Late language emergence (LLE) is a delay in language onset with no other diagnosed disabilities or developmental delays in other cognitive or motor domains. LLE is diagnosed when language development trajectories are below age expectations. Toddlers who exhibit LLE are referred to as "late talkers" or "late language learners." In this document, the term late talkers will be used.
Late talkers may present with expressive language delays only or mixed expressive and receptive delays. Children with only expressive delays exhibit delayed vocabulary acquisition and often demonstrate slow development of sentence structure and articulation. Those with mixed expressive and receptive language delays exhibit delays in language comprehension and in oral language production.
Some researchers distinguish a subset of children with LLE as "late bloomers." They posit that late bloomers catch up to their peers in language skills by 3 to 5 years of age. At onset, it is difficult to distinguish late talkers from late bloomers, as this distinction can be made only after the fact. However, there is some research to suggest that late bloomers use more communicative gestures than age-matched late talkers who remained delayed (Thal & Tobias, 1992; Thal, Tobias, & Morrison, 1991), thereby compensating for limited oral expressive vocabularies (Thal & Tobias, 1992). Research also indicates that late bloomers are less likely to demonstrate concomitant language comprehension delays when compared with children who remain delayed (Thal et al., 1991).
Late talkers may be at risk for developing language and/or literacy difficulties as they age. Late talkers who have receptive and expressive delays are at greater risk for poor outcomes than late talkers whose comprehension skills are in the normal range (Marchman & Fernald, 2013).
LLE may also be an early or secondary sign of disorders, such as specific language impairment, social communication disorder, autism spectrum disorder, learning disability, attention deficit hyperactivity disorder, intellectual disability, or other developmental disorders. In order to make a differential diagnosis, it is critical to monitor the global development of a child in domains that include, but are not limited to, cognitive, communication, sensory, and motor skills.
Incidence of LLE refers to the number of new cases identified in a specified time period. Prevalence refers to the estimated population of children who are exhibiting LLE at any given time.
Estimates vary according to the definition and criteria used to identify LLE, as well as the age and characteristics of the population.
Signs and symptoms among monolingual English-speaking children with LLE are based on parent-report measures. An extensively used set of criteria for LLE is an expressive vocabulary of fewer than 50 words and no two-word combinations by 24 months of age (Paul, 1991; Rescorla, 1989). However, it is essential to review these criteria at regular intervals (e.g., every 6 months) to assess language growth and to determine whether the child is in fact a late talker, whether language skills fall outside of developmental trajectories, or whether signs and symptoms clearly indicate a language disorder.
In making the determination, it is also important to consider other language development factors, including rate of vocabulary growth, speech sound development, emerging grammar, language comprehension, social language skills, use of gestures, and symbolic play behaviors (Olswang, Rodriguez, & Timler, 1998; Wetherby, Allen, Cleary, Kublin, & Goldstein, 2002).
For example, when compared with toddlers of the same age with typical language development, late talkers may demonstrate
Research also suggests that delays and differences in babbling before the age of 2 can predict later delays in expressive vocabulary, limited phonetic repertoire, and use of simpler syllable shapes (Fasolo, Majorano, & D'Odorico, 2008; Oller, Eilers, Neal, & Schwartz, 1999; Stoel-Gammon, 1989).
Approximately 50% to 70% of late talkers are reported to catch up to peers and demonstrate normal language development by late preschool and school age (Dale, Price, Bishop, & Plomin, 2003; Paul, Hernandez, Taylor, & Johnson, 1996). In a study by Rice, Taylor, and Zubrick (2008), the prevalence of language impairment at age 7 was 20% for children with a history of LLE compared with 11% for controls. That is, only one in five late talkers had language impairment at age 7.
Although many late talkers go on to perform within the normal range on expressive and receptive language measures by kindergarten age (Ellis Weismer, 2007; Rescorla 2000, 2002), their scores on such measures continue to be lower than those of children with a history of typical language development, matched for socioeconomic status (SES; Paul, 1996; Rescorla, 2000, 2002).
For example, school-age children who had been identified as late talkers demonstrated
(Girolametto, Wiigs, Smyth, Weitzman, & Pearce, 2001; Rescorla, 2002, 2005, 2009; Rice et al., 2008)
Delayed language comprehension has been shown to be a significant predictor of language outcomes in late talkers (Ellis Weismer, 2007; Thal et al., 1991). Deficits in comprehension are associated with language deficits at later ages (Thal et al., 1991).
For some children, LLE may be an early indicator of specific language impairment (SLI). Children who continue to have poor language abilities below chronological age expectations (by late preschool or school age) that cannot be explained by other factors (e.g., low nonverbal intelligence, sensory impairments, or autism spectrum disorder) may be identified at that point as having SLI (Archibald & Gathercole, 2007).
The causes of LLE in otherwise healthy children are not known. However, several variables are thought to play a role.
Based on research comparing late talkers with typically developing peers on variables linked with language development, a number of risk factors for LLE have been proposed, including:
Early identification and intervention can mitigate the impact of risk factors (Guralnick, 1997, 1998; National Research Council, 2001; Thelin & Fussner, 2005). Therefore, it is important for speech-language pathologists to recognize these risk factors when identifying LLE and considering service delivery options.
The National Joint Committee on Learning Disabilities (NJCLD; 2007) suggests a number of protective factors that may buffer children and families from factors that place them at risk for later language and learning problems. These include:
See Shonkoff and Phillips (2000) [PDF] for more information about the nature of early development and the role of early experiences.
Speech-language pathologists (SLPs) play a critical role in providing services to families and their children who are at risk for developing, or who already demonstrate, delays or disabilities in language-related play and symbolic behaviors, communication, language, and speech. The professional roles and activities of the SLP include prevention and advocacy, clinical services (screening, assessment, and diagnosis; planning, implementing, and monitoring treatment), consultation and education, service coordination and transition planning, administration, and research. See ASHA's Scope of Practice in Speech-Language Pathology (ASHA, 2016).
Appropriate roles for SLPs include
As indicated in the Code of Ethics (ASHA, 2010), SLPs who serve this population should be specifically educated and appropriately trained to do so. They require knowledge of the variability characterizing typical development, as well as the normal variations in interactive styles associated with language development and successful communication. Careful consideration of the influence of sociocultural factors on communicative interactions and language development is also essential.
Because late talkers remain at risk for later language and literacy problems, early assessment and periodic monitoring are essential to track language development and identify any problems that might arise. For children who present with signs and symptoms of LLE, the typical diagnostic pathway includes a broad check of speech and language developmental status, along with periodic monitoring via screening and systematic observation. If monitoring indicates persistent delays over time and/or additional developmental complications arise, a complete assessment may be warranted.
It is important that the speech-language pathologist (SLP) use screening and assessment tools that provide the most representative sample of the child's behaviors across a range of people and activities within the child's natural environments. Ideally, screening and assessment take place in the child's home or child care setting. The SLP can also gather information about the child's language skills through parent and caregiver report. Parental perspectives on the child's skills relative to the beliefs and values of the family and their culture are relevant aspects to consider.
Screening and assessment results are interpreted within the context of a child's overall development and in collaboration with family members and with other professionals as appropriate. Contextualized interpretation is important, because communication is only one aspect of children's interactions with the environment.
Careful screening by an SLP is warranted to identify young children at risk for language disorders and to determine the need for further speech-language/communication assessment or referral for other professional services. Screening is also an important component of prevention, family education, and support for young children and their families.
Screening measures may involve direct interaction with the child, parent report on a standardized instrument, or both. In fact, the validity of the screening process may increase when professional-administered measures are combined with parent-completed measures (Glascoe, 1999). For screening purposes, however, either standardized testing or parent report is adequate, provided that the measure used has adequate psychometric properties.
Screening typically includes
Screening may result in recommendations for
If other developmental complications arise, or if periodic monitoring indicates persistent delays, a comprehensive speech and language assessment may be indicated. The comprehensive assessment takes into account the most common concerns for late talkers—failure to begin using words, absence of a "vocabulary spurt," and failure to begin combining words in the 2nd year of life—and any other communication concerns specific to the individual child. Components of the assessment may change over time, depending on the child's age and stage of development.
For late talkers who have not yet acquired verbal language, the assessment focuses on preverbal behaviors, including play, gesture, and other forms of nonverbal communication and interaction. For children who display various forms of communication (e.g., gestures, vocalizations, words), the assessment evaluates their ability to use these forms to communicate successfully with others. See ASHA's Practice Portal page on Augmentative and Alternative Communication (AAC).
Although the scope of this page is children from 2 to 4 years of age, younger children may be referred to an SLP with concerns regarding language development. Based on the presenting symptoms, the SLP may conduct a comprehensive speech-language assessment and consider the need for early intervention. Additionally, referrals may be made to other professionals, if the symptoms suggest disorders or conditions other than, or in addition to, language delay. (See information about the Child Find mandate.)
Pre-assessment planning. Professionals from a variety of disciplines have encouraged the use of pre-assessment planning for young children (Boone & Crais, 2001; Crais, Roy, & Free, 2006). Pre-assessment planning involves one or more professionals who meet with the child and family to gather information and plan the upcoming assessment. Common goals for planning include identifying what the family needs and wants from the assessment process, the roles that family members (and caregivers) would prefer to take in the assessment, and the child's areas of strength and need (Boone & Crais, 2001).
Assessment typically includes
Given the influence that families have on their children's growth and development and the fact that children's language learning takes place in the context of interacting with those close to them, it is important for the SLP to gather information about the child's interactions with his or her caregivers. Consider differing communication styles—which are influenced by social and cultural factors—that impact the caregiver-child interaction. A number of measures are available for observing these types of interactions, and they vary with respect to their psychometric properties. In addition to considering the psychometric properties of these tools, keep in mind that a number of other factors can affect the way children interact with their caregivers, including
Assessment is accomplished using a variety of measures and activities, including both standardized and nonstandardized measures, as well as formal and informal assessment tools. SLPs have the obligation to ensure that standardized measures used in assessment show robust psychometric properties that provide strong evidence of their quality (Dollaghan, 2004).
An assessment battery typically includes the following procedures and data sources:
For bilingual children, appropriate assessment in all languages is necessary to differentiate between a linguistic difference and a true communication disorder (see bilingual service delivery). In most cases, the use of standardized tests alone is not sufficient. Test scores are invalid for individuals who are not represented in the normative group for the test's standardization sample, even if the test is administered as instructed. In these cases, the tests cannot be used to determine the presence or absence of a communication disorder. Non-normed (criterion) measures, along with observation, language sampling, ethnographic interviewing, and dynamic assessment procedures are fundamental to differentiating a difference from a disorder (see cultural competence and dynamic assessment: additional ASHA resources).
For a more detailed discussion of procedures and data sources that might be utilized in assessment, see assessment tools, techniques, and data sources.
Assessment may result in
When interpreting the data gathered during the comprehensive assessment, be aware of the variations in early vocabulary growth and early word combinations in young children. As single indicators of later language outcomes, individual differences in acquisition of these skills before the age of 4 are not highly predictive of later language outcomes. In addition, children with receptive language delay have poorer prognoses than children with predominantly expressive delay (American Psychiatric Association, 2013).
With this in mind, the SLP differentiates normal variations in language development from language delay or language disorder and from comorbid conditions associated with language delay or disorder (e.g., autism and social communication disorder).
Strategies for sharing information depend on factors such as the purpose of the assessment (e.g., determining eligibility for services or monitoring and reassessing language skills), the assessment approach and tools used, and the preferences of the individual family and professionals.
Regardless of the strategy used, there are a number of common principles that promote a collaborative exchange of information between service providers and families.
Key cultural and linguistic considerations include
The ability to learn and use language does not appear to be negatively affected by learning more than one language (Pearson, 2013). When combined vocabularies are measured, researchers have found that bilingual children acquire vocabulary at the same rate as their monolingual peers (Hoff et al., 2012; Junker & Stockman, 2002; Pearson, 1998). Pearson (1998) found that using strategies such as conceptual scoring (i.e., scoring the meaning of a word, regardless of the language in which it is produced) when assessing linguistic skills across languages is an effective way to demonstrate that the skills of typically developing bilingual children are on a par with those of monolingual children. These findings support the belief that LLE is not a result of introducing a second language or simultaneously acquiring two languages.
If a child demonstrates difficulties in the acquisition of his or her native language and a second language, an evaluation may be warranted. Understanding the normal processes and phenomena of second-language acquisition and simultaneous bilingualism is important to ensure accurate assessment of bilingual clients.
Some children may experience a silent period during the initial phase of second-language acquisition. During this time, "the child is building up competence in the second language via listening, by understanding the language around him" (Krashen, 2009, p. 27). Speaking ability in the second language emerges once the child has developed sufficient competence via listening and understanding (Krashen, 2009). This should not be confused with LLE. Further, examination of the native language should indicate typical development in that context, and thus, the silent period is only indicative of learning processes in the second language.
The goal of language intervention is to stimulate overall language development and to teach language skills in an integrated fashion and in context, so as to enhance everyday communication and enhance the family's ability to support the child's development. Services and supports are individualized for each child and family.
For toddlers and preschoolers with LLE, the speech-language pathologist (SLP) can help remediate problems and potentially prevent future difficulties and the need for subsequent school-based services (ASHA, 1991). When intervention is indicated, the frequency and degree of intervention can vary along a continuum from indirect to direct speech-language services.
When making treatment decisions, it is critical to identify the nature and severity of the language delay and its overall effect on communication, the presence of risk factors, and the child's global developmental skills.
Each child has a unique language profile that may be influenced by the language(s) spoken at home, cultural background, and family constellations. It is important to consider these factors when developing an intervention plan. For more information on culturally and linguistically appropriate service delivery, see bilingual service delivery.
Indirect intervention consists of activities to stimulate language development. Typically, the SLP provides ideas and sample activities for parents and caregivers to engage in with the child. Enrichment activities, such as book sharing and play groups, are encouraged. An approach that utilizes and encourages multiple modes of communication (e.g., speech, gestures, signs, and pictures) is also encouraged.
The SLP may continue to monitor the child on a regular basis during this time and consult with parents and caregivers as needed. For some children, the SLP may provide families with more focused language stimulation activities (e.g., language models designed specifically for that child) and monitor on a more frequent basis.
Interaction styles that have been shown to stimulate language competence and enhance communication in young children include
(Girolametto, Weitzman, Wiigs, & Pearce, 1999; Kaiser, Hester, & McDuffie, 2001; Wilcox, 1992; Yoder & Warren, 2001)
It is essential that treatment be founded on the highest quality evidence available. Goals are frequently selected with consideration given to developmental appropriateness and the potential for improving the effectiveness of communication and academic and social success. Effective early intervention ensures that services are
A key component to the success of intervention with toddlers is working closely with families. IDEA (2004) requires that families have the opportunity to share concerns and priorities that may guide or influence treatment. Based on the work of Bailey (2004) and Winton (1996), the following key activities can guide the gathering of this type of information:
A family-centered approach aligns with the federal mandate to provide services in natural environments. Collaborating with parents/caregivers regarding routines and everyday activities helps to
There are a number of different approaches and strategies for working with toddlers with language delay and disorder. Interventions can vary along a continuum of naturalness (Fey, 1986), ranging from contrived or drill-based activities in a therapy room (clinician directed), to activities that are play based and include everyday activities in natural settings (child centered), to those that use activities and settings that combine both approaches (hybrid). One example of a hybrid approach is dialogic reading, an interactive technique in which adults prompt children with questions and engage them in discussions while reading together (Zevenbergen & Whitehurst, 2003).
Augmentative or alternative communication methods may be considered as a temporary means of communication for late talkers. Research shows that use of AAC may aid in the development of natural speech and language (Lüke, 2014; Romski et al., 2010; Wright, Kaiser, Reikowsky, & Roberts, 2013). See ASHA's Practice Portal on Augmentative and Alternative Communication.
Whichever technique is used, the cultural background of the child and his or her family is also considered. There are many cultures for which play-based therapies and child-directed play may not be appropriate. In the cultures of some individuals, "It may be even less natural to engage in child-led play-based interactions, as this is sometimes inconsistent with social roles and expectations" (Wing, et al., 2007, p. 23). This relays the importance of providing services in a manner that best fits the child's needs, given the cultural environment in which he or she lives. Similarly, interventions focused on labeling and rehearsing information can be culturally inappropriate for some families.
For more information about language intervention and a description of specific treatment approaches, see the Treatment section of spoken language disorders.
To gain access to early intervention services, a child first must qualify for intervention according to state agency guidelines. Some late talkers will qualify for special education services based on the results of an evaluation conducted by school district personnel to satisfy the Child Find mandate. Speech and language services may be indicated for children identified as having, or being at risk for, communication impairment.
If the child is determined to be eligible for services, an Individual Family Service Plan (IFSP) is developed in accordance with Part C of IDEA, which covers children from birth to 3 years of age. The IFSP is a written plan for providing early intervention services that
When a child reaches the age of 3, he or she transitions from preschool to school-based services, in accordance with Part B of IDEA, which ensures that all children with disabilities receive a free and appropriate public education (FAPE). At this point, an Individualized Education Program (IEP) is developed. For more information about eligibility for services in the schools, see ASHA's eligibility and dismissal in schools, IDEA Part B Issue Brief: Individualized Education Programs and Eligibility for Services, and 2011 IDEA Part C Final Regulations. Also see ASHA's Learning Disabilities and Young Children: Identification and Intervention.
One of the goals of IDEA (2004) is to ensure a seamless transition process for families moving from one program to another as well as timely access to appropriate services. It is stipulated that there be a transition plan that includes participation by representatives from each program, as well as family members.
The SLP offers assistance to families and team members, appropriate to his or her role. For example, when the SLP functions as the IFSP service coordinator, he or she has direct responsibility for oversight of transition activities and will need to be knowledgeable about a wide range of resources in the community. Alternatively, as a member of the IFSP team, the SLP assists the family and the other team members by helping make the transition process as smooth and as positive as possible for the family.
SLPs and a variety of other professionals, in collaboration with families and caregivers, may be involved in the selection and delivery of services and supports for young children. It is essential that these professionals have the capacity to collaborate effectively and, collectively, possess knowledge of typical and atypical patterns of development in the domains of cognition; communication; emergent literacy; and motor, sensory, and social-emotional functioning. Following is a list of the roles of some of the professionals who, in addition to the child's pediatrician, may be involved in early intervention:
Other professionals who may be involved include childcare providers, educational diagnosticians, educational therapists, reading specialists, social workers, child and developmental psychologists, pediatric neurologists, and child psychiatrists.
In addition to determining the type of speech and language treatment that is optimal for children with LLE, SLPs consider other service delivery variables—including format, provider, dosage, and timing—that may impact treatment outcomes.
This list of resources is not exhaustive and the inclusion of any specific resource does not imply endorsement from ASHA.
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Content for ASHA's Practice Portal is developed through a comprehensive process that includes multiple rounds of subject matter expert input and review. ASHA extends its gratitude to the following subject matter experts who were involved in the development of the Late Language Emergence page.
In addition, ASHA thanks the members of the Ad Hoc Committee on the Roles and Responsibilities of Speech-Language Pathologists in Early Intervention whose work was foundational to the development of this content. Members of the Committee were M. Jeanne Wilcox (chair), Melissa A. Cheslock, Elizabeth R. Crais, Trudi Norman-Murch, Rhea Paul, Froma P. Roth, Juliann J. Woods, and Diane R. Paul (ex officio). ASHA Vice Presidents for Professional Practices in Speech-Language Pathology Celia Hooper (2003-2005) and Brian B. Shulman (2006-2008) served as the monitoring officers.