Late language emergence (LLE) refers to a delay in language onset without any other developmental delays or disabilities. Children with LLE may have delays in an expressive language only or mixed expressive and receptive delays. These children may be at risk for developing language and/or literacy difficulties and other disabilities such as autism spectrum disorder, learning disability, intellectual disability, social communication disorder, or attention-deficit/hyperactivity disorder. It is essential to consider hearing loss and monitor the child’s overall development to make a differential diagnosis.
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LLE Versus Late Bloomers
There is a subset of children with LLE called “late bloomers” who catch up with their peers over time. It can be challenging to differentiate between children with LLE and late bloomers initially. However, some studies suggest that late bloomers may use more communicative gestures to compensate for limited expressive vocabularies and are less likely to have concomitant language comprehension delays compared to children who remain delayed. (Thal et al., 1991).
Is it common?
Estimates of the prevalence of LLE vary depending on the age range and criteria used for identification. Prevalence estimates range between 10% and 20% for 2-year-old children and increase to around 16-17.5% for 30- to 36-month-old children. When both receptive and expressive language are taken into account, the estimated levels are generally lower compared to the estimates derived solely from expressive language. Children with a family history of LLE are more likely to exhibit LLE than those without a history. Males are at a three times higher risk of experiencing LLE than females. A higher prevalence of LLE has been observed in toddler-age twins, with a greater proportion in monozygotic twins than in dizygotic twins.
What are the signs?
Late Language Emergence (LLE) is commonly characterized as a condition where children fail to acquire an expressive vocabulary of more than 50 words and do not use two-word combinations by the time they reach 24 months of age. Assessing language growth regularly and considering other language development factors, such as speech sound development, emerging grammar, and language comprehension, is essential.
Approximately 50-70% of children who experience Late Language Emergence (LLE) manage to catch up to their peers and exhibit normal language development by the end of preschool and during school age. However, their language scores on assessments remain lower than children with typical language development. Some children with LLE may have language impairment, and receptive language skills, expressive vocabulary size, and socioeconomic status are the best predictors of language outcomes.
What are the causes?
Although the exact causes of late language emergence (LLE) in healthy children are not entirely clear, several risk factors have been identified. Child factors that increase the risk of LLE include being male, delayed motor development, low birth weight, and early language development. Family factors include a family history of LLE, the presence of siblings, lower maternal education, and lower socioeconomic status. Reading and sharing books with infants every day, providing opportunities for informal play, and primarily being cared for in childcare centers are protective factors that can help children and families cope with the identified risk factors. Early identification and intervention can help reduce the impact of these risk factors.
Role of Speech therapists
Speech therapists are crucial in providing services to children with delays or disabilities in language-related areas. Their professional roles include clinical/educational services, prevention and advocacy, and education, administration, and research. Appropriate roles for speech therapists include:
- Recognizing children with late language emergence (LLE).
- Providing prevention information to families and groups at risk.
- Educating family members about communication development and intervention.
- Counseling families of children with LLE.
- Collaborating with pediatricians to highlight the importance of surveillance and ongoing screening.
When a further assessment is needed, appropriate roles of the speech therapist include:
- Conducting a comprehensive evaluation.
- Diagnosing the presence of a language disorder.
- Developing treatment plans.
- Consulting and collaborating with other professionals.
- Serving as a service coordinator.
Speech therapists should be specifically educated and appropriately trained, considering sociocultural factors on communicative interactions and language development.
How to assess a person?
To track language development and identify any potential issues, it is crucial to conduct an early assessment and periodic monitoring, especially for children with late language emergence (LLE) who are at risk of later language and literacy problems. The screening process by a speech-language pathologist (SLP) helps identify young children at risk of language disorders and determine if further speech and language assessments are necessary or if a referral for other professional services is required.
In line with the World Health Organization’s ICF (International Classification of Functioning, Disability and Health) framework, a comprehensive assessment is carried out to identify impairments in body structure and function, comorbid deficits or conditions, limitations in activity and participation, contextual factors, and the impact of communication impairments on the child’s and family’s quality of life.
The assessment should also consider contextual factors that may influence language development, such as social and cultural factors.
What are the Treatments?
The range of language interventions for toddlers and preschoolers with late language emergence can vary from services that are not directly focused on language development to those that are. Language intervention aims to foster language development comprehensively and instruct language abilities in a combined way and within relevant settings. The level of service is individualized for each child and family, taking into consideration the nature and severity of the language delay and other developmental delays or disabilities.
The indirect intervention involves activities to stimulate language development that parents and caregivers can engage in with the child, while direct intervention involves activities designed and implemented by a speech-language pathologist. A family-centered approach is critical to successful intervention with toddlers, and collaboration with parents and caregivers can help identify the child’s learning opportunities and communication goals. Effective intervention is comprehensive, coordinated, and team-based; developmentally supportive; family-centered; and culturally and linguistically responsive.
Different treatment approaches can be used to help children with language delays or disorders. These approaches can vary in terms of how natural they are, ranging from more structured and directed by the clinician to more child-centered and naturalistic, and some use a combination of both approaches. Augmentative and alternative communication methods may also be considered.
When choosing the most appropriate treatment approach for children with language delay or disorder, it is essential to take into account their cultural background and that of their family. Bilingualism has not been demonstrated to impede language development or therapeutic outcomes in the context of language disorders.
Access to early intervention services
To receive early intervention services, a child must meet the state agency guidelines, and an Individual Family Service Plan (IFSP) is developed according to the Part C of IDEA. SLPs play different roles during the transition period, assisting the family and other team members. The interdisciplinary team can include various professionals, such as audiologists, occupational therapists, and school psychologists. The service delivery options should consider the structure of the treatment session, the person providing the treatment, frequency, intensity, and duration of service, and the location.
Late language emergence (LLE) refers to a delay in language onset without any other developmental delays or disabilities. Estimates of the prevalence of LLE vary depending on the age range and criteria used for identification. Prevalence estimates range between 10% and 20% for 2-year-old children and increase to around 16-17.5% for 30- to 36-month-old children. Children with LLE may have delays in an expressive language only or mixed expressive and receptive delays. LLE may lead to language and/or literacy difficulties and other disabilities such as social communication disorder.
Identifying and intervening early can reduce the harmful effects of risk factors. Language intervention for toddlers and preschoolers with LLE can range from indirect to direct services. Language intervention aims to promote comprehensive language development by teaching language skills in an integrated manner and within relevant contexts. Effective intervention is comprehensive, coordinated, team-based; developmentally supportive; family-centered; and culturally and linguistically responsive.
Written by: Dr. Jaafar Said
Edited and Reviewed by: Dr. Juhairah Magarang-Said