The signs of speech and language delay in young internationally adopted children
This article was inspired by a telephone consultation with a prospective parent concerned about a 3 year old child from South America, who she was considering for adoption. A pediatrician evaluated the child and gave him a “clean bill of health” but was doubtful about his speech: the child was not talking at all and instead pointed at things as a means of expressing himself. The child had a hearing test which came back fine. The parent wanted to know how this situation with an obvious language delay could be interpreted, and what the prognosis for recovery from such delay might be. As required for the consultation, the parent provided a list of questions that she wanted to discuss with me. The questions were very detailed and well formulated, and I felt that the same concerns may be on the minds of many other adoptive parents, as significant developmental delay is not an exception, but rather a rule with many internationally adopted children. Here are several questions and answers that came up during the consultation.
Doctor: I will start with some clarification of terminology: we have to distinguish between the speech and the language. Speech relates to articulation and fluency of utterances; the clarity with which we are speaking and the un-interruptedness, smoothness of our expression. Speech is only one characteristic (out of many) of a much more complex phenomenon that is called language. Language is a human ability to communicate and reason though a system of oral and written symbols. A person may have problems with speech but not with the language and vise verse.
Patient: For a child who already has a serious speech delay (say only a few words at the age of 3) in the native language, what do you see happen when they have to try to learn a new language once adopted? Does it usually set them back that much further?
Doctor: Yes, it does. A child’s mastery of the native language is the best predictor of the rate of learning the English language. Language delay in the native tongue almost automatically translates into a delay in learning English. That is why an assessment in the native language is a must in international adoption in order to start language remediation immediately and concurrently with language learning.
Patient: Will a developmental assessment and may be some IQ testing of a 3 year old provide us with a good amount of information to determine what is going on with the child, or do you specifically feel it is necessary to find a speech & language pathologist down in donor country to evaluate the child?
Doctor: It is better to collect good medical and developmental information and let a specialist in the States (the one who is specializing in international adoption) to make an assessment. IQ testing at this age does not have much sense – any IQ index will have a miserable predictive validity, particularly for a prospective international adoptee. Developmental assessment done by a trained medical doctor will be more informative and reliable than any IQ testing. If you are able to find a good speech pathologist in Guatemala, it may be worth doing the assessment there. At least you may have some data for analysis.
Patient: Would you recommend any specific type of testing for this child?
Doctor: A set of developmental tests should be used. In the US I would include such instruments and procedures as observation of play and daily activities, interview with care-givers, play and interaction, Bayley Scales of Infant Development, Mullen Scales of Early Learning, Brigance Inventory of Early Childhood, Developmental Assessment of Young Children Scale, and others.
Patient: Is it at all possible to distinguish “healthy late bloomers” with speech delays versus those with Expressive Language Disorder?
Doctor: In a “late bloomer” all other psychological functions of a child (except for expressive language) are developing age-appropriately. However, it is unlikely that internationally adopting parents will be dealing with late bloomers; given their children’s background, they are more likely to encounter a significant developmental delay or even language disability, which both call for intensive remedial efforts. And the earlier these efforts begin, the better may be the prognosis. In these situations any “wait and see” attitude will be a mistake.
Patient: How language delayed can a child be before they would likely qualify as having a disorder rather then just a delay?
Doctor: The development of all language skills has a time frame, usually measured by months, when these skills are expected to emerge and become fully functional. If the skill is not detected or is limited by a certain time, we may have a developmental delay (or maturational delay as it is sometimes called). The time frame may be short or long, it depends on the skill and the environment in which it is formed. For example, mildly unclear articulation in a child from a middle class family is generally acceptable up to the age of 6. After this age parents should be concerned. But an unclear articulation in an 8-year-old child is a red flag. If there is a significant delay (more than a year) or a significant distortion of the skill, – we can talk about language disorder. With international adoptees we have to take into consideration a non-stimulating environment they were born into, which will cause a delay in development of all psychological functions. It’s a trade mark of international adoptees, and that is the most important reason why they should be assed by specialists on arrival: to separate a typical developmental delay from disability, requiring intervention as soon as possible.
Patient: If at age 3, a child engages in much pointing to express himself, would this indicate language issues, or are there other things that could just as much be the issue?
Doctor: The quality of this pre-verbal gesturing is important. If the child is “functional” in using gestures (his gesturing is to the point, has objective sense and subjective meaning, is not random, etc.) – this may be a normal stage of language development (usually observed in typically developing child between the ages of 6 months to 2 years. In children from dysfunctional families and institutions this stage may be extended way far to 3 years. It is important to see, also, if any verbalization accompanies these gestures.
Patient: I have read that mental retardation is a common cause of speech delay. What is the best way to assess a 3-year-old for mental retardation?
Doctor: The best way is a global assessment of this child’s development: vision, hearing, gross-motor movement, fine-motor dexterity, means of communication, emotional state, cognitive skills and process, expected at certain chronological age, etc. Delayed language could be a sign of mental retardation (MR) only combined with other symptoms of MR, such as cognitive limitations (IQ below 70), deficiency in adaptive behavior (measured by a specialized scale), and a history of developmental delays.
Patient: When a child has significant speech delays at age 3, does he/she have a good chance of catching up over the next few years with the professional services help, or will the child most likely always have speech/language issues and will need lifelong interventions?
Doctor: Each child would have an individual history of recovery: for some of them the damage could be so profound that language issues will stay with them for a long time. In general, however, as clinical experience and research show, timely and proper remediation will improve their functioning significantly, up to complete recovery.
Patient: Is there a strong correlation between speech delays and such issues as ADHD, learning disabilities, etc.?
Doctor: Yes, there is. About 70% of ADHD children have different degree of speech and language issues. Learning disability has strong correlation to language functioning, because all literacy skills are language-based.
Patient: What is the average speech delay you might see in a 3 year old boy in a typical European orphanage? 6 months, 1 year delay, 2 years?
Doctor: From several months to over a year -- it’s a 25 to 75 percent delay in the native language skills
Patient: Anything I should specifically try to observe in the child, since I might have opportunity to visit.
Patient: Since the adoption process will probably take about 6 months, this child would remain in the native country in foster care…If we could start services for him during this time period, would such services be best in Spanish or English, since he will be coming to the states?
Doctor: The services should be in Spanish: that’s the child’s native language and the only receptive language he has.
Dr. Boris Gindis is a child psychologist specializing in psycho-educational issues of older internationally adopted children. He is chief psychologist at the Center for Cognitive-Developmental Assessment and Remediation, the lead instructor at Bgcenter Online School, the author of many publications on international adoption issues and frequent presenter at conferences and workshops. firstname.lastname@example.org www.bgcenter.com