SPEECH
The
Who Does Not Talk:
Young Child Observations
on
Causes and
Management
Ronald J. Friedman, Ph.D.
M to
expect begin speaking intelligible OST PARENTS
a
normal child
words
during
his second year of life and to begin to put words together into meaningful phrases and sentences during his third year. A substantial portion of children, however, do not display the usual language development, and this can be of considerable concern not only to the parents but to the physician as well. A number of factors may contribute to the delayed appearance or even absence of speech in preschool children. In this paper, we discuss some of these considerations from the viewpoint of developmental psychology and endeavor to provide information that might be useful in work with children and in
parent counseling. Normal Rate of
Speech Development
the first year of life, the major developments include the of about one-half of the major emergence and phonemes* simple morphemes.** Even within this first year, environmental factors can be important in language development. For example, babies under six months of age.
During language
Department of Applied Psychology, The Ontario Institute for Studies in Education, Toronto, Ontario, Canada. * The basic sounds of a language; for the most part vowels and consonants. ** The smallest linguistic unit with a meaning of its own. It is composed of one or more phonemes.
living
in
unstimulating orphanage
environ-
have often been found to be language retarded-both in the frequency of their vocalizations and the number and type of sounds emitted.’ It is difficult to determine when a child actually says his first meaningful word. Eager parents often misinterpret sounds which vaguely resemble words. When mothers’ reports are used as basic data, the first word is said to be spoken at an average ments
age of 11 months. During the second year, swift and dramatic improvements in language ability take place. At about 10 months, the average child begins to respond to simple commands. The first word, generally a single or duplicated syllable such as &dquo;bye-bye,&dquo; &dquo;mama,&dquo; or &dquo;dada,&dquo; is spoken around the first birthday. One examiner recorded that the average child had spoken 37 different words by the age of two, with the range being from six to 126 words. These figures, it should be noted, are based only on spontaneous talk during periodic routine examinations. Most normal children begin to walk before they talk, but exceptions are numerous. Several investigators report that progress in linguistic development may slow down or even cease while new motor skills are being mastered. It does seem that speech development is held in abeyance at the times when motor progress is most rapid.
403
Downloaded from cpj.sagepub.com at MCGILL UNIVERSITY LIBRARY on April 2, 2015
speech of the two-year-old is composed mainly of nouns, verbs, and adjectives. Typically, each of these is used to express entire thoughts (for example, hot is used to The
mean
the
two-year-old nouns
or
is child
to
conjunctions
It is unusual for a place adjectives before
hot).
water
to
use
in his
prepositions, articles, or speech. The child does
these forms or construct sentences that resemble adult language until he is four or five years old. Typically, a child’s total effective vocabulary-his ability to speak or understand test words-is substantially greater than those words which he will spontaneously verbalize. By two years of age, a child’s total effective vocabulary is in excess of 250 words. not use
Mental Retardation
.
a child can hear adequately, if he has defect in the speech producing mechanism, and if he has no obvious damage to the brain in those areas known to be associated with the production of speech, the single most common cause underlying delayed speech development or absence of speech is mental retardation. Morse precisely, in this instance, the absence of speech is not a specific disorder but is, in fact, one aspect of the child’s total retardation. A young child’s language development is probably the best indicator of his level of intellectual functioning. A mental age of 18-24 months must be reached before a child can be able to talk. A moderately retarded child will approach five years of age before reaching this level of mental de-
If
no
velopment. A mentally
retarded child will frequently considerable exhibit disparity between his motor development and his language development. The developmental motor milestones may be well within normal limits, yet the child may still be mentally retarded. His language development is the most sensitive measure of this. Careful attention should be given to the sensory capacity of the child because of the substantial number of children who come to be diagnosed in the schools as mentally retarded, but upon care-
ful examination also show some sort of sensory deficit. However, if the child can hear, and it is clear that no physical defect in the speech-producing mechanism underlies the absence of speech, the next need is for a comprehensive psychologic examination designed to obtain some indication of his level of intellectual functioning. He should be given an individual standardized intelligence test, most typically the Stanford-Binet Intelligence Scale, although a number of other tests are equally appropriate. Of course, a psychological evaluation of a very young child, particularly a child without language, can be quite unreliable. Even among normal children, variations in measured IQ between ages two and five years of 15 to 20 IQ points are not uncommon. Therefore, the diagnosis of mental retardation in a two- or threeyear-old child must be approached cautiously. For the child with delayed speech development, it is feasible to provide a program of language stimulation. Since the effectiveness of such a program will be a function of the child’s intellectual limitations, these programs are often of little significant value. Care should be taken, nevertheless, to advise parents not to curtail their normal verbal interchanges with the youngster despite the frustration engendered by the child’s seeming &dquo;unwillingness&dquo; to talk. Parents should be encouraged to talk to the child who is without speech, to read to him, and to continue to encourage speech (although not coercively). Advance counseling that progress will be slow and that their child cannot be forced to speak is helpful to most parents.
Psychoses
c~r
Other Emotional
Disturbances
Language disorders are frequently associated with infantial autism, childhood schizophrenia, and other severe emotional disturbances. However, compared with men’ tal retardation the overall incidence of psychoses in children is extremely low. In fact, the -legitimacy of this diagnosis with young children is questioned by many write ers. For this possibility, the history is extremely important for diagnosis. Inconsis-
404
Downloaded from cpj.sagepub.com at MCGILL UNIVERSITY LIBRARY on April 2, 2015
language development would be more suggestive of a diagnosis of psychosis or tent
autism than of mental retardation. In a severely emotionally disturbed child, one anticipates bizarre or unusual speech patterns rather than complete absence of the development of speech as is encountered in
severely emotionally disturbed child, one anticipates bizarre or unusual speech patterns rather than complete absence of the development of speech as is In
a
encountered in mental retardation. mental retardation. For example, in I 1 autistic children Kanner and Eisenberg observed that while three failed to develop speech altogether, eight developed a precocity of articulation which was coupled with unusual facility in rote memory. The children were able to repeat endless numbers of rhymes, catechisms, lists of names, and other semantically useless exercises.2
Aphasia In
some
production
children, difficulties in speech can
be related
to
demonstrable
impairment. It is proper to label these children &dquo;aphasic.&dquo; For a time, the terms &dquo;congenital aphasia&dquo; or &dquo;developmental aphasia&dquo; enjoyed some popularity, but it is often impossible to demonstrate, unequivocally, that central nervous system damage exists. In the strictest sense, it would be appropriate to label as aphasic only those children who have clearly suffered traumatic brain injury and have lost some or all language skills. A diagnosis of aphasia for a child who has never had language would be virtually impossible to central
nervous
system
make. For the most part, educational programs in language development and reading for children diagnosed as aphasic are similar to curricula for mildly retarded children. ’
Elective Mutism The electively mute child may be defined as a child who does not speak, but who has
speech or language disorder and no physical defect of the speech-producing mechanism. He is not aphasic, nor is he of sufficiently deficient general intelligence so as to be unable to formulate speech and language. The term elective mutism was first used by Tramer to describe two children who spoke only to certain people.3 Most frequently, electively mute children will speak to immediate family members; within the immediate family it is usually the mother. Consequently, elective mutism frequently escapes attention until the child is no
five or six years old and is enrolled in school. In general, electively mute children can be divided into two groups. Those in the first group appear to use refusal to speak in order to manipulate their immediate environment. With those in the other group, it appears as if speaking is sufficiently anxiety-producing so that the child chooses to remain mute. The reduction in anxiety that results from mute behavior serves as a reward and reinforces the act of remaining mute. Characteristically, these children are described by their parents, teachers, and friends as shy and socially inept. Parents frequently admit that they too are shy and socially withdrawn and may describe other family members as being similar.
Delay
in
speaking
should not be
ignored
in
the hope that the child will grow out of it. It should be regarded as a sign that calls for
intelligent diagnostic study. Elicitation of speech from these children is difficult and frustrating. Those techniques that seek to force the child to speak appear doomed to failure from the start, because the pressure simply serves to increase the child’s anxiety or fear, thus decreasing the probability of the response of speech. As the electively mute child grows older and becomes more competent in the management of his environment, he generally tends to begin to speak. Most treatment
regimens including psychotherapeutic techniques that attempt to speed this process have largely met with failure. At present, the 405
Downloaded from cpj.sagepub.com at MCGILL UNIVERSITY LIBRARY on April 2, 2015
that can be done at home and in school is to provide an atmosphere wherein the child’s anxiety is lessened. most
Other Causes
Children with articulation problems or other speech defects frequently choose to avoid speech because of embarrassment. In some instances, elaborate ruses or systems of gestures become established substitutes for speech. Typically, this form of mutism de-
velops in response to unpleasant experiences associated with speech production in the means of a should not be difficult. history Treatment, or at least evaluation, by a speech therapist is indicated in most instances. When such a child is severely lacking in ego strength or has evidence of serious defects in his ability to relate to others, consideration may be given to psychologic or psychiatric evaluation as well. Parents often try to explain absence of speech in a child by pointing out that it is not necessary that he talk. An older child may reportedly &dquo;speak for&dquo; the younger child. In other cases, parents may feel they have reinforced their own gestures, grunts, and other signs so as to spoil the child and make it unnecessary that he speak. This may occur to some limited extent in certain families, but by themselves these types of behavior are insufficient to explain the absence of speech.
past. Accurate
careful
diagnosis by
Some writers have distinguished between organic and functional (psychogenic) causes of delayed speech. While practical in that it makes clear that there may be more than one cause for a problem and places emphasis on psychologic factors, this distinction is not clear-cut-even in theory. Moreover, even organic conditions may give rise to secondary psychologic effects which increase the
handicap. Delayed speech
in a two- to three-year-old child should not be ignored. There are a number of anecdotal reports of men who as children were late talkers, and who in later life distinguished themselves intellectually, but there is little documented evidence of such cases. Delay in speaking should not be ignored in the hope that the child will grow out of it. It should be regarded as a sign that calls for intelligent diagnostic study. The advisability of neurologic, psychologic, or psychiatric evaluations should be considered for every child with delayed speech.
References 1. Brodbeck, A. M., and Irwin, O. C.: The speech behavior of infants without families. Child Dev. 17: 145, 1946. 2. Kanner, L., and Eisenberg, L.: Early infantile autism, 1943-1955. In Psychiatric Research Reports, American Psychiatric Association, 55,
April, 1957. 3. Tramer, M.: Elekitiver mutism bei kindern. Z. Kinder-Psychiatr. 1: 30, 1934.
406
Downloaded from cpj.sagepub.com at MCGILL UNIVERSITY LIBRARY on April 2, 2015
The
Who Does Not Talk:
Young Child Observations
on
Causes and
Management
Ronald J. Friedman, Ph.D.
M to
expect begin speaking intelligible OST PARENTS
a
normal child
words
during
his second year of life and to begin to put words together into meaningful phrases and sentences during his third year. A substantial portion of children, however, do not display the usual language development, and this can be of considerable concern not only to the parents but to the physician as well. A number of factors may contribute to the delayed appearance or even absence of speech in preschool children. In this paper, we discuss some of these considerations from the viewpoint of developmental psychology and endeavor to provide information that might be useful in work with children and in
parent counseling. Normal Rate of
Speech Development
the first year of life, the major developments include the of about one-half of the major emergence and phonemes* simple morphemes.** Even within this first year, environmental factors can be important in language development. For example, babies under six months of age.
During language
Department of Applied Psychology, The Ontario Institute for Studies in Education, Toronto, Ontario, Canada. * The basic sounds of a language; for the most part vowels and consonants. ** The smallest linguistic unit with a meaning of its own. It is composed of one or more phonemes.
living
in
unstimulating orphanage
environ-
have often been found to be language retarded-both in the frequency of their vocalizations and the number and type of sounds emitted.’ It is difficult to determine when a child actually says his first meaningful word. Eager parents often misinterpret sounds which vaguely resemble words. When mothers’ reports are used as basic data, the first word is said to be spoken at an average ments
age of 11 months. During the second year, swift and dramatic improvements in language ability take place. At about 10 months, the average child begins to respond to simple commands. The first word, generally a single or duplicated syllable such as &dquo;bye-bye,&dquo; &dquo;mama,&dquo; or &dquo;dada,&dquo; is spoken around the first birthday. One examiner recorded that the average child had spoken 37 different words by the age of two, with the range being from six to 126 words. These figures, it should be noted, are based only on spontaneous talk during periodic routine examinations. Most normal children begin to walk before they talk, but exceptions are numerous. Several investigators report that progress in linguistic development may slow down or even cease while new motor skills are being mastered. It does seem that speech development is held in abeyance at the times when motor progress is most rapid.
403
Downloaded from cpj.sagepub.com at MCGILL UNIVERSITY LIBRARY on April 2, 2015
speech of the two-year-old is composed mainly of nouns, verbs, and adjectives. Typically, each of these is used to express entire thoughts (for example, hot is used to The
mean
the
two-year-old nouns
or
is child
to
conjunctions
It is unusual for a place adjectives before
hot).
water
to
use
in his
prepositions, articles, or speech. The child does
these forms or construct sentences that resemble adult language until he is four or five years old. Typically, a child’s total effective vocabulary-his ability to speak or understand test words-is substantially greater than those words which he will spontaneously verbalize. By two years of age, a child’s total effective vocabulary is in excess of 250 words. not use
Mental Retardation
.
a child can hear adequately, if he has defect in the speech producing mechanism, and if he has no obvious damage to the brain in those areas known to be associated with the production of speech, the single most common cause underlying delayed speech development or absence of speech is mental retardation. Morse precisely, in this instance, the absence of speech is not a specific disorder but is, in fact, one aspect of the child’s total retardation. A young child’s language development is probably the best indicator of his level of intellectual functioning. A mental age of 18-24 months must be reached before a child can be able to talk. A moderately retarded child will approach five years of age before reaching this level of mental de-
If
no
velopment. A mentally
retarded child will frequently considerable exhibit disparity between his motor development and his language development. The developmental motor milestones may be well within normal limits, yet the child may still be mentally retarded. His language development is the most sensitive measure of this. Careful attention should be given to the sensory capacity of the child because of the substantial number of children who come to be diagnosed in the schools as mentally retarded, but upon care-
ful examination also show some sort of sensory deficit. However, if the child can hear, and it is clear that no physical defect in the speech-producing mechanism underlies the absence of speech, the next need is for a comprehensive psychologic examination designed to obtain some indication of his level of intellectual functioning. He should be given an individual standardized intelligence test, most typically the Stanford-Binet Intelligence Scale, although a number of other tests are equally appropriate. Of course, a psychological evaluation of a very young child, particularly a child without language, can be quite unreliable. Even among normal children, variations in measured IQ between ages two and five years of 15 to 20 IQ points are not uncommon. Therefore, the diagnosis of mental retardation in a two- or threeyear-old child must be approached cautiously. For the child with delayed speech development, it is feasible to provide a program of language stimulation. Since the effectiveness of such a program will be a function of the child’s intellectual limitations, these programs are often of little significant value. Care should be taken, nevertheless, to advise parents not to curtail their normal verbal interchanges with the youngster despite the frustration engendered by the child’s seeming &dquo;unwillingness&dquo; to talk. Parents should be encouraged to talk to the child who is without speech, to read to him, and to continue to encourage speech (although not coercively). Advance counseling that progress will be slow and that their child cannot be forced to speak is helpful to most parents.
Psychoses
c~r
Other Emotional
Disturbances
Language disorders are frequently associated with infantial autism, childhood schizophrenia, and other severe emotional disturbances. However, compared with men’ tal retardation the overall incidence of psychoses in children is extremely low. In fact, the -legitimacy of this diagnosis with young children is questioned by many write ers. For this possibility, the history is extremely important for diagnosis. Inconsis-
404
Downloaded from cpj.sagepub.com at MCGILL UNIVERSITY LIBRARY on April 2, 2015
language development would be more suggestive of a diagnosis of psychosis or tent
autism than of mental retardation. In a severely emotionally disturbed child, one anticipates bizarre or unusual speech patterns rather than complete absence of the development of speech as is encountered in
severely emotionally disturbed child, one anticipates bizarre or unusual speech patterns rather than complete absence of the development of speech as is In
a
encountered in mental retardation. mental retardation. For example, in I 1 autistic children Kanner and Eisenberg observed that while three failed to develop speech altogether, eight developed a precocity of articulation which was coupled with unusual facility in rote memory. The children were able to repeat endless numbers of rhymes, catechisms, lists of names, and other semantically useless exercises.2
Aphasia In
some
production
children, difficulties in speech can
be related
to
demonstrable
impairment. It is proper to label these children &dquo;aphasic.&dquo; For a time, the terms &dquo;congenital aphasia&dquo; or &dquo;developmental aphasia&dquo; enjoyed some popularity, but it is often impossible to demonstrate, unequivocally, that central nervous system damage exists. In the strictest sense, it would be appropriate to label as aphasic only those children who have clearly suffered traumatic brain injury and have lost some or all language skills. A diagnosis of aphasia for a child who has never had language would be virtually impossible to central
nervous
system
make. For the most part, educational programs in language development and reading for children diagnosed as aphasic are similar to curricula for mildly retarded children. ’
Elective Mutism The electively mute child may be defined as a child who does not speak, but who has
speech or language disorder and no physical defect of the speech-producing mechanism. He is not aphasic, nor is he of sufficiently deficient general intelligence so as to be unable to formulate speech and language. The term elective mutism was first used by Tramer to describe two children who spoke only to certain people.3 Most frequently, electively mute children will speak to immediate family members; within the immediate family it is usually the mother. Consequently, elective mutism frequently escapes attention until the child is no
five or six years old and is enrolled in school. In general, electively mute children can be divided into two groups. Those in the first group appear to use refusal to speak in order to manipulate their immediate environment. With those in the other group, it appears as if speaking is sufficiently anxiety-producing so that the child chooses to remain mute. The reduction in anxiety that results from mute behavior serves as a reward and reinforces the act of remaining mute. Characteristically, these children are described by their parents, teachers, and friends as shy and socially inept. Parents frequently admit that they too are shy and socially withdrawn and may describe other family members as being similar.
Delay
in
speaking
should not be
ignored
in
the hope that the child will grow out of it. It should be regarded as a sign that calls for
intelligent diagnostic study. Elicitation of speech from these children is difficult and frustrating. Those techniques that seek to force the child to speak appear doomed to failure from the start, because the pressure simply serves to increase the child’s anxiety or fear, thus decreasing the probability of the response of speech. As the electively mute child grows older and becomes more competent in the management of his environment, he generally tends to begin to speak. Most treatment
regimens including psychotherapeutic techniques that attempt to speed this process have largely met with failure. At present, the 405
Downloaded from cpj.sagepub.com at MCGILL UNIVERSITY LIBRARY on April 2, 2015
that can be done at home and in school is to provide an atmosphere wherein the child’s anxiety is lessened. most
Other Causes
Children with articulation problems or other speech defects frequently choose to avoid speech because of embarrassment. In some instances, elaborate ruses or systems of gestures become established substitutes for speech. Typically, this form of mutism de-
velops in response to unpleasant experiences associated with speech production in the means of a should not be difficult. history Treatment, or at least evaluation, by a speech therapist is indicated in most instances. When such a child is severely lacking in ego strength or has evidence of serious defects in his ability to relate to others, consideration may be given to psychologic or psychiatric evaluation as well. Parents often try to explain absence of speech in a child by pointing out that it is not necessary that he talk. An older child may reportedly &dquo;speak for&dquo; the younger child. In other cases, parents may feel they have reinforced their own gestures, grunts, and other signs so as to spoil the child and make it unnecessary that he speak. This may occur to some limited extent in certain families, but by themselves these types of behavior are insufficient to explain the absence of speech.
past. Accurate
careful
diagnosis by
Some writers have distinguished between organic and functional (psychogenic) causes of delayed speech. While practical in that it makes clear that there may be more than one cause for a problem and places emphasis on psychologic factors, this distinction is not clear-cut-even in theory. Moreover, even organic conditions may give rise to secondary psychologic effects which increase the
handicap. Delayed speech
in a two- to three-year-old child should not be ignored. There are a number of anecdotal reports of men who as children were late talkers, and who in later life distinguished themselves intellectually, but there is little documented evidence of such cases. Delay in speaking should not be ignored in the hope that the child will grow out of it. It should be regarded as a sign that calls for intelligent diagnostic study. The advisability of neurologic, psychologic, or psychiatric evaluations should be considered for every child with delayed speech.
References 1. Brodbeck, A. M., and Irwin, O. C.: The speech behavior of infants without families. Child Dev. 17: 145, 1946. 2. Kanner, L., and Eisenberg, L.: Early infantile autism, 1943-1955. In Psychiatric Research Reports, American Psychiatric Association, 55,
April, 1957. 3. Tramer, M.: Elekitiver mutism bei kindern. Z. Kinder-Psychiatr. 1: 30, 1934.
406
Downloaded from cpj.sagepub.com at MCGILL UNIVERSITY LIBRARY on April 2, 2015
