How is a child evaluated to determine if there is a delay or disorder?
Typically, a child is accompanied by their caregiver to an office setting where the evaluation will take place. The caregiver serves as the informant and provides information pertinent to the child’s development including birth history, medical history, areas of concern and developmental milestones. The SLP evaluates the child using formal, standardized tests that are designed to assess specific areas as well as informal observations. Standardized test scores are obtained which will determine if a delay or disorder is present. Informal observations are recorded and taken into consideration when making recommendations.

What is the difference between a delay and a disorder?
The order in which children learn speech sounds and language is predictable. Most children follow the same pattern of development. When a child is developing speech and language skills in the typical order but is doing so at a slower pace, a speech and or language delay is present. However, when a child presents with gaps in development or uses language forms that not typically used by any child at any age, this may be a sign of a disorder.

How do you know if you should recommend a speech/language evaluation?
Research has shown that the brain has the most plasticity between birth and age seven- allowing for new skills to be acquired easier. Therefore, the earlier the child is diagnosed and can receive the necessary treatment, the better his/her prognosis. Treating language difficulties early on can prevent potential problems with behavior, learning, reading, and social interaction.

Expressive Language

defined as the words children use to express themselves- not be confused with speech

Typical Development from age 2.6- 5 years:

Age 2.6-3 years

  • Uses 3-4 word sentences
  • Asks simple questions
  • Combines 3-4 words in SVO format – daddy throw ball
  • Simple irregular past tense
  • ‘is’
  • Uses possessives
  • Uses negatives ‘won’t’, ‘can’t’, ‘don’t’ 
  • Expresses negation with no, not
  • Uses you, your, she, he, we
  • Uses ‘that’, ‘these’, ‘those’
  • Tells self generated fictional narratives
  • Produces who and how questions
  • Has vocabulary of at least 200-300 words

Age 3- 3.6 years

  • Tells how an object is used
  • At 36 months gives simple account of experiences and tells understandable stories
  • Uses pronouns
  • Begins to share experiences with children
  • Uses third person (s) ‘he runs’
  • Uses fillers- um, yeah
  • ‘why’ stage
  • Recalling and giving details of a past experience
  • More consistent use of ‘they’, ‘us’, ‘his’, ‘her’, ‘hers’
  • Answers questions logically
  • Tells about remote events
  • Uses you, they
  • Uses 800 words
  • Uses ‘is’, ‘are’, ‘and’, ‘am’

Age 3.6- 4 years

  • Completes analogies
  • Long detailed conversation
  • Possessive ‘s’ consistent
  • Asks what were, what was- emerging
  • 4-5 words in sentence
  • Uses superlative form of adjective
  • Tells two events in order of sequence
  • Repeats sentences
  • Uses auxiliaries
  • Uses 1000 – 1500 words
  • Asks ‘how’, ‘why’, ‘when’
  • ‘Is + ing’
  • ‘Not’ consistently
  • Uses ‘got’
  • Because’ emerging
  • ‘Myself’
  • ‘Are’, ‘their’, ‘they’
  • Asks ‘what were’, ‘what was’ emerging
  • Complex sentences used
  • Uses ‘would’, ‘should’, ‘could’
  • Imaginary conditions- ‘I hope’
  • More consistent use of ‘ours’, ‘theirs’, ‘myself’, ‘yourself’
  • Tells stories mixing real and unreal

Age 4- 5 years

  • Uses complete sentences with 4-5 words minimal
  • Asks ‘how’ and ‘where’ questions
  • Uses prepositions (on, behind, next to, front)
  • Uses irregular and regular past tense
  • Tells narratives as sequence of events
  • Accurately relays a long story
  • Describes a procedure
  • Defines words
  • Names categories
  • Uses comparative form of adjectives
  • Uses ‘know’, ‘think’, ‘forget’, and ‘remember’
  • Uses ‘nobody’, ‘no one’, and ‘nothing’
  • Narratives have a sequence of events but no central character or theme

What are some indications there may be an expressive language delay or disorder?

  • Only uses a few words
  • Uses gestures more than words

  • Difficulty with syntax (word order)

  • Refers to self by own name rather than use age appropriate pronoun

  • Difficulty labeling, requesting- unable to come up with the name (word finding)
  • Uses non-specific words including ‘that’, ‘over there’, ‘this one’
  • Does not engage in conversation

  • Difficulty formulating a thought, question

  • Minimal commenting on activities throughout the day

  • Little verbal interaction with peers

  • Behavioral issues- may ‘go with the flow’ (good child) or act out due to difficulty expressing self

Receptive Language

defined as the ability to decode words and know what they mean

Typical Development from age 2.6- 5 years:

Age 2.6-3 years

  • Comprehension usually precedes production- at 30 month 2,400 words, at 36 months, 3600 words
  • Understands plurals
  • Understands some descriptive words such as big/little, wet, dirty, fast/slow
  • Understands question forms ‘what’ and ‘where’
  • Understands part/whole relationships 
  • Carries out two related commands
  • Responds to commands using on, under, down, over here, jump
  • Understands turn taking
  • Identifies objects by use (what do we cut with)
  • Listens to a 10 minute story
  • Identifies actions

Age 3- 3.6 years

  • Knows ‘in front’, ‘behind’, ‘under’, ‘next to’
  • Identifies hard/soft, rough/smooth
  • Supplies last word of a line (the apple grows on the __)
  • Begins to understand sentences involving time concepts (we are going to the zoo tomorrow)
  • Follows two to three part commands
  • Answers simple ‘wh’ questions (who, what, where)
  • Comprehends 1200 words
  • Shapes  (circle, square)
  • Able to match sets
  • Responds appropriately to ‘how’ questions
  • Responds to commands involving two objects or actions
  • Groups objects
  • Understands ‘not’

Age 3.6- 4 years

  • Can  make inferences
  • Understands simple ‘who’, ‘what’, ‘where’, ‘why’, ‘when’ questions
  • Three actions carried out
  • Two events in sequence order
  • Comprehends 2000 words
  • Answers to how much, how long
  • Answers what if questions- what would you do if you fell down
  • Understands negatives
  • Understands relationships expressed by ‘if…then’ or ‘because’ sentences
  • Can do simple verbal analogies (daddy is a man and mommy is a ___)
  • Compares objects

Age 4- 5 years

  • Pays attention to a short story and answers questions about it
  • Understands past, present, and future verbs
  • Understands most prepositions
  • Understands time concepts (night, day, today, yesterday)
  • Understands about 2500- 2800  words
  • Understands passive sentence
  • Understands complex directives
  • Understands concept of numbers up to 3
  • Recognizes 1-3 colors
  • Answers questions about function
  • Answers complex 2-part questions
  • By age five may understand as many as 8,000 words

What are some indications there may be a receptive language delay or disorder?

  • Difficulty following directives (one step, two step, related, unrelated)
  • Asks “what” often after being given a directive or asked a question (auditory processing)

  • Often mistaken for the child who does not want to listen

  • When given a directive with multiple steps may only be able to complete one or the other not the entire directive

  • Difficulty identifying age appropriate common items, actions, prepositions, pronouns, as well as pre-academic skills

  • Answers “wh” questions inconsistently and/or incorrectly

  • May repeat what is said to them
  • Behavioral issues- may seem to be doing his ‘own’ thing, zone out or appear to not pay attention to activities such as a book, circle time

  • Does not engage in conversation

  • Short attention or easily distracted (auditory processing)

  • Slow response to questions


also known as “social language”

Involves three major communication skills:

  • Using language for different purposes- greeting, informing, demanding, promising, requesting, commenting
  • Adapting or changing language according to the needs or expectations of the listener or situation
  • Following rules for conversation and narrative

Typical Development from age 2.6- 5 years:

Age 2.6-3 years

  • Asks questions to get information
  • Begins to maintain dialogue with adult
  • Uses contextual cues to stay on topic
  • Uses information from other speaker 
  • Begins to verbally share experiences with children

Age 3- 4 years

  • Engages in longer dialogues
  • Uses more fillers to acknowledge partners message- uh-huh, yeah, ok
  • Begins using language for fantasies, jokes, teasing
  • Makes conversational repairs when listener has not understood
  • Assumes the role of another person in play
  • Begins code switching when talking to younger children
  • Requests permission
  • Corrects others
  • Offers solutions to problems
  • Asks many questions about events and environment

Age 4- 5 years

  • Uses indirect requests
  • Uses twice as many effective utterances as a three year old to discuss emotions and feelings
  • Narrative development characterized by unfocused chains- stories have a sequence of events no central character or theme
  • Predicts outcomes of stories
  • Verbalizes opinion
  • Defines words
  • Anticipates future events

What are some indications there may be a pragmatic delay/disorder?

  • Poor eye contact
  • Difficulty turn taking in games as well as in communication

  • Does not attend to speaker

  • Short attention

  • Topic shifts are common

  • Tends to play alone

  • Does not approach peers and/or walks away when approached by a peer

  • More comfortable with adults

  • Poor pretend play skills

  • Difficulty behaving appropriately in various situations

  • Does not respond to the speaker

  • Turns towards adult for assistance in communicating to a peer

What can be done in the classroom setting to facilitate social interactions and develop pragmatic language skills?

  • Structured interactions- pairing two children for a specific activity
  • Modeling dialogue for a particular activity

  • Routine interactions- greeting/ taking leave

  • Participation in group activities- being the ‘helper’ at snack time

  • Jobs in classroom that involve communication with peers

  • Encouraging parents to enroll in after school activities that are structured, language based and follow a routine
  • Teaching phrases that will help the child express themselves- and practice using them!

  • Sending home a list of activities done each day by child so parents can participate in a dialogue about the day and have the answers

  • Reminders about staying on topic- we are talking about __now, are we talking about___

  • Pretend play

  • Holding objects at eye level

Central Auditory Processing Disorder (CAPD)

Individuals with CAPD may present with difficulties with read, spoken, and written words. However, they typically can derive the meaning of language from written words. Auditory processing is a term used to describe what happens when your brain recognizes and interprets the sounds around you. The “disorder” part of auditory processing disorder means that something is adversely affecting the processing or interpretation of the information.

CAPD goes by many other names. Other common names are auditory perception problem, auditory comprehension deficit, central auditory dysfunction, central deafness, and so-called “word deafness.”
The cause of CAPD is often unknown. In children, auditory processing difficulty may be associated with conditions such as dyslexia, attention deficit disorder, autism, autism spectrum disorder, specific language impairment, pervasive developmental disorder, or developmental delay. Sometimes this term has been misapplied to children who have no hearing or language disorder but have challenges in learning. A hearing test should be conducted to rule out a hearing impairment. An audiologist is responsible for diagnosing CAPD and typically cannot do so until the child is at least 6.5-7.0 years old.

What are the symptoms of possible CAPD?

Children with auditory processing disorder typically have normal hearing and intelligence. Over time, they may have learned to compensate for their auditory processing weakness; however, these skills will not always be efficient. They may be observed to have:

  • Difficulty with reading, comprehension, spelling, and vocabulary
  • Trouble recognizing subtle differences between sounds in words- small changes in sounds can be big changes in meaning and can lead to a multitude of problems in academic and daily life. 
  • Poor listening skills/ poor attention
  • A dislike of reading because it is difficult and tedious
  • Difficulty listening in the presence of background noise
  • Say “what”, “I don’t know”, “huh” often
  • Problems carrying out multi-step directions
  • Noticeable fatigue at the end of the day
  • Stronger academic performance in quiet, one-on-one learning setting or small groups
  • A need for more time to process information and may need the information to be repeated
  • Trouble paying attention to and remembering information presented orally
  • Low academic performance
  • Speech and language problems
  • Sensitivity towards certain sounds
  • Behavior problems
  • Language difficulty (e.g., they confuse syllable sequences and have problems developing vocabulary and understanding language)
  • Difficulties reading and writing because they are directly linked to language
  • Difficulty spelling due to hearing sounds incorrectly
  • Low frustration tolerance due to not being understood or not able to understand what is going on
  • Difficulty localizing sounds
  • Difficulty processing new vocabulary or information
  • Weaknesses in phonics, reading and spelling
  • Inconsistent performance
  • May seem lazy, over dependent, or inattentive

What treatments are available for CAPD?

Much research is still needed to understand CAPD problems, related disorders, and the best intervention for each child. Several strategies are available to help children with auditory processing difficulties. Some of these are commercially available, but have not been fully studied. Any strategy selected should be used under the guidance of a team of professionals, and the effectiveness of the strategy needs to be evaluated. Researchers are currently studying a variety of approaches to treatment. Several strategies you may hear about include:

  • Auditory trainers are electronic devices that allow a person to focus attention on a speaker and reduce the interference of background noise. They are often used in classrooms, where the teacher wears a microphone to transmit sound and the child wears a headset to receive the sound. Children who wear hearing aids can use them in addition to the auditory trainer. FM system- a wireless amplification system. 
  • Environmental modifications such as classroom acoustics, placement, and seating may help. An audiologist may suggest ways to improve the listening environment, and he or she will be able to monitor any changes in hearing status.
  • Exercises to improve language-building skills can increase the ability to learn new words and increase a child’s language base.
  • Auditory integration training may be promoted by practitioners as a way to retrain the auditory system and decrease hearing distortion. However, current research has not proven the benefits of this treatment.

Language Processing Disorder (LPD)-

Individuals with LPD demonstrate difficulty with both heard and read words. 

Accommodations/ modifications for children with APD or LPD

  • Send materials home in advance- books that will be read, vocabulary, themes that will be targeted
  • Break up multi- step directives- “wash your hands first; come back to the table after” versus “wash hands; come back to the table”
  • Have the child repeat back directives to ensure they understand 
  • Seat child away from window, doors, areas where there may be more noise or distraction
  • Smaller group instruction
  • Assign the child a “buddy” 
  • Classroom modifications- carpeting, felt bottom chairs, white erase boards
  • Allow extra time for the child to think about and form their thoughts
  • Omit non-essential details- keep language simple
  • Get down to their level
  • Use visuals and gestures
  • Don’t choose this child first when going around to answer a question
  • Allow for breaks from work
  • When giving directions make sure the room is quiet, child is looking at you
  • Decreasing noise levels
  • Games to play- “telephone”, “simon says”, “grocery shopping list”
  • Paraphrase and restate key information

The Importance of Social Interactions

Social interaction includes not only conversations but also the identification and understanding of nonverbal cues. These cues, including facial expression, tone of voice and eye contact, provide important information when interacting with others. We learn these cues with experience throughout childhood and gradually integrate them into any social interaction.

Pragmatics refers to the way people use language in social situations and the way that language is interpreted. Pragmatics focuses not on what people say but how they say it and how others interpret their utterances in social contexts

The single best predictor of a healthy emotional interaction is a lot of face- face communication. It’s the best way to learn emotions and develop human-contact skills. Emotional literacy is the ability to read someone else’s or your own emotions so you can tune into their feelings. Children with good emotional intelligence are smarter, happier and more resilient. Children are physically healthier and score higher academically.

  • 4T rule- no texting, tapping, talking on cell or TV viewing when others talk
  • Always look at the color of the talker’s eyes
  • Talk about feelings
  • Role-playing and acting can expand perspective taking
  • Make books available
  • Two- Kind Rule
  • Encourage children to learn one new thing about their friend or family member
  • Play cooperative games

The American Academy of Pediatrics offers the following advice for screen time:

  • Avoid screen time in infants and children under 2
  • Limit screen time in children older than 2 years old to no more than 2 hours a day
  • Establish “screen free” zones in your home, such as in the bedroom and dining room
  • Consider the rating system of shows, movies, and games to avoid exposing your child to inappropriate content
  • Monitor your child’s use of screens and put questionable content into context
  • Teach your child about the use of advertising on children
  • Offer your child educational media and non-electronic content in the form of books, newspapers, and board games
  • Encourage your child to play outside, read, participate in hobbies, and use their imaginations in free play

68 percent of the communication experts polled by the American Speech-Language-Hearing Association said they foresee widespread tech overuse as a communication “time bomb” that could irreparably damage the communication skills for generations to come.