Carlisa: Understanding the Unique Developmental Profile of a 28-Month-Old Toddler with Expressive Language Delay and Sensory Processing Differences

Carlisa is a bright, socially engaged 28-month-old girl who demonstrates strong receptive language skills, consistent eye contact, and warm attachment behaviors—but whose expressive vocabulary remains at approximately 22 words, with no two-word combinations observed consistently. Diagnosed with expressive language delay (ELD) by a pediatric speech-language pathologist at 24 months and identified with mild-to-moderate sensory processing differences—particularly auditory hypersensitivity and tactile defensiveness—Carlisa’s profile reflects a common yet highly individual neurodevelopmental pattern seen in 1 in 12 toddlers aged 24–36 months (CDC, 2023 National Health Interview Survey). This article synthesizes clinical observations, standardized assessment data, peer-reviewed intervention research, and practical strategies used across her home, childcare center (Little Sprouts Early Learning Center, licensed by NY State Office of Children and Family Services), and weekly telehealth sessions with a Board-Certified Behavior Analyst (BCBA) and ASHA-certified SLP. All recommendations align with NAEYC’s 2022 Position Statement on Developmentally Appropriate Practice and AAP’s 2023 Clinical Report on Early Language Delay.

Developmental Snapshot: Carlisa at 28 Months

At her most recent multidisciplinary evaluation (conducted April 12, 2024), Carlisa scored within the average range on cognitive and fine motor subtests of the Bayley Scales of Infant and Toddler Development–Fourth Edition (Bayley-4), with standard scores of 98 (cognitive) and 95 (fine motor). However, her expressive language composite score was 72—more than 1.8 standard deviations below the mean—placing her in the borderline clinical range. Her receptive language score was 91, confirming a significant expressive-receptive gap. She independently walks, climbs stairs alternating feet with rail support, stacks 8 blocks, and imitates 3-step actions (e.g., stir, pour, wipe)—all age-appropriate per CDC’s Milestone Moments checklist. Yet she does not point to request, uses only one gesture consistently (a palm-up reach), and relies on leading adults’ hands to indicate wants.

Carlisa’s social-emotional development is notably advanced. She initiates joint attention 4–5 times per 10-minute observation (per Early Social Communication Scales coding), responds reliably to her name, and engages in parallel play with sustained attention averaging 4.2 minutes (observed during three 15-minute classroom samples). She shows clear preferences for specific peers—especially 30-month-old Mateo—and shares toys unprompted in 68% of opportunities during structured play groups. Her emotional regulation is emerging: she recovers from frustration within 90 seconds when offered a visual choice board, but without support, tantrums last an average of 3.7 minutes (range: 1.2–6.8 min), per parent log data collected over 14 days.

Standardized Assessment Data Summary

The following table presents key metrics from Carlisa’s April 2024 evaluation battery:

Behavioral Patterns in Daily Routines

Carlisa’s behavior varies predictably across environments and times of day. At home, she displays highest verbal output during morning routines—saying ‘cup’, ‘shoe’, and ‘up’ an average of 7.3 times per 30-minute window (parent tally sheet, April 2024). In contrast, expressive attempts drop to fewer than 2 utterances per half hour during transitions (e.g., post-lunch cleanup, pre-nap winding down). Her childcare provider at Little Sprouts reports that Carlisa vocalizes more frequently during outdoor play (mean: 5.1 word approximations/hour) than indoor circle time (0.8/hour), correlating with reduced auditory load and increased movement input.

Her sensory-related behaviors are consistently documented: she covers both ears and hums when the classroom vacuum cleaner operates (sound pressure level measured at 78 dB(A) using a calibrated Extech 407730 sound level meter), avoids finger painting despite enjoying water play, and becomes distressed when wearing socks with visible seams (Cotton On Kids seamless socks tested; she tolerated 92% cotton, 8% spandex blend but rejected 100% cotton crew socks with double-stitched cuffs). Notably, deep-pressure input—such as 5 minutes of weighted blanket use (1.5 lbs, 20” x 30”, weighted with glass beads per Harkla Safety Guidelines)—reduces her self-soothing humming episodes by 64% during nap transition, per teacher log data.

Communication Attempts and Nonverbal Strategies

While Carlisa’s spoken vocabulary remains limited, she employs several reliable nonverbal communication methods:

• Consistent use of a palm-up reach gesture to request items (used in 94% of observed requesting opportunities)
• Pointing with index finger to show interest (but not to request—only 12% of points are imperative)
• Bringing objects to adults while making eye contact (e.g., handing a toy car to caregiver while looking back and forth between adult and car)
• Using facial expressions to convey emotion: wide-eyed surprise (87% accuracy in adult identification), furrowed brow for frustration (91%), and open-mouthed smile for joy (100%)
• Imitating environmental sounds (e.g., ‘vroom’, ‘meow’) with accurate prosody but no referential intent

These behaviors reflect intact social motivation and intentionality—key protective factors for language acquisition. Research by Tager-Flusberg et al. (2021, Journal of Speech, Language, and Hearing Research) confirms that toddlers with ELD who demonstrate high rates of prelinguistic gestures like pointing and showing have 3.2× greater likelihood of developing phrase speech within 12 months compared to peers lacking such gestures.

Evidence-Based Intervention Approaches

Carlisa receives three tiers of support: (1) daily embedded language stimulation at home, (2) classroom-based milieu teaching delivered by her lead teacher (certified in Hanen’s It Takes Two to Talk program), and (3) biweekly 30-minute telehealth sessions with a speech-language pathologist using the More Than Words curriculum (Hansa Centre, Toronto). All strategies are grounded in the principles of Naturalistic Developmental Behavioral Interventions (NDBIs), shown in a 2023 meta-analysis (Pediatrics, Vol. 151, No. 4) to yield effect sizes of d = 0.71 for expressive language growth in toddlers with ELD.

Key techniques include:

1. Responsive Interaction: Adults wait 5 seconds after Carlisa’s vocalization or gesture before modeling a slightly more complex utterance (e.g., she says ‘up’ → adult responds ‘Up! You want up!’ while lifting her). This ‘contingent responding’ occurs in ≥80% of opportunities during home video probes.
2. Environmental Engineering: Visual supports—including a laminated choice board with Velcro-backed photos of 4 core items (‘milk’, ‘ball’, ‘book’, ‘blanket’)—are placed at child-height on her bedroom door. Carlisa selects items independently in 73% of morning routine trials.
3. Motor-Supported Language: Using the PROMPT (Prompts for Restructuring Oral Muscular Phonetic Targets) approach, her SLP guides jaw-lip-tongue placement for target words using gentle tactile cues. For ‘ball’, she now produces /b/ + vowel with lip rounding 62% of trials (baseline: 11%).

Home Implementation: What Works Consistently

Carlisa’s parents implemented four evidence-based routines with fidelity (verified via weekly coaching video review):

• Mealtime Modeling: During breakfast, her mother narrates actions using 1–2 word phrases (“Milk poured.” “Toast crunchy.”) while holding food items near her mouth—increasing Carlisa’s vocalizations by 4.1 per meal (baseline: 1.8).
• Book-Embedded Pausing: Using Dear Zoo (Rod Campbell, Pan Macmillan, 2020 board book edition), they pause 3 seconds before revealing each animal, modeling the target word once (“Lion!”). Carlisa now produces spontaneous approximations of ‘lion’ and ‘elephant’ in 41% of readings.
• Sound Play Routine: Daily 5-minute sessions using the Speech Buddies articulation cards (TLC Therapy Tools, Model #SB-002), focusing on /b/, /m/, and /p/ sounds paired with mirror work. Her syllable production accuracy improved from 29% to 57% over 8 weeks.
• Transition Song: A custom 12-second melody sung to cue diaper changes (“Diaper time, change time, clean and dry!”) reduced resistance from 78% to 22% of occurrences.

Importantly, these strategies avoid demanding imitation or drill. Instead, they capitalize on Carlisa’s intrinsic motivation—her fascination with cause-effect (e.g., dropping spoons to hear clatter), love of repetition (she requests Goodnight Moon 3.2 times/day), and responsiveness to rhythmic input (her babbling rate increases 37% during musical play with Hape Wooden Xylophone).

Sensory Integration Strategies That Reduce Barriers

Because auditory and tactile sensitivities interfere with Carlisa’s willingness to engage in language-rich activities, sensory accommodations are integrated into every setting. Her occupational therapist (OTR/L certified in SIPT Level II) designed the following protocol, validated through ABC (Antecedent-Behavior-Consequence) data collection:

At Little Sprouts, her classroom includes a designated ‘calm corner’ equipped with a weighted lap pad (1.2 lbs, 12” x 16”, filled with polypropylene pellets), noise-dampening headphones (Puro Sound Labs BT2200, max output 85 dB), and a textured sensory bin containing kinetic sand (Play-Doh brand, 2 lb. tub) and smooth river stones (1.5–2.5 cm diameter). When presented with a new peer or loud activity, Carlisa now self-selects this space 89% of the time—up from 17% at baseline—and returns to group play within 2.3 minutes (SD = 0.9), versus 6.1 minutes previously.

Her OT also introduced a ‘tactile ladder’—a graduated exposure sequence using materials ranked by texture coarseness (measured with a Mitutoyo Surftest SJ-410 profilometer):

1. Foam puzzle mat (Ra = 12.4 µm roughness)
2. Microfiber towel (Ra = 28.7 µm)
3. Denim fabric swatch (Ra = 41.2 µm)
4. Bristle brush (Ra = 112.5 µm)

Each session begins with 30 seconds on the least rough surface, progressing only when Carlisa maintains relaxed hand posture (thumb adducted, fingers extended). After 6 weeks, she tolerates 90 seconds of brushing on her forearms—previously eliciting immediate withdrawal.

Collaboration Between Home and Early Care Settings

Effective coordination between Carlisa’s family and Little Sprouts relies on shared documentation and aligned goals. Weekly communication occurs via the HiMama app (version 5.12.1), where teachers upload 2–3 short videos (≤30 sec) of target interactions (e.g., Carlisa using her choice board), and parents respond with voice notes describing similar moments at home. This asynchronous exchange ensures consistency without burdening staff time—each entry takes under 90 seconds to complete.

Shared goal tracking uses a simple color-coded system:

• Green: Target behavior occurred ≥3 times/day (e.g., ‘uses “up” to request’)
• Orange: Occurred 1–2 times/day (e.g., ‘imitates /b/ sound’)
• Red: Not observed (e.g., ‘uses two-word phrase’)

This system, adapted from the Pyramid Model’s Progress Monitoring Framework, has increased parent-teacher alignment from 58% to 92% agreement on goal status over 10 weeks. Monthly in-person meetings (45 minutes, held in Carlisa’s classroom during her nap) focus exclusively on problem-solving—not reporting—with agendas co-created using Google Forms.

Measuring Meaningful Progress

Progress is tracked using objective, observable metrics—not subjective impressions. Key indicators include:

• Word count via Language Environment Analysis (LENA) device worn 2x/week (3-hour samples): Baseline mean = 19.4 words/hour; current mean = 32.7 words/hour (+68%)
• Frequency of spontaneous two-word combinations: Zero at baseline; now observed 2.1 times/week (‘more milk’, ‘big ball’, ‘mommy up’)
• Reduction in physical aggression: From 4.3 incidents/week (hitting during transitions) to 0.7/week, following introduction of visual timers (Time Timer Original, 20-minute model) and choice boards
• Increased tolerance for oral exploration: Accepts teething toys with varied textures (Zoli Teether, silicone; Manhattan Toy Winkel, plastic) for ≥2 minutes, up from <15 seconds

These data points are reviewed every 21 days using run charts, allowing the team to detect trends earlier than traditional quarterly assessments. As of May 2024, Carlisa’s expressive vocabulary has expanded to 34 words—including 5 newly acquired verbs (‘go’, ‘eat’, ‘open’, ‘fall’, ‘push’)—and she produced her first true two-word phrase (“Go park!”) during a community walk to Riverside Park.

What Families Can Do Right Now

If your toddler resembles Carlisa—socially connected, understanding language well, but speaking few words—you can begin supporting expressive growth immediately, without waiting for formal diagnosis. Start with these three actionable steps backed by randomized controlled trial evidence:

First, reduce questions. Toddlers with ELD often shut down when asked ‘What’s this?’ or ‘Where’s your nose?’. Instead, narrate what you see: “You’re pushing the red car fast!” (Simpson et al., 2022, Journal of Early Intervention). Parents who replaced 80% of questions with statements saw 2.4× faster vocabulary growth over 12 weeks.

Second, pause intentionally. Wait full 5 seconds after your child looks at something interesting—even if they don’t vocalize. This ‘expectant pause’ signals that their communication is valued and expected. In Carlisa’s case, increasing pauses from 1.5 to 5 seconds raised her vocal responses from 12% to 47% of opportunities.

Third, follow their lead relentlessly. If Carlisa spends 4 minutes lining up cars, join silently—then comment on what she’s doing (“Cars all in a row!”), not what she ‘should’ do. Joint engagement duration predicts later language outcomes more strongly than vocabulary size at 24 months (Garrity & Gulsrud, 2023, Autism Research).

Finally, trust developmental timing. While early intervention is vital, many toddlers with expressive delays catch up spontaneously. A landmark longitudinal study (Zhang et al., 2020, Pediatrics) followed 217 children with ELD at 24 months: 61% reached age-appropriate expressive language by 36 months without intensive therapy. Carlisa’s trajectory—steady growth across multiple domains, strong social reciprocity, and absence of autism screening concerns—places her solidly in this favorable prognostic group.

Her story reminds us that language development isn’t linear, nor is it solely about words. It’s about connection, agency, and the quiet confidence that comes when adults listen—not just to what a child says, but to how they show up in the world. Carlisa doesn’t need to ‘catch up’—she needs to be met where she is, with tools that honor her sensory reality and amplify her innate communicative intent. And in doing so, we don’t fix a deficit—we nurture a unique, unfolding human being.

For families seeking resources: The American Speech-Language-Hearing Association’s Identifying Communication Disorders in Young Children toolkit (2023) offers free milestone checklists and video examples. The STAR Institute’s Sensory Processing Disorder Checklist for Toddlers provides parent-friendly guidance on distinguishing typical sensory preferences from clinically significant differences. And Little Sprouts’ public resource page (littlesproutsnyc.org/family-support) hosts downloadable visual schedules, sound-level charts, and bilingual (English/Spanish) modeling scripts—all vetted by NYS Early Intervention professionals.

Carlisa’s journey continues. Her next milestone isn’t just ‘more words’—it’s singing along to the ‘Wheels on the Bus’ melody, initiating ‘peek-a-boo’ with a peer, or using her choice board to ask for ‘more bubbles’ at the sensory table. Each of these moments is measurable, meaningful, and deeply human—and each is already within reach.