Dear Tanya,

My son is 23 months old and is not speaking. He has said three words, very clearly, only once and then never said them again despite much praise and encouragement. His three-year-old sister talks non-stop.

He makes sounds and gurgles but makes no real attempt to speak. He has started having big tantrums when he is frustrated and, as he is big for his age, these can get quite hairy. He seems to understand when we speak to him but makes no attempt to indicate what he wants except by crying or screaming. He loves looking at books, listening to stories and playing outside and is very self-contained but not shy. He sleeps well and eats well. He is uncomfortable with crowds and prefers his home surroundings. He also rarely looks at people when they speak to him and it takes real encouragement for him to look even into our eyes.

I am wondering whether his late speech is partly because for the past six months I have been unwell and until I had type 1 diabetes diagnosed two months ago, I was feeling terrible. It was hard to get up in the morning and both the children had less one-to-one interaction. I had a real struggle to get a diagnosis, which meant endless trips to the doctors, lots of tears and feeling that I was going mad as I was told repeatedly that I was imagining my symptoms. I am wondering if this has meant that he has missed out on something that I could have given him in the past six months, or whether the upheaval has taken its toll on his development.

Joselyn

In this age of vigilant and overanxious parenting, I often meet those who have concerns about their child's behaviour when it is actually within “normal” limits. However, I also know that some parents are afraid of being perceived as neurotic and so do not seek help even when it is warranted. From what you describe, I think you must press for a professional assessment. I realise it is ironic that I should say this, but there are times when we should not be seduced by psycho-

emotional explanations of behaviour; when a good all-round medical assessment is necessary.

I try hard never to be alarmist - it is unhelpful and disempowering. But I do feel strongly that your instinctive concern about your son's lack of language at almost two years old is justified and must be followed up. Sometimes parents are more astute than the professionals (who can, at times, be dismissive and see a problem as only the imaginings of a “neurotic mother” or, in your recent experience, those of a “neurotic patient”).

All children develop at their own pace but in general most have a grasp of approximately ten words by 15 months, 50 words by 20 months and as many as 200 words by 24 months. Your son is clearly some way off this. I think that you must seek advice from your GP and health visitor, then get a referral to your community paediatric service for a full assessment. These services offer a multidisciplinary approach to assessing children, so you will come into contact with speech and language therapists. You could, however, also call your primary care trust and refer your son directly to the speech and language therapy service.

Alternatively, to see someone privately, contact the Association of Speech and Language Therapists in Independent Practice at www.helpwithtalking.com.

Between the ages of 1 and 2 most children will increase their vocabulary every month, producing two questions, for example, “where Daddy?” or “what that?” and statements such as “juice now”. As your son sounds unable to do this, a full assessment will, first, determine if he has a language disorder or a speech disorder.

A language disorder could involve problems with receptive language (understanding others) or with expressive language (communicating thoughts and feelings). A speech disorder is when there are problems with producing sounds that are correct or fluent. This could be caused by a condition such as childhood apraxia of speech (CAS), where a child's brain has difficulty in moving the muscles that are necessary for speech. CAS can be identified if a child shows dysarthia: poor muscle tone in the lips, jaw and tongue. Again, this would be picked up by speech and language therapists and paediatric specialists.

For advice and support on matters concerning communication in children, see www.ican.org.uk; in the resources section you can order a copy of Learning to Talk; Talking to Learn, a DVD that I made with the charity on helping to develop children's speech and language skills.

Another cause of communication problems may be a developmental disability such as autism. Children with autism can have difficulties with communication, socialising, integrating with others and movement. As every child is unique, every child with autism comes with his or her own combination of strengths and also difficulties. Such children do show extremely limited speech and sometimes may lose words that they were previously able to say. They may find it hard to express what they want or need and can show sudden outbursts of emotion.

Eye contact is often poor, as are social skills generally. Changes in routine can be extremely unsettling for a child with autism and there may be some self-stimulating movements, for example, hand-flapping. For more information go to www.autism.org.uk.

It is all too easy to read your description of your son and jump to the conclusion that he has some difficulties on the autistic spectrum. But only a thorough assessment from a

child development team can really enable an accurate understanding of your son's behaviour, so I am merely suggesting a range of possibilities for an assessment team to think about.

The most important thing to remember is that your son before, during and after assessment is the still same boy. If there are problems, it is important that these are picked up early so that he is not misunderstood and therefore labelled as a problem when he is older, and so that he can be treated and the whole family supported. There are many innovative treatments for all the conditions that I have described, and the earlier they start, the better the outcome.

You also wonder whether your recent illness and lack of diagnosis has taken its toll on your son's ability with speech and language. Children have to be entirely neglected and left to watch an awful lot of TV for their development to be drastically affected and I suspect that, although you were tired a lot of the time, your children were still loved and nurtured by you and others. I don't want to diminish the miserable period of illness for you all, and quite possibly there may be some emotional fallout from this tough time, but I doubt that a relatively short six-month period could account for all your son's delayed linguistic development.

Good luck with this next stage, and please let me know what the assessments conclude. I would like to write again and look more specifically at how your son can be supported to be a happy and functioning little boy.

If you have a problem, e-mail Dr Tanya Byron

at: drtanyabyron@thetimes.co.uk

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