Dear Pediatrician: Please Don’t Say That!

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Recently, a new client came in for therapy. He was a little over three years of age with limited verbal abilities, and a number of stereotypical behaviors consistent with autism spectrum disorder. During the course of parental interview, the child’s mother mentioned that he had previously briefly received early intervention services but aged out from the early intervention system after only a few months. As we continued to discuss the case, his mother revealed that she had significant concerns regarding her son’s language abilities and behavior from a very early age because it significantly differed from his older sister’s developmental trajectory. However, every time she brought it up to her pediatrician she invariably received the following answers: “Don’t compare him to his sister, they are different children” and “Don’t worry, he will catch up”, which resulted in the child being referred for early intervention services when he was almost 3 years of age, and unable to receive consistent speech therapy services prior to aging out of the program all together.

This is not the first time I heard such a story, and I’m sure it won’t be the last time as well. Sadly, myself and other speech language therapists are very familiar with such cases and that is such a shame. It is a shame, because a parent was absolutely correct in trusting her instincts but was not validated by a medical professional she trusted the most, her child’s pediatrician. Please don’t get me wrong, I am not playing the blame game or trying to denigrate members of another profession. My aim today is rather different and that is along with my colleagues to continue increasing awareness among all health professionals regarding the early identification of communication disorders in children in order for them to receive effective early intervention services to improve their long-term outcomes.

Whenever one “Googles” the term “Language Milestones In Children” or “When do children begin to talk?” Numerous links pop-up, describing developmental milestones in children. Most of them contain fairly typical information such as: first word emerge at approximately 12 months of age, 2 word combinations emerge when the child has a lexicon of approximately 50 words or more, which corresponds to a period between 18 months to 2 years of age, and sentences emerge when a child is approximately 3 years of age. While most of this information is hopefully common knowledge for many healthcare professionals working with children including pediatricians, is also important to understand that when the child comes in for a checkup one should not look at these abilities in isolation but rather look at the child holistically. That means asking the parents the right questions to compare the child’s cognitive, adaptive, social emotional, as well as communicative functioning to that of typically developing peers or siblings in order to determine whether anything is amiss. Thus, rather than to discourage the parent from comparing their child to typically developing children his age, the parents should actually be routinely asked the variation of the following question: “How do your child’s abilities and functioning compare to other typically developing children your child age?”

Whenever I ask this question during the process of evaluation or initiation of therapy services, 90% of the time I receive highly detailed and intuitive responses from well-informed parents. They immediately begin describing in significant detail the difference in functioning between their own delayed child and his/her siblings/peers. That is why in the majority of cases I find the background information provided by the parent to be almost as valuable as the evaluation itself. For example, I recently assessed a 3-5 year-old child due to communication concerns. The pediatrician was very reluctant to refer to the child for services due to the fact that the child was adequately verbal. However, the child’s parents were insistent, a script for services was written, and the child was brought to me for an evaluation. Parents reported that while their child was very verbal and outgoing, most of the time they had significant difficulty understanding what she was trying to tell them due to poor grammar as well as nonsensical content of her messages. They also reported that the child had a brother , who was older than her last several years. However, they stated that they had never experienced similar difficulties with the child’s brother when he was her age, which is why they became so concerned with each passing day regarding the child’s language abilities.

Indeed, almost as soon as the evaluation began, it became apparent that while the child’s verbal output was adequate, the semantic content of those messages as well as the pragmatic use in conversational exchanges was significantly impaired. In other words, the child may have been adequately verbose but the coherence of her discourse left a lot to be desired. This child was the perfect candidate for therapy but had parents not insisted, the extent of her expressive language difficulties may have been overlooked until she was old enough to go to kindergarten. By then many valuable intervention hours would have been lost and the extent of the child deficits have been far greater.

So dear pediatrician, the next time a concerned parent utters the words: “I think something is wrong…” or “His language is nothing like his brother’s/sister’s when s/he was that age” don’t be so hasty in dismissing their concerns. Listen to them, understand that while you are the expert in childhood health and diseases, they are the expert in their own child, and are highly attuned to their child’s functioning and overall abilities. Encourage them to disclose their worries by asking follow-up questions and validating their concerns.

There are significant benefits to receiving early targeted care beyond the improvement in language abilities. These include but are not limited to: reduced chances of behavioral deficits or mental illness, reduced chances of reading, writing and learning difficulties when older, reduced chances of impaired socialization abilities and self-esteem, all of which can affect children with language deficits when appropriate services are delayed or never provided. So please, err on the side of caution and refer the children with suspected deficits to speech language pathologists. Please give us an opportunity to thoroughly assess these children in order to find out whether there truly is speech/language disorder/delay. Because by doing this you truly will be serving the interests of your clients.

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