What is the treatment for expressive language disorder in a 19-month-old male?

Treatment for Expressive Language Disorder in a 19-Month-Old Male

Immediately refer this child for comprehensive speech-language evaluation and begin intensive speech-language therapy (15-20 hours per week) combined with parent training in communication strategies, as early intervention before age 3 has superior outcomes and there is good evidence that speech-language therapy is effective for expressive language disorders. 1, 2, 3

Immediate Actions

Referral and Assessment

• Refer immediately to a speech-language pathologist for comprehensive evaluation without waiting, as interventions started before age 3 have greater impact than those begun after age 5 1
• Conduct speech/language assessment beginning at this age (19 months falls within the recommended 6-18 months assessment window) and routinely thereafter 4
• Evaluate for any underlying conditions that may contribute to language delay, including hearing assessment by an audiologist to rule out conductive or sensorineural hearing loss 2
• Screen for autism spectrum disorder using M-CHAT-R/F, as communication disorders are hallmark features and emergence of speech and language is typically delayed in ASD 4, 1

Core Intervention Strategy

• Implement speech-language therapy with intensity of 15-20 hours per week delivered by trained therapists, as intensive interventions show moderate to large effect sizes for expressive language 4
• Begin parent training immediately (5 hours per week minimum) to implement communication strategies at home, as parent involvement is essential for generalization and long-term success 4, 1, 5
• Delivery can be home-based (parent-managed), center-based (clinic), or combination depending on resources and family needs 5

Specific Therapeutic Approaches

Speech-Language Therapy Components

• Target expressive vocabulary development, as interventions for vocabulary difficulties show strong effect sizes (SMD=0.89) 3
• Address expressive morphosyntax (grammar and sentence structure), though recognize this may show slower progress than vocabulary 6, 3
• Implement augmentative communication strategies early (sign language, gestures, picture exchange) to promote language use and help avoid frustration, particularly if verbal expression remains severely limited 4, 5

Parent-Implemented Strategies

• Train parents in alternative communication modalities including Picture Exchange Communication System, sign language, and activity schedules for children not yet using words 5
• Teach parents techniques to enhance social reciprocity and communication development appropriate to the child's developmental level, including guided participation, careful selection of play materials, and organization of environment 5
• Parents should implement learned strategies 20+ hours per week at home to supplement therapist-delivered sessions 4

Evidence for Effectiveness

Therapy Outcomes

• Speech-language therapy shows positive effects for children with expressive language disorders, with good evidence of effectiveness 2, 3
• No significant differences exist between clinician-administered intervention and intervention implemented by trained parents, supporting the parent training approach 3
• Children with lower initial scores show more improvement than those with higher initial scores, indicating all severity levels benefit from intervention 6

Intensity Considerations

• Studies showing positive outcomes typically involve 15-30 hours per week of intervention 4
• Parent involvement as co-therapists is mandatory for optimal outcomes, not optional 1, 5

Critical Pitfalls to Avoid

• Do not adopt a "wait and see" approach – begin interventions immediately as early intensive intervention before age 3 has superior outcomes compared to starting after age 5 1
• Do not implement therapy without active parent training and involvement, as parent participation as co-therapists is essential for generalization across settings 1, 5
• Do not assume the child will "grow out of it" – children whose difficulties persist into primary school may have long-term problems with literacy, socialization, behavior and school attainment 2
• Do not overlook hearing evaluation – rule out hearing loss as a contributing factor, as recurrent otitis media and conductive hearing loss are common causes of language delay 4, 2
• Do not delay referral waiting for the child to reach a specific age – the median time from concern to diagnosis is already too long, and interventions should begin as soon as concerns are identified 1

Monitoring and Adjustment

• Reassess language skills every 3-6 months using standardized measures to track progress in expressive vocabulary, morphosyntax, and overall communication 4, 6
• Adjust intervention intensity and strategies based on the child's response, with particular attention to which specific deficits show improvement versus those requiring modified approaches 5
• Expect more rapid gains in vocabulary than in morphosyntax, as expressive morphosyntax typically shows slower progress and may be a persistent characteristic requiring ongoing intervention 6, 3