Understanding Speech delay among children:

Clinical Cases

SUPERIOR UNIVERSITY LAHORE

Subject: Adult Psychopathology

Topic: Speech delay among children

Submitted To: Ma’am Ayesha Zafar

SEMESTER: MS-CLINICAL PSYCHOLOGY SPRING 2024

BATCH: 2023-2025

Submitted by:
Syeda Mahwish Raees

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Case summary:

A.B.C, aged 3 years and 10 months, was assessed due to concerns including delayed speech,
restlessness, stubborn behavior, poor compliance, and poor socialization reported by his mother.
He was born via caesarean to consanguineous parents in Dubai, with an uneventful pregnancy
and birth.

Developmentally, A.B.C achieved some milestones within expected ranges but exhibited delays
in crawling, speech, and bladder/bowel control. Clinical observations noted that while his
physical development was average, he showed discomfort in new environments, had a low
attention span, and was reluctant to engage with activities or follow commands.

Formal assessments, including the Portage Guide Early Educational Program, subjective
symptom ratings, and the Assessment of Basic Language and Learning Skills (ABLLS-R),
highlighted developmental delays in cognition (2 years) and socialization (2 years). A.B.C
demonstrated strengths in color matching but struggled with puzzles, naming common pictures,
and social interactions such as greetings and peer play.

Based on his history, test results, and clinical observations, A.B.C was diagnosed with "Speech
Delayed." Recommendations include implementing a Structured Individualized Educational
Program (IEP) focusing on speech therapy, behavior modification, occupational therapy for
motor skills, adaptive skills training, play therapy, and parental psychoeducation. Short-term
goals aim to improve on-seat behavior, reduce hyperactivity, build attention, and enhance
compliance. Long-term goals involve ongoing monitoring of progress and ensuring continuity of
interventions.

In conclusion, A.B.C’s case underscores the need for comprehensive support and intervention to
address his developmental delays, particularly in speech and socialization, with a focus on
tailored therapies and parental involvement to optimize his overall development and functioning.

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Understanding Speech Delay:

Speech delay refers to a situation where a child’s speech development is significantly behind that
of their peers. This can affect various aspects of communication, including the ability to produce
sounds, form words, and construct sentences. Speech delay can be part of a broader language
delay, which also includes difficulties with understanding and using language.

Types of Speech Delay:

1. Expressive Language Delay: Difficulty in expressing thoughts and ideas verbally.

2. Receptive Language Delay: Difficulty in understanding and processing language.

3. Mixed Receptive-Expressive Language Delay: Challenges in both understanding and

using language.

Common Causes:

1. Hearing Impairments:

o Ear Infections: Frequent ear infections (otitis media) can cause temporary
hearing loss, impacting speech development.

o Hearing Loss: Congenital or acquired hearing loss can prevent a child from
hearing sounds clearly, making it difficult to learn to speak.

2. Developmental Disorders:

o Autism Spectrum Disorder (ASD): Children with autism may have speech
delays along with other social and communication challenges.

o Intellectual Disabilities: Cognitive impairments can affect the ability to learn and
use language.

3. Environmental Factors:

o Lack of Stimulation: Children need to hear and practice language. A quiet

environment with limited interaction can delay speech.

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 o Bilingual Homes: Children exposed to multiple languages might take longer to
start speaking but usually catch up later.

4. Medical Conditions:

o Neurological Disorders: Conditions like cerebral palsy or muscular dystrophy

can affect the muscles needed for speech.

o Genetic Syndromes: Syndromes such as Down syndrome or fragile X syndrome

often include speech delays.

Identifying Speech Delay:

Parents and caregivers can look for the following signs at different ages:

 By 12 Months: Not babbling or making sounds like “mama” or “dada.”

 By 18 Months: Not using simple words, such as “no” or “milk.”

 By 24 Months: Not combining two words, such as “more juice” or “big truck.”

 By 36 Months: Not speaking in short sentences or having difficulty being understood by

others.

Supporting a Child with Speech Delay:

1. Early Intervention:

o Speech-Language Pathologist (SLP): Consulting an SLP can provide a tailored

approach to address specific speech and language issues.

o Developmental Screening: Regular screenings can help detect delays early,

allowing for prompt intervention.

2. Speech Therapy:

o Individual Sessions: One-on-one therapy focusing on the child’s unique needs.

o Group Sessions: Opportunities for practicing speech in a social setting.

3. Interactive Play:

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 o Games and Activities: Engaging in play that encourages verbal interaction, such
as naming objects, singing songs, and playing pretend.

o Communication Encouragement: Prompting the child to use words and

rewarding attempts to communicate.

4. Reading Together:

o Storytelling: Reading books aloud and discussing the pictures and story.

o Interactive Books: Choosing books with flaps, textures, and sounds to make
reading engaging.

5. Creating a Language-Rich Environment:

o Constant Interaction: Talking to the child throughout the day about activities,
surroundings, and experiences.

o Using Songs and Rhymes: Incorporating music and rhymes to make learning fun
and memorable.

Language Disorder (DSM-5 Criteria)

A. Persistent difficulties in the acquisition and use of language across modalities (i.e., spoken,
written, sign language, or other) due to deficits in comprehension or production that include the
following:

1. Reduced vocabulary (word knowledge and use).

2. Limited sentence structure (ability to put words and word endings together to form
sentences based on the rules of grammar and morphology).

3. Impairments in discourse (ability to use vocabulary and connect sentences to explain or

describe a topic or series of events or have a conversation).

B. Language abilities are substantially and quantifiably below those expected for age, resulting
in functional limitations in effective communication, social participation, academic achievement,
or occupational performance, individually or in any combination.

C. Onset of symptoms is in the early developmental period.

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D. The difficulties are not attributable to hearing or other sensory impairment, motor
dysfunction, or another medical or neurological condition and are not better explained by
intellectual disability (intellectual developmental disorder) or global developmental delay.

Speech Sound Disorder (DSM-5 Criteria)

A. Persistent difficulty with speech sound production that interferes with speech intelligibility or
prevents verbal communication of messages.

B. The disturbance causes limitations in effective communication that interfere with social
participation, academic achievement, or occupational performance, individually or in any
combination.

C. Onset of symptoms is in the early developmental period.

D. The difficulties are not attributable to congenital or acquired conditions, such as cerebral
palsy, cleft palate, deafness or hearing loss, traumatic brain injury, or other medical or
neurological conditions.

Assessment and Diagnosis

To diagnose a language or speech sound disorder, professionals typically use a combination of

the following:

1. Standardized Tests: Assessing language comprehension and production using age-

appropriate standardized tests.

2. Observations: Observing the child's communication in various settings.

3. Parent and Teacher Reports: Collecting information from parents, teachers, and
caregivers about the child's communication abilities.

4. Developmental History: Reviewing the child’s developmental milestones, including

when they began babbling, speaking first words, and forming sentences.

5. Hearing Tests: Ensuring the child does not have hearing impairments that could affect
speech development.

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Name: M.R.K

D.O.B: 09-10-2020

C.A: 3 years 10 month

D.O.A: August, 2024

Presenting Complaints :( reported by the mother)

● Speech delayed
● Restlessness
● Stubborn behavior
● Poor compliance
● Poor socialization

Family History:

He was born to consanguineous parents and single born child. He lives in Dubai. His
mother is a working woman. His father is an engineer. His primary language is Urdu. His
family history is negative for any psychological dysfunction.

Birth and Medical History:

● Condition during pregnancy Satisfactory

● Taken medicine in pregnancy Nothing

● Type of delivery Caesarean

● Birth Full term

● Birth crying Immediate

● Birth Condition of the Child Normal

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Developmental Milestones: (as reported by mother)

He achieved his developmental milestone at the following age levels.

Developmental Achieved age of The normal age of Remark

milestone milestone achievement

Smile and cooing 1 months 6-8 weeks Age appropriate

Neck holding 4 months 2-4 months Age appropriate

Sitting without 5 months 5-10 months Age appropriate

support

Crawling -------- 8-12 months Delayed

Walking 13 months 12-20 months Appropriate

Speech (one word) 18 months 8 -12 months Delayed

Sentence making ----------- 2.5 to 4 years -----------

Bladder and bowl Not yet 2.5 to 3.5 years Delayed

control

In formal assessment

 Clinical observation
 Mother interview

Clinical Observation:

It was observed that M R K has average height and normal weight according to his age .
He was wearing neat and pressed clothes. When he entered the room, he was not comfortable.
He did not respond to initial greetings. Rapport with the student was not easily built. He was
interested in exploring the environment. When examiner tried to interact, he was not comfortable
and was not enjoying the activities. He took interest when we play with the color sorting game.
He has low attention and concentration. He was not ready to follow any command.

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Behavioral Observation

Frequency of vocalization

He directs an occasional vocalization to his parent and his examiner inconsistently in a very
limited number of contexts.

Shared Enjoyment

He does not show appropriate pleasure in the examiner’s actions during more than one
activity. He shows pleasure in his own actions, interaction with a parent /therapist, or in the
available toys or activities.

Response to name

When his name is called, he does not become alert. He does not give a response to his name
and does not show compliance. He looks when an interesting or familiar vocalization or
verbalization is made.

Showing

He does not show objects and activities to another person to share the enjoyment. He
also does not likes that other people participate in the activities to create enjoyment.

Joint attention

His joint attention is good. He can spontaneously look at an object and coordinate with
looking at another person.

Facial expressions directed to others

He directs different direction of facial expressions to examiner and parent (e.g., directs
expressions indicating emotional to others or occasionally directs wider range of expressions)

Gestures

There is no spontaneous use of expressive, predictable, instrumental and emotional gestures.

Adaptation Change

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 He can tolerate change in routine and environment with minimal resistance.

Assessment Tools Applied

● Portage Guide Early Educational Program

● Subjective Rating of Symptoms

● The Assessment of Basic Language and Learning Skills (ABBLS-R)

Formal Assessment

Portage Guide Early Educational Program (PG)

Developmental Profile was done and results are as follows

Portage Early Educational Program

Portage Early Educational Program was administered to assess his developmental level in
different areas:

A developmental Profile was done and the results are as follows:

Areas Chronological Age: 3 years 10 month
Developmental Age Level

Cognition 2 years

Socialization 2 years

Cognition:

Cognitive development is a field of study in neuroscience and psychology focusing on a

child`s development in terms of information processing, conceptual, resources, perceptual skill,
language learning, and other aspects of the brain.

His matching skills are good like color matching; shape matching object matching etc. He
does not complete the puzzles from the peg board. He does not point to self when asked. He can
point or touch only one body parts when asked. He does not name common pictures. He does not
do tracing. He has an understanding of emotions and sense of danger.

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Socialization:

Social skills are ways of dealing with others that create healthy and positive interactions
with people.

He can’t respond to greetings initiated by others. His eye contact is good. He does not
tolerate adult and peer interaction and interference. His imitation skills are good but not age
appropriate and delayed imitation is also present. He can make choices when asked. There is no
appropriate peer play. He has no concept of turned taking. He does not follow rules set by an
adult during play. He gets frustrated easily when his demand is not fulfilled. He did not say
please and thank you without a reminder but he presents socially acceptable behavior in public
places.

Subjective Rating of Symptoms

Table 1
Behaviours Psychologist’s Rating (0-10)
Restlessness 6
Aggressiveness 5
Inattention 6
onset behaviour 6
stubbornness 5
crying 7
attention seeking Not seen
hitting Not seen
Spitting Not seen

Assessment of basic language and learning skills-Revised skill

tracking system (ABLLS-R)

Introduction

The assessment of basic languages and learning skills-revised (The

ABLLS-R) is an assessment, curriculum guide, and skills tracking system for

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children with language delays. The ABLLS-R contains a task analysis of many
of the skills necessary to communicate successfully and to learn from
everyday experiences and is comprised of two separate documents. The
ABLLS-R protocol is used to record scores for children. The ABLLS-R scoring
instructions and IEP development guide.

The ABLLS-R is administered and the following domains are assessed

and current targets will be given in IEP (Individualized Educational Program).

Task Task name Achieved tasks

A. Cooperation and reinforcer A1, A2, A3

effectiveness

B. Visual performance B1, B2

K. Play and leisure K2

L. Social interaction L1

M. Group instruction M1

P. Generalized responding -

Q. Reading skills -

R. Math skills -

S. Writing skills -

T. Spelling -

Case formulation 4ps:

1. Presenting Problem

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  Speech Delay: Significant delay in speech development, with first word spoken at 1 year
6 months and no sentence formation yet.
 Restlessness: Difficulty staying seated and maintaining attention.
 Stubborn Behavior: Exhibits resistance to following commands and displays non-
compliance.
 Poor Socialization: Challenges in engaging with peers and responding to social
interactions.

2. Predisposing Factors

 Consanguinity: Born to consanguineous parents, which could influence developmental

outcomes.
 Developmental History: Delayed milestones in crawling, speech, and bladder/bowel
control, though other physical milestones were met.
 Family Background: Lives in Dubai with a working mother and an engineer father.
Primary language is Urdu, and no family history of psychological dysfunction.

3. Precipitating Factors

 Delayed Speech Milestones: Speech delay was evident from an early age, with first
words and sentence formation significantly behind typical developmental timelines.
 Clinical Observations: Reports of restlessness, stubborn behavior, and poor
socialization likely intensified the need for formal assessment and intervention.

4. Perpetuating Factors

 Ongoing Communication Challenges: Persistent difficulties with speech and social

interactions contribute to continued developmental delays.
 Behavioral Issues: Non-compliance, stubbornness, and poor attention span exacerbate
the issues, making it difficult to engage in and benefit from educational activities.
 Limited Adaptive Skills: Delays in adapting to new environments, following
commands, and engaging in play contribute to sustained developmental and social
challenges.

Management plan:
Short Term Goals
Short term goals consists of
 Physical Restraints were used to improve child’s on-seat behavior.
 Physical Gross Motor Activities were used to reduce hyperactivity of the child.
 Strategies for Effective Commands to Build Compliance were used to deal with the non-
compliant behavior of the child.
 Attention Building Techniques were used to improve her attention level.

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Supportive therapy. Supportive work will be done with mother of student by showing empathy
and active listening of problem in order to make her comfortable to share every detail with the
trainee psychologist. Supportive therapy involves build, establishing and maintain a positive
therapeutic alliance, active listening and emotional release between therapist and student.
Unconditional positive regard will be given to Rayyan’s mother to build a healthy rapport and
communicative sharing between the therapist and Rayyan’s mother. (Kroneberger& Meyer,1996)

Psycho education. Rayyan’s mother will be psycho-educated regarding Rayyan’s problem in

order to make them aware of the nature of Rayyan’s problem, its severity, main symptoms,
triggering factors, etiology, prevalence, and prognosis of clients. She will also be introduced to
different techniques of behavioral therapy and the importance of her effective role as a co-
therapist during the client’s therapeutic work. (Miltenberger, 1997).
Psychoeducation will be given to the mother with the purpose of informing her about the
symptoms, severity, and prognosis of the client and the extent of her child’s condition.
Psychoeducation will help her understand Rayyan’s behavioral problems in a better way.

Behavior Modification

Shaping.

Shaping will be used to teach difficult tasks (as going upstairs) to the Rayyan’s by
providing reinforcement to closer approximation of the target behavior such as student will be
given reinforcement even when he try to speak a proper word or try to make correct sentence.
(Miltenberger, 1997).

Fading.

Fading is the gradual reducing of the reinforcement and prompts. (Miltenberger, 1997).
The reinforcement provided to the client will be gradually faded out in order to generalize his
behavior in other settings and situations.

Positive Reinforcement.

Positive reinforcement will be provided to client immediately followed by the

achievement of the target behavior which will increase the likelihood of the occurrence of

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behavior. As in the present case she will immediately be given writing a board whenever he
learns his lesson with interest. (Spiegler&Guevremont, 1998)

Differential Reinforcement.
Differential reinforcement of other behavior is defined as technique in which instructor
ignores the problematic behaviors and reinforces any other appropriate replacement behavior
within the defined period of time (Repp&Deitz, 1973). According to present case frequency of
the stubbornness behavior is reduced by differential reinforcement. As the child interaction
behaviors with other fellows could be reinforced by differential reinforcement
Positive Parenting Program.
Triple P – Positive Parenting Program is a comprehensive parent-training program with
the purpose of reducing child maltreatment and children’s behavioral problems. Triple P teaches
practical, effective ways to manage common issues which most parents will face such as temper
tantrums, meal time and bed time difficulties, wringing, disobedience, hurt others, wandering and
stubborn behavior etc. Triple P will be used with the mother of the student to ensure a healthy
safe and learning environment for the client (Spiegler&Guevremont, 1998)
Individualized educational plan (IEP).
The Individualized Educational Plan (IEP) is a written education plan for the child that
describes the special education and related services the child will receive. Each child, ages 3
through 21, who is eligible to receive special education and related services must have an
Individualized Education Program (IEP). This plan is made by considering child’s uniqueness,
his weakness that may create the hindrance in the educational process of child and his strength
that can be helpful in teaching child or giving him vocational training ( IEP, Resource guide,
2004).
Individualized Educational Plan will be devised for the Rayyan’s to enhance his academic
achievement.

Long Term Goals

● Follow up session by the psychologist to determine the changing behaviour of the child
with the help of the techniques devised.
● To maintain the desired continuation of the short-term goals is necessary.

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References:

1. American Speech-Language-Hearing Association (ASHA). (2021). "Speech Sound

Disorders in Children." Retrieved from ASHA
2. Bishop, D. V. M., & Leonard, L. B. (Eds.). (2000). Speech and Language Impairments in
Children: Causes, Characteristics, Intervention and Outcome. Whurr Publishers.
3. Cambridge University Press. (2018). Handbook of Speech and Language Disorders
edited by Jack S. Damico, Nicole Müller, and Martin J. Ball.
4. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental
Disorders (5th ed.). Washington, DC: American Psychiatric Publishing.
5. Paul, R., & Norbury, C. F. (2012). Language Disorders from Infancy Through
Adolescence: Listening, Speaking, Reading, Writing, and Communicating. Elsevier
Health Sciences.
6. Miltenberger, R. G. (2016). Behavior Modification: Principles and Procedures (6th ed.).
Cengage Learning.
7. Spiegler, M. D., & Guevremont, D. C. (2017). Contemporary Behavior Therapy.
Cengage Learning.
8. Sanders, M. R. (2003). Triple P-Positive Parenting Program: A Comprehensive
Parenting Program for Prevention and Treatment of Behavioral Problems in Children.
Australian & New Zealand Journal of Psychiatry, 37(1), 20-30.
9. Portage Guide Early Educational Program (Portage Project). (2020). Portage Guide:
Early Educational Program.
10. Partington, J. W. (2006). The Assessment of Basic Language and Learning Skills–Revised
(ABLLS-R). Behavior Analysts, Inc.
11. Harris, J. R. (1998). The Nurture Assumption: Why Children Turn Out the Way They Do.
Free Press.
12. Berk, L. E. (2020). Child Development (10th ed.). Pearson.

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