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Am Fam Physician. 2023;108(2):181-188

Patient information: See related handout on speech and language delay in children.

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial relationships.

Childhood speech and language concerns are commonly encountered in the primary care setting. Family physicians are integral in the identification and initial evaluation of children with speech and language delays. Parental concerns and observations and milestone assessment aid in the identification of speech and language abnormalities. Concerning presentations at 24 months or older include speaking fewer than 50 words, incomprehensible speech, and notable speech and language deficits on age-specific testing. Validated screening tools that rely on parental reporting can serve as practical adjuncts during clinic evaluation. Early referral for additional evaluation can mitigate the development of long-term communication disorders and adverse effects on social and academic development. All children who have concerns for speech and language delays should be referred to speech language pathology and audiology for diagnostic and management purposes. Parents and caretakers may also self-refer to early intervention programs for evaluation and management of speech and language concerns in children younger than three years.

Speech is the verbal production of language. Language is the processing of a communication system. Receptive language includes an individual's comprehension abilities. Expressive language includes conveying ideas in spoken, written, or visual forms.1

Clinical recommendation Evidence rating Comments
Developmental surveillance should be completed at every well-child visit until at least five years of age.3 C American Academy of Pediatrics consensus report that summarized findings from 24 studies to determine accuracy of screening tools; no studies met inclusion criteria for investigating improved outcomes with screening
For abnormal speech and language developmental screening findings, immediate referral is recommended rather than following conservatively.3,26 C Studies demonstrating that late talkers either have a language impairment or further delayed-language accession
Early identification and treatment of speech and language delays are recommended to avoid long-term negative impacts on social development and school performance.3,22 C American Academy of Pediatrics consensus report that summarized findings from 13 randomized control trials and one systematic review of speech and language outcomes from treatment.
American Speech-Language-Hearing Association medical review guidelines
Universal hearing screening should be completed after birth; at four, five, six, eight, and 10 years of age; and once between 11 and 14, 15 and 17, and 18 and 21 years of age.27 C American Academy of Pediatrics Bright Futures recommendation

Speech delays stem from difficulty with speech or language processing or both. Speech and language delays usually result in the ultimate achievement of normal skills but at a slower rate than expected.2 Family physicians play an important role in prompt identification of speech and language delays to mitigate the development of communication disorders, which hinder a child's development with long-lasting adverse social and academic impacts.

Speech and Language Development

Distinct milestones mark development by age (Table 1).3,4 Early speech includes sounds, such as cooing and babbling, and later incorporates word combinations that lead to full sentences. Language development begins with basic comprehension that builds to advanced language skills, including the expression of complex thoughts. Evidence suggests that critical language development occurs in the first six months of life5 and that early childhood language exposure significantly influences a child's language mastery.3

Two monthsCalms or smiles when presented with verbal and gestural cues
Reacts to loud noises
Makes sounds in addition to crying
Four monthsResponds to verbal cues with sounds
Turns head to sound of parent's voice
Makes cooing sounds
Chuckles (not yet laughter)
Six monthsResponds to verbal cues by taking turns making sounds with othersLaughs
Blows “raspberries”
Nine monthsLooks when name is calledMakes consonant sounds
Lifts arms to be picked up
12 monthsUnderstands “no”Waves “bye-bye”
Uses specific names for parents, such as mama, dada, or another special name
15 monthsLooks at a familiar object when mentioned
Follows one-step directions given with gestures and words
Tries to say one or two words besides mama or dada
Points to ask for something or to get help
18 monthsFollows one-step directions without gesturesTries to say at least three words other than mama or dada
24 monthsWhen prompted:
Points to items in a book
Points to two body parts
Says two-word phrases
Uses gestures besides waving and pointing (e.g., blowing kiss, nodding “yes”)
30 monthsFollows two-step directions
Follows simple routines when told (e.g., “It's cleanup time.”)
Points to at least one color when asked
Says around 50 words
Says at least two words with one action word
Names items in a book when prompted
Uses personal pronouns
Three yearsAvoids touching hot objects when warned
Conversation of at least two back-and-forth exchanges
Asks who, what, where, and why questions
Describes action in a picture
Says first name when asked
Mostly intelligible to strangers
Four yearsAnswers simple questionsUses at least four-word sentences
Recites words from song, story, or nursery rhyme
States next event in a well-known story
Names several colors
Talks about at least one thing that happened during their day
Five yearsFollows rules when playing games
Answers simple questions about a book or story
Conversation of more than three back-and-forth exchanges
Tells a multi-event story they heard or created
Uses or recognizes simple rhymes
Counts to 10
Names some letters and numbers when pointing to them
Uses words about time

Parents and caregivers significantly influence children's speech and language development by engaging them and promoting social interactions. Family physicians should encourage parents and caregivers to speak to babies and children often, with simplified sentences and clear pronunciation of words. Reading and play are rich opportunities for speech and language promotion that can be integrated into daily routines, helping children build vocabulary and comprehension skills.69 The American Academy of Pediatrics recommends limiting children's screen time in favor of activities focused on social interactions10; screen time has been associated with developmental delays.11,12


In the United States, up to 1 in 8 children between two and five years of age has a speech or language delay.5 Preschool children with identified speech and language delays that continue into elementary school have a higher risk of additional learning disabilities compared with children with only transient speech and language delays. 13,14 School-aged children with speech and language delays have up to a fivefold higher risk of poor reading skills that can affect the child into adulthood.14,15 Adults with a history of childhood speech or language delay are more likely to work lower-skilled jobs and experience unemployment.14,15 Additionally, these childhood speech and language delays are associated with behavior and psychosocial impairments that can persist into adulthood.14,15

Risk Factors

In 2010, the American Speech-Language-Hearing Association published a large study of nearly 5,000 children with a multivariate analysis to identify risk factors consistently associated with established outcome predictors of speech and language impairment, such as parental concerns, use of speech-language pathology services, and low receptive scores.12 The most important risk factors for speech and language impairment were being male, ongoing hearing problems, and birth weight 2,500 g or less (Table 2).12

Risk factorPredictors and associated odds ratios (95% CI)
Parental expressive concernsParental receptive concernsUse of speech-language pathology servicesLow vocabulary score
Birth weight 2,500 g or less1.50 (1.18 to 1.91)1.75 (1.27 to 2.40)1.52 (1.12 to 2.07)1.54 (1.14 to 2.09)
Male sex2.06 (1.80 to 2.35)1.84 (1.51 to 2.24)1.89 (1.58 to 2.56)1.24 (1.05 to 1.47)
Sustained hearing issues4.27 (3.12 to 5.84)6.67 (4.80 to 9.26)4.09 (2.88 to 5.80)1.60 (1.05 to 2.43)

Several other factors have not been reliably associated with speech and language delays. Although heterogeneously impacted, children negatively affected by social determinants of health or adverse childhood or family experiences should be considered at-risk of speech and language delay.8,12 Later birth order is not associated with speech and language delays.12 Multilingual environments, as well as regional, social, and cultural variations, can affect initial speech and language development, most often with an ultimate return to a normal development pattern after the early childhood years.16

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