A 20-month-old child walks independently without support, scribbles spontaneously, and appropriately follows and obeys simple commands. However, the child speaks only one meaningful word. What is the most appropriate next step in management?

Appeared in: INI-CET EXAM -2026

Explanation

A formal hearing assessment is the mandatory first step in evaluating any child with a speech or language delay.
Hearing impairment is a common and often correctable cause of delayed speech.
The child's other developmental milestones (motor, social, receptive language) are age-appropriate, suggesting an isolated problem rather than a global delay.
Ruling out a sensory deficit (hearing loss) is essential before proceeding to more complex neurodevelopmental evaluations.

Why Other Options Were Wrong

Option A: This constitutes negligence. A significant developmental delay is present, and waiting until age 5 misses the critical period for early intervention, which can have long-term negative consequences on learning and social development.
Option B: While language delay is a hallmark of Autism Spectrum Disorder (ASD), this child shows appropriate social reciprocity by following commands. A hearing test is the priority to rule out a sensory cause before considering a complex neurodevelopmental diagnosis like ASD.
Option C: A 'wait and see' approach is not appropriate for a significant developmental delay. The child's vocabulary is far below the expected range (1 word vs. 15-50 words), warranting immediate investigation, not passive observation.

Related Visual

Clinical Relevance

Nursing practice connection: This is primarily an exam-oriented knowledge point with limited direct bedside application, so retain Developmental Milestones and Management of Speech Delay as background academic context rather than a clinical decision trigger.
Nurses play a crucial role in developmental surveillance during well-child visits. Identifying delays and initiating appropriate referrals is a key responsibility.
Educating parents about the importance of ruling out hearing loss is essential. It is a non-invasive first step that can prevent misdiagnosis and lead to effective, early intervention.
What if the child was also not responding to their name and avoided eye contact? In that case, while a hearing test is still necessary, a simultaneous referral for an ASD evaluation (Option B) would be highly appropriate due to the additional red flags for a social communication disorder.

How to Approach the Question

First, identify the patient's age (20 months) and list the developmental skills mentioned in the stem.
Compare these skills to the expected developmental milestones for that age. Note which are normal (walking, scribbling, following commands) and which are delayed (speaking only one word).
Recognize that the primary issue is an isolated expressive language delay.
Evaluate the options based on standard pediatric assessment protocols. The universal first step for any speech delay is to rule out a hearing impairment.
Eliminate options that are too passive ('wait and see') or premature (jumping to a complex diagnosis like ASD without ruling out a sensory cause).

Concept Tested & Keywords

Concept Tested: Developmental Milestones and Management of Speech Delay
Stem keywords: 20-month-old child, walks independently, scribbles, follows simple commands, speaks only one meaningful word
Lead-in keywords: most appropriate next step
Clinical cues: The key finding is the discrepancy between normal motor/social development and significantly delayed expressive language.

Question ID

Q7hXWe5Igoquzb6oKdGF4p

Reference Book

E6 Nelson Textbook of Pediatrics(2024) — Volume 1 pp. 377-379, 424-426

E6 Robert Boland, Marcia L. Verduin - Kaplan and Sadock's Comprehensive Text of Psychiatry-Wolters Kluwer Health (2024) (pp 1-16525 of 16525) p. 11989-11991

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