Parenting 101: Questions for Bob Doman, Part 2

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Robert J. Doman, Jr.

Dear Bob,

I am becoming very concerned with my two-year-old son and his lack of language development, he only says a few words and recently just put his first two words together “top it”. Should I be concerned and what should I do?



Dear K,

I’m glad you asked this question; it is a question many parents should be asking. There is a wide range of function that falls within “normal” limits, so you don’t need to panic or go looking for a label. In general, however, we would like to see children functioning at the upper end of the spectrum. At age two, your son should be using between 100 and 250 words and use many couplets (two-word phrases), so with having only a few words and one “almost couplet,” it would be good to give things a push.

In evaluating children’s development, when we see a problem with what is coming out, (in your son’s case language) we look for a problem with what is going in. When it comes to language development the concerns are tonal processing (the ability to hear the various tones utilized in speech) and auditory sequential processing (the brain’s ability to link sounds together as in syllables and words). Later, as we become more concerned with how clear the speech is, we look at oral-motor ability, which involves the actual mechanics of producing the sounds vocally.

To start the process of identifying possible causes for a speech delay, take your son to an ear, nose and throat doctor (ENT) for an evaluation. An ENT specialist will check your son’s hearing, which will help identify any actual hearing loss. The hearing test itself will not be able to identify a tonal processing problem, however. At this time, voice analysis is the closest thing we have to a test that identifies tonal processing problems. However, we know that fluid accumulation in the middle ear is the most frequent reason for lack of tonal processing development. And, although the ENT doctor cannot test your son’s tonal processing directly, he can check for fluid in the middle ear with a quick, painless test called a tympanogram. Our Medical Director generally recommends you get a series of tympanograms over several weeks to establish a baseline and make sure the ears are clear and staying clear.

If your doctor finds fluid is accumulating in the middle ear, this is called otitis media. When there is a problem with language development, aggressive treatment of the otitis media is recommended to clear the ears of fluid so that your child’s tonal processing can develop normally. Parents need to be aware that otitis media can exist without any external signs or symptoms, so your child could have a chronic problem and never complain. Our experience has shown that one of the major causes of otitis media appears to be consumption of dairy products because they tend to produce mucus. In many children, otitis media can be reduced or eliminated completely by avoiding dairy products in the diet. If otitis media remains a problem, ear tubes can be placed to drain the fluid on a constant basis to prevent it from building up and interfering with auditory development.

If we suspect a tonal processing problem exists, we initiate a home-based sound therapy program to help correct the problem. Nothing is going to really help, however, unless the ears are kept clear of fluid.

The second area to investigate is auditory sequential processing. At age two, your son should be able to process two-step directions well. You should be able to say to him, “Touch your nose and tummy,” or, “Get your pig and horse,” or, “Stand up and clap your hands.” He should be able to follow directions like these without having been taught the sequence and without visual cues. Sequential processing should develop at the rate of a piece per year for the first seven to nine years, which means that a typical two-year-old can process two pieces of sequential information (i.e., follow a two-step direction), a three-year-old can process three pieces of information (follow a three-step direction), a four-year-old four pieces, and so on. Lack of auditory sequential processing ability leads to labels such as Developmentally Delayed, ADD, ADHD, Dyslexia, and Learning Disabled. To learn more about sequential processing go to and click on “Free Memory Test.” (While you’re at it, check the processing levels of everyone in your family by participating in the Simply Smarter Project 9 +/- 2. This free, on-line Project is part of NACD’s international effort to increase critical processing abilities in children and adults all over the world.)

If your son has clear ears and good tonal processing, and if he sequences two pieces of information well, then make sure he needs to speak. Try not to respond to gestures and grunts but rather encourage him to say a word or short phrase for what he wants. If he doesn’t come up with his own words at first, model the word or phrase and let him repeat it. Listen and respond to his talking, and make sure older siblings are not speaking for him but take time to let him speak for himself.

Best of luck,
Bob Doman

Reprinted from the Journal of The NACD Foundation (formerly The National Academy for Child Development)

Reprinted by permission of The NACD Foundation, Volume 20 No. 3, 2007 ©NACD