Get Talking: Normal Speech Development

 Mom A: My child is two but still not talking!

Mom B: Oh don’t you worry… I know this child who didn’t utter a word till he was three and now he refuses to stop talking!

A conversation we hear only too frequently. So who do we listen to? How long do we wait? Is there any way we can help our child speak?

Before we launch into all these questions let’s try and understand the difference between “speech” and “language”.  Imagine a little boy who can’t hear since birth. He would not get any exposure to what we say and therefore would not know what to say. Another case is that of a girl who asks for a  “tate” instead of “cake” on her fifth birthday. The difference is that this child knows what to say, but is unable to execute it correctly.  The first case was that of delayed language, the second, of a speech disorder. It follows then, that speech is the output. Language on the other hand, is within us.

Let’s visualize now, a tiny baby, about a month old. He is armed with neither language nor speech, but he still manages to make us do what he wants. He does this through the third and most important skill, communication. This is the first among the three skills to develop, and stays with the child for life. Language and speech skills join in later, as the child proceeds through development from 0 to 3 years.

What follows is a list of things we can expect our child to do at different stages of development.

0-3 months

• Listening intently, stopping activity in response to sound
• Watching your lips and eyes as you speak
• Developing different ways of crying
• Cooing, smiling in response to speech

3-6 months

• Localizes sounds with accuracy
• Can understand emotions like anger, warning, happiness through the voice
• Can produce different vocal patterns for anger, displeasure
• Babbling alone and for communication
• Beginning to respond to their own name

What we as parents could do to help our child along, is use our face, eyes and voice to the fullest. Looking at the child and smiling, singing, making funny sounds, using our voice to stress on key words, playing games like peek- a boo, help the child develop the first and most important of the three skills- communication.

6-9 months

(The child has now started sitting)

• Responds with the appropriate action for “bye”, “give”, “come”, etc.
• Understands names of family members, some common objects
• Vocalizes in sentence- like tones
• Expresses denial
• Shows some basic imitation

9-12 months

(The child is constantly on the move)

• Lots of verbal imitation
• Understands simple commands like “put it down” or “give me the ball”
• Responds with the appropriate action/ pointing/ vocalizing
• Uses some meaningful single words

This is the stage where language has begun to emerge. The parents’ job here is to continuously expose the child to language, speaking about whatever the child is attending to. The language used should be simple, using a lot of voice modulation, and  accompanied by gestures. This not only helps the child understand better; but eventually the child even learns to use the gestures or signs to communicate, before the third skill, speech, begins to develop.

12-18 months

• Indulges in more structured activities like “feeding the doll biscuits”
• Starts imitating actions for rhymes, etc. with greater accuracy
• Learns more and more words everyday
• Consistently uses verbal requests

18-24 months

• Beginnings of co operative play
• Can bring an object even if it is not in immediate sight
• Begins to follow a sequence of two simple commands
• As auditory memory increases, so does the length of utterances! (e.g. mummy come / dolly, eat apple)

24-30 months

• Understands the meaning of different language structures like adjectives (colors, sizes, taste), prepositions (in, on), possessives (mine, mummy’s)
• Consistently uses a basic sentence structure (subject- verb- object)
• Relies only on speech to express wants, needs and feelings.

30-36 months

• Follows a picture story, answering simple questions related to it
• Begins to understand causal relationships
• Uses negatives, tense and gender markers
• Counts till three (meaningfully)
• Clear articulation (at least the sounds p, b, t, d, k, g, f, v)
• Engages in a conversation, asking “where”, “how” and “when” questions
• Uses speech to form new relationships, to be a part of a group

As is evident in the 12 to 18 months list, the child starts being verbal at this stage. In other words, speech begins to emerge. The parents’ role from here onwards is even more important, since the child is ever so willing to absorb whatever comes their way. Parents should be engaging in the following activities, usually in that order.

• Modelling the correct utterance
• Prompting the child to produce it once they know the utterance
• Extension and expansion of whatever the child says

E.g.: Child: “birdie”

Parent: Yes, that’s right! That’s a little bird! It flies high up in the sky! (with actions)

Many parents are quite well informed about milestones, and are also trying their best to teach the child language. However, they often forget three basic rules:

• Create opportunities for communication.

If the child does not feel the need to communicate, he would know whatever there is to know, but never try!

• Encourage trying (use verbal, behavioral, tangible reinforcements).

Let your child know that trying to speak, whether they are successful or not, would always make you happy.

• Keep raising the bar gradually.

Follow a speech and language checklist and set your goals accordingly. A child who speaks single words and gets the job done would not bother to say three word sentences unless you indicate that you need more information!

The chart below would help recall how the three skills- communication, language and speech emerge. As the chart shows, they initially overlap and then develop together.

If a look at the chart rings alarm bells, the next logical step would be to confirm with a checklist. If the checklist confirms your doubts, see a speech therapist.

NEVER ignore the feeling that your child could be lagging behind. Remember, it’s always better to be sure. And then there is the additional benefit of being proved wrong – it makes you a relaxed and happy parent!

Pallavi Kelkar

Speech Language Pathologist

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We would like thank Pallavi for this wonderful article and covering most of parent concerns in such a practical manner. Pallavi is a mother of a precious toddler and a speech and language pathologist. She is currently pursuing her PhD along with working in a local hospital in Pune, India.

Two year olds- terrible or not?

“Tantrums” “Meltdowns” “Terrible twos”

For many parents, the most dreaded of all childhood phases. What is happening at two years old that many parents feel the need to label their child as “terrible”?? Let me explain what should parents do when their two year old is having a tantrum.
To know about what to do when a one year old appears to have a tantrum, read this.

First, realize that tantrums are entirely normal. Most kids will have tantrums between the age of 18 months and 4 years. Tantrums are just an expression of intense feelings; a young toddler feels overwhelmed, scared, or angry with something and doesn’t know how to cope with their intense feelings. These intense feelings get an outlet in a tantrum or meltdown.

So for example, a toddler is out shopping with dad. She spies an ice cream and wants one right now! If dad says no, you cannot have one right now, it becomes a power struggle and ultimately she feels frustrated that she didn’t get it. Now at 18 months she does not have the vocabulary to say “I am annoyed because I really want an ice cream but I am not getting one”. This intense feeling of annoyance or anger or frustration then manifests as a tantrum.

Children do not tantrum to manipulate parents.  However if parents keep giving in to their demands, children will learn that throwing tantrums will lead to getting what they want. When you say “no” to the demand make sure you can stick to it.

So how do we know cope with meltdowns without giving in to the demand of the child? There are two aspects to this.
1. Minimize tantrums
2. Cope with a tantrum once it is happening.

Some ways to minimize tantrums:

1. Go back to basics. A hungry or tired child is more prone to tantrums. Make sure your toddler is offered food every 2 to 3 hours and is adequately rested. Simply doing this will prevent many meltdowns.

2. Pick your battles. This is very very important. Try to say “yes” as much as possible. Does it really matter if toddler wears mismatched clothes or wants to change the cup in which you offered them milk? Make sure that the home environment is set up to minimize “no”. And once you say “No” stick to it.

3. Keep your expectations age appropriate. It is not developmentally appropriate to expect a 2 year old to keep quiet or sit down for long periods of time. If you are going to a place where quiet is required, get some quiet activities or expect to leave early.

4. Make sure you talk to your toddler about your behavior expectations, while keeping in mind their age and development. For example, do not expect a long trip at the store to be easy with a 2 year old. Have snacks or other small distractions at hand. Keep store visits short. How short will depend on your particular child’s temperament. Some children can sit still in the cart, most cannot.

5. Make sure you give your child focused, distraction free attention every day.

Some tips to cope with a tantrum once it has started:

1. Keep your cool. Remember your child is not doing this to manipulate you, your child is having a meltdown because that is how they communicates their intense feelings. Your child needs you to stay calm and collected for their sake.

2. Do not try to reason, explain or otherwise ask the child to stop crying or fussing when they are in the middle of a meltdown. Be there for your child, in a way they like. Some children can be held or picked up when having a meltdown, some need to work through it alone. Make sure that the child does not end up hurting themselves.

3. Empathize with your child without “giving in” to their demand. One way to do this is by naming the emotions experienced by a child. Say “you felt frustrated because you really wanted some ice cream but didn’t get any or you were angry because you wanted your sister’s toy and she did not share it with you”. Naming the emotions helps our children learn that those big feelings they experience have names. Over time your children will learn to express themselves with these words.

At the same time, do not give the child the ice cream or the toy. This is what is called “giving in” and over time it will teach your child that having a tantrum gets them what they want. Remember, it is not our job to keep our children happy at all costs. It’s normal for all of us to feel angry, frustrated, and helpless at some point. It is our job as parents to help our children manage these big emotions.

4. Above all, do not be afraid of your child’s meltdown. Almost all children will have meltdowns at some point in toddlerhood; try not to take it personally. This is a phase and it will pass.

To end, I would like to say that sometimes tantrums or meltdowns can be abnormal too. If your child is having aggressive, self injuring, prolonged (more than 25 minutes), very frequent (10 or more tantrums, more than once a month) then call your child’s paediatrician or get in touch with a child psychologist. Most children though will grow out of regular tantrums by age 4 or so. Till then,

Happy parenting.

A Quick Guide to Autism Spectrum Disorders.

A recent discussion on autism screening created a lot of anxious parents on the support group. So this is an attempt to provide some basic information about autism and its spectrum of disorders.

April is Autism Awareness Month. 

What is Autism?

Autism or Autism Spectrum disorder (ASD) is a brain-developmental disorder.  As more information about this becomes known, definitions of this condition get revised. The latest revision was done in 2013 but a lot of the information available online may not have been updated to reflect this.

Before the new DSM-5 guidelines came out in 2013, ASD had several different conditions under this label: Autistic Disorder, Asperger’s disorder, Pervasive developmental disorder Not Otherwise Specified (PDD-NOS), Rhett’s syndrome and childhood dis-integrative disorder (CID). We are not going to look at details of each but it’s important to know that after 2013, Rhett’s has been removed from under this umbrella.

The new DSM-5 reflects the scientific consensus that Autism, Aspergers, CID and PDD-NOS  are actually one condition with different levels of symptoms severity in two major aspects- 1) Social communication and social interaction 2) restrictive repetitive behaviors(RRB)

A diagnosis of ASD requires the child have both these aspects present. Without RRB’s a diagnosis of ASD cannot be made with just language or social deficits.

What are the signs and symptoms of ASD?

Children with ASD display a wide range of symptoms in their severity and individual abilities and behavior. As we talked about the two aspects of diagnosis earlier, let’s first look at the variety in these areas.

1. Social communication and interaction:

• Inability to have a conversation (going back and forth on a topic), less shared interests, reduced affect and failure to initiate or respond to social interactions.
• Reduced eye-contact, abnormalities in body language, inability to understand gestures and non-verbal communication.
• Difficulty with imaginative play, friends and adjusting social behavior to various social contexts.

2. Restricted, Repetitive behaviors (RRB) (At least 2 are needed for a diagnosis)

• Repetitive or stereotypical motor movements, speech or use of objects (lining up toys, flipping objects, repeating speech phrases, echolalia)
• Inflexibility for change in daily routines and verbal patterns and exhibiting extreme distress at small changes.
• Intense fixation that restricts interaction outside of that attachment to unusual objects or interests.
• Aspects of sensory processing disorder like being hypo/hyper sensitivity to pain, sounds, textures, smells and visual stimuli.

Other considerations for a diagnosis are:

1. Symptoms must be present in the early years (These may not manifest to their fullest until the demand exceeds the limited capacities)
2. Symptoms case clinically significant impairment in functioning.
3. Symptoms are not explained by any other diagnosis like intellectual disability, global developmental delays.

How can ASD be indentified?

There is no medical test to diagnose ASD. A screening is mandatory in most countries at 18 months but many symptoms used for diagnosis may not be fully clear till the child is older and higher social or communication demands are being made.

M-CHAT (Modified Checklist for Autism in Toddlers) is a screening tool used at 18 months. The checklist has a series of 20 questions to be answered in yes/no. A high score indicates high risk and the child need to be given in-depth assessment.  There is a parent follow-up interview in the new revised version of the M-CHAT (here)

ADOS-G (Autism Diagnostic Observation Schedule- Generic), ADI-R (Autism diagnosis interview-revised) and CARS (childhood autism rating scale) are the standardized assessments used for in-depth check of social, communication and RRB’s.

How can ASD be treated?

There is no cure for ASD. All treatment (medical and non-medical) is geared to allowing better functioning of the person with ASD.

Medical:

Children with ASD could find medication helpful to deal with anxiety, depression or seizures. But medication may not have desired affect so it’s extremely important to be under professional care while medications are prescribed.

Children with ASD also need to be monitored for regular health issues. Frequently due to communication issues, headaches, stomach aches and other routine issues may be missed.

Early Intervention:

A team of speech therapists, occupational and or physical therapists, special educators and psychologists are recommended to start early intervention services as soon as the child is found to be at high-risk. Several types of approaches have been found to be beneficial to children with ASD. Finding one that works for the family and child is an important aspect of early intervention.

Complimentary:

There is new evidence emerging on efficacies of dietary modifications in children with ASD. There are a whole lot of these and each one needs to be looked at carefully before trying.

So what does this mean?

• ASD is different from a pure language and attention deficit. There is a significant aspect of RRB’s to be observed before parents should worry about ASD.
• Use M-CHAT to screen your child at 18 months. In case of red flags, talk to a professional.
• Early intervention is the best and fastest way to deal with symptoms and gain best functional level of skills.
• Research is still current in the field of ASD and things are changing frequently. It is better to be informed and speak to professionals in case of concerns rather than relying on other people’s observations.

Knowing and identifying a plan is better than unsubstantiated worrying. Till then..

Happy Parenting.

Puja.

4/17/2015.

References:

Center of Disease Control and Prevention.

http://www.cdc.gov/ncbddd/autism/index.html

American Psychiatric Association, DSM-5.

http://www.dsm5.org/Documents/Autism%20Spectrum%20Disorder%20Fact%20Sheet.pdf

Autism Speaks

https://www.autismspeaks.org/science/science-news/revised-m-chat-improves-autism-screening-toddlers

Kim SK. Recent update of autism spectrum disorders. Korean J Pediatrics, 2015. 58(1): 8-14.

http://www.ncbi.nlm.nih.gov/pubmed/25729393

Milestones: What is all the fuss about?

Heard this before?

“My child walked at 10 months, isn’t it amazing?”, “Oh no! My child is 14 months and taking a few wobbly steps. I am so concerned!”

Often, our concern about our child’s development is overwhelming. At such times, having something to measure against is reassuring. A developmental checklist provides parents a good way of keeping track of their child’s development. Typically this checklist is made of certain skills that should be visible at each age. These are called milestones. Lets understand why these are important for parents.

Development has been intricately linked with milestones from centuries.  A quick Google search revealed that the first formal assessments were used in the western world to test larger number of school kids at the same time after schooling became compulsory. However the first formal standardized test developed was the Stanford-Binet IQ test in 1905. The earliest developmental tests were developed by Giselle in 1911, based on observations of infants.  As standardization become more common, developmental milestones were observed in larger cohorts to formalize these ranges as well.

Development of skill is extremely individualistic. Just like two individuals following the same recipe will not be able to replicate the exact taste, no two children can grow in the same exact manner. Several studies, with twins and siblings, have shown that growing up with the same set of parents and environment does not mean the rate of development or even the qualities within the children would be the same. Holistic development of a child is a delicate balancing act of parent personality, child personality and the environment around them.

So exactly what are milestones?

1) Milestones are skills laid down at certain intervals along the path of development. But development is not linear and two dimensional like a roadway. Therefore, developmental milestones cannot be thought as one fixed point on this continuum.

2) Milestones are categorized in five distinct areas.

All these five areas are development simultaneously and are inter-linked with each other. For example: skill in the adaptive area like brushing teeth requires motor skill of upright balance and hand movements to have developed beforehand. A skill in the speech area like responding to a question requires cognitive and social skills to be in place as well.

3) Milestones are ordered in sequence from easy to complex. In the initial months, milestones in the five areas seem easy and obvious. These early skills are the foundation for later skills. Simplest example is learning the alphabet around 2 years builds to reading and language skills in pre-school years.

 4) Milestones are points fixed as the average age for that skill. So basically a large sample of children was observed and the age of achievement of a skill was noted. Then the average age was taken to be the fixed point for that skill milestone. So if there were 100 infants who were observed for sitting milestone and the earliest age was 6 months while the latest was 10 months, on the milestone checklist, sitting would be placed at 8 months.  Parents should be aware of this aspect

 5) Milestones should not be used in isolation while tracking your child’s development.  As we have discussed above, developmental areas are not independently demarcated. Skills are inter-linked. There is a cause for concern when you see a whole bunch of skills missing or lagging on one or more areas.

Why are milestones important?

1) Reassurance: Parents, especially first timers, are always concerned about raising a healthy, happy child. Following a developmental milestone checklist is the easiest and simplest way to get that reassurance.

2) Early detection:  Following the milestone checklist also gives parents an early inclination of any red flags in developmental pathways. Early detection is the key to getting the right help to prevent and intervention in case of any delays.

3) Holistic development: Tracking with milestones will allow parents to focus on holistic development of their children rather than focus only on certain socially or culturally acceptable skills.

Where can you find a good milestone checklist?

Pathways.org is an organization dedicated to creating free resources for parents to understand their child’s development. Their resources are evidence based and renowned world wide for easy of use for parents.

Here is the link to their developmental checklist.

We hope that parents are able to look at milestones with a slightly more open perspective rather than focusing on them as a rigid entity. The most important aspect of development is progress- adding something new in learning various skills by exploring their environment and limits of their movements.

Till then,

Happy Parenting!

Puja

4/12/2015