CHALLENGING CASE: DEVELOPMENTAL DELAYS AND REGRESSIONS Expressive Language Delay in a Toddler* CASE recognition of language delay remains the most elu- Shelly is a 20-month-old white female whose par- sive for child care clinicians. Compared with motor ents thought she was in excellent general health and social-adaptive skills, language acquisition mon- when she came to her pediatrician for a health su- itoring in pediatric practice is challenging for at least pervision visit. A developmental survey consisting two reasons: (1) The clinician is often dependent on of focused questions revealed that Shelly spoke only historical information from a parent or other care- occasionally with a vocabulary limited to five words. giver, especially in the first 3 years of life when a Although motor and social skills were age-appropri- toddler’s speech output in an office setting may be ate, verbal expressions typically consisted of nonin- limited. In this age group, an assessment of walking telligable utterances and frequent pointing to objects. skills, pincer grasp, and block building is relatively She occasionally chatters “as if she had her own easy to accomplish compared with a successful sur- language.” Shelly reportedly responds to directions vey of expressive and receptive language; and (2) the appropriately, and she appears to hear normal hu- normal range of language skill acquisition between 1 man voices, music, and a telephone ring. and 3 years of age is broad and is affected by a Shelly has been in home day care since 10 months variety of biological and environmental factors. of age when her mother returned to work. With four The case of Shelly represents a common diagnostic other toddlers, she is cared for by a Spanish-speaking and therapeutic problem in primary care practice: a caretaker; her parents speak English at home. She is toddler with an isolated delay in expressive lan- the only child in her family; her parents remarked guage development. that they each had a sibling whose early language Pediatricians with different perspectives on the acquisition was delayed but as adults did not seem initial clinical approach to this case have been invited language impaired. to comment. Using a similar database, their clinical Shelly’s prenatal course was complicated by pre- construction of Shelly’s language delay varies in im- mature contractions treated from 30 weeks gestation portant ways that yield different diagnostic recom- with terbutaline. She was delivered at term by a mendations. spontaneous vaginal delivery without complications. Dr. Steven Parker is an Associate Professor of Apgar scores were 8 at 1 minute and 9 at 5 minutes. On physical examination, Shelly appeared robust. Pediatrics at the Boston University School of Medi- Social and visual engagement occurred easily with cine. As Director of the Division of Developmental her mother and the examiner. Growth parameters and Behavioral Pediatrics at Boston City Hospital, were at the 50th percentile. The examination was Dr. Parker’s work focuses on the care of urban, inner- normal, including her tympanic membranes (normal city children. He is the coauthor of a comprehensive appearance and compliance), palate, pharynx, facial handbook on behavioral and developmental prob- structure, and neurological assessment. Gross and lems seen in primary care pediatrics. (See book re- fine motor skills were documented at the 20- to 24- view in this issue on page 376.) month level. She responded to commands given by Dr. James Coplan is an Associate Professor in the her mother and the examiner. She was able to point Department of Pediatrics at State University of New to pictures of objects on request and correctly York in Syracuse. He is a developmental pediatrician pointed to three body parts. When asked to “go get with a specific interest in early childhood language your shoes and sit down,” she completed the task development. He developed a widely used screening after the second request. Throughout the interview instrument known as the Early Language Milestone and examination, Shelly did not say any specific Scale. words. However, she pointed to a toy and doll she Dr. Heidi Feldman is an Associate Professor of wanted during a play situation. Pediatrics in the Department of Pediatrics at the Uni- versity of Pittsburgh School of Medicine. She is a Dr. Martin Stein developmental pediatrician who also completed a Developmental assessment constitutes the founda- doctorate degree in developmental psychology. Dr. tion of pediatric health supervision. Among the ma- Feldman directs the Division of General Academic jor domains of early childhood development, the Pediatrics at the Children’s Hospital of Pittsburgh. Martin I. Stein, MD * Originally published in J Dev Behav Pediatr. 1995;16(5) University of California, San Diego PEDIATRICS (ISSN 0031 4005). Copyright © 2001 by the American Acad- School of Medicine emy of Pediatrics and Lippincott Williams & Wilkins. La Jolla, California Downloaded from www.aappublications.org/news by guest onPEDIATRICS September 28, 2021 Vol. 107 No. 4 April 2001 905 Dr. Steven Parker guage therapy is unlikely to provide appreciable This case exemplifies the most common scenario of supplemental benefits at this point. However, if language delay facing the primary care clinician: the Shelly is in a chaotic day care where there is very otherwise normal child with excellent receptive lan- little language directed at her or expectation for her guage but clear expressive language delay. to use language to express herself and if the parents The most critical feature presented in the history is do not use language in a reciprocal, eliciting way Shelly’s apparent normal receptive language. Ade- with the child (which you may observe in the course quate receptive language suggests that both the in- of the office visit), language therapy can be very puts for language (e.g., hearing) and the processing helpful, especially when the caregivers are involved. language are normal. If true, normal receptive lan- Regardless of the decision made, Shelly should be guage effectively rules out such important parts of followed up carefully by the primary care clinician. the differential diagnosis as mental retardation, au- Language testing at 2 years of age may reveal ditory processing disorder, developmental language marked improvement or continued deficits. If the disability, significant hearing loss, and other signifi- delays continue, the same process of generating a cant communication deficits (e.g., autism). differential diagnosis and potential treatment plan Shelly’s language difficulties are occurring on the should be entertained. output side of language development, which consid- There are no easy answers in this case, which is erably narrows the potential etiologies. Apraxia or both common and subtle. The clinician must walk other fine motor problems of the oral motor system, the fine line between delaying treatment in a child although plausible, are less likely in association with who will go on to have continued language deficits normal gross and fine motor skills in other areas. and for whom early treatment is beneficial and over- treating a child with a constitutional, maturational Additionally, in such cases there are often clues, such delay for whom treatment is unnecessary and for as early feeding disorders or prolonged drooling. whom labelling may present a whole set of new Bilingualism should be considered as a possible con- problems for family and child. tributing factor. Although somewhat controversial, it is fairly well established that bilingual children Steven Parker, MD achieve expressive language milestones at a slightly Boston University School of Medicine later date than their monolingual peers. In any event, Boston, Massachusetts bilingual children should catch up to monolingual children in the expressive realm by 3 years of age. REFERENCES Additionally, their receptive language should always 1. Bishop DVM, Edmundson A: Language impaired 4 year olds: Distin- be at age level. It is possible that Shelley’s task of guishing transient from persistent impairment. J Speech Hear Dis 52: simultaneously learning two languages is a factor in 156–173, 1987 her delayed expressive language. 2. Aram DM, Ekelman BL, Nation JE: Preschoolers with language disorders: 10 years later. J Speech Hear Res 27:232–244, 1984 Finally, constitutional or maturational expressive 3. Coplan J: Language delays, in Parker S, Zuckerman B (eds): Behavioral language delay should be considered. This is a diag- and Developmental Pediatrics: A Handbook for Primary Care. Boston, nosis of exclusion and is only made after one has ruled Little, Brown & Co., 1994, pp 195–199 out all of the other treatable causes of expressive language delay. In Shelly’s case, this diagnosis is Dr. James Coplan suggested by a positive family history. Against this Shelly is a 20-month-old with delayed speech. She diagnosis, however, is her female gender because it follows one-step commands, two-step commands is well established that young boys are more com- (inconsistently), and points to body parts on com- monly delayed in language skills than females. mand. Based on these observations, her receptive The diagnostic dilemma facing the primary care language skills appear to be normal. clinician is: How much of a workup should be per- We are told that Shelly’s growth parameters are at formed at this time, and should language treatment the 50th percentile. Does this include head circum- be initiated? Although the yield