Speech Delay and Autism

Talking late and autism are defined differently. Autism is defined by differences in social communication, such as sharing attention and using gestures, together with restricted or repetitive behaviors, while late talking describes words that are slow to arrive. Talking late can be one thing a clinician weighs, but on its own it cannot show whether a child is autistic.

What you’ll learn

• How autism and late talking are each defined, and where words fit in
• Why the number of words a child says cannot answer the question
• The social signs clinicians ask about before they ask about words
• Who evaluates what, and how to get help without a diagnosis

Speech Delay and Autism: What Should Parents Know?

The Centers for Disease Control and Prevention (CDC) describes autism as a developmental disability in which people often have difficulty with social communication and interaction, along with restricted or repetitive behaviors or interests. Talking is one part of communication, but the differences that define autism lie in its social side: how a child shares attention, uses gestures and connects with other people.

The American Speech-Language-Hearing Association (ASHA) points out that the diagnostic criteria for autism dropped the earlier criteria about delayed spoken language. Instead, the clinician records whether autism occurs with or without a language impairment. The CDC lists delayed language skills among the other characteristics many autistic people have, on a list kept separate from the social communication signs, so slow talking is common in autism without being what defines it.

A delay in talking can also be a sign of something else. The American Academy of Pediatrics (AAP) names hearing loss, a delay in other areas of development and autism as possibilities, with autism as only one of them. Talking late can therefore be one thing a clinician weighs, but it cannot answer the autism question by itself. There is more on speech delay in children.

What Clinicians Mean by a Late Talker

ASHA’s clinical name for what parents call late talking is late language emergence: language that is slow to begin in a child who has no other diagnosed disability, and whose thinking and movement are developing without delay. The definition describes a child whose words are slow to come while the rest of development moves along, which is one part of the bigger picture of how speech and language develop.

A late talker is still communicating, just with few words. Pointing, gesturing, making eye contact and pulling a parent over to something they want are all ways of getting a message across, and a late talker also has good understanding of language, shows people things and uses toys for what they are meant for. How a late talker differs from a speech delay is a related question with its own answer.

Autism never affects language alone. That is why the CDC’s guidance asks about sharing attention, responding to a name and using gestures as well as about talking. For the same reason, a clinician looking at a child who talks late wants to know how that child connects with people, not only how many words come out.

Why a Word Count Cannot Answer the Autism Question

Autistic children vary widely in spoken language, a range the National Institute on Deafness and Other Communication Disorders (NIDCD) sets out plainly. Some autistic children do not communicate with speech and some have very limited speech, while others have rich vocabularies and can talk about particular subjects in great detail. ASHA puts it simply for families: some autistic people may not talk at all, and others have no trouble talking.

A word count therefore cannot tell the two apart in either direction. A child with very few words may be pointing, showing and connecting in every other way, while a child with plenty of words may still have the social communication differences that define autism. The CDC also notes that some people who are not autistic show some of the signs on its list, so no single sign amounts to a diagnosis.

From clinical practice

Pointing to show something, looking back to check that a parent saw it, bringing a toy over simply to share it: the first questions about autism usually cover these. A family tends to arrive with a count of words ready.

Shared attention and connection sit at the center of how autism is defined, which is why they come first. The number of words cannot settle the matter in either direction. Some autistic children talk a great deal, and a late talker with very few words can still point, show and share.

Shared Attention, Pointing and Other Social Signs

Joint attention, or shared attention, is the clinical name for two people focusing on the same object or event, and ASHA lists difficulty with it among the social communication differences in autism, along with differences in the back-and-forth between people. There is more on how shared attention grows, and how to build it.

One way shared attention shows up is pointing to show. The AAP describes a child pointing at something interesting and looking back and forth to check that the parent is looking too. An autistic child, the AAP notes, will often point to get a parent to fetch something, not to share the enjoyment of looking at it together.

Among its examples of social communication differences, the CDC lists using few or no gestures by 12 months, such as not waving goodbye, and not sharing interests with others by 15 months, such as showing a parent a favorite object. Its examples also include avoiding or not keeping eye contact, not playing simple interactive games like pat-a-cake by 12 months, and not pointing to show something interesting by 18 months.

The National Institute of Mental Health describes the same ground in its own words: rarely sharing interest, emotion or enjoyment with others, including rarely pointing at or showing things. It also lists not responding, or being slow to respond, to a name or other spoken attempts to get attention. Each of these is about how a child connects with people, and a clinician weighs them together as a whole.

Whatever you are noticing, it helps to put it in your own words, such as how your child shows you things or gets your attention. Descriptions like these are what pediatricians and specialists ask about, and you can raise them at any visit, not only at a checkup set aside for autism questions.

Autism Questions at the 18- and 24-Month Checkups

The AAP recommends that pediatricians check every child specifically for signs of autism at the 18- and 24-month well-child visits, on top of their regular developmental check-ins, and the CDC and the National Institute of Mental Health report the same recommendation. The tool most pediatric offices use for it is a questionnaire called the M-CHAT-R/F, which parents complete at the visit.

The AAP stresses that checking for signs of autism is not the same as diagnosing it, and that a result calling for a closer look does not mean a child will be diagnosed. The CDC adds that there is no medical test for autism, such as a blood test. An autism diagnosis, the AAP explains, generally rests on specific behavioral testing and observation, together with a good deal of information from the family.

Who Evaluates Autism, and Who Evaluates Talking

An autism evaluation and a speech-language evaluation are different appointments with different jobs. The AAP says a primary care pediatrician can diagnose autism, or may refer a family to a developmental pediatrician, a child psychologist or another autism specialist. ASHA describes autism testing as usually done by a team that knows autism, which may include a medical doctor, a neurologist, a developmental psychologist and a speech-language pathologist, who tests communication and social skills. An audiologist may also test hearing to rule out hearing loss.

A speech-language evaluation is narrower. For a toddler with a language delay, the AAP says a pediatrician may order a hearing check and send the family on to a speech and language therapist. The therapist evaluates what the child says, called expressive language, and how much speech and gesture the child understands, called receptive language. The steps for setting one up are covered in arranging a speech evaluation for a child.

Getting Help Does Not Require a Diagnosis

Early intervention, the state program that supports children under three, does not depend on a label. Under Part C of the Individuals with Disabilities Education Act (IDEA), the federal law behind it, a child can qualify by having a developmental delay in an area such as communication, measured with appropriate evaluation tools. A diagnosed condition likely to cause delay is a second, separate route into services, not a requirement.

The CDC tells parents they do not need to wait for a doctor’s referral or a medical diagnosis to get a free evaluation of their child’s development, and that eligible children can receive services without an autism diagnosis. Parents can go directly to the state’s early intervention program, and every state provides that evaluation at public expense.

The two paths can also run side by side. The AAP says a child under three who is waiting for an autism evaluation should also be referred to the state’s early intervention program, so support can begin before any diagnostic appointment takes place.

Common Questions From Parents

Is Talking Late a Sign of Autism?

Talking late can be one of the things clinicians consider, but alone it cannot answer the question. Delayed language is common in autism, yet the CDC keeps it apart from the social communication signs that define autism, such as sharing attention and pointing to show something interesting.

Can an Autistic Child Have Lots of Words?

Yes. The NIDCD describes some autistic children who do not use speech, some with very limited speech and others with large vocabularies who discuss particular topics in depth. A big vocabulary cannot settle the question, any more than a small one can.

What Are the Early Social Communication Signs Doctors Ask About?

They center on sharing: pointing to show something and checking that you saw it, waving goodbye, showing you a favorite toy, eye contact, games like pat-a-cake, and turning when called. The CDC notes that some children who are not autistic show some of these too.

What Is the Autism Questionnaire at the 18-Month Checkup?

Usually it is the M-CHAT-R/F, which the AAP names as the questionnaire pediatric offices use most, and parents complete it themselves. The AAP recommends checking for signs of autism at both the 18- and 24-month visits, and is clear that this is not a diagnosis.

Who Can Diagnose Autism?

A primary care pediatrician can make the diagnosis, according to the AAP, or can refer the family to a child psychologist, a developmental pediatrician or another specialist. With no blood test or other medical test for autism, a diagnosis comes from behavioral testing, observation and information from the family.

Does My Child Need a Diagnosis to Get Early Intervention?

No. Under Part C of IDEA, a child under three can qualify through a delay in development, in communication for example, with a diagnosis as a separate route. The CDC says parents need neither a referral nor a diagnosis for a free developmental evaluation.

Can a Speech Evaluation and an Autism Evaluation Happen Together?

They are separate appointments with separate jobs. ASHA says autism testing is usually done by a team that may include a speech-language pathologist, who looks at communication and social skills, so it is worth asking who will be on the team.

Reviewed by Monica d’Errico-Franklin, M.S., CCC-SLP

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