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Pediatrician John D. Michael discusses his article, “How attention therapy transforms speech delay in young children.” In this engaging conversation, John explains that sustained attention is crucial for developing effective speech and conversation skills in young children. He outlines how attention therapy teaches children to focus on adults rather than screens and toys, thereby enhancing their ability to respond, follow instructions, and build foundational language skills. John offers actionable takeaways for parents and therapists, emphasizing the importance of early intervention and a progressive approach to nurturing communication abilities.
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Transcript
Kevin Pho: Hi and welcome to the show. Subscribe at KevinMD.com/podcast. Today, we welcome John D. Michael. He’s a pediatrician. Today’s KevinMD article is “How attention therapy transforms speech delay in young children.” John, welcome to the show.
John D. Michael: Thank you very much.
Kevin Pho: All right. So tell us, before talking about the article itself, some context behind it. What made you write it in the first place and submit it to KevinMD?
John D. Michael: For many years, I have been practicing pediatrics. In my training and in my clinical practice, I have been taught that when a child who is two years of age or three years of age has a delay in their speech, you should send them to a speech therapist. And then I realized that some of these kids were not progressing as well as they should. The speech therapist would ask for more sessions, and the child still wasn’t progressing as much as he or she should.
So I started looking into why this was happening and why these children were not progressing. It turned out, after I went to many speech therapists and behavior therapists for children who have autism or other areas where they’re delayed in their recognition or their speech or their attention, many of these children—and I think close to 80 percent—don’t just have only a speech delay. They also have what’s called an attention delay. They don’t always respond to their name right away. They don’t always follow directions appropriately. They don’t always understand what is said to them, and that is what is causing their speech delay.
So I decided to look into this even further, and I found out that if you were able to get these kids to pay better attention, follow directions better, they would then be able to do much better with their therapy because they would be following the directions and paying attention to the therapist, as well as to their caregivers and their parents. So I decided to put this together in a handout. I wrote it out, and over the past five years, I have put these together, all my handouts, into a book. The book is titled Attention Therapy. Once you get the child’s attention, and the child follows your directions better, the child will learn much better—not only for speech development but also in school.
Kevin Pho: So when you say that some children have an attention delay, go deeper. What exactly does that mean?
John D. Michael: Many of these children—most of them—have a delay in their ability to understand what is said to them and recognize that people’s voices are more important than what they want to do. Many of these kids are a bit self-directed and are more interested in what they think about than what another person wants them to think about.
I discovered that most children have developed good attention by 12 months of age. By 15 months of age, if they’re not responding to their name, if they’re not following directions, if they’re not doing what they should be doing, then they have an attention problem. Many children by 18 months of age are really having severe issues. I have seen recently, over the last several years, many more children who have these delays. They don’t have autism fully—many do, but many don’t—but what they do have is what is called an attention delay, where they’re more interested in following their own interests and not always following what is told to them or said to them by their parents.
Kevin Pho: And people who have this attention delay, they’re not necessarily on the autism spectrum. Is that correct?
John D. Michael: That is correct, and I don’t know why this is happening. There’s been a lot of research about this, and nobody seems to know what is going on. But there are many more children now who don’t fully fulfill the criteria for autism but who have an attention delay. They’re not always responding to their name. When you ask a mom or dad, “How often do you call your child’s name to get their attention?” they’ll say, “Well, I have to call several times.” These children don’t always follow directions, like when you say, “Give me the toy,” or “Put the toy on the table,” they will not do that.
I don’t know why this is happening, but a lot of children have this going on, and it’s being missed by many pediatricians who are assessing these kids for their usual one-year-old, 15-month-old, 18-month-old, two-year-old evaluations. The pediatricians are not trained to look at this, and they’re missing it.
Kevin Pho: And as far as you know from your research, are there any risk factors or demographic clues that would predispose some of these children to attention delays?
John D. Michael: That’s a very good question, and the answer is no one yet has figured out why this is going on. We do know that the criteria for the diagnosis of autism changed in 2013, and then between then and now, the autism spectrum has become much wider, and more kids are now being diagnosed with it because the spectrum criteria have been expanded so much. But I’m seeing children who are not fully on the spectrum but are having these attention delays.
The other issue is that when these attention delays are handled and improved, the kid’s speech improves, and their learning improves. That’s why I wrote my book, Attention Therapy, which is on Amazon, for anybody who wants to know about how to do this.
Kevin Pho: So how does one diagnose a child who may have an attention delay?
John D. Michael: That’s an excellent question also. It’s hard, and many people miss it because you don’t ask the right questions. What you need to do is, when a child is 18 months of age or two years of age—and those are two excellent times to check for this—you ask the caretaker, the mother, the father, or whoever, “How many times do you have to call your child’s name before he or she pays attention?” You also have to ask the normal developmental questions: “Does your child follow directions? Does your child ask you for help? Does your child point to things?” Those usual developmental questions. If the child does not do these things, then you have an issue going on.
I always tell—one more thing—I always tell pediatricians when I talk to them, look at the child’s face and see if the child references someone who talks to them. Many people don’t do that, but that’s an important issue. If a child does not reference or look at someone who talks to them, then they’re not paying attention.
Kevin Pho: So if you suspect the child has an attention delay, tell us the path forward. What are some potential therapeutic steps?
John D. Michael: Well, if the child has an attention delay, then the child often has a speech and language delay as well. And this is not hyperactivity or anything like that, or ADHD. There’s no diagnosis for this yet; this is in-between and not yet recognized.
So, the path forward would be to try to teach the child to pay attention. There are many different ways. Some work, some don’t work as well. The way I have figured it out is to get something the child wants and then take that object and hold it up to your nose. For instance, if a child wants a train, you hold it up to your nose like this, and then the child looks up toward your face. As soon as the child looks at your face, you give the child the train. You do that several times, and the child then realizes, “If I look at my father, if I look at my mother, I will get something.” There are other ways of doing it that I have in my book—talking about how to get the child to look at you and listen to you and pay attention.
Kevin Pho: And in terms of the prognosis and your success rate for these techniques, are most children able to overcome their attention delay?
John D. Michael: The answer to that question is yes and maybe. There are some children who do very well with this, and I’ve had many parents tell me they really appreciate this because the child is now improving quite a bit. And there are a few who do not improve a lot, and I’m not sure yet why. There has not been a lot of data yet established to figure out what is going on with this, and that’s what I’m trying to do right now—trying to keep track of why they improve.
Kevin Pho: Obviously you’re an expert in attention therapy—you wrote a book—but for those pediatricians and parents who may be listening to you, is this something that their own pediatrician can refer to? Are there specialists who can help specifically with this?
John D. Michael: That’s the other issue, and it’s a difficult situation because there are many behaviorists out there and many speech therapists out there who are dealing with children like this. Some of them know how to handle it and do a good job, and I know some of them. Some of them try their best to handle it but don’t know how to handle it—they don’t know that they don’t know how to handle it.
That’s why I put this together, because certain methods don’t work as well as others, and it depends on the child’s personality. One therapy does not fit all children—it depends on how the child responds. But you have to recognize it first before you can actually put therapy together. Unfortunately, many doctors—family doctors, pediatricians—who see children don’t recognize that this is an issue, and I am finding it to be an issue. More research needs to be done.
Kevin Pho: And just to be clear, most of the treatment techniques are behavioral health–related. There’s no role, for instance, for medications that can treat this?
John D. Michael: This appears to be a brain development issue, and it’s not a physical issue or a chemical issue that you can treat with medication or with injections. This is a behavioral issue and a brain developmental issue.
Kevin Pho: So tell us a success story where you diagnosed someone with attention delay that perhaps led to speech delay. You instituted some of the techniques we’re talking about, and you really moved the needle for that patient. What would that look like?
John D. Michael: Yes, about a month ago, there was a family with a child who had a significant speech delay. Parents recognize when a child has a speech delay; they don’t always recognize the attention part of it. So the child came to us, referred by the pediatrician for a speech delay. When we looked at that child—he was two years old, a boy who was two—it turned out he didn’t always respond to his name appropriately, and he didn’t always follow the directions his parents asked for. So we then told them that they would really be helping him if they would try to use the attention therapy method.
Over six months—it doesn’t work within one or two months, it takes several months for the child’s brain and the child to recognize what’s going on—they said the child is now responding to his name and now following directions better and has developed better speech. The big issue is how to document this and how to put it in some kind of data so we have that available. That has not yet been done, so there are people out there who say, “Are you sure what you’re doing is correct? Do you really know what’s going on?” The answer is, we’re still in the beginning stages of this to figure out how this is working and how well it is working. Unfortunately, I don’t yet know that.
Kevin Pho: We’re talking to John D. Michael. He’s a pediatrician. Today’s KevinMD article is “How attention therapy transforms speech delay in young children.” John, let’s end with some take-home messages that you would like to leave with the KevinMD audience.
John D. Michael: I think that my experience has been amazing in finding this out. I think it’s very important for both parents and for physicians to be aware: If they’re seeing children 18 months, two years of age, even three years of age who are having any delays in their speech or their attention or their development, they should not just look at speech alone. They should figure out if there is a referencing or attention issue—if the child’s not sharing, not looking at them, or is just looking at the object rather than at the parent’s face. They should then recognize that that can be, and probably is, causing the speech delay. That needs to be dealt with first. Because if the child just gets speech therapy and not attention therapy, the child will not pay attention, and it will take much longer for the child to learn.
Kevin Pho: John, thank you so much for sharing your perspective and insight. Thanks again for coming on the show.
John D. Michael: Thank you for having me.
