows descriptive words (such as, "big" or "happy")
• Answers many simple questions
• Follows two-step commands (such as, “Get your shoes and come here.”)
• Uses three- to four-word sentences
• Uses at least 100 words by 2 years of age
• Uses question inflection to ask for something (such as, "My ball?")
• Begins to use plurals, such as "shoes" or "socks" and regular past tense verbs (such as, "jumped")
• Speech pronunciation is improving, but may still leave off ending sounds; strangers may not be able to understand much of what is said

3 to 4 years

• Answers simple questions (such as, "What do you do when you are hungry?")
• Groups objects into categories (such as, foods or clothes)
• Recognizes colors
• Uses 300 to 500 words by 3 years of age
• Describes the use of objects (such as, "You eat with a fork")
• Has fun with language; enjoys poems and recognizes language absurdities such as, "Is that an elephant on your head?")
• Expresses ideas and feelings rather than just talking about the world around him
• Uses verbs that end in "ing" (such as, "walking" or "talking")
• Uses most speech sounds, but may distort some of the more difficult or later developing sounds, (such as l, r, s, sh, ch, v, z, th)
• Uses consonants in the beginning, middle, and ends of words. Some of the more difficult consonants may be distorted, but tries to say them
• Strangers are able to understand much of what is said

4 to 5 years

• Answers "why" questions
• Lists items that belong in a category (such as, animals or vehicles)
• Understands more abstract spatial concepts (such as, "behind" or "next to")
• Understands complex questions
• Uses some irregular past tense verbs (such as, "ran" or "fell")
• Describes how to do things (such as, painting a picture)
• Speech is understandable, but makes mistakes pronouncing long, difficult, or complex words (such as, "hippopotamus")
• Understands time sequences (such as, what happened first, second, or third)
• Carries out a series of three directions
• Understands rhyming
• Engages in conversation
• Produces sentences that can be eight or more words in length
• Uses compound and complex sentences
• Describes objects
• Uses imagination to create stories

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Speech Therapy for Toddlers

What is speech therapy.

• Language Development
• Signs of Delay
• Speech Therapy Activities
• A Parent's Role

Frequently Asked Questions

Speech therapy is a treatment led by a speech and language pathologist (SLP) or speech therapist. It helps a person communicate and speak more clearly. Toddlers may develop language or speech impairments due to illness, hearing problems, or brain disorders.

This article covers speech and language milestones, causes of speech disorders, diagnosis, what happens in speech therapy, and how parents can help their toddlers. 

Dragana991 / Getty Images

Speech therapy is a treatment that helps a person speak or communicate more effectively. It is performed by specially trained speech and language pathologists (SLPs) or speech therapists. They help their patients better understand others, pronounce words clearly, or put words together. 

There are different types of speech therapy and their use will depend on the age of the child and what they are experiencing. For example, therapy practices vary for children with apraxia (difficulty pronouncing different syllables), stuttering, aphasia (difficulty speaking due to damage to the brain), and difficulty swallowing, and for late talkers.

Language Development (Newborn to Toddler)

While delay does not always mean there’s a problem, it’s important to recognize when a toddler misses a developmental milestone. The following are general guidelines of speech and language development for babies and toddlers:

Newborns communicate through crying. Their cries may sound the same at first but start to vary as they grow. They also cry to express emotions, and parents begin to understand what different cries mean.

High-Pitched Crying

A high-pitched cry not resolved by comforting or eating may mean that an infant is experiencing discomfort or pain.

Newborns pick up on rhythms of speech and their parents' voices within the first few weeks of life. Between 1 and 4 months old, they become more alert to sounds and may startle more easily or turn to look for the source of the noise. 

Around 2 to 3 months old, infants start smiling and cooing, which often sounds like "ah" or "eh." Babies begin laughing by 3 to 4 months old.  

By 5 or 6 months old, infants imitate adult sounds produced by babbling or shrieking. Babbling involves repeating sounds such as "ba," "ma," or "ga."  

7–12 Months

Seven-month-old infants hear words as distinct sounds and try to repeat them. By 9 months old, they start to understand expressions and simple commands like "no," recognize words for objects, and respond to their names.

Ten- to 12-month-olds follow simple commands such as "give mommy your cup." They also begin to say simple words such as "dada" or "bye-bye."

A Toddler's First Words

Most 1-year-olds can say a few words such as “up” or “dog” but do not put words together in a sentence.

13–18 Months

By 18 months, a toddler puts two words together and says phrases such as "push it." They often communicate in gestures that get more complex over time.

Toddlers this age start recognizing objects, body parts, pictures, or people. For example, if you ask, "Where is your nose?," they will be able to point to it.  

19–24 Months

By 24 months old, toddlers know and say 50 or more words. They start to form two- to three-word sentences. Two-year-olds can usually communicate their needs, such as “I want more milk,” and follow two-step commands.

Speech and Language Developmental Timeline

Children develop at different speeds and may not follow the typical timeline. If you are concerned about the delay, contact your pediatrician or healthcare provider as soon as possible. Early treatment can make a difference.

Signs of Speech or Language Delay in Toddlers

The following are general guidelines to help parents know if they should have their young child evaluated for speech or language problems:

• A baby who does not vocalize or respond to sound
• A 1-year-old who does not use gestures, such as pointing
• An 18-month-old who would rather use gestures than sounds
• An 18-month-old who has difficulty imitating sounds or understanding simple requests
• A 2-year-old who imitates speech but doesn’t talk spontaneously
• A 2-year-old who can say words but not communicate more than their immediate needs or follow simple directions
• A 2-year-old who has a raspy or nasal-sounding voice

Understanding the Words of a Toddler

Parents and regular caregivers usually understand about 50% of a toddler’s speech by 2 years old and 75% by 3 years old.

Speech or language delays can occur due to problems with the structures of the mouth, head injuries, chronic illnesses, or brain disorders.  

If the cause is a brain disorder, it can be difficult to coordinate their tongue, lips, and mouth to make sounds or words. 

Hearing problems can make it difficult to imitate or understand language. This is not always a problem that is apparent at birth. Chronic ear infections can cause hearing damage in one or both ears.

A speech therapist will perform tests with your toddler to check the following:

• What your child understands
• What your child can say 
• Clarity of speech
• How the structures in their mouth work together to form words and eat

The following are diagnostic tests or scales a speech therapist may perform with your toddler:

• Bayley Scales of Infant and Toddler Development (Bayley-III) : Bayley-III is used worldwide to measure all aspects of development from birth to 42 months. A speech therapist administers the language portion by watching the child follow instructions and identify people and objects. It helps them know if the child is on track or needs further evaluation. 
• Preschool Language Scales–Fifth Edition (PLS)-5 English : The PLS-5 is an interactive screening tool designed for infants and young children. Speech therapists measure all areas of language through a play-based approach. 
• Differential Ability Scales Assessment–Second Edition (DAS-II) : The DAS-II provides a scale to help speech therapists better understand how a child processes information. This allows them to develop appropriate activities for therapy.
• Goldman-Fristoe Test of Articulation 3 (GFTA-3) : The GFTA-3 involves asking a child to identify colorful drawings and measures their ability to pronounce consonants.
• The Rossetti Infant-Toddler Language Scales: This test is specifically designed for children from birth to 36 months old. It involves a parent interview, as well as observation of the child performing tasks.

What Happens During Speech Therapy?

The speech therapist will plan and perform activities to help your toddler with skills based on their specific needs. Therapy may occur in small groups or individually. 

Language building activities include using picture books, repetition, talking, and playing. If a toddler has difficulty pronouncing certain words, the therapist will teach them how to make the sound or say specific words. 

Sometimes speech therapists help toddlers with speech mechanics. This involves teaching them how to move their mouth or tongue to pronounce a word. They may also prescribe lip, tongue, or jaw exercises to continue at home.

What Concerns are Addressed During Speech Therapy?

Some of the concerns that SLPs may address during speech therapy include:  

• Speech mechanics
• Word pronunciation
• Volume or quality of speech
• Social communication skills
• Trouble swallowing

How Can Parents Help?

It helps to talk and read to your child frequently. Use correct names and speak in a slow and clear voice. When giving direction, keep things simple. Kneeling to their level can them focus on what you are saying.

If your child points at a glass of water, help them connect the gesture and language by asking, “Do you want water?” When they don’t pronounce words accurately, emphasize the correct pronunciation when responding.

Waiting for a Response

When asking a question such as “Do you want a drink?,” try waiting for a response. This helps your toddler learn to communicate back to you. 

Chronic illnesses, brain disorders, and hearing problems can cause a toddler to have delayed speech or language development. Speech therapy can help them learn to communicate more effectively. 

Parents can help by talking to their children often, speaking clearly, and emphasizing correct pronunciation. If your child is in speech therapy, it’s helpful to perform exercises prescribed by your speech therapist at home.

A Word From Verywell

Not all children follow a typical timeline for speech and language development. Sometimes they are focused on learning a new task, such as walking, and put language development on the back burner. They often catch up later. 

If your toddler is experiencing a language or speech delay, talk with your child’s healthcare provider. If there is a problem, getting help early can make a difference.

A toddler should start speech therapy any time after 3 months old if they experience developmental delays in speech or language. This may seem young, but a speech therapist can monitor the signs if there is a delay. Early intervention can make an impact. 

The estimated national average cost for the United States is $218 per session. However, many insurances and most state Medicaid programs cover speech therapy. It can be helpful to find an in-network clinic to decrease your out-of-pocket expenses. 

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By Brandi Jones, MSN-ED RN-BC Jones is a registered nurse and freelance health writer with more than two decades of healthcare experience.

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Speech and Language Developmental Milestones

On this page:

How do speech and language develop?

What are the milestones for speech and language development, what is the difference between a speech disorder and a language disorder, what should i do if my child’s speech or language appears to be delayed, what research is being conducted on developmental speech and language problems.

• Your baby's hearing and communicative development checklist

Where can I find additional information about speech and language developmental milestones?

The first 3 years of life, when the brain is developing and maturing, is the most intensive period for acquiring speech and language skills. These skills develop best in a world that is rich with sounds, sights, and consistent exposure to the speech and language of others.

There appear to be critical periods for speech and language development in infants and young children when the brain is best able to absorb language. If these critical periods are allowed to pass without exposure to language, it will be more difficult to learn.

The first signs of communication occur when an infant learns that a cry will bring food, comfort, and companionship. Newborns also begin to recognize important sounds in their environment, such as the voice of their mother or primary caretaker. As they grow, babies begin to sort out the speech sounds that compose the words of their language. By 6 months of age, most babies recognize the basic sounds of their native language.

Children vary in their development of speech and language skills. However, they follow a natural progression or timetable for mastering the skills of language. A checklist of milestones for the normal development of speech and language skills in children from birth to 5 years of age is included below. These milestones help doctors and other health professionals determine if a child is on track or if he or she may need extra help. Sometimes a delay may be caused by hearing loss, while other times it may be due to a speech or language disorder.

Children who have trouble understanding what others say (receptive language) or difficulty sharing their thoughts (expressive language) may have a language disorder. Developmental language disorder  (DLD) is a language disorder that delays the mastery of language skills. Some children with DLD may not begin to talk until their third or fourth year.

Children who have trouble producing speech sounds correctly or who hesitate or stutter when talking may have a speech disorder. Apraxia of speech is a speech disorder that makes it difficult to put sounds and syllables together in the correct order to form words.

Talk to your child’s doctor if you have any concerns. Your doctor may refer you to a speech-language pathologist, who is a health professional trained to evaluate and treat people with speech or language disorders. The speech-language pathologist will talk to you about your child’s communication and general development. He or she will also use special spoken tests to evaluate your child. A hearing test is often included in the evaluation because a hearing problem can affect speech and language development. Depending on the result of the evaluation, the speech-language pathologist may suggest activities you can do at home to stimulate your child’s development. They might also recommend group or individual therapy or suggest further evaluation by an audiologist (a health care professional trained to identify and measure hearing loss), or a developmental psychologist (a health care professional with special expertise in the psychological development of infants and children).

The National Institute on Deafness and Other Communication Disorders (NIDCD) sponsors a broad range of research to better understand the development of speech and language disorders, improve diagnostic capabilities, and fine-tune more effective treatments. An ongoing area of study is the search for better ways to diagnose and differentiate among the various types of speech delay. A large study following approximately 4,000 children is gathering data as the children grow to establish reliable signs and symptoms for specific speech disorders, which can then be used to develop accurate diagnostic tests. Additional genetic studies are looking for matches between different genetic variations and specific speech deficits.

Researchers sponsored by the NIDCD have discovered one genetic variant, in particular, that is linked to developmental language disorder (DLD), a disorder that delays children’s use of words and slows their mastery of language skills throughout their school years. The finding is the first to tie the presence of a distinct genetic mutation to any kind of inherited language impairment. Further research is exploring the role this genetic variant may also play in dyslexia, autism, and speech-sound disorders.

A long-term study looking at how deafness impacts the brain is exploring how the brain “rewires” itself to accommodate deafness. So far, the research has shown that adults who are deaf react faster and more accurately than hearing adults when they observe objects in motion. This ongoing research continues to explore the concept of “brain plasticity”—the ways in which the brain is influenced by health conditions or life experiences—and how it can be used to develop learning strategies that encourage healthy language and speech development in early childhood.

A recent workshop convened by the NIDCD drew together a group of experts to explore issues related to a subgroup of children with autism spectrum disorders who do not have functional verbal language by the age of 5. Because these children are so different from one another, with no set of defining characteristics or patterns of cognitive strengths or weaknesses, development of standard assessment tests or effective treatments has been difficult. The workshop featured a series of presentations to familiarize participants with the challenges facing these children and helped them to identify a number of research gaps and opportunities that could be addressed in future research studies.

What are voice, speech, and language?

Voice, speech, and language are the tools we use to communicate with each other.

Voice is the sound we make as air from our lungs is pushed between vocal folds in our larynx, causing them to vibrate.

Speech is talking, which is one way to express language. It involves the precisely coordinated muscle actions of the tongue, lips, jaw, and vocal tract to produce the recognizable sounds that make up language.

Language is a set of shared rules that allow people to express their ideas in a meaningful way. Language may be expressed verbally or by writing, signing, or making other gestures, such as eye blinking or mouth movements.

Your baby’s hearing and communicative development checklist

Birth to 3 months, 4 to 6 months, 7 months to 1 year, 1 to 2 years, 2 to 3 years, 3 to 4 years, 4 to 5 years.

This checklist is based upon How Does Your Child Hear and Talk ?, courtesy of the American Speech–Language–Hearing Association.

The NIDCD maintains a directory of organizations that provide information on the normal and disordered processes of hearing, balance, taste, smell, voice, speech, and language.

Use the following keywords to help you find organizations that can answer questions and provide information on speech and language development:

• Early identification of hearing loss in children
• Speech-language pathologists

For more information, contact us at:

NIDCD Information Clearinghouse 1 Communication Avenue Bethesda, MD 20892-3456 Toll-free voice: (800) 241-1044 Toll-free TTY: (800) 241-1055 Email: [email protected]

NIH Publication No. 00-4781 September 2010

*Note: PDF files require a viewer such as the free Adobe Reader .

Volume 21 Supplement 1

Defined preventive interventions for children under five years of age: evidence summaries for primary health care in the WHO European region

• Open access
• Published: 08 September 2021

Screening for language and speech delay in children under five years

• Sophie Jullien   ORCID: orcid.org/0000-0001-5587-626X 1  

BMC Pediatrics volume  21 , Article number:  362 ( 2021 ) Cite this article

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We looked at existing recommendations and supporting evidence on the effectiveness of universal screening for language and speech delay in children under 5 years of age for short- and long-term outcomes.

We conducted a literature search up to the 20th of November 2019 by using key terms and manual search in selected sources. We summarized the recommendations and the strength of the recommendation when and as reported by the authors. We summarized the main findings of systematic reviews with the certainty of the evidence as reported on the accuracy of the screening tests for detecting language and speech delay, the efficacy of existing interventions for children with language and speech delay, and the potential harms associated with screening and the associated interventions.

Several screening tools are used to assess language and speech delay with a wide variation in their accuracy. Targeted interventions improve some measures of speech and language delay and disorders. However, there is no evidence on the effectiveness of such interventions in children detected by screening with no specific concerns about their speech or language before screening. There is no evidence assessing whether universal screening for language and speech delay in a primary care setting improves short and long-term outcomes (including speech and language outcomes and other outcomes). Finally, there is no evidence on the harms of screening for language and speech delay in primary care settings, and there is limited evidence assessing the potential harms of interventions.

Introduction

The World Health Organization (WHO) European Region is developing a new pocket book for primary health care for children and adolescents in Europe. This article is part of a series of reviews, which aim to summarize the existing recommendations and the most recent evidence on preventive interventions applied to children under 5 years of age to inform the WHO editorial group to make recommendations for health promotion in primary health care. In this article, we looked at existing recommendations and supporting evidence on the effectiveness of universal screening for language and speech delay in children under 5 years of age for short- and long-term outcomes.

Why is the detection of language and speech delay important?

Language is the coding system that permits conceptualisation, reasoning and understanding, while speech is one vehicle for expressing language through combined sounds [ 1 ]. Language or speech delay refers to cases where the development of the ability to understand and speak is correct but slower than what is accepted as normal, whereas language or speech disorders refer to cases where the speech or language ability deviate from what is expected as normal development [ 2 , 3 ]. Language disorders can involve the form (phonology, morphology, syntax), the content (semantics), and the function of language in communication (pragmatics), or in any combination [ 3 ]. Speech disorders refer to difficulty with forming specific words or sounds and/or with fluency, needed to communicate with others [ 2 ]. Language and speech disorders can exist by themselves or combined [ 3 ].

School-aged children with language or speech delay may be at increased risk of learning and literacy disabilities, including difficulties with reading and writing. Children with such conditions may also be at higher risk for behaviour and psychosocial adjustment, which may persist into adulthood [ 4 ].

The median prevalence of isolated speech and language delays and disorders (this is without associated developmental delay, autism spectrum disorder or intellectual disability) was estimated at 6% (range from 5 to 12%) among children between two and 5 years of age in the United States [ 3 , 4 ].

Language and speech are two of the main domains of child development, or neurodevelopment, together with gross and fine motor skills, social and personal skills, activities of daily living, and cognition. These domains are characterized by continua, this is that one end of the diagnostic spectrum has a border with normality [ 5 ]. Language and speech disorders can occur with other developmental disabilities, such as autism spectrum disorder, or with emotional or behavioural disorders, such as attention deficit hyperactivity disorder (ADHD), and might be detected as early manifestations of such disorders [ 2 ]. Early identification of children with language and speech delay and disorder would allow interventions at an early stage, before these problems interfere with learning abilities and behavioural adjustment, to reach better health, academic and social outcomes [ 3 ]. Universal screening of all preschool children has been suggested to this end, for early detection and intervention and potentially better outcomes [ 6 ]. However, the identification of children with language and speech delay through universal screening is challenging. Cultural, socioeconomic and contextual factors make these children a variegated group, which is difficult to evaluate with a simple screening tool [ 7 ].

As reminded by the Canadian Task Force on Preventive Health Care, “screening differs from developmental surveillance, which refers to ongoing monitoring by clinicians of a child’s development, identification of risk factors and elicitation of parental concerns” [ 6 ].

Finally, although hearing loss is related to language and speech delay, we do not address universal screening for hearing loss in newborns in this document.

Key questions

How accurate are the screening tests for detecting language and speech delay in children under 5 years of age?

Are the interventions for children identified with language and speech delay effective for improving (short- and long-term) language and speech outcomes?

Does screening programme for detection and early intervention of language and speech delay in children younger than 5 years improve short- and long-term outcomes?

What are the potential harms of screening and interventions for language and speech delay for children and their family?

Search methods and selected manuscripts

We described the search methods, data collection and data synthesis in the second paper of this supplement (Jullien S, Huss G, Weigel R. Supporting recommendations for childhood preventive interventions for primary health care: elaboration of evidence synthesis and lessons learnt. BMC Pediatr. 2021. https://doi.org/10.1186/s12887-021-02638-8 ).

The search was conducted up to the 20th of November 2019, by manual search and by using the search terms “language” and “speech”. We included any document that addressed at least one of the key questions. We did not find any relevant document from the WHO. We found recommendations and their supporting evidence from the United States Preventive Services Task Force (USPSTF) (2015). The Centers for Disease Control and Prevention (CDC) addresses “Language and speech disorders in children” in their website, mainly addressed to the general public. They promote observation of the children by their parents concerning the developmental milestones and provide recommendations on what should be done for children identified with speech or language concern. However, we did not find any recommendations from the CDC regarding universal screening. The current recommendation from the UK National Screening Committee (UK NSC) is based on an external review published in 2005. According to their website, they are currently reviewing the recommendations on this topic, although it is also stated that the updated review is estimated to be completed by November 2013.

The Royal College of Paediatrics and Child Health (RCPCH) dedicates a whole chapter on child development in their recent book, which includes a section on screening and speech and language disorders. The PrevInfad workgroup (Spanish Association of Primary Care Pediatrics) (2017) and the Canadian Task Force on Preventive Health Care (2016) developed documents with recommendations and supportive evidence on developmental delay with generic measures covering all aspects of development, but do not address language and speech delay as a single domain for universal screening. For the feasibility of this review, we cite these sources as reference for readers, but we did not summarise them.

The search in the Cochrane library by using the search terms ‘language’ OR ‘speech’ in titles returned 11 reviews and one protocol. By screening the titles and abstracts, we included one review (Law 2003) and one protocol (Law 2017). Although published earlier than 2010, we included the Law 2003 review as we judged it was relevant for this summary document. The protocol we identified is for updating the Law 2003 review. We identified one additional systematic review (Kasper 2011) by hand search of the references of the manuscripts identified by the above methods.

All the included manuscripts for revision in this article are displayed in Table  1 .

Existing recommendations

We summarized the existing recommendations and the strength of recommendations as per their authors in Table  2 .

Existing evidence

The USPSTF commissioned a systematic review of the latest evidence on screening for speech and language delays and disorders in children under 5 years of age, to update their 2006 recommendations of screening in a primary care setting [ 3 , 8 ]. The review focused on screening children under 5 years of age who have not been previously identified with another disorder or disability that may cause speech or language impairment. The review authors assessed screening instruments specific to speech and language conditions, but also more general developmental screening tools with speech and language components. Another inclusion criterion was that screening tools needed to be feasible and interpretable within a primary care setting [ 4 ]. The review authors included randomized controlled trials (RCTs), systematic reviews, and cohort studies of screening and surveillance for speech and language delays and disorders, where children who screened positive received formal diagnostic assessment for speech and language delays and disorders by the age of 6 years. The literature search was conducted up to July 2014.

Another systematic review aimed to evaluate the effectiveness of universal screening for specific language impairment in preschool children in German [ 12 ]. To this end, and similarly to the methodological approach of the USPSTF review, the question was divided into a review of the evidence from studies evaluating screening programmes, diagnostic tools, and speech and language interventions. The literature search was conducted up to May 2008.

In the RCPCH book, the authors described general points regarding the diagnosis, screening and other considerations on developmental delay. They focused on several domains of child development that they considered were needed to be checked [ 5 ]. The first domain they addressed is “Speech and language disorders”.

Risk factors

Although a focused research question on the identification of potential risk factors for speech and language disorders is beyond the scope of this summary document, we judged it relevant to report those identified by Wallace et al., the review commissioned by the USPSTF [ 3 ]. The USPSTF systematic review included 31 cohort studies (24 with multivariate analysis to control for other factors) and one review of studies on characteristics of late-talking toddlers. The review authors identified male gender, family history of speech or language impairment, lower levels of parental education, and various perinatal risk factors (e.g., prematurity, birth difficulties, and low birth weight) as potential risk factors for speech and language disorders.

Accuracy of the screening tests for detecting language and speech delay in children younger than 5 years

The systematic review conducted by Wallace et al. evaluated four key questions to assess the accuracy of screening tools for the identification of children in the primary care setting for diagnostic evaluations and interventions: (1) “What is the accuracy of these screening techniques and does it vary by age, cultural/linguistic background, whether it is conducted in a child’s native language, or by how the screening was administered (i.e., parent report, parent interview, direct assessment of child by professional)?”; (2) “What are the optimal ages and frequency for screening?”; (3) Is selective screening based on risk factors (i.e. targeted screening), more effective than unselected, general population screening (i.e. universal screening)?; and (4) “Does the accuracy of selective screening vary based on risk factors? Is the accuracy of screening different for children with an inherent language disorder compared with children whose language delay is due to environmental factors?”

The review authors found no studies addressing the key questions 2, 3, and 4. They included 24 studies addressing the first key question, five good- and 19 fair-quality studies. The included studies evaluated the accuracy of 20 different screening tools, seven screening tools administered by parents, and 13 by trained examiners. Studies were conducted in the US (14 studies), the UK (six studies), Australia, Canada, Germany and Sweden. The review authors summarized the characteristics of included studies in supplementary tables and present the accuracy of findings separately for screening tools administered by parents and by trained examiners [ 3 ]. The performance characteristics varied widely. Overall, the screening tools administered by parents performed better than those administered by trained examiners. Screening tools for detecting a true speech and language delay or disorder reported by parents presented a median sensitivity of 81% (range from 50 to 94%) and a median specificity of 87% (range from 45 to 96%). Positive predictive values (PPV) ranged from 18 to 92%, and negative predictive values (NPV) ranged from 67 to 98%. When reported by trained examiners (nurses, primary care providers, teachers or paraprofessionals), the screening tools showed a median sensitivity of 74% (range from 17 to 100%) and a median specificity of 91% (range from 46 to 100%). PPV ranged from 6.6 to 100% and NPV ranged from 89 to 100% (except for one study with a reported NPV of 15%).

In conclusion, “the USPSTF found inadequate evidence on the accuracy of screening instruments for speech and language delay for use in primary care settings” [ 4 ]. “No one instrument clearly demonstrated the best characteristics or one age as optimal for screening” [ 3 ]. In addition, the authors highlighted the difficulties in comparing the performance of screening tools because of the heterogeneity in terms of screening tools used, populations screened and settings [ 4 ].

Kasper et al. found no studies that evaluated diagnostic instruments for specific language impairment in the German language [ 12 ].

For the RCPCH chapter on “Developmental reviews and the identification of impairments/disorders”, the authors reviewed the literature up to 2019 [ 5 ]. It is worth citing a paragraph from this chapter: “To date, no neurodevelopmental assessment beyond the neonatal period has been generally acknowledged to meet the WHO/Wilson and Jungner criteria for screening programmes. Screening approaches have been examined in relation to autism, language disorders, and conduct disorder, but key criteria have not been met: in particular, the requirements for a sensitive and specific screening test, for cost-effectiveness, and for evidence that early intervention produces better outcomes than waiting until problems manifest themselves before intervening. This lack of evidence for early intervention may appear counterintuitive in the context of knowledge that brain plasticity and thus potential gains are greater in younger children. In general, neurodevelopmental screening has failed to meet the WHO screening criteria because of lack of evidence of effectiveness, rather than evidence of lack of effectiveness. While it is possible to evaluate how well a screening test functions in a relatively small constrained population, it is much more difficult to carry out gold standard tests in large populations and it can also be challenging to follow up large groups of children to establish the productivity of a screening procedure over time” [ 5 ]. Finally, “while it is tempting to focus on the accuracy of the assessments employed for the identification of difficulties, it is important to stress that the conversations between professional and parent or carer about a child’s development should, if possible, be founded on an existing trusting relationship between the two parties” [ 5 ].

Effectiveness of interventions targeting young children with language and speech delay in short- and long-term outcomes

There is a wide range of interventions for children with speech and language delay and disorders, which include speech-language therapy sessions and assistive technology [ 4 ].

Wallace et al. identified 13 RCTs and one systematic review that evaluated the effect of speech and language interventions on speech outcomes. Four RCTs were conducted in the US, three in Australia, three in the UK, two in Canada and one in New Zealand. Two RCTs were judged to be of good quality, and the remaining 11 and the systematic review of fair quality. The review authors summarized the characteristics of the included studies and outcomes in supplementary tables. They found that most of the included trials showed significant positive results of treating young children with language delays and disorders (6 of the 11 trials) or speech sounds problems (6 of the 8 trials) and treating toddlers and pre-school children for fluency problems (2 of the 2 trials) [ 3 ]. However, the review authors described multiple factors that limit their confidence in the interpretation of these findings. The evidence comes from small trials, with a lack of replicated positive findings for most treatment approaches and a lack of data regarding compliance to treatment. The review authors could not perform a meta-analysis because there was a high degree of heterogeneity between the trials regarding the age of the children, the interventions (different agents, intensity, content and strategies), the outcome measures, and the way results were reported. In addition, the applicability of this evidence to universal screening in a primary care setting is also limited. Indeed, the identified trials “did not report treatment effectiveness in children whose speech and language delay had actually been detected by screening; instead, the delays had often been identified as a result of parent or teacher concerns”, and most studies were conducted in populations with a high prevalence of speech and language disorders [ 3 ]. The USPSTF also looked at the effect of speech and language interventions on other outcomes. They identified five studies with inconsistent findings on outcomes including socialization, reading comprehension, parental stress, and child well-being or attention level [ 3 ]. In conclusion, the USPSTF authors found evidence that interventions improve some measures of speech and language for some children. However, they found inadequate evidence on the effectiveness of such interventions for speech and language delay and disorders among children detected by universal screening, and on their effectiveness on outcomes not specific to speech (e.g., academic achievement, behavioural competence, socioemotional development, and quality of life) [ 4 ].

An older Cochrane review was conducted to examine the effectiveness of speech and language interventions for children with primary speech and language delay and disorder [ 11 ]. This review is currently being updated [ 10 ]. In the review published in 2003, authors included RCTs evaluating children or adolescents with primary speech and language delay/disorder who received “any type of intervention designed to improve an area of speech or language functioning concerning either expressive or receptive phonology (production or understanding of speech sounds), expressive or receptive vocabulary (production or understanding of words), or expressive or receptive syntax (production or understanding of sentences and grammar)” [ 11 ]. They identified 36 papers, of which 25 contributed to the meta-analysis. Eight of these papers were also included in the systematic review conducted by Wallace et al. (the remaining seven trials included in the Wallace review were published after the 2003 Cochrane review). Law et al. found that speech and language interventions are effective for children with phonological or vocabulary difficulties but that there is less evidence concerning the effectiveness of these interventions for children with receptive difficulties, and mixed findings concerning the effectiveness of expressive syntax interventions. There were no significant differences between intervention administered by trained parents and professionals. Like the review conducted by Wallace et al., they found a high degree of heterogeneity between included studies, and applicability of the findings to children with speech and language delay detected by universal screening is limited (all included studies were conducted in children already diagnosed with a speech and language delay or disorder).

The German review identified 16 RCTs, including seven trials already included in both reviews by Wallace et al. and by Law et al., and five trials included in one of the two reviews [ 12 ]. Overall, the review authors found positive effects from language therapies in the short term, but no evidence of benefits from earlier treatment initiation.

The RCPCH did not identify more recent evidence to add on the findings from the USPSTF review, but “Gillberg makes the valuable point that it is not good enough to ‘wait and see’ how developmental problems will unfold: around two-thirds of children with significant language delay at 30 months will manifest a range of significant associated neuropsychiatric problems as they grow older and many of these problems are likely to benefit from early intervention” [ 5 ].

Benefits of universal screening programmes and early intervention

Kasper et al. identified one study (reported in two manuscripts) evaluating speech and language screening, although authors “did not explicitly report results for children with specific language impairment” and therefore “it is not clear to what extent the study results apply to the children in the focus of this review” [ 12 ]. Overall, the review authors concluded that there was no evidence of benefits of universal screening of preschool children with specific language impairment [ 12 ].

Wallace et al. identified no study that determined whether universal screening for language and speech delay improves language and speech or other outcomes [ 3 ]. There is a “critical need for studies specifically designed and executed to address whether universal screening for speech and language delay and disorders in young children in primary care settings leads to improved speech, language, or other outcomes” [ 4 ].

On this aspect, authors from the RCPCH say: “One area where screening is recommended by some authors is universal screening for speech and language followed by appropriate targeted intervention. The problem is that there is still insufficient evidence to support the recommendation of screening. There are a number of reasons for this including the variability of the gold standard measures against which screening tests are evaluated, the tendency for such measures to both under-refer (low sensitivity) and over-refer (low specificity), and the difficulty of establishing predictive validity when the trajectory of language development can be so variable especially in early years – exactly when such measures are commonly recommended” [ 5 ].

Potential harms of screening and interventions for language and speech delay for children and their family

The potential harms of screening and interventions for speech and language disorders in young children in primary care “include the time, effort, and anxiety associated with further testing after a positive screen, as well as the potential detriments associated with diagnostic labelling” [ 4 ].

We found no studies that assessed the potential harms of screening for language and speech delay and disorders. Wallace et al. identified three studies that examined adverse effects of interventions and reported no negative impacts on children or parents [ 3 ]. None of the studies included in the systematic review conducted by Kasper addressed side effects or undesired effects of speech and language interventions [ 12 ]. The USPSTF found inadequate evidence on the harms of universal screening and interventions for speech and language delay and disorders in children aged 5 years or younger [ 4 ].

Summary of findings

Several screening tools are used to assess language and speech delay in primary care settings, with a wide variation in their accuracy. The USPSTF found no single screening tool with the best characteristics for screening.

There is evidence that targeted interventions improve some measures of speech and language delay and disorders. However, there is no evidence on the effectiveness of such interventions in children detected by universal screening, this is screening all children with no specific concerns about their speech or language before screening.

There is no evidence on whether universal screening programmes for detecting language and speech delay for early treatment improves short and long-term outcomes (including speech and language outcomes and other outcomes).

Potential harms of screening for language and speech delay include burden for the families in terms of time and resources. However, there is no evidence on the harms of universal screening for language and speech delay, and there is limited evidence assessing the potential harms of interventions.

Well-designed trials evaluating the most accurate screening tool and looking at benefits of universal screening for language and speech delay in young children are needed.

Availability of data and materials

Not applicable.

Abbreviations

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Acknowledgments

I am very grateful to María Jesús Esparza, Laura Reali, and Gottfried Huss for carefully reviewing and providing valuable feedback for each article. I am also grateful to Ralf Weigel and Gottfried Huss for proofreading the final version of this document.

About this supplement

This article has been published as part of BMC Pediatrics Volume 21, Supplement 1 2021: Defined preventive interventions for children under five years of age: evidence summaries for primary health care in the WHO European region. The full contents of the supplement are available at https://bmcpediatrics.biomedcentral.com/articles/supplements/volume-21-supplement-1 .

Publication charges for this article have been funded by the Friede Springer endowed professorship for Global Child Health at the Witten Herdecke University, Germany.

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SJ was identified as the researcher in the development of the synthesis of evidence and writing the report. For each selected topic on preventive interventions, SJ defined the key questions, established and run the literature search, screened the returned manuscripts for eligibility, extracted data and summarized the existing recommendations and supporting evidence. The principal advisors of this project were Dr. Gottfried Huss, MPH General Secretary of ECPCP, Project- Coordinator and Prof. Ralf Weigel, Friede Springer endowed professorship of Global Child Health, Witten/Herdecke University (scientific advice). The author(s) read and approved the final manuscript.

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Speech Therapy Milestones for your 3 to 5 year old

Are you concerned that your 3, 4 or 5 year old may need speech therapy? Here are some key milestones to use to better understand whether your concerns should be investigated further.

Your child’s speech and language development from ages 3 to 5 years old can be separated into two categories.

• Receptive . This is their ability to understand words and sounds
• Expressive . This is their ability to use speech and gestures to communicate.

Speech and language development becomes more advanced beginning around age 3 and can continue through the age of 5. Receptive language skills – or their ability to understand words and sounds – become more sophisticated during this period. She or he should be able to make subtle distinctions between objects and relationships. They should be able to understand multi-step requests. Most children also gradually speak more fluently and use proper grammar more consistently.

Review the table below to better understand how your child’s receptive and expressive language should be developing between 3 years and 5 years old. You can often provide helpful hints to exercise their skills. For example, you can ask your 5 year old son “Is that Bobby’s mom?” and then later ask him “Who is that?”

It is important to remember that there is no correct starting time for these skills and children develop differently. If you are unsure, be sure to talk to your physician or a qualified speech therapist. Our professional speech therapists offer free screenings via Zoom – signup below if you are interested in finding out more.

Are you concerned about your child’s speech development? We are qualified speech therapists and can help. Contact us and receive a free screening on Zoom.

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September 17, 2018

Child Speech Therapy: Expressive Language Skills

Hearing your child’s voice for the first time is an exciting, monumental part of parenthood. As the first babbles turn into words, and eventually sentences, your child’s expressive language is developing. Receptive language is the ability to understand language, as expressive language is the ability to use words, sentences, gestures, and writing to communicate with others.

Richard Leeming

What is expressive language and why is it important?

Expressive language allows a person to communicate wants, needs, thoughts and opinions. Expressive language is the ability to request objects, make choices, ask questions, answer, and describe events. Speaking, gesturing (waving, pointing), writing (texting, emailing), facial expressions (crying, smiling), and vocalizations (crying, yelling) are all variations of expressive language. Children with poor expressive language skills may become frustrated when they cannot communicate their wants and needs. Temper tantrums may occur when they feel tired, sick or hungry and cannot express their current needs.

How do expressive language skills develop?

Expressive language is developed within the first few days after birth. Babies learn to communicate when they are hungry, uncomfortable or tired through crying and facial expressions. They learn to laugh when they are enjoying an interaction with a parent or caregiver, and smile when they are happy. These are all forms of communication. In order for expressive language skills to develop, a child also needs to have strong receptive language, attention, play, social pragmatics and motivation.

• Receptive language skills is the comprehension of language which is an underlying skill to label objects, answer questions appropriately, and use language in the intended way.
• Adequate attention skills is an underlying skill for all developmental tasks. The ability to sustain attention is important in order to finish one’s thought and effectively communicate to others.
• Play skills encourage children to explore their surroundings. Play can be an intrinsic motivator for young children to communicate by requesting, interacting, and labeling toys.
• Pragmatic skills is the way language is used day to day in social situations. Adequate pragmatic skills allows a person to participate in conversation appropriately.

Expressive Language Milestones & Activities:

The following, outlines expressive language milestones from birth to 7 years old in three categories: birth, preschool, and school age. Learn about the typical developmental stages as well as activities to try at home.

Birth- 3 years old

0-1 years old:

• Produces pleasure sounds (cooing and gooing)
• Makes noises when talked to
• Protests or rejects through gestures or vocalizations
• Cries differently for different intentions
• Attempts to imitate facial expressions and movements of caregivers
• Laughs during parent interaction
• Between 7-12 months, child will start to babble sounds together (mama, dada)
• Uses a representational gesture (such as waves bye-bye, claps hands, moves body)

Activities to Try at Home:

• Talk to your child. When your child is developing language, they learn through role models. Talk to your child about your day, what you are doing, and what they can see. It may feel strange at first to talk to your baby without them responding, but the more you talk, the more they learn.
• Read. It is never too early to start reading books to your child. Point out familiar pictures in the books. If you are reading about animals, make the animal sounds associated with each animal.
• Imitate. Imitate all sounds, gestures, and facial expressions your child makes. Repeat a noise they make, and wait for a response. Encouraging imitation can help your child participate in social turn-taking and start to imitate your words.

1-2 years old

• First words develop around 12 -14 months (hi, mama, dad)
• Takes turns vocalizing with another person
• Uses at least two different consonant sounds (early signs include p, b, t, d, m)
• Around 18-24 months, child begins putting 2 words together (“more cookie,” “no book,” “all done”)
• Uses one-to-two word questions such as  “go bye bye?” or “where mommy?”
• Uses a variety of nouns (e.g. mom, dog) and verbs (e.g. eat, sleep)

Activities to Try at Home

• Books. Reading books is a great opportunity to expose your child to a wide variety of vocabulary. Books to encourage early development of common vocabulary include First 100 words , Where is Baby’s Belly Button , Brown Bear, Brown Bear, What Do You See? , and Dear Zoo .
• Puzzles. Encourage “requesting” while playing with puzzles by holding out two puzzle pieces and having your child name the piece they want. Your child should be able to name objects consistently and model two-word phrases such as “want __” or “give ___”. Pets Peg puzzle , Farm Wooden Chunky Puzzle , and Vehicle puzzle are great puzzles to encourage early concepts.

2-3 years old

• Participates in play with another person for 1 minute while using appropriate eye contact
• Repeats words spoken by others
• Has a word for almost everything
• Speaks in two-three word sentences
• Asks what or where questions (e.g. “what’s that?”)
• Ask yes and no questions
• Will add “no” in front of verbs to refuse activities (e.g. “no go”)
• Imitates turn-taking in games or social routines
• Games. Simple turn-taking games help children learn how to wait and take turns which is a necessary skill in conversations. Fun toddler games include Let’s Go Fishin’ , Seek-a-boo , and Hi Ho Cherry-O .
• Expand sentences. Imitate your child’s speech and add on extra words to make it grammatically correct. For instance, if you child says “more juice”, you can repeat “I want more juice”.

3-4 years old

• Names objects in photographs
• Uses words for a variety of reasons (requests, labels, repetition, help, answers yes/no, attention)
• Around 3 years, child combines 3-4 words in speech
• Answers simple who, what, and where questions
• Uses about 4 sentences at a time
• Child’s speech can be understood by most adults
• Asks how, why, and when questions
• Yes/no game. Make a game out of yes/no questions by asking your child funny questions such as “Is your name Bob?”, “Can you eat dirt?”, “Do you like ice cream?” Then have your child make up silly questions to try to trick you!
• Ask questions. While running errands, ask your child questions about the community. For instance, “where do we buy food?”, “who helps you when you are sick?”, or “what do you do if it’s raining?”

4-5 years old

• When given a description, child can name the described object. For example, “What is round and bounces?”
• Answers questions logically. For example, “what do you do if you are tired?”
• Uses possessives (the girl’s, the boy’s)
• Tells a short story
• Keeps a conversation going
• Talks in different ways depending on the place or listener
• I-spy. Describe common objects around the house by giving descriptive clues such as what it looks like, what you do with it, where you would find it, etc. Have your child guess what you are talking about! Include objects out of sight to encourage your child to determine objects on their own, and then have them go on a scavenger hunt to find it.
• Make up stories. Build a blanket fort, grab a flashlight, and create fairy tale stories. Toys may be used as prompts to help make up a story. Incorporate each part of a story including setting, characters, beginning, middle, and end.

5-6 years old

• Child can tell you what object is and what it’s used for
• Answers questions about hypothetical events. For example, “What do you do if you get lost?”
• Uses prepositions (in, on, under, next to, in front of) in sentences
• Uses the possessives pronouns her and his
• Names categories of objects such as food, transportation, animals, clothing, and furniture
• Asks grammatically correct questions
• Completes analogies. For instance, you sleep in a bed, you sit on a chair
• Uses qualitative concepts short and long
• Category games. Name 5 , Scattergories , and Hedbanz are fun and engaging games to work on naming categories.
• Simon says. Play a game of simon says using prepositions. For instance, Simon says put the book on the table. Once your child is familiar with the game, have them be Simon and give directions using prepositions.

6-7 years old

• Child is able to names letters
• Answers why questions with a reason
• Able to rhymes words
• Repeats longer sentences
• Able to retell a story
• Describes similarities between two objects

Activities at Home

• Read rhyming books. Dr. Seuss books are great to teach rhyming. Read a page and have your child identify the words that rhyme.
• Movies. After watching a movie, have your child summarize the plot. Guide your child by breaking it up into beginning, middle, and end.

If you feel your child is developmentally delayed in his or her expressive language skills, contact Lumiere Children’s Therapy for a speech-language evaluation. Our speech therapists can formally assess your child’s expressive language skills, create age-appropriate goals, and develop a therapeutic program unique to your child’s needs.

“Baby Talk: Communicating With Your Baby.” WebMD , WebMD, www.webmd.com/parenting/baby/baby-talk#2 .

Expressive Language (Using Words and Language). (n.d.). Retrieved from https://childdevelopment.com.au/areas-of-concern/using-speech/expressive-language-using-words-and-language/

“How to Support Your Child’s Communication Skills.” ZERO TO THREE , www.zerotothree.org/resources/302-how-to-support-your-child-s-communication-skills .

Mattingly, R. (2018, September 13). Typical Development . Lecture presented in University of Louisville, Louisville.

Zimmerman, Irla Lee., et al. PLS-5 Preschool Language Scales: Fifth Edition. NCS Pearson, 2011.

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Learning to talk: 3 to 5 years

Your child will soon be putting words together to form sentences and you can encourage them to chat by asking lots of questions.

Try to get into the habit of asking them to tell you about their day, whether that's on the way home from nursery or over dinner. Let them take the lead and enjoy what a little story teller they're becoming!

Video: Talk to each other when you're out and about

Watch dad talk to his daughter about what they see and hear on their journey to the park. He mimics the sounds of what he sees and gets his daughter to join in too.

Activities for your daily routine

Counting during mealtimes is an excellent way to teach your child about numbers.

To get started, cut the food into small pieces and count each item as you place them on your child's plate. Group similar foods together and let your child know what's on their plate and how many of each item there is.

Then, count everything as a total. For example, you could say, "You have two pieces of toast and three slices of apple. How many do you have in total?".

Don't worry if your child wants to try the food along the way. Cut some extra pieces so you have enough for the task.

Choose finger foods for counting

Choose foods that are solid and big enough for your child to pick up and count. Use your fingers to count visually and ask your child to count with you.

Prepare food together

If you’re baking or preparing food at home, get your child involved in the preparation. Let them help with counting and measuring the ingredients.

Interactive story time is a fun activity to do with your child. It helps them communicate, express themselves, and move around.

When you read a story next, try copying things from the book. For example, if the story talks about a tree, pretend to be a tree.

To act like a tree, lift your arms and move them like leaves in the wind. Make sure you have enough space for both you and your child to join in.

Set the scene

You could really bring the story to life through using audio. You could search for background music that reflects the story, for example the sounds of birds or rain.

Choose a book they know well

See if your child can fill in the gaps in parts of the story by telling you what happens next.

Out and about

Listen out for sounds and noises when you're walking or travelling together.

If something takes your child's interest, ask them to explain what they can hear and see.

You could ask questions like "is it a loud sound?" or "have you heard it before?".

To make the task more fun, ask your child to copy the noise to see if they can recreate it.

Later on, you can ask them again what they saw and heard.

Help your child to focus

At this age, your child may be paying attention to many things at once. To help them listen, try using phrases like "Please stop, it's time to listen".

Create a story about sounds

You could get creative and make up a story together about the noisy bus you got on earlier or the baby you saw in the park.

Video: Read and talk about books together

Watch mum being led by the child’s book interests during reading time. She reads familiar books so her son can anticipate what’s coming next.

Little tips for everyday play

• start conversations by asking questions with lots of possible answers, for example, "What is your favourite toy?" and "What do you want to do tomorrow?"
• encourage them to problem solve, for example "Your favourite hat is missing, what shall we do?"
• when you're looking at picture books together, ask your child if they remember what happens or if they can guess what happens next
• chat about words that start with the same sound, for instance, words beginning with "p"
• think of as many rhyming words as you can for different objects you can see
• try role-playing games together, like shopping – set items out on the sofa, give your child a bag and some pretend money, and take it in turns to be the shopkeeper
• play a make-believe journey like going into space – make a rocket out of a cardboard box you decorate together, or cushions, and pile in a few toy passengers
• start a simple game with your child by making up a story together about their favourite toy going to the beach and encourage your child to take the lead
• play "I spy!"
• a fun way to help your child listen and learn new words is to create an obstacle course with blankets and cardboard boxes and set challenges like, "Crawl under the blanket" or "Sit in the box" – take it in turns so they can practise giving the instructions

Tiny Happy People on the BBC website has fun activity inspiration to help your child learn to talk, play and sing.

Libraries are a free way to access age appropriate books. Some also run story time sessions for parents and their children. Find your local library service on gov.uk .

Your local council may offer activities too. Find learning activities for your child on gov.uk .

Family hubs

Family hubs offer support to children, young people and their families. They provide a single place to go for support and information from a variety of organisations, making it easier to get the support you need.

They can provide guidance on issues such as feeding your baby or toddler, mental health and parenting support.

Family Hubs are currently operating in 75 local authorities across England.

How to help their speech development

• use things your child is interested in for play, follow their lead and make sure you're physically at their level while playing
• if you notice your child looking or pointing at something, talk to them about it before they lose interest in it
• picture books introduce your child to new things they haven't seen yet in real life – ask them to tell you the story, or talk about what the characters might be thinking and feeling
• make reading, singing and playing even more fun by using lots of actions and different voices
• take turns to make noises or speak – your child will be able to hold longer conversations, so slow down your speech, give them plenty of time to respond and listen carefully to what they have to say
• talk to your child in short, simple sentences, as it's easier for them to understand you and have a go at copying when they are ready
• try to use the same book or sing the same song, as young children learn a lot from repetition

Learning more than 1 language

It's important to talk to your child in the language or languages you use.

A child learning more than 1 language should babble and say their first words in the same way as a child learning one language.

It is important not to confuse this slight delay with language difficulties – most children quickly catch up.

For more help on languages, have a look at the parent's questions on the National Literacy Trust website .

Help and advice

If your child is in nursery, the nursery will continue to review their development. When your child goes to school, your health visitor will inform the school nursing team about any extra support they're having.

If your child needs extra support, your health visitor or the school nurse can help. They may put you in touch with a speech and language therapist and you may also be offered support.

Ask your health visitor for support whenever you need it, they will be able to provide tips and advice.

Remember, children learn to talk at different ages. If you are worried, speak to your health visitor or nursery key worker. Or contact your local speech and language therapy service for advice.

For more ideas on how you can help your child, visit:

• Royal College of Speech and Language Therapists: Speech and language therapy
• Speech and Language UK

Early learning and development

90% of your child's brain growth takes place before they turn 5. Discover more advice and activities for ages 0 to 5 to help you make the most of every moment.

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JEDDA RUPERT, MD, PAMELA HUGHES, MD, AND DANIEL SCHOENHERR, MD

Am Fam Physician. 2023;108(2):181-188

Patient information: See related handout on speech and language delay in children .

Author disclosure: No relevant financial relationships.

Childhood speech and language concerns are commonly encountered in the primary care setting. Family physicians are integral in the identification and initial evaluation of children with speech and language delays. Parental concerns and observations and milestone assessment aid in the identification of speech and language abnormalities. Concerning presentations at 24 months or older include speaking fewer than 50 words, incomprehensible speech, and notable speech and language deficits on age-specific testing. Validated screening tools that rely on parental reporting can serve as practical adjuncts during clinic evaluation. Early referral for additional evaluation can mitigate the development of long-term communication disorders and adverse effects on social and academic development. All children who have concerns for speech and language delays should be referred to speech language pathology and audiology for diagnostic and management purposes. Parents and caretakers may also self-refer to early intervention programs for evaluation and management of speech and language concerns in children younger than three years.

Speech is the verbal production of language. Language is the processing of a communication system. Receptive language includes an individual's comprehension abilities. Expressive language includes conveying ideas in spoken, written, or visual forms. 1

Speech delays stem from difficulty with speech or language processing or both. Speech and language delays usually result in the ultimate achievement of normal skills but at a slower rate than expected. 2 Family physicians play an important role in prompt identification of speech and language delays to mitigate the development of communication disorders, which hinder a child's development with long-lasting adverse social and academic impacts.

Speech and Language Development

Distinct milestones mark development by age ( Table 1 ) . 3 , 4 Early speech includes sounds, such as cooing and babbling, and later incorporates word combinations that lead to full sentences. Language development begins with basic comprehension that builds to advanced language skills, including the expression of complex thoughts. Evidence suggests that critical language development occurs in the first six months of life 5 and that early childhood language exposure significantly influences a child's language mastery. 3

Parents and caregivers significantly influence children's speech and language development by engaging them and promoting social interactions. Family physicians should encourage parents and caregivers to speak to babies and children often, with simplified sentences and clear pronunciation of words. Reading and play are rich opportunities for speech and language promotion that can be integrated into daily routines, helping children build vocabulary and comprehension skills. 6 – 9 The American Academy of Pediatrics recommends limiting children's screen time in favor of activities focused on social interactions 10 ; screen time has been associated with developmental delays. 11 , 12

Epidemiology

In the United States, up to 1 in 8 children between two and five years of age has a speech or language delay. 5 Preschool children with identified speech and language delays that continue into elementary school have a higher risk of additional learning disabilities compared with children with only transient speech and language delays. 13 , 14 School-aged children with speech and language delays have up to a fivefold higher risk of poor reading skills that can affect the child into adulthood. 14 , 15 Adults with a history of childhood speech or language delay are more likely to work lower-skilled jobs and experience unemployment. 14 , 15 Additionally, these childhood speech and language delays are associated with behavior and psychosocial impairments that can persist into adulthood. 14 , 15

Risk Factors

In 2010, the American Speech-Language-Hearing Association published a large study of nearly 5,000 children with a multivariate analysis to identify risk factors consistently associated with established outcome predictors of speech and language impairment, such as parental concerns, use of speech-language pathology services, and low receptive scores. 12 The most important risk factors for speech and language impairment were being male, ongoing hearing problems, and birth weight 2,500 g or less ( Table 2 ) . 12

Several other factors have not been reliably associated with speech and language delays. Although heterogeneously impacted, children negatively affected by social determinants of health or adverse childhood or family experiences should be considered at-risk of speech and language delay. 8 , 12 Later birth order is not associated with speech and language delays. 12 Multilingual environments, as well as regional, social, and cultural variations, can affect initial speech and language development, most often with an ultimate return to a normal development pattern after the early childhood years. 16

Children simultaneously learning two or more languages spend less time with each language, and multilingual children tend to perform lower on standardized language tests compared with similarly aged monolingual children. 16 Nonetheless, bilingual status is not associated with increased risk of speech and language delays, and the language used to screen for delays does not affect their identification. 12 , 16

Screening and Surveillance

In the primary care setting, speech and language delay may be identified through milestone surveillance and the use of formal screening tools to assess milestone progression. Screening is the use of validated, standardized tools at specific ages to identify developmental delays. 5 Surveillance, the process of recognizing at-risk children, comprises eliciting caregiver concerns, reviewing developmental history, identifying risk factors, and observing the child during the visit. 3

The American Academy of Pediatrics guidelines recommend surveillance at every well-child visit, with particular attention before elementary school entry at four to five years of age. 3 In February 2022, the American Academy of Pediatrics, using Centers for Disease Control and Prevention (CDC) guidance, released updated milestones ( Table 1 3 , 4 ) and related parent-oriented materials to facilitate milestone surveillance. 4 These evidence-based milestones reflect skills that most children (at least 75%) should achieve at the specified age. 4 The CDC's comprehensive list of milestones, Milestone Tracker app, and additional free resources can be accessed at https://www.cdc.gov/ActEarly/Materials . American Family Physician published an editorial about the CDC's revised milestones. 17 Children with parental, caretaker, or physician concerns based on surveillance should undergo developmental screenings. 3

The American Academy of Family Physicians currently supports the U.S. Preventive Services Task Force 2015 recommendation, which states that there is insufficient evidence to recommend for or against universally screening asymptomatic children five years or younger for speech and language deficits with a validated tool. 5 , 18 The U.S. Preventive Services Task Force concluded that no screening tool is superior for identification of milestone delays at any age, based on a systematic review. 5 , 15

Multiple screening tools are available for milestone assessments. Screening tools that rely on parental report are common in the primary care setting because of ease of completion and no need for trained examiners. 15 The Ages and Stages Questionnaire evaluates communication, gross motor, fine motor, problem-solving, and personal-social domains for children up to five-and-half years of age ( https://agesandstages.com/ ), whereas the Survey of Well-Being of Young Children combines assessments of developmental milestones, childhood behavioral symptoms, and family context from infancy to five years of age ( https://pediatrics.tuftsmedicalcenter.org/the-survey-of-wellbeing-of-young-children/overview ). Other tools relying on parental report focus predominantly on language and speech concerns (e.g., the Communicative Development Inventories [ https://mb-cdi.stanford.edu/ ] and the Language Development Survey [ https://aseba.org/research/the-language-development-survey-lds/ ]). Screening tools requiring trained examiners, such as the Screening Kit of Language Development, are not practical for use in primary care and do not identify speech and language issues more effectively than less complicated screening methods. 15

Initial Evaluation

The differential diagnosis for speech and language delays is broad. These delays can be classified as secondary to other conditions or as primary conditions without apparent underlying causes. 2 , 19 Table 3 outlines common primary and secondary causes of speech and language delays. 2 , 20 – 25 Many neurodevelopmental disorders cause secondary speech and language delays. Associated disorders can predominantly affect development of speech, language, or both.

Family physicians can elicit clues from the child's history provided by parents or caretakers to augment milestone surveillance and to identify speech and language delays and associated causes ( Table 4 ) . 1 , 2 , 22 Any abnormal surveillance warrants additional evaluation with a validated screening tool. Pertinent physical examination elements include the HEENT (head, eyes, ears, nose, and throat) examination, with particular attention to the ears and mouth for structural abnormalities, such as cleft palate, and a neurologic examination to assess for motor dysfunction. 22

Referral Recommendations

Specialist consultation is appropriate for children with screening abnormalities, parent concerns, or physician concerns, 3 , 19 , 22 beginning with speech-language pathology and audiology evaluations. Watchful waiting is not recommended for late talkers, such as children with a vocabulary of fewer than 50 words at 24 months or older or without word combinations or children not meeting screening test thresholds. 3 , 26 Delays in care may result in long-lasting adverse effects on communication development. 26 One study focusing on children with speech and language delays persisting into school age noted an association between long-standing speech and language abnormalities and social and attention deficits. 14 The American Speech-Language-Hearing Association recommends early identification and treatment of speech and language delays to minimize these adverse effects on social development and school performance. 22

Immediate referral should be considered for expressive or receptive language concerns or deficits noted after two years of age, speech and language milestone regression, and speech that remains incomprehensible after two years of age. 19 , 22 , 26 Referral criteria are the same for monolingual and bilingual children. Speech and language interventions are most effective when introduced in all spoken languages, which may require the assistance of interpreters. 21

The American Academy of Pediatrics recommends universal hearing screening after birth; at four, five, six, eight, and 10 years; and between 11 and 14 years, 15 and 17 years, and 18 and 21 years. 27 If testing has not recently been performed in a child with a suspected speech or language delay, an audiologist should evaluate for underlying hearing loss. 27 When speech and language delays are suspected to be secondary to neurodevelopmental disorders, physicians can also consult behavioral health specialists, including pediatric psychologists and psychiatrists, for further evaluation and management. Specialists in pediatric neurology and developmental pediatrics are helpful for diagnosis and treatment, although local availability may be limited. Figure 1 outlines an approach to the initial evaluation and management of a child with speech and language concerns.

Early Intervention

Early intervention programs are government-funded multi-disciplinary programs designated to support families with young children and infants with developmental delays. These self-referral programs offer speech and language therapy, occupational therapy, and physical therapy services to children younger than three years. Services are free of charge or priced according to income. Parents and guardians of children younger than three years can directly contact state-run early intervention programs through information found on the CDC website ( https://www.cdc.gov/ncbddd/actearly/parents/state-text.html ). Parents and guardians of children three years or older can contact any local public elementary school to request school system evaluation for special education services, regardless of whether the child is enrolled at that facility. Parents may find additional information on the associated CDC website ( https://www.cdc.gov/ncbddd/actearly/concerned.html/#childthree ).

This article updates previous articles on this topic by McLaughlin 1 and Leung and Kao . 28

Data Sources: PubMed and Cochrane databases were searched using terms speech, language, and developmental delay. The search included randomized controlled trials, meta-analyses, clinical trials, and clinical reviews. Additionally, an Essential Evidence Plus summary report on this topic was used to assist in the literature review. Search dates: February 2023 and June 21, 2023.

The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Uniformed Services University of the Health Sciences, the U.S. Air Force, the U.S. Department of Defense, or the U.S. government.

McLaughlin MR. Speech and language delay in children. Am Fam Physician. 2011;83(10):1183-1188.

Neurodevelopmental disorders. In: Diagnostic and Statistical Manual of Mental Disorders . 5th ed. American Psychiatric Association; 2013: 31–96.

Lipkin PH, Macias MM; Council on Children With Disabilities, Section on Developmental and Behavioral Pediatrics. Promoting optimal development: identifying infants and young children with developmental disorders through developmental surveillance and screening. Pediatrics. 2020;145(1):e20193449.

Zubler JM, Wiggins LD, Macias MM, et al. Evidence-informed milestones for developmental surveillance tools. Pediatrics. 2022;149(3):e2021052138.

Siu AL. Screening for speech and language delay and disorders in children aged 5 years or younger: US Preventive Services Task Force recommendation statement. Pediatrics. 2015;136(2):e474-e481.

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