Lost words at 20 months — regression OSCE · Paeds Cases

Prompt

20-month-old with loss of words and pointing over 10 weeks; worried caregiver.

Objectives

Confirm true developmental regression with a skill timeline. [1]
Triage threat and progressive red flags. [1] [9]
Explain an urgent plan including hearing assessment and parallel referrals. [1] [3]
Safety-net and close loops with teach-back. [14] [17]

12-minute station. Caregiver present with a 20-month-old. Interpreter available if needed — use professional interpretation, not the child. [13]

Open with the caregiver’s story and respect concern. [1]
Build acquisition-and-loss history for language, social, motor and adaptive skills. [1] [7]
Screen for seizures, encephalopathy features, hearing concerns and safeguarding. [1]
Examine interaction, neurology screens and growth/head circumference. [3]
Explain that this is regression, not routine late talking. [1]
Plan urgent hearing assessment, developmental/autism-pathway evaluation as indicated, and medical work-up guided by findings. [3] [11]
Start interim supports; name owners and dates; safety-net further loss, seizures and reduced alertness. [14] [17]

Pass: confirms regression, avoids wait-and-see, includes hearing, parallel referrals, clear counselling and safety-net. [1] [3] [17]

Fail: pure reassurance; screen treated as full neurological clearance; child used as interpreter; no closed-loop plan. [1] [9] [13]

[1]Lipkin PH Promoting Optimal Development: Identifying Infants and Young Children With Developmental Disorders Through Developmental Surveillance and Screening. Pediatrics, 2020.PMID 31843861
[3]Moeschler JB Comprehensive evaluation of the child with intellectual disability or global developmental delays. Pediatrics, 2014.PMID 25157020
[7]Pickles A Loss of language in early development of autism and specific language impairment. Journal of child psychology and psychiatry, and allied disciplines, 2009.PMID 19527315
[9]Loo KK Diagnostic Overshadowing: Insidious Neuroregression Mimicking Presentation of Autism Spectrum Disorder. Journal of developmental and behavioral pediatrics : JDBP, 2022.PMID 35943376
[11]Robins DL Validation of the modified checklist for Autism in toddlers, revised with follow-up (M-CHAT-R/F). Pediatrics, 2014.PMID 24366990
[13]Boylen S Impact of professional interpreters on outcomes for hospitalized children from migrant and refugee families with limited English proficiency: a systematic review. JBI evidence synthesis, 2020.PMID 32813387
[14]Starmer AJ Changes in medical errors after implementation of a handoff program. The New England journal of medicine, 2014.PMID 25372088
[17]Burvenich R Effectiveness of safety-netting approaches for acutely ill children: a network meta-analysis. The British journal of general practice : the journal of the Royal College of General Practitioners, 2025.PMID 39117428

Expected actions

Open with the caregiver’s story and respect concern. [1]

Build acquisition-and-loss history for language, social, motor and adaptive skills. [1] [7]

Screen for seizures, encephalopathy features, hearing concerns and safeguarding. [1]

Examine interaction, neurology screens and growth/head circumference. [3]

Explain that this is regression, not routine late talking. [1]

Plan urgent hearing assessment, developmental/autism-pathway evaluation as indicated, and medical work-up guided by findings. [3] [11]

Start interim supports; name owners and dates; safety-net further loss, seizures and reduced alertness. [14] [17]

Marking

Pass: confirms regression, avoids wait-and-see, includes hearing, parallel referrals, clear counselling and safety-net. [1] [3] [17]

Fail: pure reassurance; screen treated as full neurological clearance; child used as interpreter; no closed-loop plan. [1] [9] [13]

[1]Lipkin PH Promoting Optimal Development: Identifying Infants and Young Children With Developmental Disorders Through Developmental Surveillance and Screening. Pediatrics, 2020.PMID 31843861
[3]Moeschler JB Comprehensive evaluation of the child with intellectual disability or global developmental delays. Pediatrics, 2014.PMID 25157020
[7]Pickles A Loss of language in early development of autism and specific language impairment. Journal of child psychology and psychiatry, and allied disciplines, 2009.PMID 19527315
[9]Loo KK Diagnostic Overshadowing: Insidious Neuroregression Mimicking Presentation of Autism Spectrum Disorder. Journal of developmental and behavioral pediatrics : JDBP, 2022.PMID 35943376
[11]Robins DL Validation of the modified checklist for Autism in toddlers, revised with follow-up (M-CHAT-R/F). Pediatrics, 2014.PMID 24366990
[13]Boylen S Impact of professional interpreters on outcomes for hospitalized children from migrant and refugee families with limited English proficiency: a systematic review. JBI evidence synthesis, 2020.PMID 32813387
[14]Starmer AJ Changes in medical errors after implementation of a handoff program. The New England journal of medicine, 2014.PMID 25372088
[17]Burvenich R Effectiveness of safety-netting approaches for acutely ill children: a network meta-analysis. The British journal of general practice : the journal of the Royal College of General Practitioners, 2025.PMID 39117428