Journal of Child and Adolescent Psychiatric Nursing ISSN 1073-6077

Warning Signs in the Development of Speech, Language, and Communication: When to Refer to a Speech-Language

Pathologistjcap_292 175..184 Lorain S. Wankoff, PhD

Lorain S. Wankoff, PhD, is Speech-Language Pathologist, Windward School, White Plains, New York, USA.

Search terms: TOPIC: Because of the link between communication impairments and psychiatric Collaboration, communication, speech and disorders, it is important for nurses and other healthcare professionals to know the language delay, speech and language warning signs for the need for a communication/speech/language evaluation for evaluation, speech-language pathology children during infancy through early childhood. Author contact: PURPOSE: This article presents an overview of the role of speech-language [email protected]; [email protected], pathologists (SLPs); the expected developmental achievements for youngsters from with a copy to the Editor: [email protected] infancy to age 5 in speech, language, and communication; and the clinically signifi- cant warning signs that indicate a need for speech/language assessment. doi: 10.1111/j.1744-6171.2011.00292.x SOURCES: Sources for this article included published literature on the topic along with the clinical judgment and expertise of the author, a certified SLP. CONCLUSIONS: Warning signs for referral to an SLP may be subtle and may present in developmental, academic, behavioral, or social–emotional realms. Col- laboration between nurses and communication professionals will allow for early identification and intervention. Early detection of speech and language disabilities is key to maximizing the effects of early intervention, resulting in more positive com- munication outcomes in later life. It has been found that speech and language delays and disorders, with symptoms left untreated, can cause difficulties in learning and socialization that can last into adolescence and beyond. Early identification of chil- dren with developmental delay or developmental disabilities may lead to interven- tion at a young age when chances for improvement may be best.

higher risk for developing reading disabilities (Catts & When to Refer to a Speech-Language Kamhi, 2005). Other areas of interest to the SLP include the Pathologist (SLP): Language and child’s temperament, his or her cognitive development, and Communication Warning Signs in Children sensory and motor developments, as well as behavioral Healthcare providers and psychiatric professionals,who work regulation. with children and their families, are in a unique position to identify warning signs or symptoms of possible communica- What Are the Risk Factors for Speech and tion, language, and speech disabilities. Early detection of Language Disabilities? these warning signs and referral for a communication, lan- guage, and speech assessment is important for the well-being The most consistently reported risk factors for speech and of a particular child. Thus, collaboration and the sharing of language difficulties include a family history of speech and information between the mental health professional and language delay, male gender, premature delivery, and low speech-language pathologist (SLP) are of utmost importance. birth weight. Early identification of children with develop- Speech and language deficits can be indicators of psychiat- mental delay or developmental disabilities, such as marked ric conditions or developmental disorders. For example, hearing deficits or craniofacial abnormalities, will lead to youngsters with deficits in the pragmatic component of lan- intervention at a young age when chances for improvement guage (i.e., the social use of language) may be at greater risk may be best. It has been found that speech and language for autism (Prizant & Meyer, 1993). In the school-age years, delays and disorders with symptoms left untreated can cause children with rapid naming or word retrieval deficits are at difficulties in learning and socialization that can last into

Journal of Child and Adolescent Psychiatric Nursing 24 (2011) 175–184 © 2011 Wiley Periodicals, Inc. 175 Warning Signs in the Development of Speech, Language, and Communication: When to Refer to a Speech-Language Pathologist adolescence and beyond. Particular evidence has been found especially in the areas of autism and specific language impair- for the efficacy of speech and language intervention for ment (Dale, Price, Bishop, & Plomin, 2003; Tager-Flusberg expressive, phonological, and vocabulary deficits (Abbeduto et al., 2009; Wetherby et al., 2004). However, this article is not & Boudreau, 2004; Law, Garrett, & Nye, 2003; U.S. Preventive meant to be a primer on specific language and speech disor- Services Task Force [USPSTF], 2006). ders. For further study, there are scholarly and popular resources that are available, which outline the predictors and risk factors for language growth in children, as well as symp- What Is the Link Between Psychiatric toms of specific speech and language disabilities (Agin, Geng, Disorders and Speech and Communication & Nicholl, 2003; Brinton et al., 2007; Chapman, 2007; Paul, Disorders? 2007; Weismer, 2007). The link between communication impairments and psychiat- ric disorders is evident to most mental health professionals What Is the Current Domain of the SLP? (Nelson, Benner, & Cheney, 2005). The Diagnostic and Statis- tical Manual, Fourth Edition–Text Revision of the American The domain of the SLP was expanded and dramatically Psychiatric Association (2000) described the developmental revised beyond simply articulation, voice, and stuttering as a disabilities that include speech and language deficits as part of result of the“linguistics revolution”in 1957 (Chomsky,1957). the criteria for diagnosis, e.g., mental retardation, pervasive Since then, “SLPs” have developed standardized and non- developmental disorder, and autism spectrum disorders. In standardized methods of assessing the essential components addition, there are behavioral and/or emotional disabilities of language including form (syntax, morphology, phonology, where speech and language deficits may be comorbid and and suprasegmental features of language, such as intonation, often do co-occur (e.g., attention deficit disorder, opposi- pitch, volume, stress, and juncture), content (semantics), and tional defiant disorder, conduct disorder, overanxious disor- use (pragmatics), as well as the essential features of speech der, or dysthymia; American Psychiatric Association, 2000; including articulation, voice, and fluency (Lahey, 1988). It is Giddan, 1991). only in the last decade that the scope of practice for the SLP According to the USPSTF (2006), “speech and language has broadened to include the domains of reading and writing delay affects 5% to 8% of preschool children.” These delays (American Speech-Language-Hearing Association, 2001; often persist into the school years and may be associated with Foster & Miller, 2007). lowered school performance and psychosocial problems. In a SLPs also assess and treat speech-related deficits in oromo- recent epidemiological study, Pinborough-Zimmerman et al. tor functioning, which impact feeding, sucking, or swallow- (2007) found a great degree of overlap between speech and ing abilities or dysphagia. It should be noted that feeding language impairments and other psychiatric disabilities. abilities are required for the health and development of the Their results indicated that the prevalence of communication youngster and are prerequisite to the development of early disorders among 8-year-olds in one area of the United States communication skills (American Speech-Language-Hearing was 6.3% of the population (of 1,000 children). Furthermore, Association, 2008; Kent & Vorperian, 2007). the percentage of communication disorder cases with autistic The social–emotional development of the child is of para- spectrum disorder was 3.7%, and the overall proportion of mount importance because children with significant attach- communication disorder cases with intellectual disability was ment and regulatory disorders may display communication 4%. The most frequent emotional/behavioral disorder delays. For example, for the very young infant, parental con- co-occurring with communication disorders was attention cerns may be expressed regarding the baby that is difficult to deficit hyperactivity disorder (6.1%) followed by anxiety dis- engage or soothe. Deficits in social–emotional development order (2.2%), and conduct disorder (1.1%). and/or sensory regulation may be coupled with difficulties Research indicates that a large proportion of children initiating or maintaining engagement with others. Similarly, admitted for psychiatric care have language challenges and toddlers or preschoolers may be reported or observed to be that most children with substantial language disabilities have excessively shy, quiet, anxious, inattentive, or withholding psychosocial difficulties. Unfortunately, these problems (Geller & Foley, 2009; Gerber & Wankoff, 2010; Greenspan, worsen for adolescents with language impairment, as the DeGangi, & Weider, 2001; Guralnick, 2005). challenges in older children are linked not only to psychiatric As cognitive abilities are linked to language abilities during disorders but to teenage suicide as well (Baltaxe,2001; Benner, a young child’s growth and development, researchers in child Nelson, & Epstein, 2002; Fujiki, Brinton, & Clarke, 2002; language have learned to view play as a window to the cogni- Toppleberg, Medrano, Pena Morgens, & Nieto-Castanon, tive development of a young child (Westby, 2000). While 2002; Way, Yelsma, Van Meter, & Black-Pond, 2007). some states require a significant gap between cognition and Evidence-based practice and research in assessment and language for a child to be eligible for speech and language ser- intervention for language disabilities have led to recent work vices, research suggests that some children without a discrep-

176 Journal of Child and Adolescent Psychiatric Nursing 24 (2011) 175–184 © 2011 Wiley Periodicals, Inc. Warning Signs in the Development of Speech, Language, and Communication: When to Refer to a Speech-Language Pathologist ancy in their cognitive and language profiles can benefit from tures, or vocalizations), might be at greater risk for a commu- speech and language intervention as well (American Speech- nication and/or language disability (Greenspan et al., 2001; Language-Hearing Association, 2008; Carr & Felice, 2000; Zero to Three, 2005). Cole, Coggins, & Vanderstoep, 1999). Children that exhibit little evidence of exploratory play or For the toddler, preschooler, or school-aged child, chal- interest in the environment or minimal sensory exploration lenges in behavioral regulation may be an indicator for the through vision, touch, or hearing should also be further need for a speech and language evaluation. Similarly, the assessed by an SLP (Westby, 2000). youngster with behavioral noncompliance, inattentiveness, or poor frustration tolerance may also have subtle weaknesses in communication and/or language skills that can be identi- What Are the Warning Signs at 8–12 Months? fied and treated by competent and well-trained SLPs (Fujiki et al., 2002; Giddan, 1991; Hill & Coufal, 2005; Hyter, While 8–12-month-old babies are not expected to be con- Rogers-Adkinson, Self, Simmons, & Jantz, 2001; Nelson et al., versing at this age, nonverbal communication must be care- 2005). fully scrutinized. The child who typically does not produce a According to speech and language development research, plethora of communicative acts (e.g., joint attention or ges- the specific language and cultural background of a child has a tural communication) can be a candidate for the SLP to marked impact on the nature and course of the child’s first- assess. In particular, the child who rarely uses facial expres- and second-language acquisition if the child is bicultural. sion and gesture, as well as the child who rarely requests This information enables the SLP to distinguish language dif- attention, requests actions, or requests objects, or who rarely ferences from language disabilities (American Speech- protests may be at greater risk for communication, Language-Hearing Association, 2008; National Association language, and speech disturbances (American Speech- for the Education of Young Children, 2005). Language-Hearing Association, 2008; Crais, Douglas, & Healthcare professionals that come in contact with chil- Campbell, 2004; Crais, Watson, & Baranek, 2009; Paul, dren and their families must be cognizant of even subtle Chawarska, Klin, & Volkmar, 2007; Tomasello, Carpenter, & warning signs that might suggest the need for a licensed SLP Liszkowski, 2007; Weismer, 2007; Westby, 2000; Wetherby to do an in-depth assessment of communication skills. et al., 2004). Finally, the child who does not typically utilize Research in speech and language development has demon- more than one consonant or syllable in babbling might strated that in areas such as social–emotional development, benefit from the evaluation that a licensed SLP can provide behavioral regulation, and/or literacy skills, although the (Mitchell, 1997). SLPs might not be the first evaluation that is arranged, the need for further testing and/or intervention by a licensed SLP must be considered (Table 1). What Are the Warning Signs at 12–18 Months? Twelve- to 18-month-old children who lack vocal, verbal, or What Are the Warning Signs During Infancy? gestural reciprocity or turn-taking, or who are deficient in the (Below 8 Months of Age) comprehension of simple words, concepts, or one-step direc- Children with feeding difficulties, medical conditions, motor, tions should be referred for a speech and language evaluation. or sensory impairments are at greater risk for speech and lan- There are also more subtle warning signs for the need for an guage difficulties (American Speech-Language-Hearing evaluation by an SLP. For the 12–18-month-old child who is Association, 2008; Joint Committee on Infant Hearing Year, not yet searching for objects, demonstrating an awareness of 2007; Kent & Vorperian, 2007; USPSTF, 2006). Research has object function, or not yet combining objects in play, there shown that the roots of communication, language, and may be a higher risk for a speech and language disability to speech appear to reside in the “affective engagement” or develop (Kennedy, Sheridan, Radlinski, & Beeghly, 1991; “intersubjectivity,” which occur during the early months of Lyytinen, Poikkeus, Laakso, Eklund, & Lyytinen, 2001; Weth- life (American Speech-Language-Hearing Association, 2008; erby, Allen, Cleary, Kublin, & Goldstein, 2002; Wetherby, Bloom, 1995). Affect display is evident through facial expres- Cain,Yonclas, & Walker, 2008). Children who do not express a sion and gaze, gesture, and vocalization, as well as turn-taking range of meanings (e.g., use of “more,”“up,”and “bird”) or a and nonverbal conversations through the use of sound play, range of pragmatic intentions (e.g., requests, comments, and even as early as 2–3 months. greetings), or who produce fewer than two communicative In the social–emotional realm, children who have a limited acts per minute might also be at greater risk for a language range of affect display, difficulties with “affective atunement” disability later on (American Speech-Language-Hearing (i.e., little or no reciprocity either with eye gaze, body ges- Association, 2008; Calandrella & Wilcox, 2000; Crais et al.,

Journal of Child and Adolescent Psychiatric Nursing 24 (2011) 175–184 © 2011 Wiley Periodicals, Inc. 177 Warning Signs in the Development of Speech, Language, and Communication: When to Refer to a Speech-Language Pathologist

Table 1. Checklist for Language and Communication Warning Signs in Children

Age range Communication language and speech warning signs Birth to 8 months of age 1. Notable feeding difficulties. 2. Notable medical, motor, or sensory impairments (e.g., visual and hearing). 3. Little exploratory play. 4. Limited range of affect display or affective engagement. 5. Limited vocalizations. 8–12 months 1. Little to no joint attention or gestural communication. 2. Little to no affect display. 3. Little or no responsivity to others. 4. Rarely produces communicative acts (e.g., requests and protests). 5. Babbling is restricted to not more than one consonant-vowel combination. 12–18 months 1. Lack of vocal, verbal, or gestural reciprocity. 2. Lack of comprehension of simple words, concepts, or one-step directions. 3. Limited object search and object play and lack of demonstrating an awareness of object function. 4. Restricted range of meanings expressed (e.g., more, up, and bird) and/or restricted range of communicative functions expressed (e.g., requests, comments, greetings, etc.). 5. Very low frequency of communicative acts produced per minute (e.g., fewer than two per minute). 18–24 months 1. Does not combine objects in play or produce symbolic play (e.g., pretend play) schemas. 2. Meager and slow growing vocabulary. 3. Virtually no multiword utterances. 4. Lack of reciprocal communication or “circles of communication.” 5. Rarely initiates but typically imitates or echoes the language heard. 2–3 year olds 1. Lack of elaborate play schemas; prefers to play alone; does not enjoy symbolic play; and does not take pleasure in peer interactions. 2. Lack of grammatical complexity (e.g., relatively few sentences with more than one verb). 3. Does not express a range of meanings (e.g., “more juice,” “no cookie,” and “pretty baby”) or a range of pragmatic intentions (e.g., requesting objects, requesting action, protesting, and greeting). 4. Rarely initiates but typically imitates or echoes the language heard. 5. Is not typically producing a substantial number of contingent or topic-related utterances and at least five communicative acts per minute. 6. Poor intelligibility for family members, as well as strangers. 7. Persistent dysfluencies (e.g., hesitations, repetitions, prolongations, and interjections). 8. Typically noncompliant (i.e., does not follow instructions but rather “follows their own agenda”). 3–4 year olds 1. Typically not intelligible to strangers. 2. Little or no conversational competence, i.e., lack of topic initiation, maintenance, or change; little turn-taking. 3. Little or no vocabulary growth. 4. Minimal use of grammatical markers for tense, person, and number. 5. Does not discuss non-present events; has not begun to tell narratives. 6. Apparent noncompliance, inattentiveness, anxiety, or oppositionality, which can be comorbid with language comprehension deficits. Kindergarten children 1. Very poor intelligibility. 2. Poor expressive language. 3. Deficient listening comprehension. 4. Resistance to learning concepts about print, phonological awareness games (e.g., sound games), or letter-sound correspondence. 5. Numbers 2–6 above. First and second graders 1. Difficulty learning to read. 2. Poor expressive language skills (e.g., weaknesses in vocabulary, word retrieval, making inferences or ambiguity detection, and conversational skills). 3. Challenges in listening comprehension skills for conversation, television shows, movies, or jokes. 4. Apparent noncompliance, inattentiveness, anxiety, or oppositionality, which can be comorbid with language comprehension deficits. Third and fourth graders 1. Poor expressive language (i.e., difficulty answering questions or formulating verbal messages or managing conversations). 2. Deficits in listening and/or reading comprehension. 3. Challenges in decoding unfamiliar words. 4. Apparent noncompliance, inattentiveness, anxiety, or oppositionality, which can be comorbid with language comprehension deficits.

178 Journal of Child and Adolescent Psychiatric Nursing 24 (2011) 175–184 © 2011 Wiley Periodicals, Inc. Warning Signs in the Development of Speech, Language, and Communication: When to Refer to a Speech-Language Pathologist

2009; Kennedy et al., 1991; Mundy & Burnette, 2005). Thus, sense of efficacy on the part of the child during interactive these children would benefit from a speech and language exchanges as children develop self-esteem as communicators evaluation as well. and develop secure and rewarding relationships with caregiv- ers (Hummel & Prizant, 1993; Prizant et al., 1990; Prizant & Meyer, 1993). Thus, babies who are difficult to soothe and What Are the Warning Signs at 18–24 who rarely take pleasure from human interactions, children Months? who are excessively shy and quiet, and children who are rela- Most children at the age of 18–24 months will develop a single tively passive and nonresponsive require monitoring in the word vocabulary of at least 50 words and then will begin to areas of speech, language, and communication and/or lan- produce multiword utterances with a greater range of mean- guage comprehension or production via a speech/language ings and a greater range of pragmatic functions than at the and communication assessment. previous time frame (Gerber, 2003; Lahey, 1988). Neverthe- Play will evolve from simple exploratory play to acting out less, there are 10–15% of children who do not have the 50 knowledge of the function of objects, as well as knowledge of words at 24 months but will perform up to par on standard- the relationships among people,objects,and events.At 2 years ized measures when they are 3 or 4 years of age. The 50-word of age, the child can pretend that one object represents some- criterion at 24 months of age can be used as a red flag for thing else, e.g., a cloth as a quilt or blanket (American Speech- screening more broadly and for monitoring the child’s speech Language-Hearing Association, 2008; Kennedy et al., 1991; and language development more closely over time. Children Lyytinen et al., 2001). who are late talkers and who have very slow vocabulary growth between 24 and 36 months are likely to have poorer What Are the Warning Signs for grammatical outcomes at age 3 (American Speech-Language- 2–3-Year-Olds? Hearing Association, 2008; Rescorla, 2002; Rescorla, Mirak, & Singh, 2000). In addition, it is expected that the 18–24 month The 2–3-year-old child with typical speech and language skills old will be participating in “circles of communication” turn- is typically capable of engaging in mini conversations and taking and reciprocity with those around him or her syntactically complex language (a good indicator of begin- (Greenspan, 1992; Greenspan et al., 2001; Zero to Three, ning syntactic complexity is the presence of more than one 2005). verb). Typical warning signs displayed by children of this age Warning signs for the need for a communication, lan- group, which indicate the need for an evaluation by an SLP, guage, and speech assessment for 2–3-year-olds may be are the following: These youngsters do not yet combine manifested in the communication, language, or speech skills objects in play or typically produce symbolic play schemas (or lack thereof) within any of the components of language (e.g., pretending an object is something other than the object or any of the parameters of speech. Despite the fact that itself) (American Speech-Language-Hearing Association, children continue to make errors of over-regularization 2008; Kennedy et al., 1991; Lyytinen et al., 2001). Thus, they (such as “goed” for “went”) and overgeneralization of mor- might be at higher risk for speech and language challenges. phophonological rules (such as “sheeps” for “sheep”), chil- Other typical warning signs for the need for a communica- dren will be increasingly proficient in using a variety of tion language and speech assessment for children in the inflections and morphophonological markers including 18–24-month range may include a meager vocabulary at 24 markers for tense, person, and number (Lahey, 1988; Paul, months, very slow vocabulary growth beyond 24 months 2007; Westby, 2000). (American Speech-Language-Hearing Association, 2008; A warning sign may even include a lack of elaborate play Rescorla et al., 2000), virtually no multiword utterances pro- schemas on the part of the child (American Speech- duced, and/or a lack of reciprocal communication or circles of Language-Hearing Association, 2008; Paul, 2007; Westby, communication (Greenspan et al., 2001; Zero to Three, 2005). 2000). The child whose language is characterized by a lack of If a child rarely initiates language but, rather, typically imi- grammatical complexity (e.g., relatively few sentences with tates or echoes the language that he or she hears, healthcare more than one verb) and, as in the prior stage, language that professionals must be vigilant in recommending a speech and typically does not express a range of meanings (e.g., “more language evaluation (Gerber, 2003). juice,”“no cookie,”and“pretty baby”) or a range of pragmatic Deficits in the social–emotional realm may be less discrete intentions (e.g., requesting objects, requesting action, pro- and obvious than the typical speech and language warning testing, and greeting) needs further screening or evaluation signs. Research has indicated that social–emotional difficul- by an SLP (Gerber, 2003; Lahey, 1988). The child who rarely ties in children are often comorbid with communication initiates language but rather typically imitates or echoes the and/or language disabilities (Bates, O’Connell, & Shore, language that he or she hears must be referred for a commu- 1987). Social–emotional development involves a growing nication language and speech evaluation (Paul, 2007). Also, a

Journal of Child and Adolescent Psychiatric Nursing 24 (2011) 175–184 © 2011 Wiley Periodicals, Inc. 179 Warning Signs in the Development of Speech, Language, and Communication: When to Refer to a Speech-Language Pathologist

2–3-year-old who is not typically producing a substantial inattentiveness, anxiety, or oppositionality, which can be number of contingent or topic-related utterances and at least and frequently are comorbid with language comprehension five communicative acts per minute would also benefit from a deficits. referral to an SLP (Crais et al., 2009; Wetherby et al., 1988). For the 2–3-year-old whose intelligibility is poor for family What Are the Warning Signs for Kindergarten members, as well as strangers, or whose speech is character- Children? ized by persistent dysfluencies (e.g., hesitations, repetitions, prolongations, and interjections), a communication, lan- For this age group, children are expected to develop “emer- guage, and speech evaluation is in order (American Speech- gent literacy”skills or concepts about print. These crucial pre- Language-Hearing Association, 2008; Paul, 2007). cursory skills for reading and writing include the following: Less obvious warning signs might be found in the how to hold a book, how to turn the pages of a book, a famil- behavioral or socio–emotional realm. Preschoolers who are iarity with logos, and a beginning awareness of “metalinguis- typically minimally verbal, who prefer to play alone or not tic skills” (i.e., an awareness of words, syllables, sounds, and at all, and who do not enjoy symbolic play may be camou- letters) (Justice & Kaderavek, 2004). A critical metalinguistic flaging deficits in communication, language, or speech. skill that appears toward the end of kindergarten is “phono- Similarly, preschoolers who are typically noncompliant, who logical awareness.” Phonological awareness skills, such as do not appear to take pleasure from peer interactions, and word recognition,syllable segmentation,sound isolation,and who do not follow instructions but rather “follow their own categorization, indicate a readiness for the awesome task of agenda” may be camouflaging relative weaknesses in learning to read. communication or in the comprehension or production of The child who will be successful in learning to read will language. develop an array of important metalinguistic skills that enable the child to be analytical about language within any of the components of language. Thus, with regard to the sounds What Are the Warning Signs for of the native language, the child may begin to demonstrate a 3–4-Year-Olds? rhyming ability.Metalinguistic skills also include the ability to Typically, developing children in this age category become make judgments about grammaticality or detect linguistic even more linguistically capable especially with peers. These ambiguity (multiple meanings). Recent research has docu- children have begun to use grammatical markers in their mented the link between metalinguistic ability and reading expressive speech (Brown, 1973; Hadley, 2006). If there has skills (Cairns, Waltzman, & Schlisselberg, 2004; Wankoff & been exposure to mainstream narratives in the culture of the Cairns, 2009). child, the ability to tell a story sequentially will also begin to Notable deficits in speech intelligibility, language produc- appear (Owens, 2008; Paul, 2007). Intelligibility is sufficient tion, or communication would constitute significant warning so that people outside of the family will usually understand signs for the need for a referral. More subtle signs for kinder- his speech. garteners include deficits in listening or language compre- The need for a communication, language, and speech hension and little interest in learning concepts about print. assessment is reflected by little or no conversational compe- Poor metalinguistic skills (e.g., word identification, syllable tence including a lack of topic initiation, topic maintenance, segmentation, or phoneme awareness, e.g., the ability to topic change, and little turn-taking in conversations (Gerber, isolate, categorize, or segment sounds), as well as little interest 2003; Lahey, 1988). Again, if there has been little or no in or knowledge about the links between sounds and letters vocabulary growth, a referral to an SLP is in order (Rescorla (i.e., phoneme/grapheme correspondences), would indicate et al., 2000). Three to 4-year-olds who have minimal use of that a referral to an SLP would be advisable in order to rule grammatical markers for tense, person, and number are also out any concomitant speech and language challenges (Catts, in need of a communication, language, and speech evaluation Adolf, Hogan, & Weismer, 2005; Hogan, Catts, & Little, 2005; (Hadley, 2006). Puolakanaho et al., 2008). Less obvious signs include the 3–4-year-old who is not following instructions, not typically engaging in What Are the Warning Signs for First and meaningful conversation on a variety of topics, not discuss- Second Graders? ing non-present events, i.e., past or future events, and not beginning to tell narratives. Furthermore, for the child By the middle of first grade, if the child continues to have who is typically not intelligible to strangers, a communica- great difficulty learning to read, a speech and language evalu- tion speech and language evaluation is recommended ation might be warranted. Sometimes there can be subtle lan- (Lahey, 1988; Owens, 2008; Paul, 2007). Subtle warning guage weaknesses that will sabotage the child’s attempts at signs may be construed as evidence of noncompliance, moving forward with literacy skills. These weaknesses can be

180 Journal of Child and Adolescent Psychiatric Nursing 24 (2011) 175–184 © 2011 Wiley Periodicals, Inc. Warning Signs in the Development of Speech, Language, and Communication: When to Refer to a Speech-Language Pathologist manifested as difficulties with oral language in specific areas, “chicken-and-egg” phenomenon, Reed (2005) suggested that e.g., vocabulary, making inferences, and/or problems with while “Communicative failures may result in psychosocial ambiguity detection (van Kleek, VanderWoude, & Hammett, difficulties, psychosocial difficulties may be part of the syn- 2006; Speece, Roth, Cooper, & Paz, 1999; Wankoff & Cairns, drome of specific language impairment”(p. 116).As the child 2009). Thus, language weaknesses that are either obvious or with a speech and language disability is likely to have fewer subtle can wreak havoc on developing literacy skills. Particu- meaningful peer relationships than the typically developing lar problems with writing may also indicate underlying lan- child, language intervention with the speech and language- guage weaknesses (Larsen & Nippold, 2007; Moats, 2000; impaired youngster targets not only speech and language Moats & Smith, 1992; Nippold, 2007). issues but also issues of self-esteem and challenges in forming Challenges that would indicate the need for a communica- relationships with others (Baker & Cantwell, 1982; Gualtieri, tion, language, and speech assessment for first and second Koriath, Van Bourgondien, & Saleeby, 1983; Prizant et al., graders include auditory language comprehension issues for 1990). conversations, television, stories, or jokes (Slaughter & Early detection and intervention of communication, lan- McConnell, 2003). Again, challenges in letter–sound knowl- guage, and speech disabilities is critical as it is an important edge, blending abilities (e.g., the child’s ability to read novel prognostic indicator for most speech and language disabili- consonant-vowel-consonant sequences with short vowels) ties. Thus, the information discussed in this article is invalu- constitute more subtle warning signs at this stage as well. able, and collaboration among health professionals and consultants is imperative if nonspeech professionals are to be cognizant of the warning signs in speech and language devel- What Are the Warning Signs for Third and opment, as well as the possible social–emotional, behavioral, Fourth Graders? and academic challenges that may disguise underlying com- At this age range, reading aloud is characterized by automa- munication deficits. ticity. Children will typically read fluently and decode unfa- miliar words. By the third grade, good comprehension requires not only access to vocabulary but also the ability to References make inferences while reading.At this level,children will typi- Abbeduto, L., & Boudreau, D. (2004). Theoretical influences in cally be able to make predictions, draw conclusions, and be research on language and development and intervention in reflective about the stories they read (Laing & Kamhi, 2003). individuals with mental retardation. Mental Retardation and Productivity, complexity, and accuracy in written language Developmental Disabilities Research Reviews, 10, are also expected at this time (Puranik, Lombardino, & 184–192. Altmann, 2008). Agin, M., Geng, L., & Nicholl, M. (2003). The late talker: What to Warning signs for the need for a communication,language, do if your child isn’t talking yet. New York: St. Martin’s Press. and speech assessment for third and fourth graders will typi- American Psychiatric Association. (2000). Diagnostic and cally be in the areas of expressive language, i.e., the produc- statistical manual of mental disorders (4th ed., Text revision). tion of language or speech. Less obvious signs include deficits Washington, DC: Author. in listening comprehension or subtle pragmatic deficits in American Speech-Language-Hearing Association. (2001). Roles topic control or conversational skills. Subtle signs also include and responsibilities of the speech-language pathologist with challenges in decoding of unfamiliar words while reading. respect to reading and writing in children and adolescents. The child who does not consistently read with comprehen- Rockville, MD: American Speech-Language-Hearing Association. sion can be evaluated and treated by an SLP (Kamhi, 2003; American Speech-Language-Hearing Association. (2008). Roles Laing & Kamhi, 2003; Lyytinen et al., 2001). Finally, if the and responsibilities of Speech-Language Pathologists in early child’s written language lacks productivity, accuracy, and/or intervention: Guidelines. Retrieved from www.asha.org/policy complexity, a referral to an SLP can be helpful (Green, 2009; Baker, L., & Cantwell, D. (1982). Psychiatric disorders in children Mackie & Dockrell, 2004; Scott, 2005). with different types of communication disorders. Journal of Communication Disorders, 15, 113–126. Implications Baltaxe, C. (2001). Emotional, behavioral and other psychiatric disorders of childhood associated with communication One of the most important goals for children with communi- disorders. In T. Layton, E. Crais, & L. Watson (Eds.), Handbook cation, language, and speech challenges is to help them foster of early language impairment in children (pp. 63–125). Albany, a sense of self—a sense of their own agency as intentional, NY: Delmar. interactive individuals. 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