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Early Language Delay and Risk for Language Impairment

Erica M. Ellis and Donna J. Thal
San Diego State University and University of California, San Diego
San Diego, CA

Abstract
Clinicians are often faced with the difficult task of deciding whether a late talker
shows normal variability or has a clinically significant language disorder. This
article provides an overview of research investigating identification,
characteristics, outcomes, and predictors of late talkers. Clinical implications for
speech-language pathologists in the identification and treatment of children who
are late talkers are discussed.
Early language delay (late talking) may be the first clear diagnostic sign of later
language impairment. Research has shown that children who have language
impairment at 5 years of age are likely to continue to have clinically significant
problems throughout the school years (e.g., Bishop & Edmundson, 1987; Tomblin,
Zhang, Buckwalter, & OBrien, 2003). The earlier years of language development,
however, are characterized by a huge amount of normal variability (see, for example,
Bates, Bretherton, & Snyder, 1988; Fenson, Dale, Reznick, Bates, Thal, & Pethick,
1994). Clinicians are often faced with the difficult task of deciding whether a late
talker shows normal variability or has a clinically significant language disorder. The
challenge of this task has been addressed in a substantial literature over the past 25
years (see, for example, Ellis Weismer & Evans, 2002; Ellis Weismer, 2000, 2007;
Paul, 1991,1996, 1997, 2000; Rescorla & Schwartz, 1990; Rescorla, 2002, 2005a,
2005b; Rice, Taylor, & Zubrick, 2008; Thal, & Bates, 1988; Thal, Tobias, & Morrison,
1991; Thal & Tobias, 1994; Thal & Katich, 1996; Whitehurst & Fischel, 1994). In this
article, we provide an overview of the findings from that literature and discuss their
clinical implications for early assessment of clinically significant language disorders.

Identification
Late talkers are usually identified when they are around 2 years old when
parents become concerned about their small expressive vocabulary. In the early
1980s, researchers began to respond to these concerns through a number of
longitudinal studies designed to determine the long-term outcome of early expressive

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vocabulary. Criteria for early delay included 2 or more standard deviations below the
mean on a test of expressive language (e.g., Whitehurst & Fischel, 1994), fewer than
50 words, or no word combinations produced according to parent report between 18
and 34 months of age (e.g., Paul, 1991, Rescorla & Schwartz, 1990) or at or below the
10th percentile on parent report of expressive language between 18 and 32 months of
age (e.g., Thal & Bates, 1988, Ellis Weismer & Evans, 2002) or at 2 years of age (e.g.,
Bishop, Price, Dale, & Plomin, 2003; Dale, Price, Bishop & Plomin, 2003). A more
recent study (Rice et al., 2008) used parent report of fewer than 70 words and no word
combinations as one criterion and identified another (overlapping) group of late talkers
using a six-item composite measure of receptive and expressive language from the
ASQ Communication Scale (Bricker & Squires, 1999). In these studies, researchers
either chose children who had normal receptive vocabulary (Bishop et al., 2003; Dale
et al., 2003; Rescorla & Schwartz, 1990; Whitehurst & Fischel, 1994) or allowed the
range of receptive vocabulary to vary without systematically measuring it in relation to
outcome (Hadley & Holt, 2006; Paul, 1991, 1996; Rice et al., 2008; Thal, Reilly,
Seibert, Jeffries, & Fenson, 2004). These children have been referred to in the
literature as children with specific expressive language delay or children with late
emerging language. In a small subset of studies (Thal & Bates, 1988; Thal, et al, 1991;
Thal & Tobias, 1994), late talkers were identified using expressive vocabulary, but
receptive vocabulary and use of gestures were measured systematically. In a later set
of coordinated studies (Thal, 2000, 2005a, 2005b; Thal & Sizemore, 2007), two types
of late talkers were identified: children with delay in expressive vocabulary but normal
vocabulary comprehension (late producers) and those with delays in both expressive
and receptive language (late comprehenders). To do this, however, the age of
identification was pushed back to 16 months of age so that the MacArthur-Bates
Communicative Development Inventory: Words and Gestures (CDI) could be used to
identify receptive vocabulary and use of gestures. In all of the studies, children were
free of any other factors known to be related to language disorders (e.g., neurological
disorders, hearing impairment, autism, or cognitive impairment).

Characteristics
In addition to early vocabulary delay, late talkers have been shown to combine
words later than other children (Dale et al., 2003) and to have delays in phonological
development (Carson, Klee, Carson, & Hime, 2003; Law, Boyle, Harris, Harkness, &
Nye, 2000; Paul, 1991; Rescorla & Ratner, 1996; Thal, Oroz, & McCaw, 1995). They
are also reported to be more likely to have a family history of early language delay, to
be male, and to have been born at less than 85% of their optimal birthweight or less
than 37 weeks gestation (Zubrick, Taylor, Rice, & Slegers, 2007). In this early period of
vocabulary acquisition, late producers were likely to use gestures to communicate
much like or more than typically developing children, while late comprehenders were
likely to use fewer gestures, more like younger children who have the same level of
comprehension vocabulary (Thal & Katich, 1996; Thal, et al., 1991; Thal & Tobias,

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1994, Thal & Sizemore, 2007). Studies focused on slightly later ages showed that late
talkers tended to develop grammatical skills later than children with a history of
normal language development (Hadley & Holt, 2006; Paul, 1996; Rescorla, 2002; Thal
et al, 2004; Dale et al., 2003), and they also had trouble producing novel words (Ellis
Weismer, 2007; Ellis Weismer & Evans, 2002).

Outcomes
Results from the studies with children who had normal receptive vocabulary or
that allowed the range of receptive vocabulary to vary without systematically
measuring it in relation to outcome (see above) have shown that the majority of late
talkers move into the normal range for vocabulary typically by 3 years of age and for
grammar and discourse skills by school age (Ellis Weismer, 2007; Paul, 1996;
Rescorla, 2000, 2002; Rescorla & Lee, 2000; Rice et al., 2008; Whitehurst & Fischel,
1994), regardless of intervention history. However, even though most late talkers
scored well within the normal range and would not be identified as children with
specific language impairment, they remained significantly lower than typically
developing controls (Paul, 1996; Rescorla, 2005a, 2005b; Rice et al., 2008; Thal, 2005
a & b; Thal, Miller, Carlson, & Vega, 2006). In addition, a greater proportion of late
talkers than typically developing children have been identified as language delayed at
2-4 years (Dale et al., 2003) and at 7 years (Rice et al., 2008) of age. Children with
delays in both comprehension and production were somewhat different. Over the short
term, children identified as late comprehenders remained delayed compared to those
delayed only in production in both vocabulary and mean length of utterance (Thal et
al., 1991). In a large scale unselected sample (N=1100) in which CDI was administered
at intervals from 10 to 28 months of age, children were identified as either late
comprehenders or late producers. Children identified as late comprehenders at 16
months showed a significantly slower rate of growth in comprehension vocabulary
from 10 to 13 and 13 to 16 months on the CDI, and their expressive vocabulary was
significantly lower than that of children identified as late producers or typically
developing at 16- and 28-months of age (Thal, 2000). In a follow-up of 577 of those
children at 6 years of age (Thal, 2005a, 2005b), formal diagnoses of specific language
impairment were obtained. At that age 2.2 percent of the children were diagnosed as
having specific language impairment (a language disorder characterized by difficulty
acquiring and using language in the absence of any identifiable etiology; Leonard,
1998) by a certified speech-language pathologist. When diagnosis was examined
within each group, 1.5% of the typically developing children (n=461), 3.7% of the late
producers (n=81), and 8.6% of the late comprehenders (n=35) had clinical diagnoses of
specific language impairment (Thal, 2005a, 2005b). In a related study of gesture use
at 6 years of age, late comprehenders (who had used fewer gestures at 20-months of
age) used more gestures to communicate (Thal & Sizemore, 2007), a finding that is
consistent with reports of gesture use by school-age children with specific language
impairment (Evans, Alibali, & McNeil, 2001). These results are consistent with the

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earlier studies (Thal et al., 1991; Thal & Tobias, 1992, 1994) that pointed to delayed
comprehension and lower use of communicative gestures from 16-32 months of age as
potential markers of greatest risk for clinically significant language delay. They appear
to be inconsistent with a report by Paul (2000) that receptive communication on the
Vineland Adaptive Behavior Scales (VABS) did not predict school age outcome in her
longitudinal cohort of late talkers. We suggest three possible reasons for this
difference: (a) the CDI used by Thal provide a much richer sample of comprehension
vocabulary than the VABS, (b) comprehension delay was not an independent variable
in the original conceptualization of the Paul study so it was not systematically
explored, and/or (c) there was a much smaller sample of late comprehenders in the
Paul study.

Predictors
Statistical models based on correlation and regression have been used most
widely to identify predictors of later language performance from the earlier age at
which late talkers were identified. Many predictors of continued lower language than
typically developing controls have been reported, including age at intake (Paul, 1993;
Rescorla & Schwartz, 1990), gender (Paul, 1993), expressive vocabulary level (Dale et
al., 2003; Ellis Weismer, 2007; Fischel, Whitehurst, Caulfield, & DeBaryshe, 1989),
consonants produced (Whitehurst, Smith, Fischel, Arnold, & Lonigan, 1991), receptive
language level (Ellis Weismer, 2007; Thal et al., 1991; Thal & Tobias, 1992), nonverbal
items on the Bayley scales of infant development (Ellis Weismer, 2007), and use of
gesture (Thal et al., 1991; Thal & Tobias, 1992). In the longest follow-up study
Rescorla (2005 a, 2005b) reported that expressive vocabulary level in her 2- to 3-year-
old cohort of late producers predicted their scores on other measures of language at
13 and 17 years of age. In order for predictive statistical models to be clinically useful,
categorical outcome measures (e.g., language delayed versus typically developing) are
essential. In addition, analyses that indicate the accuracy of our predictions are
critical. They include sensitivity (the proportion of children with later language delay
that had been predicted to be delayed), specificity (the proportion of children with
normal language that had been predicted to have later normal language), positive
predictive value (the proportion of children with a prediction of later delay who in fact
had the delay), and negative predictive value (the proportion of children with a
prediction of later normal development who did have normal language later). For early
identification of language impairment in late talkers, we are most interested in the
positive predictive value. To our knowledge, two large studies of more than 1,000 late
talkers use these methods.
Dale et al. (2003) used logistic regression to determine whether twins who were
classified as late producers at 2 years of age were also classified as having clinically
significant language difficulties at 3 and 4 years of age and whether those with typical
language at 2 continued to have typical language development. Although all of the

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correlations between 2-year language abilities and language skills at 3 and 4 were
highly statistically significant, the sensitivity and positive predictive values were low.
Dale et al. concluded that the prediction equations fail to detect the majority of
children who will have continuing language difficulties (p. 554) and classification of
outcome on the basis of data on 2-year-olds was far too inaccurate to be clinically
useful (p. 544). Thal (2005 a, 2005 b) also used logistic regression to examine
predictors of continued delay from 16- to 28-months of age in the cohort of 1,100
children sampled with the CDI. She found that a combination of family history of
language impairment, lower paternal education, lower use of later gestures on the
CDI, and identification as a late comprehender at 16 months of age predicted
continued delay in vocabulary or grammar at 28 months of age. The specificity (.93),
and negative predictive value (.99) were very high, indicating that these criteria do a
good job of identifying children who start out and will stay in the normal range. The
sensitivity (.80) was also strong, indicating that children who were delayed at 28-
months had been characterized by these factors at 16 months. The positive predictive
value, on the other hand, was low (.16), indicating that many of the children who were
characterized by these factors at 16-months were not delayed at 28 months. In other
words, there were a large number of false positives at 16 months. A likelihood ratio
indicated that children who met these criteria at 16 months of age were 11.3 times
more likely to be delayed in expressive language at 28 months, consistent with the
strong sensitivity of these factors.

Clinical Implications
Implications of this research apply directly to identifying which late talkers need
clinical intervention. This has been an area of considerable discussion and
disagreement within the field of speech-language pathology. Recommendations have
included no therapy (wait and see) with follow up if the child continues to lag (e.g.,
Whitehurst, Arnold, Smith, Fischel, Lonigan, & Valdez-Menchaca, 1991), periodical
monitoring over short (3- 6 month) periods (watch and see) with enrollment in
therapy if no positive changes are seen (e.g., Paul, 1996, 2000), and intervention of
various kinds, from clinician to parent administered (e.g., Ellis Weismer, 2000;
Girolametto, Pearce, & Weitzman, 1996, 1997;). It is clear that we cannot pinpoint
specific individuals who have clinically significant language delay during the early
stages of language development: The normal variability in this period of development is
too large. It is also apparent that the majority of children who have language disorders
by school age were late talkers; and there is evidence that those with delayed
comprehension are at even greater risk than those with specific expressive language
delay. In addition, positive effects of intervention with late talkers have been
demonstrated over the short term for expressive vocabulary size and use, mean length
of utterance, socialization skills, and reduction of parental stress (Ellis Weismer, 2000;
Girolametto et al., 1996, 1997; Whitehurst et el., 1991). A risk factor model of decision
making for late talkers has been proposed in the past (see, for example, Olswang,

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Rodriguez, & Timler, 1998; Thal & Katich, 1996; Thal, 2000). We believe that newer
data continue to support using such a model. What factors and how to weight them
poses another question for which we can offer a tentative answer. We propose a model
in which family history of language impairment or early language delay, delay in both
vocabulary comprehension and production, and little to no use of some other form of
symbolic or proto-symbolic communicative form (such as communicative gestures) are
given the strongest weight. Children with these characteristics would be at highest
risk for continued language delay. These factors have been predictive of greater risk for
clinically significant language disorders over a number of studies and the information
is easy to collect using parent report instruments. Other risk factors would include
environmental factors (such as impoverished or high risk environments), delays in
symbolic play and/or social skills, presence of otitis media, and parent needs. The
greater the number of factors present, particularly if the three most strongly weighted
predictors are present, the greater the risk for continued language delay and the
greater the need for clinical intervention.

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