Speech Delays and Disorders: Often the Tip of the Iceberg, so be sure to dig deep enough

7 years ago

In a prior post, I referred to a new patient of mine - Sienna. Sienna was approved for services because of her speech sound disorder; that is, her speech was not clear enough for her age.  

Good rule of thumb:  A 3.0 year old child should be 90% intelligible to a stranger. That means that no one should be requesting a repetition from that child more than once out of every 10 utterances/messages, or so.

Anyway, as Sienna separates more from mom and attaches to me by playing with play-doh, spinning tops, a huge pet shop full of dogs and cats and fish as well as a Dora game, I am truly learning what makes this child tick. Recall that Sienna presents with severe separation anxiety from mom, fine motor deficits, gross motor delays and social aloofness in the classroom. She is not on the autistic spectrum - I say that with absolute certainly. She had been an enigma to me, until today.

In the Dora game, Dora and her friends are confounded by a bunch of "problems" that they must solve in order to reach the playground and win the game. Each of these little problems depends on a very important semantic notion (or meaning about the world) - causality. Causality involves understanding that one effect causes the next, so if the water spills on the floor, we trust that a 3 year old understands that it spilled because the cup fell off the table and, further, she understands that the cup fell off the table because she pushed it, and further, she understands that she pushed it because she was angry and so on and so on. These are called causal chains and continue to grow throughout life (and by the way, for those of you with kids who are reading challenged, this is a major piece necessary for reading comprehension).

Anyway, Sienna has become quite verbal and uses many lengthy and complex sentences when she speaks; however, when she came to each Dora "problem", she was stuck dead in her tracks and handed the problem to me to explain. I asked her to do so and heard a jumbled mess of events. Realizing that this was a challenge, I stopped asking.

Axe to Grind:  America is in love with testing their children. STOP testing and teach them - tell them the answers! That's what they're here for. STOP asking questions altogether! Just comment, comment, comment and the child will follow. Questions are a huge problem in interactions, so just stop.

I stated the causal chain as SIMPLY as possible, as few words as possible:

"Oh, poor Dora. She can't go. She can't open the gate. It's locked. She needs the key."

After opening the gate, I said, "Dora opened the gate because turned the key."

I thought Sienna would "avoid" the games' "problem" spaces but she did the opposite; she cheated her way (some finagling with the spinner!!) onto every problem space and handed them to me. She then listened with rapt attention as I explained each.


This little girl is having some major problems figuring out chains of events - what happens if you do this? what happens if you do that? why does this happen? what happens if I leave mom too long?

The world does not make sense to this little girl and she is evidencing higher-order language challenges. 

Geraldine Wallach refers to the "centrality of language" - a wonderful concept. Language is central to everything - or almost everything - we do. It helps us in so many ways and when disruptions occur, the world can be a scary place.

I observed one of my language-delayed patients in his preschool and it went something like this:

Teacher: Jake, come on over. We're making cards for Mom.

Jake does not respond; rather, he continues with puzzles. This annoys the teacher, who relates how difficult he is and that this lack of response and non-compliance is typical with him.  Right after that comment....

Teacher: Sari, you too. Come over here and make your card.

Sari: I don't wanna. I don't wanna cut.

Teacher: I'll cut it for you. Come on over.

Sari walks over and is readily helped by both teachers.

Now, here is your test. What was the same about these scenarios and what was different? Both children did not want to make the cards b/c both knew that they would encounter challenges, probably with the fine motor aspects of it.

And the critical difference??? One could verbalize it and one could not. One was then described as adorable and compliant but the language impaired child was described as difficult and non-compliant. 

Beware judging a child's behavior:  always look for the underlying causes and interpret it from the child's perspective.

The centrality of language -

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