Speech delay and autism red flags: when to stop waiting

If you are worried about your child's talking, get it checked now rather than waiting. Some late talkers catch up on their own, but others have a hearing problem, a language disorder or autism, and these do best when help starts early. A check that finds nothing has cost you very little. A check that finds something has gained your child months.

When should a baby start talking?

Most babies say "mama" or "dada" (or another special name for a parent) by their first birthday. By 1 year, most also wave bye-bye and understand "no".¹

Talking starts long before words. Babies coo in the early months, then babble strings like "ba-ba-ba". They turn to your voice and play back-and-forth sound games with you.

Understanding usually runs ahead of speaking. A one year old may follow far more than they can say. Gestures matter just as much as words at this age. Waving, reaching up to be lifted and pointing are all early ways of talking.

How many words should an 18 month old say?

By 18 months, most children try to say three or more words besides "mama" and "dada".²

At this age most children also follow a simple one-step instruction, such as "give it to me", without you pointing.² They point to show you something interesting, like a dog or an aeroplane.²

That skill, pointing to share, is one Dr Dutta always asks about. A child who points only to get things, but never to show you things, needs a closer look.

What should a 2 year old be saying?

By 2 years, most children put at least two words together, such as "more milk" or "papa come".³

Most 2 year olds can also:³

• Point to pictures in a book when you ask, "Where is the cat?"
• Point to at least two body parts when asked.
• Use gestures beyond waving and pointing, such as nodding yes or blowing a kiss.

The two-word step is the key one. Repeating a phrase from a cartoon is not the same as putting two words together on their own.

Is it true that boys talk late and I should just wait?

No. Some children do catch up on their own, but no one can tell in advance which ones will.

The milestones used by the CDC were chosen so that most children, at least 75 percent, reach them by that age.⁴ The experts who set them said one aim was to discourage a "wait and see" approach.⁴ So a missed milestone is a reason to check, whether the child is a boy or a girl.

The Indian Academy of Pediatrics advises developmental screening for all children at 9 to 12 months and at 18 to 24 months, not only when someone is worried.⁵ Dr Dutta hears "his father talked late too" every week. Sometimes it is true. But that is not a reason to skip a check.

What are the red flags for speech delay?

Any of these is a reason to see your paediatrician soon:

• By 1 year: no waving, no "mama" or "dada", no simple games with you like pat-a-cake.¹
• By 18 months: not trying to say three or more words, or not pointing to show you things.²
• By 2 years: not joining two words together.³
• At any age: losing words or social skills the child used to have.⁶

The last one is the most urgent. A child who said words at 15 months and has stopped by 20 months should be seen soon, not at the next routine visit.

Does my child need a hearing test for speech delay?

Yes. Indian guidance says vision and hearing should be checked in every child with delayed development, before formal developmental tests are done.⁵

A child who turns to a door banging can still have partial hearing loss, or loss in one ear. In small children, hearing is tested with machines that need no cooperation, such as OAE or BERA.

A common, treatable cause is glue ear (fluid behind the eardrum after repeated colds). Guidelines advise a hearing test if glue ear lasts 3 months or more.⁷ Antibiotics, steroids and antihistamines are not recommended for glue ear.⁷ A passed newborn hearing screen does not rule out hearing loss that develops later.

What are the early signs of autism in toddlers?

Autism shows mainly in two areas: how a child communicates and connects with people, and repeated patterns of behaviour.⁸ Late talking on its own does not mean autism.

Signs listed by the CDC include:⁹

• Not responding to their name by 9 months.
• Few or no gestures, such as waving, by 12 months.
• Not showing you things they like by 15 months.
• Not pointing to show you something interesting by 18 months.
• Avoiding eye contact.
• Lining up toys and getting upset when the order changes.
• Flapping hands, rocking or spinning.
• Getting upset by small changes, or unusual reactions to sounds, smells or textures.

Many typical children line up toys or dislike loud noises. It is the overall pattern that matters, which is why a trained person should assess it.

Can a child make eye contact and still have autism?

Yes. NICE tells doctors not to rule out autism because a child makes good eye contact, smiles or shows affection to family.⁶

The same guidance says pretend play, or language milestones that seem normal, should not rule it out either.⁶ Autism looks different in every child. Some autistic toddlers are very loving with their parents but do not share interest or play with others.

Grandparents often say, "He looks at me and laughs, so how can he be autistic?" Dr Dutta understands the hope in that. But if other signs are there, an assessment is still worth doing.

My child has stopped saying words he used to say. Is that serious?

Yes, it needs prompt attention. NICE advises that a child under 3 who loses language or social skills should be referred straight to an autism team.⁶

For a child over 3 who loses language, or a child of any age who loses movement skills, NICE advises first seeing a paediatrician or paediatric neurologist.⁶

Loss of skills is never part of normal development. Write down which words or skills have gone and roughly when. A short phone video from a few months ago can help the doctor a great deal.

What is the M-CHAT test for autism?

The M-CHAT-R/F is a short yes-or-no questionnaire that parents fill in, with a follow-up interview if some answers raise concern. It screens toddlers for autism.¹⁰

In a study of over 16,000 toddlers checked at 18 and 24 month visits, children who still screened positive after the follow-up interview had about a 48 percent chance of autism, and about a 95 percent chance of some developmental delay or concern.¹⁰ So a positive screen almost always means the child needs help of some kind.

A screen is not a diagnosis. And a negative screen in a child you are still worried about is not a reason to stop asking.

At what age can autism be diagnosed?

Doctors can diagnose autism in some children from about 18 months of age.⁸ The American Academy of Pediatrics recommends autism screening for all children at 18 and 24 months.⁸

The Indian Academy of Pediatrics also advises autism screening at 18 to 24 months, and again at 3 years if the first screen was negative.⁵

In the M-CHAT study, children were diagnosed about 2 years younger than the usual age of diagnosis in the US at the time.¹⁰ Those two years matter, because they are years of therapy that can start sooner.

Does early intervention for autism and speech delay really help?

Yes. In a trial of toddlers diagnosed with autism between 18 and 30 months, children given 2 years of an intensive therapy programme, run by trained therapists and parents, improved more in IQ and daily living skills than children given usual community services.¹¹

The Indian Academy of Pediatrics advises starting therapy soon after a delay is noticed, even before a formal diagnosis is made.⁵ You do not need a label to start speech therapy, or to change how you talk and play at home.

Depending on the child, help may include speech and language therapy, occupational therapy and parent coaching. Many children's hospitals in Kolkata have child development clinics.

Does screen time cause speech delay or autism?

Heavy screen time is linked with weaker language, but it does not cause autism. A review of 42 studies found that more screen time and background TV went with lower language skills.¹²

The same review found that watching educational shows together with an adult, and starting screens later, went with stronger language.¹² These were observational studies, so they show links rather than proof of cause.

"Virtual autism" is a social media phrase, not a diagnosis. Some children with lots of screen time and few words improve once screens are cut back. But please do not assume autism signs are "only the phone" and wait. Cut screens and get an assessment at the same time.

Does speaking two languages at home cause speech delay?

No. Two languages do not cause a language disorder, though a bilingual toddler may know fewer words in each single language.

In one study of toddlers aged about 2 years, bilingual children knew fewer words in each language than children learning one language. But their total number of words across both languages was similar.¹³ Each language grew with how much the child heard it.¹³

NICE warns doctors not to explain away a language delay just because the family mainly speaks a language other than English.⁶ A real delay shows up in every language. Keep speaking Bangla, Hindi or whatever you speak most richly. Dropping it does not fix a delay and can cut a child off from grandparents.

Should we teach our baby sign language?

It is fine if you enjoy it, but it does not make babies talk sooner. In a randomised trial, babies whose mothers used baby signs from 8 to 20 months had the same language results as other babies.¹⁴

There was one pleasant finding. Mothers who used signs became more tuned in to their babies' non-verbal cues.¹⁴ That kind of close attention is good for any baby.

Signs also do not hold back speech. If your baby enjoys signing "more" or "milk", carry on, and say the word out loud each time.

Is stuttering normal in a toddler?

Stuttering often starts in the preschool years. In one community study, about 11 percent of children had started to stutter by age 4.¹⁵

In that study, boys and twins were more likely to stutter.¹⁵ Children who stuttered actually had slightly stronger language skills, and in the first year after onset most were not harmed by it.¹⁵ Only about 6 percent had recovered within 12 months, so many children stutter for longer than a year.¹⁵

At home, speak slowly and calmly, give your child time to finish, and do not finish words for them. See a speech therapist if your child seems upset, avoids talking, or struggles with tension in the face or body when speaking.

How can I help my late talker at home?

Talk with your child, not at them, many times a day. Ordinary routines are the best therapy room.

• Get down to your child's level and follow what they are interested in.
• Name what they look at: "Ball. Red ball."
• Add one word to what they say. If they say "car", you say "big car".
• Wait. Leave pauses so your child has a turn.
• Read picture books and sing rhymes every day.
• Switch off background TV, and watch any screen time together.¹²

When should I see a doctor about my child's speech?

Book a check with your paediatrician if any of these apply:

• Your child has missed any milestone in the red flag list above.
• Your child has lost words, babble or social skills at any age.⁶
• Your child does not respond to their name, or you are not sure they hear well.
• An autism screen such as the M-CHAT is positive.
• A teacher, relative or you yourself keep feeling something is not right.

An assessment that shows your child is on track is a good result. One that finds a difference early is also a good result, because help can start now.