When Should I Start My Child in Speech Therapy?

Has your child begun exhibiting atypical or disrupted speech patterns, like stuttering, that are concerning you? Does their speech or language still seem “babyish,” while their peers are starting to sound more grown-up? Is your child over the age of three difficult for even familiar adults to understand? You may be wondering if and when you should sign them up for speech therapy. If so, this guide is for you. First, we’ll answer the question, and then we’ll delve into the reasons to support it.  

Research overwhelmingly agrees that starting speech therapy around or before preschool (usually ages 3-5) is ideal. This time is crucial for a child’s cognitive, linguistic, social, and emotional development. Therefore, it is the best time to start therapy for several strategic and developmental reasons.

The preschool age range is characterised by rapid language acquisition. What a child learns at this age becomes the foundation of their lifelong communication skills. During this time, children dramatically expand their vocabularies, refine their grammatical structures, and become more adept at using language for a variety of purposes. If there are speech or language delays, this period is crucial for intervention, as the foundational language skills established at this age can affect future academic and social success.

As children approach school age, they need certain linguistic and cognitive skills to succeed in an academic environment. For example, phonological awareness (recognising and manipulating sounds in words) is crucial for reading readiness. Addressing speech and language concerns early, such as in preschool, can better prepare children for school-aged academic challenges.

Preschool years are also formative for social development. Children play with their friends, learn to share, take turns, and express their needs and feelings. Effective communication is critical for these interactions. Children with speech or language difficulties may face challenges in making friends or may experience social isolation.

In preschool, children start developing a stronger understanding of themselves. They become more aware of how they fit into their world and how they compare to peers. Children with speech challenges might start to recognise their differences. This recognition could impact their self-esteem and confidence, potentially making their disfluencies more severe or more challenging to overcome. 

Unaddressed speech or language issues can sometimes manifest as behavioural problems. A child might become frustrated because they can't communicate their needs or feelings, leading to tantrums or withdrawal. Early intervention can prevent or mitigate these secondary behavioural concerns by helping children effectively express their wants and needs.

Humans are somewhat distinct from other species in their capacity to develop and express language. Humans require exposure to rich language opportunities and to incorporate this into play to foster their own language development. 

For example, many species of songbirds have an innate ability to produce the full repertoire of their species-specific songs. However, for these songs to develop normally, the young bird must hear them during a critical period of development. A young bird raised in isolation, without hearing any songs from its species, will still produce a song, but it will be a simpler, improvised version of the species-typical song. Over time, this isolated bird can refine its song by listening to its own vocalisations, but it's not the same as a bird raised with conspecifics (members of the same species). The zebra finch, when raised in isolation, will still produce a song, but it will differ from the normal zebra finch song.

In contrast, a human raised in isolation (a feral child or a child in conditions of extreme neglect) during the critical period for language development will not acquire language naturally. Such children might produce sounds, but they don't develop the complex and structured system of language. An infamous case is that of "Genie," a girl discovered in the 1970s who was raised in near-total isolation until the age of 13. Despite intensive training after her discovery, she never fully acquired language.

Adults who've acquired language, but go years without speaking, often retain their linguistic skills. For instance, prisoners held in solitary confinement or individuals who've taken a vow of silence might not speak for years. However, when they eventually communicate again, they typically retain their language abilities, although some nuances might be affected. An individual's vocabulary might become outdated, or they may have trouble recalling certain words, idioms or slang, but the fundamental structure of the language remains intact.

Once language has been fully acquired and solidified in the brain, it remains resilient, even without consistent use.

All of this suggests there is a window during which an individual must learn the language correctly in order to have the best chances of retaining strong linguistic abilities for the rest of their life. This window is called the critical period.

The critical period for language acquisition refers to a window in early life during which the brain is especially receptive and responsive to linguistic input. If a child doesn’t experience proper language exposure during this period, it becomes exceedingly difficult, if not impossible, to acquire language later in life at a native level. 

In the context of language acquisition, the critical period often refers to the time from birth until around puberty; however, most researchers agree that the window starts closing around age 7.

The theory behind the critical period is ingrained in the concept of neural plasticity, which is the brain's remarkable capacity to change its structure and function based on experiences and learning. In early childhood, the brain grows quickly, forming a plethora of neural connections. This high level of plasticity allows children to swiftly absorb and process linguistic input. During this dynamic process, weak or unused neural connections are pruned, making the brain more efficient based on experience and use. At the same time, a neurotransmitter called GABA (gamma-aminobutyric acid) stabilises neural networks, making them less susceptible to change. As a result, as we transition to adulthood, the brain's plasticity diminishes due to these neurobiological processes, making it harder to learn new language or skills as effortlessly as in childhood. 

The normal speech and language milestones for a developing human will vary depending on their environment and genetic predispositions. However, these developmental milestones can offer some guidance and direction.

• Coos and makes pleasure sounds

• Has a different cry for different needs

• Smiles at familiar faces and voices

• Babbles with both short and long groups of sounds (e.g., "baba" or "bibibi")

• Uses non-crying sounds to get attention

• Uses gestures to communicate (e.g., moving arms excitedly)

• Begins to use communicative gestures, like waving or shaking head for "no"

• Begins to articulate consonant sounds such as "b," "m," "d," and "n."

• May simplify words by repeating syllables (e.g., "baba" for "bottle").

• Imitates different speech sounds

• Produces first true word(s)

• Vocabulary expands from 1-2 words to about 50 words

• Begins combining two words (e.g., "more juice")

• Points to named body parts

• Follows simple 1-step directions (e.g., "Sit down")

• Starts to articulate sounds like "p," "h," "w," and "g."

• Has a word for almost everything

• Uses 2-3 word phrases to talk about and ask for things

• Speech is understood by familiar listeners most of the time

• Understands differences in meaning (e.g., in/on, big/little)

• Improves in clarity with sounds like "k," "t," "f," and "ng."

• Answers simple questions

• Uses sentences with 4 or more words

• Talks about what happened during the day

• Speech is understood by most

• Starts to articulate more sounds like "l," "sh," and "ch."

• Uses sentences that give details (e.g., "I have a big blue toy")

• Tells longer stories

• Says most sounds correctly, except perhaps “l, s, r, v, z, ch, sh, th”

• Uses the same grammar as the rest of the family

During the critical period of language development, it's not uncommon for children to exhibit disfluencies (i.e. disruptions of the flow of speech), phonological processes (i.e. patterns of sound errors), or articulation differences as they navigate the complexities of language acquisition. Differentiating between typical developmental differences and those that might warrant early intervention can be essential for parents and professionals.

• Whole-word repetitions: These are when a child might repeat a whole word. For example, "Mommy, mommy, can I go outside?"

• Phrase repetitions: Repeating a phrase or part of a sentence. For instance, "I want... I want... I want that toy."

• Telegraphic Speech: Young children often use short, simple sentence structures, omitting smaller words such as "is," "the," or "and." For example, they might say "Mommy shoe" instead of "It's Mommy's shoe."

• Phonological processes: These are sound errors that can be normal in young children as they learn language, but most of them should disappear by or around age 3. There are three general categories of phonological processes: Substitution, where one sound is replaced with another (e.g. “tootie” for cookie); assimilation, where one sound is changed to be more like another sound in the same word (e.g. “bub” for bus); and syllable structure changes, where the word has syllables added or removed, such as “balack” for black, or “nana” for banana.

• Echolalia: Especially common in toddlers, this is when children repeat words or phrases they hear, often as a way of practising language (e.g. Repeating "milk" after hearing someone else say it).

• Concrete Interpretations: Young children often take language quite literally. Phrases like "raining cats and dogs" can be confusing until they learn about idioms.

• Pronoun Confusion: Young children might mix up pronouns, such as saying "him" instead of "he" or "me" instead of "I."

• Overgeneralisations: Children may apply a grammatical rule where it doesn't belong. For example, they might say "goed" instead of "went" or "foots" instead of "feet."

• Hesitations: Pauses before answering or continuing a sentence, which can sometimes be accompanied by "um" or "uh."

• Experimenting with Sounds and Words: Children may make up their own words or play with sounds in words just for the fun of it. 

• Interjections: Using filler words such as "like," "you know," "so," etc., as in, "I was, like, going to the store."

• Revisions: Making changes to what they're saying as they speak, for instance, "I want the red... I mean the blue toy."

• Absence of babbling: Baby isn’t babbling in the same way as their peers are. This can be an early warning sign.

• Eye contact: Baby doesn’t make eye contact with you when you are making baby talk with them.

• Limited Use of Gestures: Young toddlers (by 18 months) should be using a variety of gestures, such as pointing or waving.

• Prolonged sounds: Holding onto a sound for an extended period, e.g., "Sssssssee the cat?"

• Repetitions of parts of words: Repeating only part of a word, like "wa-wa-wa-want" instead of "want."

• Blocks: Moments when speech seems to be 'stuck' or 'blocked.' A child might struggle to produce a sound even though they're trying.

• Inconsistent errors: Making different mistakes when attempting the same word (e.g., saying "kitty" as "tikky" then "kikky").

• Groping: Visibly struggling to position the lips, tongue, or jaw to make a sound.

• Issues with longer words or phrases: A child might say shorter words clearly but jumble longer words.

• Vocabulary issues: Using generic words like "thing" instead of specific names, struggling to name common objects, or misnaming common objects.

• Difficulty forming sentences: Producing sentences that are shorter than peers', lacking complexity, or jumbled in word order.

• Difficulty understanding language: Problems following directions, answering questions, or understanding stories relative to their age level.

• Patterns of sound errors: Such as replacing all sounds made in the back of the mouth (like "k" or "g") with sounds made in the front of the mouth (like "t" or "d"). For instance, "cat" becomes "tat" and "go" becomes "do."

• Substitutions: Replacing one sound with another (e.g. "wabbit" for "rabbit").

• Omissions: Leaving out a sound (e.g. "nana" for "banana").

• Additions: Adding an extra sound (e.g. "balack" for "black")

• Distortions: Producing a sound in an unfamiliar way, e.g., a "slushy" /s/ where the tongue sticks out between the teeth.

• Hoarseness or breathiness: Voice may sound rough, airy, or strained.

• Pitch issues: Speaking too high, too low, or in a monotone for their age and gender.

• Resonance disorders: Speech may sound nasal (as if talking with a nose pinched) or denasal (like having a cold).

• Limited Vocabulary: If by age 2, a child is not using at least 50 words and isn't combining two words to make short phrases.

• Loss of Skills: Any regression in language skills, where a child loses words they once knew, should be taken seriously.

• Lack of Interest in Social Interactions: If a child seems uninterested in other children, doesn't engage in pretend play, or doesn't make-believe by 3 years old.

• Difficulty Playing with Others: By age 3, if a child doesn't engage in play with peers or prefers to play alone.

• Incomprehensible Speech: By age 4, if a child's speech is still largely incomprehensible to unfamiliar adults.

• Issues with Pragmatics: By school age, if a child struggles with understanding or participating in typical conversational rules, like taking turns in a conversation or using appropriate eye contact.

If any of these signs or symptoms are persistent and don't seem to fit the child's developmental stage, consulting a speech-language pathologist can be beneficial. They can provide a comprehensive assessment and offer guidance on interventions and supports.

Children who have problems communicating can have these struggles exacerbated by anxiety through several mechanisms. This is especially prevalent in disfluencies like stuttering, but may also apply to other speech differences. 

Anxiety triggers the body's "fight or flight" response (their sympathetic nervous system), leading to physical changes such as increased heart rate, muscle tension, and rapid breathing. Increased muscle tension, especially in the speech muscles, can make it more difficult for a child to use the techniques they are learning in therapy.

Children who are anxious about their speech might start avoiding speaking situations, certain words, or sounds that they find challenging. This avoidance can lead to more disruptions in their speech, delayed development, and can limit their ability to practise speaking with others.

Anxiety may make it more difficult for the child to focus on speaking, as they may be preoccupied with worries and thoughts. This can further interrupt speech development.

Anxious children may be hyper-aware of how listeners are reacting to their speech. Any perceived negative or impatient reaction can increase the child's anxiety in real-time, leading to more pronounced communication disorders.

A negative feedback loop can develop where anxiety exacerbates speech disorders leading to more negative experiences and increased anxiety about future speaking situations, further intensifying the disorder.

As children grow older, they become more attuned to social norms and peer interactions. Anxiety about being different or fear of teasing can lead to increased stress about speaking and exacerbate the symptoms of their disorder.

Self-awareness about speech, much like other aspects of self-awareness, evolves gradually during childhood. Children's awareness of their speech, especially if they have a speech disorder, can vary significantly based on the individual.

In general, here's a developmental trajectory of children's awareness of their speech:

1. Early Infancy (0-1 year): Infants are primarily responsive to the intonation patterns in speech, and while they don't have self-awareness about their own "speech" (babbling), they engage in vocal play and experiment with sound production.

2. Toddlerhood (1-3 years): As language develops, toddlers become more capable of expressing their needs and desires. They may start to show signs of frustration if they are not understood, which indicates some level of awareness of their communicative intent. By around age 2, many children start recognising when they or others mispronounce words, though they may not yet correct them. It's also during the latter part of this stage that children with speech disorders might begin to show initial signs of awareness of their differences, especially if those differences lead to communication breakdowns.

3. Preschool Years (3-5 years): Many children in this age range become increasingly sensitive to their own speech and language abilities, especially in comparison to peers. They can recognise and often correct their mistakes in speech. Children who stutter or have other speech disorders might show clearer signs of awareness, such as frustration, avoidance behaviours, or mentions of the speech difference.

4. Early School Years (5-7 years): As children enter school, they face increased social and academic demands related to speech and language. Peer comparisons become more prominent, and children are more likely to notice if they speak differently from others. This period can be particularly critical for children with speech differences, as their self-awareness can lead to feelings of embarrassment, pride, or indifference, depending on their experiences and support system.

5. Middle Childhood and Beyond (8 years and older): Children continue to refine their speech and language skills, and by this stage, they typically have a well-developed sense of their abilities and challenges. They are quite aware of how they sound, how they are perceived by others, and the implications of their speech on their social and academic lives.

Research has shown that children often become aware of their speech differences between ages 2 and 5, but the exact age can vary significantly among individuals^[2].

When a child exhibits communication difficulties that may require intervention, parents are often the first to notice and play a crucial role in seeking appropriate help. 

Below are several factors parents are encouraged to consider:

1. Duration and Consistency: It's not uncommon for children to experience brief periods of disfluency, especially during language development spurts. Persistent disfluencies lasting more than six months, or those that become increasingly frequent or severe, should be taken seriously.

2. Associated Behaviours: Look for tension, physical signs of struggle when speaking (e.g., blinking, clenched fists, facial grimacing), or avoidance behaviours, such as  circumlocution (using different words to avoid one that might trigger a stutter) or refusing to speak in certain situations.

3. Emotional Response: If the child is showing frustration, embarrassment, or anxiety about their speech, it may be suggestive of a more significant issue. Their emotional well-being is just as important as the functional aspect of their speech.

4. Family History: A family history of speech and language disorders can increase the likelihood of a child having prolonged speech difficulties.

5. Impact on Communication: Consider if the disfluency is affecting the child's ability to communicate effectively. If they're often misunderstood or they're avoiding speaking because of their speech, the child may benefit from  intervention.

6. Age-Appropriateness: Some speech patterns might be developmentally appropriate for younger children but concerning if they persist past a certain age. For instance, frontal lisping (i.e. “th” for “s”) can be typical for a toddler, but may warrant intervention if it continues past the age of 4 or 5. However, lateral lisping, when air escapes over the sides of the tongue and into the cheeks resulting in a slushy sound, is not normal at any age and requires intervention. 

7. Other Developmental Concerns: Speech disorders can sometimes accompany other developmental issues. If a child has challenges in areas like motor skills, socialisation, or cognitive development alongside speech concerns, a comprehensive assessment might be beneficial.

Even if you're unsure about how serious your child’s developmental speech differences are, consulting a speech-language pathologist (SLP) can provide clarity. An SLP can conduct a comprehensive evaluation, give advice, and suggest ways to help. 

Research consistently shows that early intervention leads to the best outcomes. If you’re concerned, it’s better to seek advice sooner rather than later. Even if therapy isn’t needed right away, an SLP can offer oversight and direction.

The "wait and see" approach acknowledges that children develop at different rates. Some children might display atypical speech patterns or disfluencies that resolve on their own with time. 

Some of the reasons you might choose the “wait and see” approach include: 

1. Developmental Variability: Children’s developmental timelines can differ significantly. Some might start speaking earlier, while others might take a bit more time but still fall within the range of typical development. Given this variability, it's sometimes appropriate to allow a child some additional time to outgrow certain speech or language behaviours before considering intervention.

2. Transient Disfluencies: Many children go through periods of stuttering-like behaviour, especially during language development spurts. For some children, this is just a phase, and the disfluencies decrease as their linguistic and motor skills become more coordinated.

3. Minimising Potential Stigma: Jumping into intervention without waiting can sometimes label a child unnecessarily, leading to potential stigmatisation. If there's a good chance the child might naturally grow out of a speech or language phase, it might be best to hold off on formal intervention.

4. Cost and Time: Interventions, evaluations, and therapies can be time-consuming and costly. If there's a likelihood that a child's issue might resolve on its own, some families opt to wait a bit before committing resources.

The "wait and see" approach shouldn’t mean ignoring the issue. Parents and professionals should closely monitor the child's progress. If the child's speech or language seems to be improving, the decision to wait might be validated. If not, or if things worsen, it may be time to reconsider.

However, now that you know about the critical period, you should be aware that waiting too long can sometimes have downsides. Evidence shows that early interventions are more effective. For example with stuttering, one study found that, when children are introduced to the Lidcombe program between ages 3 and 5, they are over 7.5 times more likely to not stutter within 6.3 months than if they had no intervention at all^[3].

Even if parents decide to take the "wait and see" approach, consulting a speech-language pathologist can be beneficial. SLPs can provide guidance on what to watch for, offer strategies to support development at home, and help determine if and when more formal intervention might be necessary.

For a child exhibiting atypical speech and language development, starting therapy between the ages of 3-5, and no later than 7, is recommended. This is because children undergo crucial language and social development during this time, which is vital for success in school. 

If in doubt, always consult a speech-language pathologist.