Shelly is a 20-month-old white female whose parents thought she was in excellent general health when she came to her pediatrician for a health supervision visit. A developmental survey consisting of focused questions revealed that Shelly spoke only occasionally with a vocabulary limited to five words. Although motor and social skills were age-appropriate, verbal expressions typically consisted of nonintelligable utterances and frequent pointing to objects. She occasionally chatters "as if she had her own language." Shelly reportedly responds to directions appropriately, and she appears to hear normal human voices, music, and a telephone ring.
Shelly has been in home day care since 10 months of age when her mother returned to work. With four other toddlers, she is cared for by a Spanish-speaking caretaker; her parents speak English at home. She is the only child in her family; her parents remarked that they each had a sibling whose early language acquisition was delayed but as adults did not seem language impaired.
Shelly's prenatal course was complicated by premature contractions treated from 30 weeks gestation with terbutaline. She was delivered at term by a spontaneous vaginal delivery without complications. Apgar scores were 8 at 1 minute and 9 at 5 minutes.
On physical examination, Shelly appeared robust. Social and visual engagement occurred easily with her mother and the examiner. Growth parameters were at the 50th percentile. The examination was normal, including her tympanic membranes (normal appearance and compliance), palate, pharynx, facial structure, and neurological assessment. Gross and fine motor skills were documented at the 20- to 24-month level. She responded to commands given by her mother and the examiner. She was able to point to pictures of objects on request and correctly pointed to three body parts. When asked to "go get your shoes and sit down," she completed the task after the second request. Throughout the interview and examination, Shelly did not say any specific words. However, she pointed to a toy and doll she wanted during a play situation.