a child with speech impediment

What is a nonverbal learning disorder? Tim Walz’s son Gus’ condition, explained

Gus Walz stole the show Wednesday when his father, Minnesota Gov. Tim Walz, officially accepted the vice presidential nomination on the third night of the Democratic National Convention. 

The 17-year-old stood up during his father’s speech and said, “That’s my dad,” later adding, “I love you, Dad.”

The governor and his wife, Gwen Walz, revealed in a People interview that their son was diagnosed with nonverbal learning disability as a teenager.

A 2020 study estimated that as many as 2.9 million children and adolescents in North America have nonverbal learning disability, or NVLD, which affects a person’s spatial-visual skills.

The number of people who receive a diagnosis is likely much smaller than those living with the disability, said Santhosh Girirajan, the T. Ming Chu professor of biochemistry and molecular biology and professor of genomics at Penn State.

“These individuals are very intelligent and articulate well verbally, but they are typically clumsy with motor and spatial coordination,” he told NBC News. “It’s called a learning disorder because there are a lot of cues other than verbal cues that are necessary for us to keep information in our memory.”

People with NVLD often struggle with visual-spatial skills, such as reading a map, following directions, identifying mathematical patterns, remembering how to navigate spaces or fitting blocks together. Social situations can also be difficult. 

“Body language and some of the things we think about with day-to-day social norms, they may not be able to catch those,” Girirajan said. 

Unlike other learning disabilities such as dyslexia, signs of the disability typically don't become apparent until adolescence. 

Early in elementary school, learning is focused largely on memorization — learning words or performing straightforward mathematical equations, at which people with NVLD typically excel. Social skills are also more concrete, such as playing a game of tag at recess. 

“But as you get older, there’s a lot more subtlety, like sarcasm, that you have to understand in social interactions, that these kids might not understand,” said Laura Phillips, senior director and senior neuropsychologist of the Learning and Development Center at the Child Mind Institute, a nonprofit organization in New York.

In her own practice, she typically sees adolescents with NVLD, who usually have an average or above average IQ, when school demands more integrated knowledge and executive functioning, such as reading comprehension or integrating learning between subjects. They also usually seek help for something else, usually anxiety or depression, which are common among people with NVLD. 

Sometimes misdiagnosed as autism

Amy Margolis, director of the Environment, Brain, and Behavior Lab at Columbia University, is part of a group of researchers that is beginning to call the disability “developmental visual-spatial disorder” in an effort to better describe how it affects people who have it.

People with NVLD are “very much verbal,” Margolis said, contrary to what the name suggests.

The learning disability is sometimes misdiagnosed as autism spectrum disorder. Margolis led a 2019 study that found that although kids with autism spectrum disorder and NVLD often have overlapping traits, the underlying neurobiology — that is, what’s happening in their brains to cause these traits — is unique between the two conditions.

Margolis is trying to get NVLD recognized by the DSM-5, the handbook health care providers use to diagnose mental health conditions. Without such official recognition, people with NVLD can struggle to get the resources they need, such as special class placements or extra support in school.

“Without an officially recognized diagnosis, it’s hard for parents to understand how to seek information, and then communicate to other people what kinds of things might be challenging for their kid,” Phillips said, adding that widespread awareness is key to helping these families navigate NVLD.

Kaitlin Sullivan is a contributor for NBCNews.com who has worked with NBC News Investigations. She reports on health, science and the environment and is a graduate of the Craig Newmark Graduate School of Journalism at City University of New York.

Tim Walz’s son, Gus, has nonverbal learning disorder. What is that?

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After his heartfelt reaction to his father’s acceptance speech at the Democratic National Convention thrust him into the spotlight , 17-year-old Gus Walz has become one of the most high-profile people with nonverbal learning disorder.

The condition doesn’t mean Gus can’t speak — he does. After hearing his dad, Minnesota Gov. Tim Walz, describe his family as “my entire world” Wednesday night, the tearful teenager rose to his feet, pointed toward the stage and said, “That’s my dad!”

Gus is one of millions of Americans with nonverbal learning disorder. A 2020 study in JAMA Network Open estimated that 3% to 4% of children and adolescents in the U.S. may have the condition, and another study this year in Scientific Reports concluded that the prevalence in children may be as high as 8%.

The condition, known as NVLD, was first recognized in 1967 and doesn’t yet have a formal clinical definition. It is characterized by a significant gap between verbal abilities — which are just fine — and nonverbal kinds of learning that involve visual-spatial processing, such as telling time on an analog clock, reading a map and balancing a budget.

Those challenges with spatial awareness can give children trouble with motor skills. That can make them clumsy or cause problems with tasks like tying shoes, using silverware and writing by hand, according to the NVLD Project , a nonprofit that aims to have the condition added to the American Psychiatric Assn.’s Diagnostic and Statistical Manual of Mental Disorders .

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In a way, having NVLD is like the opposite of having dyslexia , according to Scott Bezsylko, who works with neurodivergent students as executive director of Winston Preparatory School .

Reading is not a problem for kids with NVLD, who often have a large vocabulary. They’re also able to recall facts and memorize things like multiplication tables.

School becomes more challenging toward the end of elementary school, when learning becomes more about noticing patterns and applying concepts. That can cause problems with reading comprehension and more advanced kinds of math problems.

NVLD also affects higher-order thinking, which is used to organize our thoughts and plan a project that requires multiple steps.

Tim Walz and his wife Gwen told People magazine that they noticed differences between Gus and his classmates from an early age, and that those differences “became increasingly clear” as he grew older. The couple, both teachers, didn’t specify what those differences were.

Gus was recognized as having NVLD “when he was becoming a teenager,” the Walzes said, adding that he also has attention-deficit/hyperactivity disorder and an anxiety disorder.

It’s not uncommon for people with NVLD to have an ADHD diagnosis as well, according to the Child Mind Institute . Both conditions can make a child seem disorganized or inattentive; in the case of NVLD, it’s because they don’t understand the assignment being discussed.

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Some features of NVLD also overlap with those of autism spectrum disorder . People with NVLD may be socially awkward because they don’t recognize the meaning behind facial expressions, body language and other nonverbal forms of communication. They may compensate by asking a lot of questions, which can come off as annoying.

Difficulty with visual-spatial processing can make it hard for those with NVLD to respect other people’s personal space. Plus, their challenges with pattern recognition give them trouble relating past experiences to new situations.

Traits like these can make it hard to make friends, experts say. That tracks with the Walzes’ experience.

“Gus preferred video games and spending more time by himself,” his parents told People.

Column: The night Coach Walz overshadowed Oprah, Stevie Wonder and other celebrities

Tim Walz delivered an acceptance speech that checked all the political boxes. But he didn’t show much of the joy that he brought to the Democratic presidential ticket.

Aug. 22, 2024

Comedian Chris Rock said that when he learned as an adult that he had NVLD, it explained a lot of things from his past.

Although he’s great with words, “I kind of have a hard time with nonverbal cues with people. I always have,” Rock said in a 2021 interview with Extra . “They say 70% of communication is nonverbal. So my relationships, even with my family or women I dated or whatever, there was always something a little off, and I couldn’t put my finger on it.”

The causes of NVLD are not clear. Although the deficits associated with the condition involve processes that occur in the right hemisphere of the brain, studies sponsored by the NVLD Project that compared brain scans of people with and without the disorder found differences in both hemispheres .

Regardless, the condition does not affect intelligence, and people can learn strategies to compensate for their shortcomings.

Successful interventions can include practice taking a problem and breaking it up into manageable pieces, or looking for patterns in complicated texts. As their skills improve, they develop a library of “scripts” that can help them in new situations, according to the Child Mind Institute. If they don’t have a suitable script on hand, they’ll have experience with creating a new one.

The same approach may help people with NVLD get better at navigating social situations as well, experts say.

It seems the Walzes have taken this advice to heart.

“It took us time to figure out how to make sure we did everything we could to make sure Gus would be set up for success as he was growing up,” they told People.

Being neurodivergent means Gus “is brilliant [and] hyper-aware of details that many of us pass by,” the Walzes added. “What became so immediately clear to us was that Gus’ condition is not a setback — it’s his secret power.”

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Karen Kaplan covers science and medical research for the Los Angeles Times. She has been a member of the science team since 2005, including 13 years as an editor. Her first decade at The Times was spent covering technology in the Business section as both a reporter and editor. She grew up in San Diego and is a graduate of MIT and Columbia University.

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What to Know About Robert F. Kennedy Jr.’s Vocal Disorder Spasmodic Dysphonia

Robert F. Kennedy Jr. was diagnosed with spasmodic dysphonia at age 42, causing his voice to become raspy

Kevin Dietsch/Getty 

Robert F. Kennedy Jr. has an extremely hoarse voice.

The 70-year-old previously shared that his now signature raspiness is the result of a rare neurological disorder called spasmodic dysphonia, which he was diagnosed with in 1996.

“I had a very very strong voice until I was 46 years old. It was unusually strong,” he said during a news broadcast in June 2023. “It makes my voice tremble. At the time, I didn’t know what was wrong with it. But when I would go on TV, people would write me letters and say, ‘You have spasmodic dysphonia.’”

“I cannot listen to myself on TV,” he said at the time. “I will never listen to this broadcast, and I won’t listen to any. So I feel sorry for you guys having to listen to me.”

Spasmodic dysphonia is a chronic neurological speech disorder that results in involuntary spasms of the muscles that open or close the vocal folds. It causes the voice to suddenly sound breathy, strained, shaky or hoarse as if a person has lost their voice, according to the Cleveland Clinic .

The disorder affects about 50,000 people in the United States and is more likely to impact women more than men. Although spasmodic dysphonia can start at any age, it typically occurs between ages 30 and 60.

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Robert F. Kennedy Jr.

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The exact cause of spasmodic dysphonia is unknown but most cases result from a trigger in the brain and nervous system. 

According to the National Institutes of Health , spasmodic dysphonia may be hereditary. Although a specific gene for the disorder has not been identified, a mutation in a gene that causes other forms of dystonia has also been associated with spasmodic dysphonia.

There is no cure for spasmodic dysphonia and it is a lifelong condition. However, there are treatments to minimize these vocal cord spasms and help alleviate symptoms.

Botox injections — which is required every three to six months — and speech therapy are common forms of treatment. There are also more invasive treatment options, including a thyroplasty surgery or selective laryngeal adductor denervation-reinnervation (SLAD-R) surgery.

Last year, Kennedy said during an interview that he recently underwent a surgery in Japan to treat his disorder. Noting that the procedure is not yet available in the United States, he said he had titanium implanted between his vocal cords to keep them from constricting.

“I’ve done a lot of functional medicine stuff and I’ve worked with a chiropractor and I’ve worked with a lot of other people and my voice now is getting better and better,” he said. “And I think part of it was the surgery but also part of it was the therapies I’m doing now.”

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What's wrong with RFK Jr's voice? Spasmodic dysphonia explained

During  Robert F. Kennedy Jr.'s  now-suspended 2024 presidential race , many people noticed his raspy and often halting voice.

The son and nephew of slain political leaders has a rare disorder called spasmodic dysphonia — a spasm of the vocal muscles.

Kennedy is one of an estimated 50,000 people in North America with SD, as it is often referred to, a neurological condition that creates a vocal tremble in mostly middle-aged people that usually lasts for the rest of their lives.

There is no cure, but treatments can temporarily reduce symptoms.

Here's what to know about spasmodic dysphonia:

RFK Jr. and spasmodic dysphonia

Spasmodic dysphonia has recently been spotlighted due to Robert F. Kennedy Jr.’s presidential campaign. While the candidate has had the disorder for almost 30 years, his raspy, trembling voice has received more attention with a host of stump speeches, media appearances, and advertisements over his now-suspended presidential campaign.

In an  interview this spring  with the Los Angeles Times, Kennedy said his voice doesn’t tire or get worse as he speaks. It just sounds like he’s always on the verge of breaking down.

How is spasmodic dysphonia treated?

To date, no known cure for spasmodic dysphonia exists. However, several forms of treatment — including speech therapy, drugs and surgery — are available to alleviate or control the symptoms of the vocal spasms on a temporary or long-lasting basis.

Dr. Andrew Blitzer, a New Jersey ear, nose, and throat specialist,  developed  a now-common treatment for SD that involves injecting Botox into the throat muscles to control the vocal cords, the USA TODAY Network reported. Although it doesn't treat the neurological condition, it helps abate the symptoms for three to four months on average.

The problem has long been diagnosing the condition. Many of Dr. Blitzer's first patients had been seen by an average of 13 doctors and other medical personnel, from psychiatrists to speech pathologists, before they were diagnosed with SD. The situation has improved now that SD is taught more in medical schools and during ENT residencies. Still, many of Dr. Blitzer's patients come from across the U.S. and even overseas to have him treat them.

"You can make a big difference in people's lives by giving them their voice back," he said. "It's such a small procedure, but it makes a big difference."

Why did RFK Jr. drop out of the presidential race?

Robert F. Kennedy Jr.  says he will suspend his campaign in the 2024 presidential race and throw his support behind Republican nominee Donald Trump, USA TODAY reported.

In a virtual address on Friday, Kennedy clarified that he plans to remove his name from the ballot in about 10 battleground states, "where my presence would be a spoiler," a process he has already begun in states including Arizona and Pennsylvania.

Speculation  that Kennedy would drop out  began earlier this week after his running mate Nicole Shanahan said in an interview Tuesday the campaign had been  weighing a decision .

Trump earlier this week called Kennedy “a brilliant" and "very smart guy" — a far cry from April, when he called him “far more liberal than anyone running as a Democrat" and feared that Kennedy's independent candidacy might cost him votes in the general election.

Vice President Kamala Harris' campaign, in response to Kennedy's suspension, offered their ticket as an option to voters "tired of Donald Trump and looking for a new way forward."

“In order to deliver for working people and those who feel left behind, we need a leader who will fight for you, not just for themselves, and bring us together, not tear us apart," Campaign Chair Jen O’Malley Dillon said in a statement. "Vice President Harris wants to earn your support."

USA TODAY contributed to this report.

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Seventh Circuit Addresses Plan Limitations on Treatment for Autism Spectrum Disorder

EBIA   

August 28, 2024 · 5 minute read

Midthun-Hensen v. Grp. Health Coop. of S. Cent. Wis., Inc., 2024 WL 3646149 (7th Cir. 2024)

Available at https://media.ca7.uscourts.gov/cgi-bin/OpinionsWeb/processWebInputExternal.pl?Submit=Display&Path=Y2024/D08-05/C:23-2100:J:Easterbrook:aut:T:fnOp:N:3244881:S:0

A minor child’s parents filed a proposed class action lawsuit against the administrator of their employer-sponsored group health plan after the plan refused to cover speech therapy and sensory-integration therapy for treatment of the child’s autism spectrum disorder (ASD). At the time, based on its assessment of the medical evidence, the plan did not cover sensory-integration therapy as a treatment for autism at any age, and it did not cover speech therapy as a treatment for autism for children over age nine. (Developments in medical literature led the plan to begin covering these treatments about a year later.) The plan did, however, cover chiropractic treatment for certain musculoskeletal conditions in children, even though, from the parents’ point of view, such treatment lacked scientific support. This led the parents to allege that, by imposing an age-based limitation for ASD treatments while providing coverage for pediatric chiropractic treatment, the plan had applied its requirement that treatments be “evidence based” more stringently to speech and occupational therapy for ASD than it did for pediatric chiropractic care, in violation of the Mental Health Parity and Addiction Equity Act (MHPAEA). The trial court found no parity violation, concluding that the differences in coverage did not arise from the plan applying “a more restrictive strategy or process to mental health benefits” but instead reflected differences in “the acceptance of those treatments by the medical community at large.”

On appeal, the appellate court agreed with the trial court. The court noted that, due to the nature of the conditions (ASD is typically diagnosed in childhood, while musculoskeletal conditions tend to develop in older adults) the medical community literature on autism focuses more on efficacy by age. Observing that plans must make sense of the available medical literature “as they find it,” the court concluded that the plan’s policies reflecting the differing focus in the medical literature did not “pose a problem” under the MHPAEA. The court further concluded that the parents’ claim failed for a more fundamental reason: While the MHPAEA requires that treatment limitations applicable to mental health benefits be no more restrictive than treatment limitations applied to “substantially all” medical/surgical benefits covered by the plan, the parents identified only one medical benefit that was handled differently than the mental health benefits they sought. The court acknowledged that the statute and regulations do not define “substantially all” for purposes of nonquantitative treatment limitations (NQTLs) such as age-based limitations on ASD treatment but concluded that it did not need to determine exactly what substantially all means because it does not mean “one.” Opining that the parents had not seriously tried to show that the plan “as a general matter” imposed age-based treatment limitations less stringently on medical/surgical benefits than on mental health benefits, the court affirmed the trial court’s decision.

EBIA Comment: This decision has lessons for both participants and plan administrators when it comes to NQTLs and MHPAEA compliance. First, it emphasizes that participants challenging the application of an NQTL that is based on determinations in the available medical literature regarding appropriateness or effectiveness of that treatment cannot establish a parity violation by choosing a single medical/surgical benefit to compare to a mental health benefit. Rather, they must show that the process the plan followed in applying an NQTL to a mental health benefit was more stringent than the process it follows for applying NQTLs to substantially all the medical/surgical benefits covered by the plan. Second, the decision addresses-perhaps for the first time-an NQTL that limits coverage based on the covered individual’s age, concluding that such a limitation is permissible under the MHPAEA if it is reasonably based on medical research and clinical efficacy. For more information, see EBIA’s Group Health Plan Mandates manual at Section IX.E (“Mental Health Parity: Nonquantitative Treatment Limitations”). See also EBIA’s Self-Insured Health Plans manual at Section XIII.C.2 (“MHPA and MHPAEA: Mental Health Parity”).

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Hope Walz gets a shoutout in Gov. Tim Walz' speech on Wednesday at the DNC

Elena Moore

Who is Hope Walz?

Hope Walz, daughter of Democratic vice presidential nominee Minnesota Gov. Tim Walz, cheers during the Democratic National Convention in Chicago on Wednesday. Erin Hooley/AP hide caption

The NPR Network will be reporting live from Chicago throughout the week bringing you  the latest on the Democratic National Convention .

Hope Walz had a job to do: film a PSA with her dad, Gov. Tim Walz, as Minnesota enacted hands-free driving.

This was 2019 and Hope Walz, sitting in the driver's seat of a car, joked with her dad about just who was doing the texting and driving.

"We want to make sure our teen drivers are not texting—" Tim Walz started.

"No, no, no," Hope Walz interjected. "I think it's actually mostly bald men."

"Cut!" the governor called.

The video is just one of the snapshots into the relationship between Hope and Gov. Walz that has resurfaced and gone viral since Vice President Harris was deciding who to choose as her running mate.

Another video shows the two at the Minnesota State Fair in 2023.

The two had an agreement: Dad picks something old to do and Hope picks something new. Her choice? The slingshot, an extreme ride that bungees riders in an open sphere into the air and back down over and over.

Then, he said, it would be time to eat. The governor called for corndogs.

"I'm vegetarian," Hope reminded him.

"Turkey then," Walz quipped.

My daughter, Hope, tricked me into doing the most extreme ride at the Minnesota State Fair. pic.twitter.com/YeMEocwJRv — Governor Tim Walz (@GovTimWalz) September 4, 2023

The videos with his daughter are a new political dynamic that has rarely been seen on the campaign trail, according to historian Kate Anderson Brower.

"I think that's what makes it unique is her comfort level and the fact that she does seem really charismatic," Brower explained. "And the fact that they can use her in a way to tell their story."

Now that Walz has joined Harris on the ticket — Hope is on the campaign trail, even sporting a Harris-Walz camouflage hat that nods to her dad's style and, potentially, to pop culture.

Democratic vice presidential candidate Minnesota Gov. Tim Walz, and his daughter Hope, wearing a camouflage hat that has gone viral as she has stumped with her father on the campaign trail, joined Rep. Ruben Gallego, Democratic senatorial candidate in Arizona, on a campaign stop August 9 in Phoenix. Andrew Harnik/Getty Images hide caption

It's not new to see first and second children getting involved in politics while their parents are in office, but it’s still very common for families to stay private.

Harris’s two adult step-children, Ella and Cole Emhoff, have largely stayed out of the political spotlight during her time as vice president.

Now, both have a role at the convention. On Tuesday night, Cole honored his dad and Harris in a video.

What a gift from Cole. I’ll never forget this. pic.twitter.com/Hhjv99cLhJ — Doug Emhoff (@DouglasEmhoff) August 21, 2024

However, Gov. Walz enters the national spotlight with a family that is used to being a part of his political messaging.

After joining Harris on the ticket, Walz repeatedly told the story of how he and his wife struggled to start a family, undergoing years of fertility treatments.

Finally, they were able to have their first child, Hope, a story he repeated during his convention speech Wednesday in Chicago.

At one Arizona rally, the crowd started chanting: "Hope, Hope, Hope" as Hope herself looked on.

"I'm not crying, you're crying," an emotional Tim Walz said.

Brower, the historian, saw that moment as particularly striking.

"We haven't seen that sort of level of intimacy between a candidate and their child so early on in an election cycle," she said.

"I think part of that is there's kind of a sense now in this race that they've got to move things along fast because it changed very late in the game," she added. "I don't think they're going to waste any time to try to get people to know who Tim Walz is."

Hope Walz, left, wearing a campaign t-shirt, holds hands with her dad, Tim Walz, as he campaigned for Congress in 2005. William Handke hide caption

Longtime Republican strategist Kevin Madden worked on Mitt Romney’s presidential campaign in 2008 and 2012. Romney's large family joined the campaign trail and Madden viewed that as an asset.

"When you see a candidate with their family, and you see a candidate that is close to their family, traveling with their family, it helps folks identify with that candidate more easily," Madden said. "That does, oftentimes, give you another opportunity to then make an appeal on issues, on policy."

Hope may offer another advantage: appealing to young voters, a group Harris and Walz are courting.

Her dad is open to hearing from them. While running for governor, he credited his daughter for influencing his own views after the 2018 mass shooting in Parkland, Fla.

"Hope woke up like many of you did five weeks ago and said, ‘Dad, you’re the only person I know who is in elected office. You need to stop what’s happening with this,'" Walz said at the time.

Gov. @Tim_Walz : I spent 25 years in the Army and I hunt. I’ve been voting for common sense legislation that protects the Second Amendment, but we can do background checks. We can research the impacts of gun violence. We can make sure those weapons of war, that I carried in war,… pic.twitter.com/3IVaXi2RP2 — Kamala HQ (@KamalaHQ) August 6, 2024

This deviates from past relationships between political leaders and their children, said Julian Zelizer, a professor of history at Princeton University.

"The kids were kind of just, you know, 'props," he said. "This is very different."

But while the Walz family adjusts to the national attention, it is doing so with family dynamics in full display.

On the first day of the Democratic National Convention, as Walz spoke with a reporter in the stands, Hope and her teenage brother did what many kids would do if their parents were on camera. They held up bunny ears behind his head.

Soon after, Walz himself shared the video on Twitter, saying, “my kids keep me humble.”

My kids keep me humble. https://t.co/XP9kpIYjgl — Tim Walz (@Tim_Walz) August 20, 2024

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'That's my dad!': Gus Walz has emotional reaction during Tim Walz's DNC speech

In a touching moment, the youngest child of Minnesota Gov. Tim Walz had an emotional reaction during a speech from his dad during the Wednesday night program of the 2024 Democratic National Convention.

Walz, the vice-presidential running mate of Democratic presidential nominee Kamala Harris , accepted his party's nomination for vice president on Wednesday, addressing the convention in the evening's keynote speech. Part of his acceptance speech included directly speaking to his family, sitting in the United Center in Chicago: wife Gwen, 23-year-old daughter Hope and Gus, his 17-year-old son.

“Hope, Gus and Gwen – you are my entire world, and I love you,” Walz said.

Gus Walz sprung from his seat , moved by his father's words, mouthing "That's my dad! That's my dad!"

He pointed his index finger, saying "I love you, dad."

Walz: Hope, Gus, and Gwen you are my entire world. And I love you. pic.twitter.com/tf2ByA9RIs — Acyn (@Acyn) August 22, 2024

Call him Coach: Tim Walz, governor and congressman, chooses a folksier intro to voters

Gus Walz has a 'secret power'

Gus Walz, 17, is the youngest child of Walz and Gwen Walz. He has ADHD, a nonverbal learning disorder  and an anxiety disorder. In a recent statement to People Magazine, Walz and his wife, both former teachers, they had noticed his differences at an early age, and said they never considered his conditions to be an obstacle.

"Like so many American families, it took us time to figure out how to make sure we did everything we could to make sure Gus would be set up for success as he was growing up," the couple said.

"It took time, but what became so immediately clear to us was that Gus’ condition is not a setback — it’s his secret power," they added.

Media reactions to Gus Walz at the DNC

Gus' emotional, proud reaction to seeing his dad on stage at the DNC brought reactions from networks covering the event that, for a moment , transcended partisan politics.

On Fox News, Martha MacCallum and Dana Perino both talked about how moving the moment was, the Arizona Republic, part of the USA TODAY Network, reported.

"I love Gus Walz," Jen Psaki, an MSNBC host and former White House press secretary, said. "I'm going to start ugly crying just talking about him."

Dana Bash, on CNN, said, "That is the clip-and-save moment that everyone is going to be seeing. If you didn't get moved by that moment, I don't even know. What a remarkable moment just in American life."

On X, MSNBC host Stephanie Ruhle was moved even before the big moment, posting, "Forget politics. If you aren't moved seeing 17 yr old Gus Walz in tears watching his Dad walk on stage as the Vice Presidential nominee. ... then please just move on."

Contributing: Bill Goodykoontz, Arizona Republic.

How to Help a Kid With a Childhood Speech Impediment

Difficulties in speech that many call "speech impediments" are common as language develops. Just don’t wait too long to seek help.

It can be very frustrating for a child suffering from a speech impediment —be it stutter or lisp — to figure out how to join a conversation. Importantly, Speech-language pathologists practicing speech therapy don’t consider “speech impediment” to be a particularly helpful word. Speech is very complicated, requiring many skills to develop concurrently . The American Speech Language Association prefers the terms “speech delay” or “speech disorder,” both of which are fairly common.

“Speech includes how we pronounce or articulate the sounds in words, the quality of our voice, and the fluency or smoothness of delivery,” says to Melanie Potock, a pediatric speech pathologist, a feeding specialist, and the author of Adventures in Veggieland .

Dysfluencies in language – such as stuttering or repeating words or starting sentences over – may be a part of typical speech development as toddlers learn to produce these sounds. A child who may be difficult to understand when they first learn to string words into sentences will usually develop enough articulation over time to be understood. If they don’t, they may have an articulation delay or an articulation disorder.

“Delay refers to a gap in development. That stall or break in development may be mild or enough to cause concern,” explains Potock. “Children have an articulation disorder when testing shows that they are producing the sounds, syllables or words atypically when compared with other children of the same sex and age.”

Each child develops at their own pace, however, so it can be difficult to identify when typical dysfluencies become a problem. There can be a lot of factors for parents to look for, but Potock has identified some general red flags that might signal a serious issue.

Red Flags for Speech Impediments:

• Frustration : the child is frustrated by their inability to communicate. Biting, excessive whining, and tantrums may all be indicators of an inability to communicate wants and needs.
• Unintelligibility to strangers : neighbors and new friends don’t understand the child. Parents often learn to decipher developing speech patterns, but those unfamiliar with them will be confused
• Unintelligibility at home: even family members may not be able to understand a child with confusing word form, limited intelligibility, poor voice control or stuttering.
• They sound immature: parents shouldn’t compare their kids to other kids – but if other kids the same age sound more grown-up, parents may want to discuss the possibility of a speech delay with their pediatrician.
• Difficulty eating: early difficulties with feeding development may be an indicator of delays in oral motor skills and thus, directly related to speech and possibly language development.

“Parents should contact their child’s doctor to discuss the possibility of consulting with a certified speech-language pathologist if they are concerned about their child’s speech or language or notice any of the signs,” advises Potock. “Early intervention services for children birth to age 3 are available in every state in the U.S., and evaluations are free to low-cost, as is therapy, should the child qualify.”

A certified speech-language pathologist can make speech therapy fairly entertaining for a child, and it’s an excellent chance for socialization. There is some homework so parents can practice good habits at home with their child, but it’s similar to the sort of games many parents already play with their children – memory games, sorting games, and reading. If a parent suspects their child is struggling with language, they shouldn’t wait to see what happens before they bring it up with a pediatrician.

“Don’t wait,” cautions Potock. “The wider that gap grows, the longer the child will be in therapy. Parent proactively and talk to your child’s pediatrician about your concerns and he/she will guide you through the options.”

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Speech Sound Disorders in Children

What are speech sound disorders in children?

It’s normal for young children learning language skills to have some trouble saying words the right way. That’s part of the learning process. Their speech skills develop over time. They master certain sounds and words at each age. By age 8, most children have learned how to master all word sounds.

But some children have speech sound disorders. This means they have trouble saying certain sounds and words past the expected age. This can make it hard to understand what a child is trying to say.  

Speech sound problems include articulation disorder and phonological process disorder.

Articulation disorder is a problem with making certain sounds, such as “sh.”

Phonological process disorder is a pattern of sound mistakes. This includes not pronouncing certain letters.

What causes speech sound disorders in a child?

Often, a speech sound disorder has no known cause. But some speech sound errors may be caused by:

Injury to the brain

Thinking or development disability

Problems with hearing or hearing loss, such as past ear infections

Physical problems that affect speech, such cleft palate or cleft lip

Disorders affecting the nerves involved in speech

Which children are at risk for speech sound disorders?

The cause often is not known, but children at risk for a speech sound disorder include those with:

Developmental disorders such as autism

Genetic disorders such as Down syndrome

Hearing loss

Nervous system disorders such as cerebral palsy

Illnesses such as frequent ear infections

Physical problems such as a cleft lip or palate

Too much thumb-sucking or pacifier use

Low education level of the parent

Lack of support for learning in the home

What are the symptoms of speech sound disorders in a child?

Your child’s symptoms depend on what type of speech sound disorder your child has. He or she may have trouble forming some word sounds correctly past a certain age. This is called articulation disorder. Your child may drop, add, distort, or swap word sounds. Keep in mind that some sound changes may be part of an accent. They are not speech errors. Signs of this problem can include:

Leaving off sounds from words (example: saying “coo” instead of “school”)

Adding sounds to words (example: saying “puhlay” instead of “play”)

Distorting sounds in words (example: saying “thith” instead of “this”)

Swapping sounds in words (example: saying “wadio” instead of “radio”)

If your child often makes certain word speech mistakes, he or she may have phonological process disorder. The mistakes may be common in young children learning speech skills. But when they last past a certain age, it may be a disorder. Signs of this problem are:

Saying only 1 syllable in a word (example: “bay” instead of “baby”)

Simplifying a word by repeating 2 syllables (example: “baba” instead of “bottle”)

Leaving out a consonant sound (example: “at” or “ba” instead of “bat”)

Changing certain consonant sounds (example: “tat” instead of “cat”)

How are speech sound disorders diagnosed in a child?

First, your child’s healthcare provider will check his or her hearing. This is to make sure that your child isn’t simply hearing words and sounds incorrectly.

If your child’s healthcare provider rules out hearing loss, you may want to talk with a speech-language pathologist. This is a speech expert who evaluates and treats children who are having problems with speech-language and communication.                       

By watching and listening to your child speak, a speech-language pathologist can determine whether your child has a speech sound disorder. The pathologist will evaluate your child’s speech and language skills. He or she will keep in mind accents and dialect. He or she can also find out if a physical problem in the mouth is affecting your child’s ability to speak. Finding the problem and getting help early are important to treat speech sound disorders.

How are speech sound disorders treated in a child?

The speech-language pathologist can put together a therapy plan to help your child with his or her disorder. These healthcare providers work with children to help them:

Notice and fix sounds that they are making wrong

Learn how to correctly form their problem sound

Practice saying certain words and making certain sounds

The pathologist can also give you activities and strategies to help your child practice at home. If your child has a physical problem in the mouth, the pathologist can refer your child to an ear, nose, throat healthcare provider or orthodontist if needed.

Spotting a speech sound disorder early can help your child overcome any speech problems. He or she can learn how to speak well and comfortably.

How can I help my child live with a speech sound disorder?

You can do things to take care of your child with a speech sound disorder:

Keep all appointments with your child’s healthcare provider.

Talk with your healthcare provider about other providers who will be involved in your child’s care. Your child may get care from a team that may include experts such as speech-language pathologists and counselors. Your child’s care team will depend on your child’s needs and the severity of the speech sound disorder.

Tell others of your child’s disorder. Work with your child’s healthcare provider and schools to develop a treatment plan.

Reach out for support from local community services. Being in touch with other parents who have a child with a speech sound disorder may be helpful.

When should I call my child’s healthcare provider?

Call your child’s healthcare provider if your child has:

Symptoms that don’t get better, or get worse

New symptoms

Key points about speech sound disorders in children

A speech sound disorder means a child has trouble saying certain sounds and words past the expected age.

A child with an articulation disorder has problems making certain sounds the right way.

A child with phonological process disorder regularly makes certain word speech mistakes.

The cause of this problem is often unknown.

A speech-language pathologist can help diagnose and treat a speech sound disorder.

Tips to help you get the most from a visit to your child’s healthcare provider:

Know the reason for the visit and what you want to happen.

Before your visit, write down questions you want answered.

At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you for your child.

Know why a new medicine or treatment is prescribed and how it will help your child. Also know what the side effects are.

Ask if your child’s condition can be treated in other ways.

Know why a test or procedure is recommended and what the results could mean.

Know what to expect if your child does not take the medicine or have the test or procedure.

If your child has a follow-up appointment, write down the date, time, and purpose for that visit.

Know how you can contact your child’s provider after office hours. This is important if your child becomes ill and you have questions or need advice.

Fluency Disorder

• Age-Appropriate Speech and Language Milestones
• Communication Disorders in Children

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Overcoming Speech Impediment: Symptoms to Treatment

There are many causes and solutions for impaired speech

• Types and Symptoms
• Speech Therapy
• Building Confidence

Speech impediments are conditions that can cause a variety of symptoms, such as an inability to understand language or speak with a stable sense of tone, speed, or fluidity. There are many different types of speech impediments, and they can begin during childhood or develop during adulthood.

Common causes include physical trauma, neurological disorders, or anxiety. If you or your child is experiencing signs of a speech impediment, you need to know that these conditions can be diagnosed and treated with professional speech therapy.

This article will discuss what you can do if you are concerned about a speech impediment and what you can expect during your diagnostic process and therapy.

FG Trade / Getty Images

Types and Symptoms of Speech Impediment

People can have speech problems due to developmental conditions that begin to show symptoms during early childhood or as a result of conditions that may occur during adulthood. 

The main classifications of speech impairment are aphasia (difficulty understanding or producing the correct words or phrases) or dysarthria (difficulty enunciating words).

Often, speech problems can be part of neurological or neurodevelopmental disorders that also cause other symptoms, such as multiple sclerosis (MS) or autism spectrum disorder .

There are several different symptoms of speech impediments, and you may experience one or more.

Can Symptoms Worsen?

Most speech disorders cause persistent symptoms and can temporarily get worse when you are tired, anxious, or sick.

Symptoms of dysarthria can include:

• Slurred speech
• Slow speech
• Choppy speech
• Hesitant speech
• Inability to control the volume of your speech
• Shaking or tremulous speech pattern
• Inability to pronounce certain sounds

Symptoms of aphasia may involve:

• Speech apraxia (difficulty coordinating speech)
• Difficulty understanding the meaning of what other people are saying
• Inability to use the correct words
• Inability to repeat words or phases
• Speech that has an irregular rhythm

You can have one or more of these speech patterns as part of your speech impediment, and their combination and frequency will help determine the type and cause of your speech problem.

Causes of Speech Impediment

The conditions that cause speech impediments can include developmental problems that are present from birth, neurological diseases such as Parkinson’s disease , or sudden neurological events, such as a stroke .

Some people can also experience temporary speech impairment due to anxiety, intoxication, medication side effects, postictal state (the time immediately after a seizure), or a change of consciousness.

Speech Impairment in Children

Children can have speech disorders associated with neurodevelopmental problems, which can interfere with speech development. Some childhood neurological or neurodevelopmental disorders may cause a regression (backsliding) of speech skills.

Common causes of childhood speech impediments include:

• Autism spectrum disorder : A neurodevelopmental disorder that affects social and interactive development
• Cerebral palsy :  A congenital (from birth) disorder that affects learning and control of physical movement
• Hearing loss : Can affect the way children hear and imitate speech
• Rett syndrome : A genetic neurodevelopmental condition that causes regression of physical and social skills beginning during the early school-age years.
• Adrenoleukodystrophy : A genetic disorder that causes a decline in motor and cognitive skills beginning during early childhood
• Childhood metabolic disorders : A group of conditions that affects the way children break down nutrients, often resulting in toxic damage to organs
• Brain tumor : A growth that may damage areas of the brain, including those that control speech or language
• Encephalitis : Brain inflammation or infection that may affect the way regions in the brain function
• Hydrocephalus : Excess fluid within the skull, which may develop after brain surgery and can cause brain damage

Do Childhood Speech Disorders Persist?

Speech disorders during childhood can have persistent effects throughout life. Therapy can often help improve speech skills.

Speech Impairment in Adulthood

Adult speech disorders develop due to conditions that damage the speech areas of the brain.

Common causes of adult speech impairment include:

• Head trauma 
• Nerve injury
• Throat tumor
• Stroke 
• Parkinson’s disease 
• Essential tremor
• Brain tumor
• Brain infection

Additionally, people may develop changes in speech with advancing age, even without a specific neurological cause. This can happen due to presbyphonia , which is a change in the volume and control of speech due to declining hormone levels and reduced elasticity and movement of the vocal cords.

Do Speech Disorders Resolve on Their Own?

Children and adults who have persistent speech disorders are unlikely to experience spontaneous improvement without therapy and should seek professional attention.

Steps to Treating Speech Impediment 

If you or your child has a speech impediment, your healthcare providers will work to diagnose the type of speech impediment as well as the underlying condition that caused it. Defining the cause and type of speech impediment will help determine your prognosis and treatment plan.

Sometimes the cause is known before symptoms begin, as is the case with trauma or MS. Impaired speech may first be a symptom of a condition, such as a stroke that causes aphasia as the primary symptom.

The diagnosis will include a comprehensive medical history, physical examination, and a thorough evaluation of speech and language. Diagnostic testing is directed by the medical history and clinical evaluation.

Diagnostic testing may include:

• Brain imaging , such as brain computerized tomography (CT) or magnetic residence imaging (MRI), if there’s concern about a disease process in the brain
• Swallowing evaluation if there’s concern about dysfunction of the muscles in the throat
• Electromyography (EMG) and nerve conduction studies (aka nerve conduction velocity, or NCV) if there’s concern about nerve and muscle damage
• Blood tests, which can help in diagnosing inflammatory disorders or infections

Your diagnostic tests will help pinpoint the cause of your speech problem. Your treatment will include specific therapy to help improve your speech, as well as medication or other interventions to treat the underlying disorder.

For example, if you are diagnosed with MS, you would likely receive disease-modifying therapy to help prevent MS progression. And if you are diagnosed with a brain tumor, you may need surgery, chemotherapy, or radiation to treat the tumor.

Therapy to Address Speech Impediment

Therapy for speech impairment is interactive and directed by a specialist who is experienced in treating speech problems . Sometimes, children receive speech therapy as part of a specialized learning program at school.

The duration and frequency of your speech therapy program depend on the underlying cause of your impediment, your improvement, and approval from your health insurance.

If you or your child has a serious speech problem, you may qualify for speech therapy. Working with your therapist can help you build confidence, particularly as you begin to see improvement.

Exercises during speech therapy may include:

• Pronouncing individual sounds, such as la la la or da da da
• Practicing pronunciation of words that you have trouble pronouncing
• Adjusting the rate or volume of your speech
• Mouth exercises
• Practicing language skills by naming objects or repeating what the therapist is saying

These therapies are meant to help achieve more fluent and understandable speech as well as an increased comfort level with speech and language.

Building Confidence With Speech Problems 

Some types of speech impairment might not qualify for therapy. If you have speech difficulties due to anxiety or a social phobia or if you don’t have access to therapy, you might benefit from activities that can help you practice your speech. 

You might consider one or more of the following for you or your child:

• Joining a local theater group
• Volunteering in a school or community activity that involves interaction with the public
• Signing up for a class that requires a significant amount of class participation
• Joining a support group for people who have problems with speech

Activities that you do on your own to improve your confidence with speaking can be most beneficial when you are in a non-judgmental and safe space.

Many different types of speech problems can affect children and adults. Some of these are congenital (present from birth), while others are acquired due to health conditions, medication side effects, substances, or mood and anxiety disorders. Because there are so many different types of speech problems, seeking a medical diagnosis so you can get the right therapy for your specific disorder is crucial.

Centers for Disease Control and Prevention. Language and speech disorders in children .

Han C, Tang J, Tang B, et al. The effectiveness and safety of noninvasive brain stimulation technology combined with speech training on aphasia after stroke: a systematic review and meta-analysis . Medicine (Baltimore). 2024;103(2):e36880. doi:10.1097/MD.0000000000036880

National Institute on Deafness and Other Communication Disorders. Quick statistics about voice, speech, language .

Mackey J, McCulloch H, Scheiner G, et al. Speech pathologists' perspectives on the use of augmentative and alternative communication devices with people with acquired brain injury and reflections from lived experience . Brain Impair. 2023;24(2):168-184. doi:10.1017/BrImp.2023.9

Allison KM, Doherty KM. Relation of speech-language profile and communication modality to participation of children with cerebral palsy . Am J Speech Lang Pathol . 2024:1-11. doi:10.1044/2023_AJSLP-23-00267

Saccente-Kennedy B, Gillies F, Desjardins M, et al. A systematic review of speech-language pathology interventions for presbyphonia using the rehabilitation treatment specification system . J Voice. 2024:S0892-1997(23)00396-X. doi:10.1016/j.jvoice.2023.12.010

By Heidi Moawad, MD Dr. Moawad is a neurologist and expert in brain health. She regularly writes and edits health content for medical books and publications.

Understanding Speech Impediments in Children

How do you know if your child has a speech impediment? Speech impediments in children are more common than you might think. They are a type of communication disorder where “normal” speech is disrupted. The disruption can include a lisp, stuttering, stammering, mis-articulation of certain sounds and more. Another commonly used phrase for speech impediments in children is speech disorder. Often, the causes of a speech impediment are unknown. However, sometimes there are physical impairments such as cleft palate or neurological disorders such as traumatic brain injury that may be the cause of the speech impairment. We have listed below five of the most common types of speech impediments in children and a general description of each. Of course, if you suspect your child may have a speech impairment of any kind, we encourage you to visit your pediatrician or hire a Speech Therapist for more information.

Common Types of Speech Impediments in Children

• Apraxia of Speech: Apraxia involves the inconsistent producing and rearranging of speech sounds. For instance potato may become totapo. This disorder may be developmental, where the symptoms have been evident from birth, or acquired. Acquired apraxia of speech generally results from a physical impairment such as injury or stroke.
• Speech Sound Disorder: A speech sound disorder involves difficulty producing certain sounds. The sounds could include /r/, /s/, /l/,/th/, /g/, /ch/ and /sh/. For example, a child may say “wabbit” instead of “rabbit”.  Speech sound disorders are divided into two categories of speech disorders. The first is a Phonetic disorder or articulation disorder which involves the child having difficulty in learning to produce certain sounds physically. The second speech sound disorder is a Phonemic disorder. This type of speech impediment involves the child having difficulty learning the sound distinctions of a language. Luckily, this common speech impediment in children is often easily corrected. Tongue placement tools or working with a Speech Therapist can really help your child.
• Cluttering: Cluttering is a speech disorder characterized by a rapid rate making speech difficult to understand, which in turn affects the person’s fluency. This can happen if the person has a tendency to speak really fast. This can also result when an individual continues to repeat themselves in order to try to make them understood. Cluttering is also referred to as fluency disorder.
• Lisp : A lisp is a speech impediment in children who are struggling to produce the /s/ sound clearly. A frontal lisp is when a child pushes his tongue too far forward in the mouth. A lateral lisp produces a “slushy” sound because too much air is escaping out the sides of a child’s mouth.

We have identified only five of the most common types of speech impediments in children. There are a number of other speech disorders beyond what we have listed. Please refer to our free eBook  for additional information. The good news is that with consistent speech therapy and early intervention, speech impediments in children can be overcome.

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What Is a Speech Sound Disorder?

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Speech sound disorders are a blanket description for a child’s difficulty in learning, articulating, or using the sounds/sound patterns of their language. These difficulties are usually clear when compared to the communication abilities of children within the same age group.

Speech developmental disorders may indicate challenges with motor speech. Here, a child experiences difficulty moving the muscles necessary for speech production. This child may also face reduced coordination when attempting to speak.

Speech sound disorders are recognized where speech patterns do not correspond with the movements/gestures made when speaking.  

Speech impairments are a common early childhood occurrence—an estimated 2% to 13% of children live with these difficulties. Children with these disorders may struggle with reading and writing. This can interfere with their expected academic performance. Speech sound disorders are often confused with language conditions such as specific language impairment (SLI).

This article will examine the distinguishing features of this disorder. It will also review factors responsible for speech challenges, and the different ways they can manifest. Lastly, we’ll cover different treatment methods that make managing this disorder possible.

Symptoms of Speech Sound Disorder

A speech sound disorder may manifest in different ways. This usually depends on the factors responsible for the challenge, or how extreme it is.

There are different patterns of error that may signal a speech sound disorder. These include:

• Removing a sound from a word
• Including a sound in a word
• Replacing hard to pronounce sounds with an unsuitable alternative
• Difficulty pronouncing the same sound in different words (e.g., "pig" and "kit")
• Repeating sounds or words
• Lengthening words
• Pauses while speaking
• Tension when producing sounds
• Head jerks during speech
• Blinking while speaking
• Shame while speaking
• Changes in voice pitch
• Running out of breath while speaking

It’s important to note that children develop at different rates. This can reflect in the ease and ability to produce sounds. But where children repeatedly make sounds or statements that are difficult to understand, this could indicate a speech disorder.

Diagnosis of Speech Sound Disorders

For a correct diagnosis, a speech-language pathologist can determine whether or not a child has a speech-sound disorder.

This determination may be made in line with the requirements of the DSM-5 diagnostic criteria . These guidelines require that:

• The child experience persistent difficulty with sound production (this affects communication and speech comprehension)
• Symptoms of the disorder appear early during the child’s development stages
• This disorder limits communication. It affects social interactions, academic achievements, and job performance.
• The disorder is not caused by other conditions like a congenital disorder or an acquired condition like hearing loss . Hereditary disorders are, however, exempted. 

Causes of Speech Sound Disorders

There is no known cause of speech sound disorders. However, several risk factors may increase the odds of developing a speech challenge. These include:

• Gender : Male children are more likely to develop a speech sound disorder
• Family history : Children with family members living with speech disorders may acquire a similar challenge.
• Socioeconomics : Being raised in a low socioeconomic environment may contribute to the development of speech and literacy challenges.
• Pre- and post-natal challenges : Difficulties faced during pregnancy such as maternal infections and stressors may worsen the chances of speech disorders in a child. Likewise, delivery complications, premature birth, and low-birth-weight could lead to speech disorders.
• Disabilities : Down syndrome, autism , and other disabilities may be linked to speech-sound disorders.
• Physical challenges : Children with a cleft lip may experience speech sound difficulties.
• Brain damage : These disorders may also be caused by an infection or trauma to a child’s brain . This is seen in conditions like cerebral palsy where the muscles affecting speech are injured.

Types of Speech Sound Disorders

By the time a child turns three, at least half of what they say should be properly understood. By ages four and five, most sounds should be pronounced correctly—although, exceptions may arise when pronouncing “l”, “s”,”r”,”v”, and other similar sounds. By seven or eight, harder sounds should be properly pronounced. 

A child with a speech sound disorder will continue to struggle to pronounce words, even past the expected age. Difficulty with speech patterns may signal one of the following speech sound disorders:

This refers to interruptions while speaking. Stuttering is the most common form of disfluency. It is recognized for recurring breaks in the free flow of speech. After the age of four, a child with disfluency will still repeat words or phrases while speaking. This child may include extra words or sounds when communicating—they may also make words longer by stressing syllables.

This disorder may cause tension while speaking. Other times, head jerking or blinking may be observed with disfluency. 

Children with this disorder often feel frustrated when speaking, it may also cause embarrassment during interactions. 

Articulation Disorder

When a child is unable to properly produce sounds, this may be caused by inexact placement, speed, pressure, or movement from the lips, tongue, or throat.  

This usually signals an articulation disorder, where sounds like “r”, “l”, or “s” may be changed. In these cases, a child’s communication may be understood by only close family members.

Phonological Disorder

A phonological disorder is present where a child is unable to make the speech sounds expected of their age. Here, mistakes may be made when producing sounds. Other times, sounds like consonants may be omitted when speaking.  

Voice Disorder

Where a child is observed to have a raspy voice, this may be an early sign of a voice disorder. Other indicators include voice breaks, a change in pitch, or an excessively loud or soft voice.  

Children that run out of breath while speaking may also live with this disorder. Likewise, children may sound very nasally, or can appear to have inadequate air coming out of their nose if they have a voice disorder.

Childhood apraxia of speech occurs when a child lacks the proper motor skills for sound production. Children with this condition will find it difficult to plan and produce movements in the tongue, lips, jaw, and palate required for speech.  

Treatment of Speech Sound Disorder

Parents of children with speech sound disorders may feel at a loss for the next steps to take. To avoid further strain to the child, it’s important to avoid showing excessive concern.

Instead, listening patiently to their needs, letting them speak without completing their sentences, and showing usual love and care can go a long way.

For professional assistance, a speech-language pathologist can assist with improving a child’s communication. These pathologists will typically use oral motor exercises to enhance speech.

These oral exercises may also include nonspeech oral exercises such as blowing, oral massages and brushing, cheek puffing, whistleblowing, etc.

Nonspeech oral exercises help to strengthen weak mouth muscles, and can help with learning the common ways of communicating.

Parents and children with speech sound disorders may also join support groups for information and assistance with the condition.

A Word From Verywell

It can be frustrating to witness the challenges in communication. But while it's understandable to long for typical communication from a child—the differences caused by speech disorders can be managed with the right care and supervision. Speaking to a speech therapist, and showing love o children with speech disorders can be important first steps in overcoming these conditions.

Eadie P, Morgan A, Ukoumunne OC, Ttofari Eecen K, Wake M, Reilly S. Speech sound disorder at 4 years: prevalence, comorbidities, and predictors in a community cohort of children . Dev Med Child Neurol . 2015;57(6):578-584. doi:10.1111/dmcn.12635

McLeod S, Harrison LJ, McAllister L, McCormack J. Speech sound disorders in a community study of preschool children . Am J Speech Lang Pathol . 2013;22(3):503-522. doi:10.1044/1058-0360(2012/11-0123)

Murphy CF, Pagan-Neves LO, Wertzner HF, Schochat E. Children with speech sound disorder: comparing a non-linguistic auditory approach with a phonological intervention approach to improve phonological skills . Front Psychol . 2015;6:64. Published 2015 Feb 4. doi:10.3389/fpsyg.2015.00064

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PsychDB. Speech Sound Disorder (Phonological Disorder) .

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By Elizabeth Plumptre Elizabeth is a freelance health and wellness writer. She helps brands craft factual, yet relatable content that resonates with diverse audiences.

Health Library Speech Disorders

What is a speech disorder.

Many children will experience a temporary delay in speech and language development. Most will eventually catch up. Others will continue to have difficulty with communication development. Communication disorders include speech disorders and language disorders. Speech disorders are discussed in this article and some general guidelines are also given.  This will help you decide if your child needs to be tested by a speech-language pathologist.

A child with a speech disorder may have difficulty with speech sound production, voice, resonance or fluency (the flow of speech).

Speech Sound Disorders

A child with a speech sound disorder is unable to say all of the speech sounds in words. This can make the child’s speech hard to understand. People may not understand the child in everyday situations.  For most children, the cause of the speech sound disorder is unknown.  Other speech sound disorders can be linked to things such as a cleft palate, problems with the teeth, hearing loss, or difficulty controlling the movements of the mouth.

Reasons for Concern

• The child doesn't babble using consonant sounds (particularly b, d, m, and n) by age 8 or 9 months.
• The child uses mostly vowel sounds or gestures to communicate after 18 months.
• The child’s speech cannot be understood by many people at age 3.
• The child’s speech is difficult to understand at age 4 or older.

Voice Disorders

The voice is produced as air from the lungs moves up through and vibrates the vocal folds. This is called phonation. With voice disorders, the voice may be harsh, hoarse, raspy, cut in and out, or show sudden changes in pitch. Voice disorders can be due to vocal nodules, cysts, papillomas, paralysis or weakness of the vocal folds.

• The voice is hoarse, harsh or breathy.
• The voice is always too loud or too soft.
• The pitch is inappropriate for the child's age or gender.
• The voice often "breaks" or suddenly changes pitch.
• Frequent loss of voice

Resonance Disorders

Resonance is the overall quality of the voice. A resonance disorder is when the quality of the voice changes as it travels through the different-shaped spaces of the throat, nose and mouth. Resonance disorders include the following:

Hyponasality (Denasality): This is when not enough sound comes through the nose, making the child sound “stopped up.” This might be caused by a blockage in the nose or by allergies.

Hypernasality : This happens when the movable, soft part of the palate (the velum) does not completely close off the nose from the back of the throat during speech. Because of this, too much sound escapes through the nose. This can be due to a history of cleft palate, a submucous cleft, a short palate, a wide nasopharynx, the removal of too much tissue during an adenoidectomy, or poor movement of the soft palate.

Cul-de-Sac Resonance: This is when there is a blockage of sound in the nose, mouth or throat. The voice sounds muffled or quiet as a result.

Reasons for Concern:

• Speech sounds hyponasal or hypernasal
• Air is heard coming out of the nose during speech

Fluency Disorders (Stuttering)

Fluency is the natural “flow” or forward movement of speech. Stuttering is the most common type of fluency disorder. Stuttering happens when there are an abnormal number of repetitions , hesitations, prolongations, or blocks in this rhythm or flow of speech. Tension may also be seen in the face, neck, shoulders or fists. There are many theories about why children stutter. At present, the cause is most likely linked to underlying neurological differences in speech and language processing. Internal reactions from the person talking, and external reactions from other listeners, may impact stuttering, but they do not cause stuttering.

• The parents are concerned about stuttering.
• The child has an abnormal number of repetitions, hesitations, prolongations or blocks in the natural flow of speech.
• The child exhibits tension during speech.
• The child avoids speaking due to a fear of stuttering.
• The child considers themselves to be someone who stutters.

Treatment for Speech Disorders

Early intervention is very important for children with communication disorders. Treatment is best started during the toddler or preschool years. These years are a critical period of normal language learning. The early skills needed for normal speech and language development can be tested even in infants. At that age, the speech-language pathologist works with the parents on stimulating speech and language development in the home. Active treatment in the form of individual therapy usually starts between the ages of 2 and 4 years.

If you have concerns about your child’s communication skills, discuss them with your child’s doctor. The doctor will likely refer the child to a speech-language pathologist for evaluation and treatment.

All children with speech and language disorders should also have their hearing tested.

Helping Your Child

Children learn speech and language skills by listening to the speech of others, and practicing as they talk to others. Parents are the most important teachers for their child in their early years.

They can help the child by giving lots of opportunities to listen to speech and to talk. This can be done by frequently pointing out and naming important people, places, and things. They can also read and talk to the child throughout the day, especially during daily routines, interactive plays, and favorite activities. Parents can give the child models of words and sentences to repeat.

Parents can also set up opportunities for the child to answer questions and talk. Listening to music, singing songs and sharing nursery rhymes are also great ways to build speech and language skills while having fun with your child.

Last Updated 12/2023

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Childhood Speech Disorders and Disability Benefits

Technically Qualifying for Social Security

All children are eligible for Supplemental Security Income, or SSI benefits. SSI is only awarded to families with a severe financial need. This means that if you or your spouse earns a decent wage, you will not be eligible for disability benefits. The larger your family, the higher your monthly income limit will be.

For example, if you’re a single parent and you have one child, you cannot earn more than $38,000 before taxes in 2018 and still qualify for SSI. If you are a two-parent household of five, you could earn a little over $55,000 and still qualify. You can view a chart on the SSA’s website to determine how much your unique family could make while still qualifying.

Unfortunately, most children are denied SSI benefits due to household income limits. The good news is once your child turns 18, your income will no longer against your child, even if he or she still lives at home.

Medically Qualifying With a Speech Impairment

All conditions that qualify for disability benefits can be found in the Blue Book , the SSA’s manual of qualification criteria. There is a separate version of the Blue Book for both children and adults. Children do not qualify for a speech disorder alone, so this means that if your child has no other diagnoses or disabilities, he or she will unfortunately not qualify for disability benefits due to an inability to speak.

If your child’s speech impairment is cause by another condition, he or she may be eligible. There are many qualifying conditions listed in the Blue Book, but some conditions that often qualify include:

Autism can be found in Section 112.10 of the Blue Book. Under this listing, your child will qualify if he or she has measurable difficulty in any form of communication (verbal, nonverbal, social interaction) and has severely limited interests or participates in repetitive patterns of behavior. Children with autism will also need to have medical evidence proving severe difficulty with one of the following areas of physical functioning:

• Understanding and remembering information
• Interacting with others (playing with children, following adults’ instructions)
• Concentrating and accomplishing tasks
• “Adapting oneself,” which means controlling emotions in a school setting

Down syndrome, on the other hand, will automatically medically qualify with a karyotype analysis. The only exception is if your child has Mosaic Down syndrome (2% of the Down syndrome population), which often has less severe health and intellectual complications will need a little more medical evidence.

Starting Your Application

Before applying, you should always review the Child Disability Starter Kit to get a list of all documents needed before officially applying. You’ll have to apply for SSI benefits in person at your local SSA office . Your child does not have to be present for the application process. To schedule an appointment to apply in person, call the SSA toll free at 1-800-772-1213.

Helpful Resources:

Household SSI Limits: https://www.ssa.gov/ssi/text-child-ussi.htm

Childhood Blue Book: https://www.ssa.gov/disability/professionals/bluebook/ChildhoodListings.htm?PHPSESSID=2e1852cec574b204c1062189dbe882f2

Local SSA Office: https://www.disability-benefits-help.org/social-security-disability-locations

Child Disability Starter Kit: https://www.ssa.gov/disability/disability_starter_kits_child_eng.htm

Provided to ABC Pediatric Therapy Network, https://www.abcpediatrictherapy.com by:

Deanna Power

Director of Outreach

Disability Benefits Help

Developmental Checklist

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• Children's Health

What To Know About a Speech Sound Disorder in Children

A child’s early years are the most important for their development. Children with a healthy and supportive development phase will typically learn all needed abilities for social, emotional, and educational needs. They will also learn essential language, speech, sound, and fine motor skills. Still, some children end up with delays, and while most will catch up with their peers, not all do. 

One delay affecting children is known as a speech sound disorder. But what is a speech sound disorder, and what are the symptoms? 

What Is a Speech Sound Disorder

Speech sound disorders are communication disorders, primarily in children. Affected children may have trouble pronouncing certain words, speaking plainly, and making specific sounds needed to communicate. Some children may also talk with a stutter or lisp. Family, friends, and peers may struggle to understand what a speech-sound-impaired child says. 

Speech sound disorders begin to show as young children develop. Typically, as a child reaches a certain age, they should be able to pronounce certain speech sounds. When a child reaches 8 years old, they should have learned how to correctly pronounce all speech sounds. 

Still, it’s normal for a young child below age 8 to have trouble with certain speech sounds and language. Several children experience delays in speech and language but eventually catch up with their peers. Those who don’t catch up may need communication development from a speech-language pathologist. 

Speech Sound Disorder Causes

Typically, there are no known speech sound disorder causes. However, a family history may be involved. 

There are a few other conditions that may cause speech sound errors or delays, including: 

• Brain injuries 
• Developmental disability disorders, such as autism
• Genetic disorders, such as Down syndrome  
• Hearing issues or hearing loss 
• Cleft palate or cleft lip 
• Nerve disorders, such as cerebral palsy  
• Recurrent ear infections 

Children are at a greater risk for developing a speech sound disorder if the following issues are present: 

• Excessive pacifier or thumb sucking 
• Uneducated parents 
• Insufficient educational support at home 

While speech sound disorders are primarily seen in children, some adults also have them. Some children never relieve their speech sound disorders and they grow into adults with the same conditions. Other adults develop speech sound disorders after a traumatic injury, such as a stroke or brain injury .

Types of Speech Sound Disorders

There are a few types of speech sound disorders, but the main two are articulation and phonological.

Articulation disorders are when a child cannot pronounce specific words, making it hard for others to understand them. On the other hand, phonological disorders are when a child has trouble producing certain sounds of consonants or vowels. 

Articulation disorders are broken down into three groups: 

• Speech sound disorder: Speech sound disorders may be seen in children past a certain developmental age. Specific speech sounds are more complex to vocalize than others are, such as s, r, and l. 
• Phonological process disorder: Phonological process disorders happen when there is a pattern of not correctly pronouncing words. 
• Motor speech disorder: Motor speech disorders happen when a child has difficulty moving muscles required to talk. Dysarthria and apraxia are the two types of motor speech disorders. Dysarthria occurs when the face, mouth, and respiratory system muscles are weak, move slower than usual, or, in some cases, don’t move at all. Apraxia occurs when a child has trouble speaking correctly and consistently and happens due to speech coordination.

Speech Sound Disorder Symptoms

Speech sound disorder symptoms vary depending on your child’s speech sound disorder. Typically, children with these disorders will have difficulty forming word sounds, despite being at the correct age where pronouncing those sounds should be easy. You may notice your child dropping, distorting, adding, or swapping sounds. 

For example, if your child leaves off sounds from words, saying a word like “school” may come out as “coo”. If your child adds extra sounds to a word, they may say something like “puhlease” instead of “please”. If sounds are distorted, you may notice your child saying things like “thith” instead of “this. Finally, if your child is struggling with swapping sounds, you may notice your child saying words like “sowwy” instead of “sorry”. 

These are all a part of articulation disorders. When it comes to phonological disorders, they may have issues with syllables. For example, your child may say “tat” instead of “cat” or “baba” instead of “bottle”. While these sounds are expected in toddlers and younger children, if they last as the child develops more, it might be a speech disorder. 

Other possible speech sound disorder symptoms include: 

• Difficulty with jaw, tongue, and lip movements 
• Inability to speak correctly compared to other children their age 
• Unclear speech, inability for others to understand them 
• Sudden changes in volume and pitch when speaking
• Voice sounds raspy, hoarse, or congested 
• Running out of breath when speaking 
• Talking with a stutter or a lisp 
• Difficulty with certain activities such as chewing or blowing their nose

Speech Sound Disorder Diagnosis

To receive a speech sound disorder diagnosis, your child’s doctor will evaluate your child’s hearing to rule out hearing issues that may be causing speech sound problems. Once hearing loss is ruled out, your doctor may recommend that you speak to a speech expert known as a speech-language pathologist (SLP). SLPs will have the necessary knowledge and experience to make a proper speech sound diagnosis. 

The SLP will test your child’s ability to say certain words. They will also pay attention to how your child moves their jaw, lips, and tongue. Additionally, they will want to test your child’s language skills since language skills often accompany speech sound disorders. 

Your child’s SLP will evaluate your child’s accent and dialect. If the SLP determines that your child’s sounds are less clear or less developed than other children's their age, your SLP will likely diagnose them with a speech sound disorder. 

Speech Sound Disorder Treatment

Your child's speech sound disorder treatment will be unique to your child and their specific speech sound disorder. Thus, your child’s SLP will devise a strategy to help them overcome their disorder. 

The SLP will work to help your child: 

• Realize which sounds they produce are incorrect and help to fix them 
• Pinpoint problem sounds and teach your child how to correctly form them  
• Practice making specific sounds and saying certain words 

If your SLP has noticed structural differences in your child’s mouth, they will refer you to the appropriate specialist. 

As a parent, there are specific measures you can take to encourage correct speech sound development in your child, too. Regularly communicate with your child and those around you by talking or singing, inciting verbal exchanges when necessary, and reading to your child from an early age. 

Additionally, follow the SLP’s speech program strictly as advised. 

The earlier your child receives a diagnosis and treatment plan, the better. Early treatment can help your child develop correct speech and sound and learn how to correctly communicate. 

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Speech Sound Disorders

What are speech sound disorders .

As children learn to speak, they make words easier to say by deleting or changing sounds. As they grow older, children say more speech sounds. This makes their words easier to understand. If your child has a speech sound disorder, they cannot say sounds and words like other children their age.

Three types of speech sound disorders include:

• Articulation disorder: difficulty saying certain speech sounds. You may notice your child drops, adds, distorts or substitutes sounds in words.
• Phonological process disorder: where your child uses patterns of errors. The mistakes may be common in young children learning speech skills. When the errors continue past a certain age, it may be a disorder.
• Disorders that involve a combination of articulation and phonological process disorders.

Some sound changes may be part of your child’s accent or family dialect, and not a true speech disorder.

Causes of speech sound disorders

Speech sound disorders can be caused in a few ways:

• Developmental (your child was born with the disorder)
• Motor or neurological ( childhood apraxia of speech )
• Structural ( cleft lip and palate )
• Sensory or perceptual conditions (like hearing loss )

Symptoms of speech sound disorders 

Signs of a speech sound disorder can include:

• Substituting sounds in words (saying “wain” instead of “rain”)
• Distorting sounds in words (saying “thoap” instead of “soap”)
• Adding sounds to words (saying “puhlay” instead of “play”)
• Saying only one syllable in a word (saying “bay” instead of “baby”)
• Simplifying a word by repeating a syllable (saying “baba” instead of “bottle”)
• Leaving out a consonant sound (saying “at” or “ba” instead of “bat” or saying “tar” instead of “star”)
• Saying words differently each time (saying “buh” for “go” the first time, then “agah” for “go” the second time)

Contact the Center for Childhood Communication

Testing and diagnosis for speech sound disorders.

One of our speech-language pathologists (SLP) may assess your child’s speech through formal testing, language samples, play-based activities, and observations of your child’s mouth structures and movements. Our SLP will determine if your child’s sound errors are expected for their age. If not, they may have a speech sound disorder. Treatment with a CHOP SLP can help your child with their speech development.  

Treatment for speech sound disorders 

Our SLP will create goals to support your child’s speech development. Goals may include recognizing speech sounds and learning how to say speech sounds and words. Each child is unique and may have different needs. The therapy approach will depend on the specific diagnosis and your child’s needs. Once your child says a sound in therapy on their own, it will take time for them to say it consistently. Our SLP will work patiently with your child toward their speech development goals.

Speech-language therapy sessions involve you, your child, their other caregiver(s) and a SLP. Sessions may be play-based or structured with tabletop activities. This will depend on your child’s needs and abilities. Sessions also include your child's interests and your family's culture. This leads to better engagement, relevance, learning and fun.

Early recognition and diagnosis of speech sound disorders can help your child overcome speech problems. With proper treatment and support, your child can learn how to communicate clearly.

Related specialties and programs

Center for childhood communication, department of speech-language pathology, resources to help, center for childhood communication resources.

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Committee on the Evaluation of the Supplemental Security Income (SSI) Disability Program for Children with Speech Disorders and Language Disorders; Board on the Health of Select Populations; Board on Children, Youth, and Families; Institute of Medicine; Division of Behavioral and Social Sciences and Education; National Academies of Sciences, Engineering, and Medicine; Rosenbaum S, Simon P, editors. Speech and Language Disorders in Children: Implications for the Social Security Administration's Supplemental Security Income Program. Washington (DC): National Academies Press (US); 2016 Apr 6.

Speech and Language Disorders in Children: Implications for the Social Security Administration's Supplemental Security Income Program.

• Hardcopy Version at National Academies Press

2 Childhood Speech and Language Disorders in the General U.S. Population

Speech and language disorders in children include a variety of conditions that disrupt children's ability to communicate. Severe speech and language disorders are particularly serious, preventing or impeding children's participation in family and community, school achievement, and eventual employment. This chapter begins by providing an overview of speech and language development and disorders. It then addresses the following topics within the committee's charge: (1) current standards of care for assessing and diagnosing speech and language disorders; (2) causes of and risk factors for these disorders; (3) their prevalence and its relationship to age, development, and gender; and (4) common comorbidities (i.e., other co-occurring conditions).

• OVERVIEW OF CHILDHOOD SPEECH AND LANGUAGE DISORDERS

Differentiating Language from Speech

The words “language” and “speech” are often used interchangeably in casual conversation, but in the context of communication disorders, it is important to understand the differences between them. Language refers to the code, or symbol system, for transforming unobservable mental events, such as thoughts and memories, into events that can be perceived by other people. Being a competent language user requires two essential capabilities. One, known as expressive language or language production , is the ability to encode one's ideas into language forms and symbols. The other, known as receptive language or language comprehension , is the ability to understand the meanings that others have expressed using language. People commonly express themselves by speaking and understand others' meanings by listening. However, language also can be expressed and understood in other ways—for example, by reading, writing, and signing ( Crystal, 2009 ).

Speech has a narrower meaning than language because it refers specifically to sounds produced by the oral mechanism, including the lips, tongue, vocal cords, and related structures ( Caruso and Strand, 1999 ). Speech is the most common way to transmit language and, unlike language, can be observed directly. Speech disorders are sometimes mistakenly equated with language disorders, and conversely, normal speech is sometimes assumed to reflect normal language. In fact, speech disorders and language disorders can occur separately or together. For example, a child might have a speech disorder, such as extremely poor articulation, yet have intact language skills. Another child might have a language disorder, such as extremely poor comprehension, yet be able to produce speech sounds normally. Finally, some children have both language disorders and speech disorders. In young children who are producing little if any speech, it can be difficult to determine whether a speech disorder, a language disorder, or both are present. As noted in Chapter 3 on treatment, early intervention for such children generally is designed to facilitate both language and speech skills. When children reach an age that allows each area to be assessed separately, it becomes possible to narrow the focus of treatment according to whether deficits are found only in speech, only in language, or in both.

In this report, the terms “speech disorders,” “language disorders,” and “speech and language disorders” are used (see Box 1-2 ). The terms “speech disorders” and “language disorders” are used only to refer to these disorders as defined in this chapter, while the term “speech and language disorders” denotes all of the disorders encompassed by these two categories.

Overview of Speech and Language Development and Disorders

The foundations for the development of speech and language begin in utero, with the growth of the anatomical structures and physiological processes that will eventually support sensory, motor, attention, memory, and learning skills. As discussed in the later section of this chapter on causes and risk factors, virtually every factor that threatens prenatal development of the fetus—from genetic abnormalities, to nutritional deficiencies, to exposure to environmental toxins—is associated with an increased risk of developing speech and/or language disorders. Before the end of the prenatal period, fetuses are able to hear, albeit imperfectly, speech and other environmental sounds, and within a few minutes after birth they show special attention to human faces and voices. This early interest in other people appears to set the stage for forming relationships with caregivers, who scaffold the child's growing ability to anticipate, initiate, and participate in social routines (e.g., Locke, 2011 ). The social experiences and skills that occur during the infant's first months of life are important precursors to pragmatic language skills: the infant first learns to engage in reciprocal interactions and to convey communicative intentions through nonlinguistic means such as gestures, and begins to accomplish these same goals through language forms such as early words. In the first few months of life, infants show improvement in their ability to recognize increasingly detailed patterns of speech, a precursor to linking spoken words with their meanings. Also in the first months of life, infants begin to use their oral mechanisms to produce nonspeech sounds, such as cooing and squealing, as they develop control of their muscles and movements. Thus, they are able to produce increasingly consistent combinations of speech-like sounds and syllables (babbling), a precursor to articulating recognizable words (e.g., Kent, 1999 ).

Evidence from neurophysiological habituation, neuroimaging, and preferential looking studies shows that children begin to recognize speech patterns that recur in their environments early in the first year of life ( Friedrich et al, 2015 ; Pelucchi et al., 2009 ; Werker et al., 2012 ). When tested using behavioral measures, most 12- to 18-month-old children show that they can understand at least a few words in the absence of gestural or other cues to their meaning (e.g., Miller and Paul, 1995 ). They also can produce at least a few intelligible words during this period (e.g., Squires et al., 2009 ), showing that they are acquiring both expressive language and speech skills. Their speech skills progress in a systematic fashion over the next few years, as they learn first to say relatively simpler consonants (e.g., “m,” “d,” “n”) and later to say more challenging consonants (e.g., “s,” “th,” “sh”) and consonant clusters (e.g., “bl,” “tr,” “st”) ( Shriberg, 1993 ). Receptive language, expressive language, and speech all develop at a rapid pace through the preschool period as children learn to understand and say thousands of individual words, as well as learn the grammatical (or morpho-syntactic) rules that enable them to understand and produce increasingly lengthy, sophisticated, intelligible, and socially acceptable combinations of words in phrases and sentences (e.g., Fenson et al., 2007 ). These speech and language skills enable children to achieve communication goals as diverse as understanding a simple story, taking a turn in a game, expressing an emotion, sharing a personal experience, and asking for help (e.g., Boudreau, 2008 ). By the end of the preschool period, children's ability to understand the language spoken by others and to speak well enough for others to understand them provides the scaffolding for their growing independence.

The end of the preschool period is also when most children show signs that they can think consciously about sounds and words, an ability known as metalinguistic awareness ( Kim et al., 2013 ). Awareness of the phonological (sound) characteristics of words, for example, enables children to identify words that rhyme or words that begin or end with the same speech sound. Such phonological awareness skills have been linked to children's ability to learn that speech sounds can be represented by printed letters—one of the skills necessary for learning to read words ( Troia, 2013 ). Reading requires more than recognizing individual words, however. Competent readers also must understand how words combine to express meanings in connected text, such as phrases, sentences, and paragraphs. Strong evidence shows that children's receptive language skills—such as their knowledge of vocabulary and grammar—are important contributors as well to this aspect of reading comprehension ( Catts and Kamhi, 2012 ; Duke et al., 2013 ).

In short, by the time children enter elementary school, the speech and language skills they have acquired through listening and speaking provide the foundation for reading and writing. These new literacy skills are critical for learning and social development through the school years and beyond. At the same time, ongoing growth in spoken language skills contributes to building personal and professional relationships and participating independently in society.

It is worth noting that children's speech and language experiences may vary substantially depending on the values and expectations of their culture, community, and family. This point is most obvious for children being raised in multilingual environments, who acquire more than one language. Although the majority of people in the world speak two languages, bilingualism currently is not the norm in the United States, and bilingualism has sometimes been assumed to increase the risk of speech and language disorders. However, there is no evidence that speech or language disorders are more prevalent in bilingual than in monolingual children with similar biological and sociodemographic profiles ( Gillam et al., 2013 ; Goldstein and Gildersleeve-Neumann, 2012 ; Kohnert and Derr, 2012 ).

Similarly, some investigators have reported differences in the amounts and kinds of language experienced by children according to their socioeconomic circumstances, and some of these differences have been associated with scores on later tests that emphasize language skills, including tests of vocabulary and verbal intelligence ( Hart and Risley, 1995 ; Hurtado et al., 2014 ). The language spoken to children certainly influences their language skills, and some aspects of language have been linked to parents' socioeconomic and educational backgrounds (e.g., Hoff, 2013 ). However, the range of language variations observed to date has not been found to increase the risk of speech or language disorders independent of other factors associated with low socioeconomic status, including inadequate or poor-quality health care, hunger, reduced educational and social resources, and increased exposure to environmental hazards ( Harrison and McLeod, 2010 ; Parish et al., 2010 ; Pentimonti et al., 2014 ).

Speech Disorders

As described above, speech refers to the production of meaningful sounds (words and phrases) from the complex coordinated movements of the oral mechanism. Speech requires coordinating breathing (respiration) with movements that produce voice (phonation) and sounds (articulation). Respiration yields a stream of breath, which is set into vibration by laryngeal mechanisms (voice box, vocal cords) to yield audible phonation or voicing. Exquisitely timed and coordinated movements by the articulatory mechanisms, including the jaw, lips, tongue, soft palate, teeth, and upper airway (pharynx), then modify this voiced stream to yield the speech sounds, or phonemes, of the speaker's native language ( Caruso and Strand, 1999 ). Speech disorders are deficits that may prevent speech from being produced at all, or result in speech that cannot be understood or is abnormal in some other way. This broad category includes three main subtypes: speech sound disorders, voice disorders, and stuttering. Speech sound disorders can be further classified into articulation disorders, dysarthria, and childhood apraxia of speech. The speech variations produced by speakers of different dialects and non-native speakers of English are not defined as speech disorders unless they significantly impede communication or educational achievement.

Speech sound disorders , often termed articulation or phonological disorders, are deficits in the production of individual speech sounds, or sequences of speech sounds, caused by inadequate planning, control, or coordination of the structures of the oral mechanism. Dysarthria is a speech sound disorder caused by medical conditions that impair the muscles or nerves that activate the oral mechanism ( Caruso and Strand, 1999 ). Dysarthric speech may be difficult to understand as a result of speech movements that are weak, imprecise, or produced at abnormally slow or rapid rates ( Morgan and Vogel, 2008 ; Pennington et al., 2009 ). Neuromuscular conditions, including stroke, infections (e.g., polio, meningitis), cerebral palsy, and trauma, can cause dysarthria. Another rare speech sound disorder, childhood apraxia of speech , is caused by difficulty with planning and programming speech movements ( ASHA, 2007 ). Children with this disorder may be delayed in learning the speech sounds expected for their age, or they may be physically capable of producing speech sounds but fail to produce the same sounds correctly when attempting to use them in words, phrases, or sentences.

Voice disorders (also known as dysphonias ) occur when the laryngeal structures, including the vocal cords, do not function correctly ( Carding et al., 2006 ). For example, a voice that sounds hoarse or breathy may be due to growths on the vocal cords, allergies, paralysis, infection, or excessive vocal abuse when speaking. A complete inability to produce any sound, called aphonia , may be caused by inflammation, infection, or injury to the vocal cords.

Stuttering (also known as fluency disorder or dysfluency ) is a speech disorder that disrupts the ability to speak as smoothly as desired. Dysfluent speech contains an excessive amount of repetitions of sounds, words, and phrases, and involuntary breaks, or “blocks.” Severe stuttering can effectively prevent a speaker from speaking at all; it may also lead to other abnormal physical and emotional behaviors as the speaker struggles to end a particular block or avoid blocks in the future ( Conture, 2001 ).

Language Disorders

As described above, language refers to the code, or system of symbols, for representing ideas in various modalities, including hearing and speaking, reading, and writing. Language may also refer to the ability to interpret and produce manual communication, such as American Sign Language. Language disorders interfere with a child's ability to understand the code, to produce the code, or both ( American Psychiatric Association, 2013 ; WHO, 1992 ). Children with expressive language disorders have difficulty in formulating their ideas and messages using language. Children with receptive language disorders have difficulty understanding messages encoded in language. Children with expressive-receptive language disorders have difficulty both understanding and producing messages coded in language.

Language disorders may also be classified according to whether they affect pragmatics, semantics, or grammar. Pragmatic language disorders may be seen in children who generally lack social reciprocity, a contributor to the dynamic turn-taking exchanges that typify the earliest communicative interactions (e.g., Sameroff, 2009 ). A child with a receptive pragmatic language disorder may have difficulty understanding messages that involve abstract ideas, such as idioms, metaphors, and irony. A child with an expressive pragmatic disorder may have difficulty producing messages that are socially appropriate for a given listener or context. A child with a receptive semantic disorder may not understand as many vocabulary words as expected for his or her age, while a child with an expressive semantic disorder may find it difficult to produce the right word to convey the intended meaning accurately. A child with a receptive grammatical deficit may not understand the differences between word endings that indicate concepts such as past ( walked ) or present ( walking ), or may not understand complex sentences (e.g., The man that the boy saw was running away ). Similarly, a child with an expressive grammatical disorder may produce short, incomplete sentences that lack the grammatical endings or structures necessary to express ideas clearly or completely.

Language disorders can interfere with any of these subsystems, singly or in combination. For example, children with severe pragmatic deficits may appear uninterested in communicating with others. Other children may try to communicate, but suffer from semantic disorders that prevent them from acquiring the words they need to express their messages. Still other children have normal pragmatic skills and vocabularies, but produce grammatical errors when they attempt to combine words into phrases and sentences. Finally, children with phonological disorders may be delayed in learning which sounds belong in words.

As mentioned earlier, language disorders first identified in the preschool period have been linked to learning disabilities when children enter school ( Sun and Wallach, 2014 ). In fact, the Individuals with Disabilities Education Act (IDEA) (Section 300.8) defines a specific learning disability as “a disorder in one or more of the basic psychological processes involved in understanding or in using language, spoken or written, that may manifest itself in the imperfect ability to listen, think, speak, read, write, spell, or to do mathematical calculations.” Strong evidence suggests that early language disorders increase the risk of poor literacy, mental health, and employment outcomes well into adulthood (e.g., Atkinson et al., 2015 ; Clegg et al., 2015 ; Law et al., 2009 ). For this reason, children with a history of language disorders as preschoolers are monitored closely when they enter elementary school, so that services can be provided to those whose language disorders adversely affect literacy, learning, and academic achievement.

Box 2-1 summarizes the major types of speech and language disorders in children.

Types of Speech and Language Disorders in Children.

Co-occurring Speech and Language Disorders

Speech and language disorders may co-occur in children, and in children with severe disorders it is plausible that less obvious deficits in other aspects of development, such as cognitive and sensorimotor processing, may also be implicated. In the first few years of life it may be particularly difficult to determine whether a child's failure to speak is the result of a speech disorder, of a language disorder, or of both. For one thing, many speech and language abilities emerge during the early years of development, and disorders cannot be identified until children have reached the ages at which various speech and language abilities are expected. This difficulty is compounded by the fact that children under the age of approximately 30 months are often difficult to evaluate because they may be reluctant or unable to engage in formal standardized tests of their speech and language skills.

Fortunately, effective treatments for very young nonspeaking children exist that do not depend on differentiating speech from language disorders, and a child's rate of progress in treatment may provide important evidence on the nature and severity of the disorders.

• DIAGNOSING SPEECH AND LANGUAGE DISORDERS

Speech and language disorders can accompany or result from any of the conditions that interfere with the development of perceptual, motor, cognitive, or socioemotional function. Accordingly, conditions as varied as Down syndrome, fragile X syndrome, autism spectrum disorder, traumatic brain injury, and being deaf or hard of hearing are known to increase the potential for childhood speech and/or language disorders, and many children with such conditions will also have speech and language disorders. In addition, studies of children with primary speech and language disorders often reveal that they have abnormalities in other areas of development. For example, studies by Brumbach and Goffman (2014) suggest that children with primary language impairment show general deficits in gross and fine motor performance, and such children also show deficits in working memory and procedural learning ( Lum et al., 2014 ). Conversely, some children who have primary speech sound disorders as preschoolers have deficits in reading and spelling during their elementary school years ( Lewis et al., 2011 ). In short, considerable evidence suggests that spoken language skills, including speech sound production, constitute an integrated system and that clear deficits in one area may coexist with deficits in other areas that can compromise future development in language-related domains such as literacy. Intensive monitoring of speech and language development in such children is important for early detection and intervention to lessen the effects of speech and language disorders.

In many children, however, speech and language disorders occur for unknown reasons. In such children, diagnosing speech and language disorders is a complex process that requires assessing not only speech and language skills but also cognitive, perceptual, motor, and socioemotional development; biological, medical, and socioeconomic circumstances; and cultural and linguistic environments. Best-practice guidelines recommend evaluating across multiple domains and obtaining information from multiple sources, including a combination of formal, standardized, or norm-referenced tests; criterion-referenced observations by speech-language pathologists and other professionals; and judgments of familiar caregivers about the child's speech and language competence relative to community expectations for children of the same age ( ASHA, 2004 ; Nelson et al., 2006 , 2008 ; Royal College of Speech & Language Therapists, 2005 ; Shevell et al., 2003 ; Wilkinson et al., 2013 ).

On norm-referenced tests, children's scores are compared with average scores from large, representative samples of children of the same age. Children scoring below a cutoff value are defined as having a deficit, and severity is defined according to how far below average their scores fall. Deficits can range from mild to severe. In clinical practice, scores that fall more than two but less than three standard deviations below the mean are described as severely or extremely low; only 2.14 percent of children would be expected to score this poorly. Scores that fall three or more standard deviations below the mean are extraordinarily low; only 0.13 percent of children would be expected to score this poorly ( Urbina, 2014 ). Figure 2-1 represents these numbers in graphic terms. It shows that only 1 child in 1,000 would be expected to score three or more standard deviations below the mean, and only about 22 children in 1,000 would score more than two but less than three standard deviations below the mean.

In a normative sample of 1,000 children, only 1 child (shown in orange) is expected to score three or more standard deviations below the mean. Another 22 children (shown in light green) are expected to score more than two but less than three standard (more...)

In practice, few norm-referenced speech and language tests include a separate severity category for scores that are three or more standard deviations below the mean; all scores two or more standard deviations below the mean are classified together as “severe” or “very low” ( Spaulding et al., 2012 ). As noted in Chapter 1 , these clinical criteria for defining severity are not identical to the legal standards for severity specified in the regulations for the Supplemental Security Income (SSI) program, which also considers functional limitations (that are the result of the interactive and cumulative effects of all impairments) to determine the severity. Chapter 4 includes an in-depth review of how children are evaluated for disability in the SSI eligibility determination process.

Norm-referenced testing is not always possible because children may be too young or too disabled to participate in formal standardized testing procedures. In children younger than 3 years and others incapable of formal testing, behaviors and skills are compared with those of typically developing children using criterion-referenced measures or observational checklists ( Salvia et al., 2012 ). Some criterion-referenced measures involve detailed observations of specific skills, such as parent checklists of the number of words that children say. For example, 3-year-old children are expected to say 50 or more different words; those who fail to reach this criterion may be identified as having a significant vocabulary delay. Similarly, by 9-10 months of age, children are expected to communicate with their caregivers using nonlinguistic signals such as pointing and clapping; a 12-month-old who appears uninterested in others and fails to produce such basic communicative precursors to language may be identified as having a significant delay in the pragmatic domain of language. Still other criterion-referenced measures involve more global judgments of whether the child's language abilities are generally commensurate with those of peers, such as asking parents whether they are concerned about their child's ability to talk or understand as well as other children of the same age. In many cases, children are diagnosed as having language delays when their level of performance on some criterion-referenced skill is inconsistent with age to a significant degree, usually defined as a “percentage of delay” relative to chronological age. For example, a 24-month-old with the skills of children half her age (i.e., 12-month-old children) can be described as having a 50 percent delay; if her skills are comparable to those of 18-month-olds, she is described as having a 25 percent delay. In many states, delays of more than 20-25 percent are used to identify children under age 3 years for early intervention under Part C of the 2004 IDEA ( Ringwalt, 2015 ).

Validated norm-referenced tests may not be available for children who are members of cultural and linguistic communities that are not represented adequately in normative samples (e.g., AERA et al., 2014 ; Roseberry-McKibbin, 2014 ). In addition, norm-referenced test scores may be influenced by such extraneous factors as additional or confounding deficits (e.g., poor vision, inability to respond actively to test items), fatigue, and emotional state on a given day ( Urbina, 2014 ). Finally, norm-referenced testing may not adequately reflect the functional limitations that speech and language deficits impose on the child's ability to participate in some demanding, real-world contexts. For example, a child with a speech sound disorder may be able to articulate a single word reasonably clearly on a norm-referenced speech test, but be incapable of coordinating the many events necessary to produce an intelligible sentence in fast-paced, dynamic conversation. Similarly, a child with an expressive language disorder may be able to produce single words and short phrases successfully elicited by a norm-referenced test, but be incapable of producing grammatical sentences, much less stories that include them. And a child with a receptive language disorder may understand words presented individually and point to a picture on a norm-referenced test, but be unable to comprehend sentences, especially if the sentences are lengthy, complex, spoken at the normal rate of two to four words per second, or spoken in noisy or distracting environments. For all of these reasons, best diagnostic practices require that evidence from norm- and criterion-referenced testing by professionals be considered in conjunction with judgments made by people who are familiar with the child's usual functioning in his or her daily environment (e.g., Paul and Norbury, 2012 ).

• CAUSES AND RISK FACTORS

This chapter now turns to an overview of known underlying causes of speech and language disorders, followed by a summary of factors that have been associated with an increased risk of speech and language disorders having no known cause. Although prevalence estimates are available for some of the causes described below, and speech and language disorders are frequently mentioned among their sequelae, evidence on the percentage of speech and language disorders attributable solely to the underlying condition is not available. For example, Down syndrome, a chromosomal disorder with a prevalence of 1:700 live births, causes deficits spanning multiple areas of development, including not only speech and language but also cognition and sensorimotor skills, making it difficult to quantify the syndrome's causal role specifically in speech and language disorders.

Speech and Language Disorders with Known Causes

Determining the underlying etiology of a speech or language disorder is essential to providing the child with an appropriate set of interventions and the parents with an understanding of the cause and natural history of their child's disability. A variety of congenital and acquired conditions may result in abnormal speech and/or language development. These conditions include primary disorders of hearing, as well as specific genetic diseases, brain malformation syndromes, inborn errors of metabolism, toxic exposures, nutritional deficiencies, injuries, and epilepsy.

Children who are deaf or hard of hearing provide an especially clear example of the interrelationships among the many causes and consequences of speech and language disorders in childhood ( Fitzpatrick, 2015 ). Because adequate hearing is critically important for developing and using receptive language, expressive language, and speech, being deaf or hard of hearing can lead to speech and language disorders, which in turn contribute to socioemotional and academic disabilities. This is particularly the case when the onset of hearing problems is either congenital or acquired during the first several years of life. Therefore, it is essential that hearing be assessed in children being evaluated for speech and language disorders.

Childhood hearing loss may result from or be associated with a wide variety of causes, which are categorized in Box 2-2 . Hearing may be affected by disorders of either the sensory component of the auditory system (i.e., peripheral) or the processing of auditory information within the brain (i.e., central). Peripheral causes may be either unilateral or bilateral and are subdivided into conductive types, which are due to developmental or acquired abnormalities of the structures of the outer or middle ear, and sensorineural types, which are due to a variety of disorders affecting the sound-sensing organ—the cochlea—and its nerve that goes to the brain—the cochlear nerve.

Examples of Conditions Affecting Hearing Early in Life That May Affect the Development of Speech and Language.

Conductive-related causes of reduced hearing levels include congenital structural malformations of the outer and inner ear, consequences of acute or recurrent middle-ear infections, eustachian tube dysfunction, tumors, and trauma. Sensorineural types are even more diverse. A variety of genetic disorders have been identified that affect the function of the cochlea or cochlear nerve, and the disorder may be sporadic or inherited in an autosomal dominant, autosomal recessive, or X-linked manner, depending on the specific gene. Sensorineural types may be secondary to medical illness or even treatments for babies who must be placed in neonatal intensive care units because of either prematurity or a variety of perinatal disorders, such as hypoxia (oxygen deficiency), disturbances of blood flow, infections, or hyperbilirubinemia (excessive bilirubin levels that lead to jaundice and brain dysfunction known as kernicterus). Prenatal infections due to maternal cytomegalovirus, toxoplasmosis, or rubella (TORCH infections) can have a significant congenital impact on the sensorineural hearing mechanism, as can postnatal infectious illnesses such as meningitis (inflammation of membranes around the brain and spinal cord). Ironically, the treatment of meningitis or other bacterial infections with certain antibiotics can result in decreased hearing levels, as some of these life-saving drugs are ototoxic (i.e., harmful to structures of the ear). The impact of antibiotics on central hearing function is much less common in childhood and generally does not lead to total deafness.

The best-recognized cause affecting central hearing is Landau-Kleffner syndrome, or acquired epileptic aphasia, a rare condition that typically presents in early childhood with either minimal speech and language development or loss of previously acquired speech and language due to cortical deafness secondary to persistent epileptiform activity in the electroencephalogram, even in the absence of clinical seizures. Lastly, neonatal hyperbilirubinemia (kernicterus) can impact both sensorineural and central hearing, the latter as a result of dysfunction at the level of the brainstem. Importantly, in addition to the causes described above, many factors that impact hearing are themselves caused by, or co-occur with, underlying conditions that affect other aspects of children's development.

Apart from being deaf or hard of hearing, there are a diverse set of conditions that should be considered as other potential causes of speech and language disorders, as summarized in Box 2-2 . As is the case with hearing, abnormal development of anatomic structures critical to the proper generation of speech may lead to speech sound disorders or voice disorders. For example, articulation and phonological disorders may result from cleft palate. A wide variety of genetic syndromes are known to be associated with disordered speech and language development. These include well-characterized conditions that are due to an abnormal number of a specific chromosome, such as Down syndrome (associated with three rather than two copies of chromosome 21) ( Tedeschi et al., 2015 ) or Klinefelter syndrome (which occurs in boys who have a normal Y chromosome together with two or more X chromosomes, rather than one X chromosome).

Well-recognized genetic syndromes due to a mutation in a single gene (such as fragile X syndrome, neurofibromatosis type I, Williams syndrome, and tuberous sclerosis) are associated with speech or language disorders, and current research has demonstrated that alterations in small groups of genes (copy number variations such as 16p11.2 deletion) may increase the risk of a speech or language disability. In general, when indicated by history and clinical examination, these genetic conditions can be detected with clinically available blood-based laboratory tests. Primary malformations of the central nervous system—such as hydrocephalus (an expansion of the fluid-filled cavities within the brain), agenesis of the corpus callosum (the absence of the main structure that connects the right and left hemispheres of the brain), and both gross and microscopic abnormalities of cortical development (cortical dysplasia, an abnormal layering or location of neurons)—also may be associated with speech and language disorders. In general, these primary disruptions in brain anatomy may be diagnosed by magnetic resonance imaging (MRI) and in some cases discovered via an in utero maternal-fetal ultrasound examination.

A variety of prenatal and postnatal toxic exposures may result in abnormal brain development with resultant neurodevelopmental consequences. Maternal alcohol and other substance use are well recognized in this regard, as is postnatal exposure to lead. Similarly, abnormal prenatal growth, postnatal nutritional deprivation, and hypothyroidism (underactive thyroid) have developmental consequences. Injuries to the developing brain, such as perinatal stroke from brain hemorrhages or ischemia (inadequate blood supply), accidental trauma, and nonaccidental trauma (child abuse), must also be considered, as must such neoplastic conditions as primary brain tumors, metastatic disease, and the consequences of oncological therapies (e.g., chemotherapy and radiation). Some children with cerebral palsy (a condition that results in abnormal motor development and that has numerous causes) may also have an associated speech or language disorder. In addition, speech and language disorders may be secondary to poorly controlled epilepsy associated with a variety of causes, including structural abnormalities in cortical development, genetic disorders (e.g., mutations in ion channel genes), and complex epileptic encephalopathies (e.g., West, Lennox-Gastault, or Landau-Kleffner syndromes) ( Campbell et al., 2003 ; Feldman and Messick, 2009 ).

Box 2-3 presents a listing of examples of speech and language disorders with known causes.

Examples of Speech and Language Disorders with Known Causes.

Risk Factors Associated with Speech and Language Disorders with No Known Cause

In addition to the etiologies described above, a number of variables have been associated with an increased risk of childhood speech and/or language disorders with no known cause. Findings in this literature are somewhat inconsistent ( Harrison and McLeod, 2010 ; Nelson et al., 2006 ), varying with characteristics of the children examined (e.g., age, phenotype, severity, comorbidity) and with research design features (e.g., sample size, control for confounding, statistical analyses).

Studies of speech and language disorders in children, such as speech sound disorders ( Lewis et al., 2006 , 2007 ) and specific language impairment ( Barry et al., 2007 ; Bishop, 2006 ; Bishop and Hayiou-Thomas, 2008 ; Rice, 2012 ; Tomblin and Buckwalter, 1998 ), show that these conditions are familial (i.e., risk for these disorders is elevated for family members of affected individuals) and that this familiality is partially heritable (i.e., genetic factors shared among biological family members contribute to family aggregation). However, heritability estimates (i.e., the proportion of phenotypic variance that can be attributed to genetic variance) for some speech and language disorders, such as specific language impairment, have been inconsistent ( Bishop and Hayiou-Thomas, 2008 ). For example, twin studies on heritability of language disorders have shown a range of estimates of heritability, from 45 percent for deficient language achievement ( Tomblin and Buckwalter, 1998 ) to 25 percent for specific language impairment ( DeThorne et al., 2005 ). One study of 579 4-year-old twins with low language performance and their co-twins found heritability was greater for more severe language impairment, suggesting a stronger influence of genes at the lower end of language ability ( Viding et al., 2004 ). Finally, a review of twin data found that the environment shared by the twins was “relatively unimportant” in causing specific language impairment compared with genetic factors ( Bishop, 2006 ). Overall, the evidence suggests that susceptibility to speech and language disorders results from interactions between genetic and environmental factors ( Newbury and Monaco, 2010 ).

To date, the evidence best supports a cumulative risk model in which increases in risk are larger for combinations of risk factors than for individual factors ( Harrison and McLeod, 2010 ; Lewis et al., 2015 ; Pennington and Bishop, 2009 ; Reilly et al., 2010 ; Whitehouse et al., 2014 ). In a study of speech sound disorders, for example, Campbell and colleagues (2003) found that three variables—male sex, low maternal education, and positive family history of developmental communication disorders—were individually associated with increased odds of speech sound disorder, but the odds of such a disorder were nearly eight times larger in a child with all three risk factors than in a child with none of them. Based on a national database in the United Kingdom, Dockrell and colleagues (2014) report higher odds (2.5) of speech, language, and communication needs in boys than in girls, and they document a strong social gradient for childhood speech, language, and communication disorders in which the odds were 2.3 times greater for children entitled to free school lunches and living in more deprived neighborhoods than for children without these factors. It is important to note that risk indices such as odds ratios cannot provide evidence on the proportion of cases of the disorder that are caused by the factor in question, both because they could reflect the influence of some other, unknown causal factor and because they are influenced by the composition of the samples (e.g., base rate, severity) in which they are calculated.

Research has shown a strong association between poverty and developmental delays, such as language delays. For example, in a study of 513 3-year-olds who had been exposed to risk factors that included inadequate income, lack of social supports, poor maternal prenatal care, and high family stress, King and colleagues (2005) found that 10 percent of children—four times the expected 2.5 percent—had severe delays, scoring two or more standard deviations below the mean on a norm-referenced language test. Walker and colleagues (2011) showed that experiences in early life affect the structure and functioning of the brain. For example, a malnourished expectant mother who faces barriers in accessing prenatal care is at risk of having a child who is premature, is small for his or her gestational age, or experiences perinatal complications ( Adams et al., 1994 ; Walker et al., 2011 ). Children exposed to such factors in the womb are at increased risk for developing a disability such as specific language impairment ( Spitz et al., 1997 ; Stanton-Chapman et al., 2004 ). Lastly, a variety of other psychosocial factors—including deprivation of appropriate stimuli from parents and caretakers ( Akca et al., 2012 ; Fernald et al., 2013 ; Hart and Risley, 1995 ), excess media (television and screen time) exposure ( Christakis et al., 2009 ; Zimmerman et al., 2007 ), and poor sleep hygiene ( Earle and Myers, 2014 )—need to be considered as potential risk factors for speech and language disorders.

Law and colleagues (2000) found that there existed no systematic synthesis of the evidence concerning the prevalence of pediatric speech and language disorders with primary causes; their observation remains true in 2015 ( Wallace et al., 2015 ). Estimating the prevalence of these disorders with confidence is difficult for several reasons. First, because the characteristics of these disorders differ with age, the diagnostic tools by which they are identified necessarily vary in format, ranging from simple parental reports at the earliest ages to formal standardized testing at later ages. Second, because these disorders can vary in scope—from problems with relatively discrete skills (e.g., producing individual speech sounds) to problems with broader and less observable sets of abilities (e.g., drawing inferences from or comprehending language that is ambiguous, indirect, or nonliteral)—there exists no single diagnostic tool capable of addressing the full range of pediatric speech and language skills. Third, as with many pediatric psychological and behavioral disorders, diagnostic criteria involve integrating observations from multiple sources and time points.

As a result, there currently is no single reference standard for identifying pediatric speech and language disorders of primary origin in children of all ages. Instead, prevalence estimates come from studies that focused on different ages and used different diagnostic tools and criteria. Law and colleagues (2000) found a median prevalence of 5.95 percent in the four studies they reviewed; they observe that this value is consistent with several other estimates, but emphasize the need for caution pending additional evidence from well-designed population studies.

The following subsections describe prevalence estimates from studies that have attempted to distinguish speech disorders from language disorders. However, these estimates also must be viewed with caution, given differences among studies in sample composition and diagnostic criteria.

Consistent with the varying expectations for speech skills in children of different ages, estimates of the incidence (i.e., the risk of acquiring a disorder for an individual in a specified population) and prevalence (i.e., the percentage of individuals affected by a disorder in a specified population at a specific point in time) of speech disorders vary according to age, the presence of other neurodevelopmental disorders, and the diagnostic criteria employed.

Most of the literature on the prevalence of speech disorders has focused on children with articulation or phonological disorders due to unknown causes. Shriberg and colleagues (1999 , cited in Pennington and Bishop, 2009 ) report a mean prevalence of 8.2 percent for such disorders; Bishop (2010) estimates prevalence at 10 percent. The prevalence of these disorders varies with age, however, decreasing from 15-16 percent at age 3 ( Campbell et al., 2003 ) to approximately 4 percent at age 6 ( Shriberg et al., 1999 ). Evidence suggests that speech sound disorders affect more boys than girls ( Eadie et al., 2015 ), particularly in early life. In preschoolers, the ratio of affected boys to girls is 2 or 3:1, declining by age 6 to 1.2:1 ( Pennington and Bishop, 2009 ; Shriberg et al., 1999 ). Although many children with speech sound disorders as preschoolers will progress into the normal range by the time of school entry, the close ties between spoken and written language have motivated many studies of the extent to which speech sound disorders are associated with an increased risk of reading, writing, or spelling disorders. To date, evidence from several studies (e.g., Lewis et al., 2015 ; Pennington and Bishop, 2009 ; Skebo et al., 2013 ) suggests that in comparison with their unaffected peers, children with speech sound disorders but normal-range language skills may have somewhat lower reading scores than their peers, but they rarely meet eligibility criteria for a reading disability ( Skebo et al., 2013 ). However, severity has not been considered to date in studies of the relationship between speech sound disorders and reading skills ( Skebo et al., 2013 ).

Little evidence is available concerning the epidemiology of voice disorders in children (dysphonias) not attributable to other developmental disorders. In a prospective population-based cohort of 7,389 8-year-old British children, 6-11 percent were identified as dysphonic; male sex, number of siblings, asthma, and frequent upper respiratory infections were among the factors associated with an increased risk of voice disorders ( Carding et al., 2006 ).

Stuttering is estimated to have a lifetime incidence of 5 percent but a population prevalence of just under 1 percent ( Bloodstein and Ratner, 2008 ). The prevalence of stuttering before the age of 6 years is much higher than that at later ages; evidence from several sources suggests that rates of natural recovery from stuttering in children before age 6 may be as high as 85 percent ( Yairi and Ambrose, 2013 ). Evidence indicates that stuttering affects only slightly more boys than girls during the preschool period, although higher ratios of affected males to females have been observed at later ages. Finally, approximately 60 percent of cases of developmental stuttering co-occur with other speech and language disorders ( Kent and Vorperian, 2013 ).

As with speech disorders, estimates of the prevalence of language disorders vary across studies by age, the presence of other neurodevelopmental disorders, and the diagnostic criteria employed. Language disorders with no known cause, sometimes referred to as “specific” (or “primary”) language impairments (e.g., Reilly et al., 2014 ), are highly prevalent, affecting 6-15 percent of children when identified through formal norm-referenced testing in population-based samples ( Law et al., 2000 ). This is consistent with the cutoff values of 1.0-1.5 standard deviations below the mean employed in several investigations (e.g., Tomblin et al., 1997b ). By contrast, prevalence estimates are generally higher when based on parent or teacher reports. For example, in a survey of parents and teachers conducted in a nationally representative sample of 4,983 4- to 5-year-old children in Australia, McLeod and Harrison (2009) found that prevalence estimates based on parent and teacher reports were somewhat higher than those based on norm-referenced testing, with 22-25 percent of children perceived as having deficits in talking (expressive language) and 10-17 percent as having deficits in understanding (receptive language). As noted by Law and colleagues (2000) , the discrepancy between prevalence rates defined according to norm- and criterion-referenced methods could be due to a number of factors, including the inability of norm-referenced tests to capture or reflect the child's language functioning in relatively more challenging situations, such as classrooms and conversations.

Language disorders that have no known cause have been reported to affect more boys than girls, but it appears that the gender imbalance is greater in clinical than in population-based samples (e.g., Pennington and Bishop, 2009 ). For example, the ratio of affected males to females has ranged from 2:1 to 6:1 across several clinical samples, but boys were only slightly more likely to be affected than girls (1.3:1) in a large population-based sample of U.S. kindergarten children ( Tomblin et al., 1997b ).

As noted earlier, many aspects of literacy depend heavily on the language knowledge and skills that children acquire before they enter school ( Catts and Kamhi, 2012 ), and children with severe language disorders have a substantially increased risk of deficits in reading and academic achievement. Estimates vary, but children diagnosed with language disorders with no known cause as preschoolers are at least four times more likely to have reading disabilities than their unaffected peers ( Pennington and Bishop, 2009 ). Similarly, evidence from a large-scale, prospective methodologically sound cohort study of kindergarteners followed longitudinally showed that the majority of those with language disorders with no known cause continued to exhibit language and/or academic difficulties through adolescence ( Tomblin and Nippold, 2014 ).

One study that helped frame the committee's understanding of prevalence estimates of speech and language disorders was a study of specific language impairment conducted by Tomblin and colleagues (1997b) . This study selected a geographic region in the upper Midwest of the United States and sampled rural, suburban, and urban schools within that region. All eligible 5- to 6-year-old children were systematically screened and followed up with diagnostic testing for specific language impairment. Children were not included if they spoke a language other than English, failed a hearing test, or demonstrated low functioning in nonverbal intelligence (suggesting overall lower intellectual functioning). When a cutoff 1.25 standard deviations below the mean (i.e., approximately the 10th percentile, or the lowest 10 percent of the normative sample) on at least two language scores was used, the prevalence rate of specific language impairment was estimated at 7.4 percent of kindergarten children. The prevalence of specific language impairment for boys was 8 percent and for girls was 6 percent.

When the cutoff was set at two standard deviations below the mean (i.e., approximately the 2nd percentile), the prevalence estimate dropped to 1.12 percent. Using 1.25 standard deviations below the mean as the criterion, there were slightly higher rates of specific language impairment among African American and Native American children relative to white and Hispanic children. Only 29 percent of the parents of the kindergarteners diagnosed with specific language impairment reported having been informed that their children had speech or language problems. It is important to note that large-scale epidemiological studies on autism spectrum disorder, learning disorders, and attention deficit hyperactivity disorder have clearly demonstrated that active case-finding strategies lead to higher and more accurate rates of identification of children with neurodevelopmental disorders ( Barbaresi et al., 2002 , 2005 , 2009 ; CDC, 2014 ; Katusic et al., 2001 ) relative to studies depending only on parent reports. Studies that followed this sample of children with specific language impairment into their school years demonstrated that as a group, they also experienced lower academic achievement.

The Tomblin et al. (1997a) study underscores several methodological issues relevant for the current report: differences in severity level for case identification, comorbidity with other disorders considered primary disabilities, and differences in prevalence related to gender and racial or ethnic identity. Subsequent studies with the children included in this study identified low maternal and paternal education and paternal history of speech, learning, or intellectual difficulties as risk factors for specific language impairment ( Tomblin et al., 1997a ).

Table 2-1 provides a summary of prevalence estimates from the studies of U.S. children that the committee also reviewed. This list is not the result of a meta-analysis, nor is it exhaustive; rather, the table includes a number of well-designed studies that employed clear and consistent definitions. The committee reviewed numerous well-designed studies and meta-analyses from other countries (e.g., Beitchman et al., 1996a , b , c [Canada]; Law et al., 2000 [United Kingdom, others]; McLeod and Harrison, 2009 [Australia]). For the purposes of this study, however, the committee limited the summary of prevalence estimates to U.S. children. Table 2-1 includes the populations and conditions studied, the diagnostic criteria used to identify the conditions, and the prevalence of the conditions (or percent positive). Confidence intervals are included when available. As noted earlier, and as is evident from the table, the studies reviewed vary greatly in terms of ages, diagnostic tools or criteria, and methods used. The estimates presented in the table (in addition to estimates based on national survey data presented in Chapter 5 ) indicate that speech and language disorders affect between 3 and 16 percent of U.S. children.

Estimates of the Prevalence of Speech and Language Disorders from Studies of U.S. Children.

• COMMON COMORBIDITIES

An examination of comorbidities (i.e., other co-occurring conditions) of speech and language disorders is complicated by the central role of language and communication in the development and behavior of children and adolescents. Speech and language disorders are a definitional component of certain conditions, most prominently autism spectrum disorder ( American Psychiatric Association, 2013 ). Other neurodevelopmental disorders, including cognitive impairment, are universally associated with varying degrees of delays and deficits in language and communication skills ( American Psychiatric Association, 2013 ). In addition to their co-occurrence with a wide range of neurodevelopmental disorders, speech and language delays in toddlers and preschool-age children are associated with a significantly increased risk for long-term developmental challenges, such as language-based learning disorders ( Beitchman et al., 1996a , b , c , 1999 , 2001 , 2014 ; Brownlie et al., 2004 ; Stoeckel et al., 2013 ; Voci et al., 2006 ; Young et al., 2002 ). While specific language impairments (i.e., those not associated with other diagnosable neurodevelopmental disorders) are relatively common, it is likely that substantially greater numbers of children and adolescents experience significant speech and/or language impairment associated with other diagnosable disorders. Finally, speech and language delays and deficits may lead to impairments in other aspects of a child's functional skills (e.g., social interaction, behavior, academic achievement) even when not associated with other diagnosable disorders ( Beitchman et al., 1996c , 2001 , 2014 ; Brownlie et al., 2004 ; Voci et al., 2006 ; Young et al., 2002 ). This section, therefore, examines the association of speech and language disorders from the following perspectives: (1) speech and language disorders that are comorbid with other diagnosable disorders, and (2) speech and language disorders in early childhood that confer a quantifiable risk for the later development of comorbid conditions. Together, these two perspectives create a comprehensive picture of the association of speech and language disorders with other neurodevelopmental disorders.

Autism spectrum disorder is a highly prevalent neurodevelopmental disorder, affecting an estimated 1 in 68 8-year-old children in the United States ( CDC, 2014 ). By definition, all children with autism spectrum disorder have deficits in communication, ranging from a complete absence of verbal and nonverbal communication skills, to atypical language (e.g., echolalia or “scripted” language), to more subtle deficits in pragmatic (i.e., social) communication ( American Psychiatric Association, 2013 ). The formal diagnostic criteria for autism spectrum disorder require documentation of deficits in the social-communication domain ( American Psychiatric Association, 2013 ). In clinical practice, when children present with significant delays in the development of communication skills, autism spectrum disorder is one of the primary diagnostic considerations ( Myers and Johnson, 2007 ).

All children and adolescents with intellectual disability have varying degrees of impairment in communication skills ( American Psychiatric Association, 2013 ). Among those with mild intellectual disability, deficits in communication may be relatively subtle, including inability to understand or employ highly abstract language or impairment in social communication. In contrast, children and adolescents with severe or profound levels of intellectual disability may be able only to communicate basic requests, understand concrete instructions, and communicate with simple phrases or single words; others may be unable to employ or understand spoken language. A number of specific genetic disorders are directly associated with varying degrees of intellectual disability together with abnormalities of speech and language (see Box 2-3 ). Some of these genetic conditions often are also associated with specific profiles of speech and language impairment ( Feldman and Messick, 2009 ). Examples include dysfluent speech in children with Down syndrome, echolalia in boys with fragile X syndrome, and fluent but superficial social language in children with Williams syndrome ( Feldman and Messick, 2009 ).

Language-based learning disorders, including reading and written language disorders, are often associated with speech and language disorders. The association between language impairment and reading disorders has been demonstrated in studies examining the likelihood that family members of subjects with language impairment are at increased risk for reading disorder ( Flax et al., 2003 ). Both epidemiologic and clinic-based studies have demonstrated that children with speech sound disorders and language disorders are at increased risk for reading disorder ( Pennington and Bishop, 2009 ). Similarly, multiple studies have demonstrated a strong association between attention deficit hyperactivity disorder and speech and language disorders ( Pennington and Bishop, 2009 ; Tomblin, 2014 ).

The comorbidity of speech and language disorders and other neurodevelopmental disorders may not be apparent in pre-school-age children, since these very young children may not yet manifest the developmental lags or symptoms required to make comorbid diagnoses of such conditions as learning disorders and attention deficit hyperactivity disorder. In their prospective community-based study, for example, Beitchman and colleagues (1989) found significant differences in measures of “reading readiness” among 5-year-old children with poor language comprehension compared with children with either high overall speech and language ability or isolated articulation difficulties ( Beitchman et al., 1989 ). Similarly, there was a tendency for 5-year-olds with a combination of low articulation and poor language comprehension to have higher teacher ratings of hyperactivity and inattention and lower maternal ratings of social competence ( Beitchman et al., 1989 ). By age 12, the children who earlier had shown combined deficits in speech and language had significantly lower levels of reading achievement and higher rates of diagnosed psychiatric disorders (57.1 percent versus 23.7 percent for children with normal speech and language at age 5) ( Beitchman et al., 1994 ). By age 19, children with documented language impairment at age 5 had significantly higher rates of reading disorder (36.8 percent versus 6.4 percent), math disorder (53.9 percent versus 12.2 percent), and psychiatric disorders (40 percent versus 21 percent) compared with their peers with normal language ability at age 5 ( Young et al., 2002 ).

In summary, speech and language disorders are frequently identified in association with (i.e., comorbid with) a wide range of other neurodevelopmental disorders. Children with comorbid conditions can be expected to be more severely impaired and to experience greater functional limitations (due to the interactive and cumulative effects of multiple conditions) than children who do not have comorbid conditions. Furthermore, young children with language impairments are at high risk for later manifestation of learning and psychiatric disorders. It is therefore important both to carefully examine the speech and language skills of children with other developmental disorders and to identify other neurodevelopmental disorders among children presenting with speech and language impairment. Among populations of children with conditions as diverse as autism spectrum disorder, attention deficit hyperactivity disorder, traumatic brain injury, and genetic disorders, speech and language disorders may be the most easily identified impairments because of the central role of language and communication in the functional capacity of children and adolescents.

• FINDINGS AND CONCLUSIONS

2-1. Speech and language disorders are prevalent, affecting between 3 and 16 percent of U.S. children. Prevalence estimates vary according to age and the diagnostic criteria employed, but best evidence suggests that approximately 2 percent of children have speech and/or language disorders that are severe according to clinical standards. 2-2. Some speech and language disorders result from known biological causes. 2-3. In many cases, these disorders have no identifiable cause, but factors including male sex and reduced socioeconomic and educational resources have been associated with an increased risk of the disorders. 2-4. Diagnosing speech and language disorders in children is a complex process that requires integrating information on speech and language with information on biological and medical factors, environmental circumstances, and other areas of development. 2-5. Speech and language disorders frequently co-occur with other neurodevelopmental disorders and may be among the earliest symptoms of serious neurodevelopmental conditions. 2-6. Children with severe speech and language disorders have an increased risk of a variety of adverse outcomes, including mental health and behavior disorders, learning disabilities, poor academic achievement, and limited employment and social participation.

Conclusions

2-1. Severe speech and language disorders represent serious threats to children's social, emotional, educational, and employment outcomes. 2-2. Severe speech and language disorders are debilitating at any age, but their impacts on children are particularly serious because of their widespread adverse effects on development and the fact that these negative consequences cascade and build on one another over time. 2-3. Severe speech and language disorders may be one of the earliest detectable symptoms of other serious neurodevelopmental conditions; for this reason, they represent an important point of entry to early intervention and other services. 2-4. It is critically important to identify such disorders for two reasons: first, because they may be an early symptom of other serious neurodevelopmental disorders, and second, so that interventions aimed at forestalling or minimizing their adverse consequences can be undertaken.

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Speech and Language Impairments

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Table of Contents

A Day in the Life of an SLP

Christina is a speech-language pathologist. She works with children and adults who have impairments in their speech, voice, or language skills. These impairments can take many forms, as her schedule today shows.

First comes Robbie. He’s a cutie pie in the first grade and has recently been diagnosed with childhood apraxia of speech—or CAS. CAS is a speech disorder marked by choppy speech. Robbie also talks in a monotone, making odd pauses as he tries to form words. Sometimes she can see him struggle. It’s not that the muscles of his tongue, lips, and jaw are weak. The difficulty lies in the brain and how it communicates to the muscles involved in producing speech. The muscles need to move in precise ways for speech to be intelligible. And that’s what she and Robbie are working on.

Next, Christina goes down the hall and meets with Pearl in her third grade classroom. While the other students are reading in small groups, she works with Pearl one on one, using the same storybook. Pearl has a speech disorder, too, but hers is called dysarthria. It causes Pearl’s speech to be slurred, very soft, breathy, and slow. Here, the cause is weak muscles of the tongue, lips, palate, and jaw. So that’s what Christina and Pearl work on—strengthening the muscles used to form sounds, words, and sentences, and improving Pearl’s articulation.

One more student to see—4th grader Mario , who has a stutter. She’s helping Mario learn to slow down his speech and control his breathing as he talks. Christina already sees improvement in his fluency.

Tomorrow she’ll go to a different school, and meet with different students. But for today, her day is…Robbie, Pearl, and Mario.

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There are many kinds of speech and language disorders that can affect children. In this fact sheet, we’ll talk about four major areas in which these impairments occur. These are the areas of:

Articulation | speech impairments where the child produces sounds incorrectly (e.g., lisp, difficulty articulating certain sounds, such as “l” or “r”);

Fluency | speech impairments where a child’s flow of speech is disrupted by sounds, syllables, and words that are repeated, prolonged, or avoided and where there may be silent blocks or inappropriate inhalation, exhalation, or phonation patterns;

Voice | speech impairments where the child’s voice has an abnormal quality to its pitch, resonance, or loudness; and

Language | language impairments where the child has problems expressing needs, ideas, or information, and/or in understanding what others say. ( 1 )

These areas are reflected in how “speech or language impairment” is defined by the nation’s special education law, the Individuals with Disabilities Education Act, given below. IDEA is the law that makes early intervention services available to infants and toddlers with disabilities, and special education available to school-aged children with disabilities.

Definition of “Speech or Language Impairment” under IDEA

The Individuals with Disabilities Education Act, or IDEA, defines the term “speech or language impairment” as follows:

Development of Speech and Language Skills in Childhood

Speech and language skills develop in childhood according to fairly well-defined milestones (see below). Parents and other caregivers may become concerned if a child’s language seems noticeably behind (or different from) the language of same-aged peers. This may motivate parents to investigate further and, eventually, to have the child evaluated by a professional.

______________________

More on the Milestones of Language Development

What are the milestones of typical speech-language development? What level of communication skill does a typical 8-month-old baby have, or a 18-month-old, or a child who’s just celebrated his or her fourth birthday?

You’ll find these expertly described in How Does Your Child Hear and Talk? , a series of resource pages available online at the American Speech-Language-Hearing Association (ASHA): http://www.asha.org/public/speech/development/chart.htm

Having the child’s hearing checked is a critical first step. The child may not have a speech or language impairment at all but, rather, a hearing impairment that is interfering with his or her development of language.

It’s important to realize that a language delay isn’t the same thing as a speech or language impairment. Language delay is a very common developmental problem—in fact, the most common, affecting 5-10% of children in preschool. ( 2 ) With language delay, children’s language is developing in the expected sequence, only at a slower rate. In contrast, speech and language disorder refers to abnormal language development. ( 3 )  Distinguishing between the two is most reliably done by a certified speech-language pathologist such as Christina, the SLP in our opening story.

Characteristics of Speech or Language Impairments

The characteristics of speech or language impairments will vary depending upon the type of impairment involved. There may also be a combination of several problems.

When a child has an articulation disorder , he or she has difficulty making certain sounds. These sounds may be left off, added, changed, or distorted, which makes it hard for people to understand the child.

Leaving out or changing certain sounds is common when young children are learning to talk, of course. A good example of this is saying “wabbit” for “rabbit.” The incorrect articulation isn’t necessarily a cause for concern unless it continues past the age where children are expected to produce such sounds correctly. ( 4 ) ( ASHA’s milestone resource pages , mentioned above, are useful here.)

Fluency refers to the flow of speech. A fluency disorder means that something is disrupting the rhythmic and forward flow of speech—usually, a stutter. As a result, the child’s speech contains an “abnormal number of repetitions, hesitations, prolongations, or disturbances. Tension may also be seen in the face, neck, shoulders, or fists.” ( 5 )

Voice is the sound that’s produced when air from the lungs pushes through the voice box in the throat (also called the larnyx), making the vocal folds within vibrate. From there, the sound generated travels up through the spaces of the throat, nose, and mouth, and emerges as our “voice.”

A voice disorder involves problems with the pitch, loudness, resonance, or quality of the voice. ( 6 )   The voice may be hoarse, raspy, or harsh. For some, it may sound quite nasal; others might seem as if they are “stuffed up.” People with voice problems often notice changes in pitch, loss of voice, loss of endurance, and sometimes a sharp or dull pain associated with voice use. ( 7 )

Language has to do with meanings, rather than sounds. ( 8 )  A language disorder refers to an impaired ability to understand and/or use words in context. ( 9 ) A child may have an expressive language disorder (difficulty in expressing ideas or needs), a receptive language disorder (difficulty in understanding what others are saying), or a mixed language disorder (which involves both).

Some characteristics of language disorders include:

• improper use of words and their meanings,
• inability to express ideas,
• inappropriate grammatical patterns,
• reduced vocabulary, and
• inability to follow directions. ( 10 )

Children may hear or see a word but not be able to understand its meaning. They may have trouble getting others to understand what they are trying to communicate. These symptoms can easily be mistaken for other disabilities such as autism or learning disabilities, so it’s very important to ensure that the child receives a thorough evaluation by a certified speech-language pathologist.

What Causes Speech and Language Disorders?

Some causes of speech and language disorders include hearing loss, neurological disorders, brain injury, intellectual disabilities, drug abuse, physical impairments such as cleft lip or palate, and vocal abuse or misuse. Frequently, however, the cause is unknown.

Of the 6.1 million children with disabilities who received special education under IDEA in public schools in the 2005-2006 school year, more than 1.1 million were served under the category of speech or language impairment. ( 11 ) This estimate does not include children who have speech/language problems secondary to other conditions such as deafness, intellectual disability, autism, or cerebral palsy. Because many disabilities do impact the individual’s ability to communicate, the actual incidence of children with speech-language impairment is undoubtedly much higher.

Finding Help

Because all communication disorders carry the potential to isolate individuals from their social and educational surroundings, it is essential to provide help and support as soon as a problem is identified. While many speech and language patterns can be called “baby talk” and are part of children’s normal development, they can become problems if they are not outgrown as expected.

Therefore, it’s important to take action if you suspect that your child has a speech or language impairment (or other disability or delay). The next two sections in this fact sheet will tell you how to find this help.

Help for Babies and Toddlers 

Since we begin learning communication skills in infancy, it’s not surprising that parents are often the first to notice—and worry about—problems or delays in their child’s ability to communicate or understand. Parents should know that there is a lot of help available to address concerns that their young child may be delayed or impaired in developing communication skills. Of particular note is the the early intervention system that’s available in every state.

Early intervention is a system of services designed to help infants and toddlers with disabilities (until their 3rd birthday) and their families. It’s mandated by the IDEA. Through early intervention, parents can have their young one evaluated free of charge, to identify developmental delays or disabilities, including speech and language impairments.

If a child is found to have a delay or disability, staff work with the child’s family to develop what is known as an Individualized Family Services Plan , or IFSP . The IFSP will describe the child’s unique needs as well as the services he or she will receive to address those needs. The IFSP will also emphasize the unique needs of the family, so that parents and other family members will know how to support their young child’s needs. Early intervention services may be provided on a sliding-fee basis, meaning that the costs to the family will depend upon their income.

To identify the EI program in your neighborhood  | Ask your child’s pediatrician for a referral to early intervention or the Child Find in the state. You can also call the local hospital’s maternity ward or pediatric ward, and ask for the contact information of the local early intervention program.

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Help for School-Aged Children, including Preschoolers

Just as IDEA requires that early intervention be made available to babies and toddlers with disabilities, it requires that special education and related services be made available free of charge to every eligible child with a disability, including preschoolers (ages 3-21). These services are specially designed to address the child’s individual needs associated with the disability—in this case, a speech or language impairment.

Many children are identified as having a speech or language impairment after they enter the public school system. A teacher may notice difficulties in a child’s speech or communication skills and refer the child for evaluation. Parents may ask to have their child evaluated. This evaluation is provided free by the public school system.

If the child is found to have a disability under IDEA—such as a speech-language impairment—school staff will work with his or her parents to develop an Individualized Education Program , or IEP . The IEP is similar to an IFSP. It describes the child’s unique needs and the services that have been designed to meet those needs. Special education and related services are provided at no cost to parents.

There is a lot to know about the special education process, much of which you can learn at the Center for Parent Information and Resources (CPIR). We offer a wide range of publications and resource pages on the topic. Enter our special education information at: https://www.parentcenterhub.org/schoolage/

Educational Considerations

Communication skills are at the heart of the education experience. Eligible students with speech or language impairments will want to take advantage of special education and related services that are available in public schools.

The types of supports and services provided can vary a great deal from student to student, just as speech-language impairments do. Special education and related services are planned and delivered based on each student’s individualized educational and developmental needs.

Most, if not all, students with a speech or language impairment will need speech-language pathology services . This related service is defined by IDEA as follows:

(15) Speech-language pathology services includes—

(i) Identification of children with speech or language impairments;

(ii) Diagnosis and appraisal of specific speech or language impairments;

(iii) Referral for medical or other professional attention necessary for the habilitation of speech or language impairments;

(iv) Provision of speech and language services for the habilitation or prevention of communicative impairments; and

Thus, in addition to diagnosing the nature of a child’s speech-language difficulties, speech-language pathologists also provide:

• individual therapy for the child;
• consult with the child’s teacher about the most effective ways to facilitate the child’s communication in the class setting; and
• work closely with the family to develop goals and techniques for effective therapy in class and at home.

Speech and/or language therapy may continue throughout a student’s school years either in the form of direct therapy or on a consultant basis.

Assistive technology (AT) can also be very helpful to students, especially those whose physical conditions make communication difficult. Each student’s IEP team will need to consider if the student would benefit from AT such as an electronic communication system or other device. AT is often the key that helps students engage in the give and take of shared thought, complete school work, and demonstrate their learning.

Tips for Teachers

— Learn as much as you can about the student’s specific disability. Speech-language impairments differ considerably from one another, so it’s important to know the specific impairment and how it affects the student’s communication abilities.

— Recognize that you can make an enormous difference in this student’s life! Find out what the student’s strengths and interests are, and emphasize them. Create opportunities for success.

—If you are not part of the student’s IEP team, a sk for a copy of his or her IEP . The student’s educational goals will be listed there, as well as the services and classroom accommodations he or she is to receive.

— Make sure that needed accommodations are provided for classwork, homework, and testing. These will help the student learn successfully.

— Consult with others (e.g., special educators, the SLP) who can help you identify strategies for teaching and supporting this student, ways to adapt the curriculum, and how to address the student’s IEP goals in your classroom.

— Find out if your state or school district has materials or resources available to help educators address the learning needs of children with speech or language impairments. It’s amazing how many do!

— Communicate with the student’s parents . Regularly share information about how the student is doing at school and at home.

Tips for Parents

— Learn the specifics of your child’s speech or language impairment. The more you know, the more you can help yourself and your child.

— Be patient. Your child, like every child, has a whole lifetime to learn and grow.

— Meet with the school and develop an IEP to address your child’s needs. Be your child’s advocate. You know your son or daughter best, share what you know.

— Be well informed about the speech-language therapy your son or daughter is receiving. Talk with the SLP, find out how to augment and enrich the therapy at home and in other environments. Also find out what not to do!

— Give your child chores. Chores build confidence and ability. Keep your child’s age, attention span, and abilities in mind. Break down jobs into smaller steps. Explain what to do, step by step, until the job is done. Demonstrate. Provide help when it’s needed. Praise a job (or part of a job) well done.

— Listen to your child. Don’t rush to fill gaps or make corrections. Conversely, don’t force your child to speak. Be aware of the other ways in which communication takes place between people.

— Talk to other parents whose children have a similar speech or language impairment. Parents can share practical advice and emotional support. See if there’s a parent nearby by visiting the Parent to Parent USA program and using the interactive map.

— Keep in touch with your child’s teachers. Offer support. Demonstrate any assistive technology your child uses and provide any information teachers will need. Find out how you can augment your child’s school learning at home.

Readings and Articles

We urge you to read the articles identified in the References section. Each provides detailed and expert information on speech or language impairments. You may also be interested in:

Speech-Language Impairment: How to Identify the Most Common and Least Diagnosed Disability of Childhood http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2491683/

Organizations to Consult

ASHA | American Speech-Language-Hearing Association Information in Spanish | Información en español. 1.800.638.8255 | [email protected] | www.asha.org

NIDCD | National Institute on Deafness and Other Communication Disorders 1.800.241.1044 (Voice) | 1.800.241.1055 (TTY) [email protected] | http://www.nidcd.nih.gov/

American Cleft Palate and Craniofacial Association (ACPA) 1.800.242.5338 | https://acpacares.org/

Childhood Apraxia of Speech Association of North America | CASANA http://www.apraxia-kids.org

National Stuttering Foundation 1.800.937.8888 | [email protected] | http://www.nsastutter.org/

Stuttering Foundation 1.800.992.9392 | [email protected] | http://www.stuttersfa.org/

1 | Minnesota Department of Education. (2010). Speech or language impairments . Online at: https://education.mn.gov/mdeprod/idcplg?IdcService=GET_FILE&dDocName=PROD046930&RevisionSelectionMethod=latestReleased&Rendition=primary

2 | Boyse, K. (2008). Speech and language delay and disorder . Retrieved from the University of Michigan Health System website: http://www.med.umich.edu/yourchild/topics/speech.htm

4 | American Speech-Language-Hearing Association. (n.d.). Speech sound disorders: Articulation and phonological processes . Online at: https://www.asha.org/practice-portal/clinical-topics/articulation-and-phonology/

5 | Cincinnati Children’s Hospital. (n.d.). Speech disorders . Online at:  http://www.cincinnatichildrens.org/health/s/speech-disorder/

6 | National Institute on Deafness and Other Communication Disorders. (2002). What is voice? What is speech? What is language? Online at: http://www.nidcd.nih.gov/health/voice/pages/whatis_vsl.aspx

7 | American Academy of Otolaryngology — Head and Neck Surgery. (n.d.).   About your voice . Online at:  http://www.entnet.org/content/about-your-voice

8 | Boyse, K. (2008). Speech and language delay and disorder . Retrieved from the University of Michigan Health System website: http://www.med.umich.edu/yourchild/topics/speech.htm

9 | Encyclopedia of Nursing & Allied Health. (n.d.). Language disorders . Online at: https://web.archive.org/web/20090409020417/http://www.enotes.com/nursing-encyclopedia/language-disorders

10 | Ibid .

11 | U.S. Department of Education. (2010, December). Twenty-ninth annual report to Congress on the Implementation of the Individuals with Disabilities Education Act: 2007 . Online at: https://sites.ed.gov/idea/annual-reports-to-congress/