Evaluation and Management of the Child with Speech Delay

[Pages:6] 50 words; two-word phrases; dropping out of jargon; 60% to 70% of speech understood by strangers

2 to 2 ? years Vocabulary of 400 words, including names; two- to three-word phrases; use of pronouns; diminishing echolalia; 75% of speech understood by strangers

2? to 3 years Use of plurals and past tense; knows age and sex; counts three objects correctly; three to five words per sentence; 80% to 90% of speech understood by strangers

3 to 4 years Three to six words per sentence; asks questions, converses, relates experiences, tells stories; almost all speech understood by strangers

4 to 5 years Six to eight words per sentence; names four colors; counts 10 pennies correctly

Information from Schwartz ER. Speech and language disorders. In: Schwartz MW, ed. Pediatric primary care: a problem oriented approach. St. Louis: Mosby, 1990:696?700.

Epidemiology Exact figures that would document the prevalence of speech delay in children are difficult to obtain because of confused terminology, differences in diagnostic criteria, unreliability of unconfirmed parental observations, lack of reliable diagnostic procedures and methodologic problems in sampling and

Psychosocial deprivation

Autism

Elective mutism

Receptive aphasia

Cerebral palsy

MENTAL RETARDATION

Mental retardation is the most common cause of speech delay, accounting for more than 50 percent of cases.8 A mentally ret global language delay and also has delayed auditory comprehension and delayed use of gestures. In general, the more sever slower the acquisition of communicative speech. Speech development is relatively more delayed in mentally retarded childr development.

In approximately 30 to 40 percent of children with mental retardation, the cause of the retardation cannot be determined, ev investigation.9 Known causes of mental retardation include genetic defects, intrauterine infection, placental insufficiency, m the central nervous system, hypoxia, kernicterus, hypothyroidism, poisoning, meningitis or encephalitis, and metabolic diso

HEARING LOSS

Intact hearing in the first few years of life is vital to language and speech development. Hearing loss at an early stage of dev speech delay.

Hearing loss may be conductive or sensorineural. Conductive loss is commonly caused by otitis media with effusion.10 Such and averages from 15 to 20 dB.11 Some studies have shown that children with conductive hearing loss associated with midd years of life are at risk for speech delay.4,11 However, not all studies find this association.12 Conductive hearing loss may also of the middle ear structures and atresia of the external auditory canal.

Sensorineural hearing loss may result from intrauterine infection, kernicterus, ototoxic drugs, bacterial meningitis, hypoxia, certain syndromes (e.g., Pendred syndrome, Waardenburg syndrome, Usher syndrome) and chromosomal abnormalities (e.g Sensorineural hearing loss is typically most severe in the higher frequencies.

MATURATION DELAY

Maturation delay (developmental language delay) accounts for a considerable percentage of late talkers. In this condition, a of the central neurologic process required to produce speech. The condition is more common in boys, and a family history o present.13 The prognosis for these children is excellent, however; they usually have normal speech development by the age o

EXPRESSIVE LANGUAGE DISORDER

Children with an expressive language disorder (developmental expressive aphasia) fail to develop the use of speech at the u normal intelligence, normal hearing, good emotional relationships and normal articulation skills. The primary deficit appear results in an inability to translate ideas into speech. Comprehension of speech is appropriate to the age of the child. These ch supplement their limited verbal expression. While a late bloomer will eventually develop normal speech, the child with an e will not do so without intervention.13 It is sometimes difficult, if not impossible, to distinguish at an early age a late bloomer expressive language disorder. Maturation delay, however, is a much more common cause of speech delay than is expressive accounts for only a small percentage of cases. A child with expressive language disorder is at risk for language-based learni Because this disorder is not self-correcting, active intervention is necessary.

BILINGUALISM

A bilingual home environment may cause a temporary delay in the onset of both languages. The bilingual child's comprehen normal for a child of the same age, however, and the child usually becomes proficient in both languages before the age of fi

PSYCHOSOCIAL DEPRIVATION

Physical deprivation (e.g., poverty, poor housing, malnutrition) and social deprivation (e.g., inadequate linguistic stimulatio emotional stress, child neglect) have an adverse effect on speech development. Abused children who live with their families delay unless they are also subjected to neglect.15 Because abusive parents are more likely than other parents to ignore their c verbal means to communicate with them, abused children have an increased incidence of speech delay.16

or years.

RECEPTIVE APHASIA

A deficit in the comprehension of spoken language is the primary problem in receptive aphasia; production difficulties and s disability. Children with receptive aphasia show normal responses to nonverbal auditory stimuli. Their parents often describ listening" rather than "not hearing." The speech of these children is not only delayed but also sparse, agrammatic and indist children with receptive aphasia gradually acquire a language of their own, understood only by those who are familiar with t

CEREBRAL PALSY

Delay in speech is common in children with cerebral palsy. Speech delay occurs most often in those with an athetoid type o factors, alone or in combination, may account for the speech delay: hearing loss, incoordination or spasticity of the muscles mental retardation or a defect in the cerebral cortex.

Clinical Evaluation A history and physical examination are important in the evaluation of children with speech delay. The information obtained appropriate studies for further evaluation (Tables 3 and 4).

TABLE 3

Historical Information in the Evaluation of Speech Delay in Children

Historical data

Possible etiology

Developmental history

Delay in language milestones

Speech delay

Delay in motor milestones

Cerebral palsy

Generalized delay in developmental milestones

Mental retardation

Maternal illness during pregnancy

Intrauterine infection (e.g., rubella, toxoplasmosis, cytomegalovirus inclusion disease) Hearing loss, mental retardation

Maternal phenylketonuria

Mental retardation

Maternal hypothyroidism

Mental retardation

Maternal use of drugs (e.g., alcohol)

Mental retardation

Placental insufficiency

Mental retardation, cerebral pals

Perinatal history

Prematurity

Cerebral palsy

Hypoxia

Mental retardation, cerebral pals

Birth trauma

Cerebral palsy

Intracranial hemorrhage

Mental retardation, hearing loss,

Kernicterus

Mental retardation, hearing loss,

Feeding difficulties, excessive drooling

Cerebral palsy

Past health

Encephalitis, meningitis

Mental retardation, hearing loss

Recurrent otitis media

Hearing loss

Mumps

Hearing loss

Hypothyroidism

Mental retardation, hearing loss

Head trauma

Mental retardation, hearing loss

Seizures

Cerebral palsy, mental retardatio

Use of medications

Ototoxic drugs

Hearing loss

Physical Examination Findings in the Evaluation of Children With Speech Delay

Physical findings

Possible etiology

Short stature, obesity, hypogonadism

Prader-Willi syndrome

Microcephaly, macrocephaly

Mental retardation, cerebral pal

Deformities of auricle or external ear canal

Hearing loss

Enlarged pinna, macroorchidism

Fragile X syndrome

Upward slanting eyes, Brushfield spots, epicanthic folds, brachycephaly, simian creases Down syndrome

Goiter

Pendred syndrome

Caf? au lait spots

Neurofibromatosis

Adenoma sebaceum, shagreen patches, hypopigmented spots

Tuberous sclerosis

White forelock, cutaneous hypopigmentation, hypertelorism, heterochromia

Waardenburg syndrome

Retinitis pigmentosa, obesity, hypogonadism, polydactyly

Bardet-Biedl syndrome

Retinitis pigmentosa, cataracts

Usher syndrome

Chorioretinitis

Congenital toxoplasmosis, cong

Lack of eye contact, stereotyped repetitive motor activity

Autism

Spasticity, hyperreflexia, clonus, extensor plantar response, contractures

Cerebral palsy

Athetosis, choreoathetosis, ataxia

Cerebral palsy

Dysarthria

Cerebral palsy

HISTORY

A thorough developmental history, with special attention to language milestones, is extremely important in making the diag concerned if the child is not babbling by the age of 12 to 15 months, not comprehending simple commands by the age of 18 years of age, not making sentences by three years of age, or is having difficulty telling a simple story by four to five years o also be concerned if the child's speech is largely unintelligible after three years of age or if the child's speech is more than a comparison with normal patterns of speech development. Generalized delay in all aspects of developmental milestones sugg cause of a child's speech delay.

The medical history should include any maternal illnesses during the pregnancy, perinatal trauma, infections or asphyxia, ge weight, past health, use of ototoxic drugs, psychosocial history, language(s) spoken to the child, and family history of signifi

PHYSICAL EXAMINATION AND SCREENING TESTS

A precise measurement of the child's height, weight and head circumference is necessary. A review of the appropriate param can help in early identification of some types of speech delay. Any dysmorphic features or abnormal physical findings shoul neurologic examination should be performed and should include vision and hearing evaluations.

The Early Language Milestone Scale (Figure 1) is a simple tool that can be used to assess language development in children years of age.19 The test focuses on expressive, receptive and visual language. It relies primarily on the parents' report, with o The test can be done in the physician's office and takes only a few minutes to administer.7 For children two and one-half to 1 Picture Vocabulary Test?Revised20 is a useful screening instrument for word comprehension. If the child is bilingual, it is im language performance with that of other bilingual children of similar cultural and linguistic backgrounds.

FIGURE 1. Early Language Milestone Scale. Reprinted with permission from Coplan J. ELM scale: the early language milestone scale. Austin, Tex.: Pro-Ed, 1987.

A comprehensive developmental assessment is essential, because a delay in speech development is the most common early intellectual impairment. The Denver Developmental Screening Test is the most popular test in clinical use for infants and yo

Children whose results indicate an abnormal condition require more definitive testing with one of the standardized and valid most widely used intelligence tests for assessing the intellectual and adaptive functioning of a child are the Stanford-Binet I Scales of Infant Development, the Wechsler Intelligence Scale for Children?Revised (WISC?R), and the Wechsler Preschoo Intelligence (WPPSI).

DIAGNOSTIC EVALUATION

All children with speech delay should be referred for audiometry, regardless of how well the child seems to hear in an office whether other disabilities seem to account for the speech delay.8 Special earphones that shut out background noise may imp Tympanometry is a useful diagnostic tool. When coupled with results from pure-tone audiometry, measurement of eardrum tympanometer helps to identify a potential conductive component (e.g., middle ear effusion) that might otherwise be missed response provides a definitive and quantitative physiologic means of ruling out peripheral hearing loss.22 It is especially use children.22 The auditory brain-stem response is not affected by sedation or general anesthesia.

Additional tests should be ordered only when they are indicated by the history or physical examination. A karyotype for chr DNA test should be considered in children who have the phenotypic appearance of fragile X syndrome. An electroencephal children with seizures or with significant receptive language disabilities. The latter may occasionally be related to subclinica temporal lobe.4

Management The management of a child with speech delay should be individualized. The health care team might include the physician, a an audiologist, a psychologist, an occupational therapist and a social worker. The physician should provide the team with in the speech delay and be responsible for any medical treatment that is available to correct or minimize the handicap.

A speech-language pathologist plays an essential role in the formulation of treatment plans and target goals. The primary go teach the child strategies for comprehending spoken language and producing appropriate linguistic or communicative behav pathologist can help parents learn ways of encouraging and enhancing the child's communicative skills.

In children with hearing loss, such measures as hearing aids, auditory training, lip-reading instruction and myringotomy ma reconstruction of the external auditory canal, ossicular reconstruction and cochlear implantation may be necessary. The use as universal hearing screening may help to identify hearing loss at an early age.

Psychotherapy is indicated for the child with elective mutism. It is also recommended when the speech delay is accompanie depression. In autistic children, gains in speech acquisition have been reported with behavior therapy that includes operant c

Parents and caregivers who work with children with speech delay should be made aware of the need to adjust their speech t

2. Ansel BM, Landa RM, Stark-Selz RE. Development and disorders of speech and language. In: Oski FA, DeAngelis CD, eds. Principles Philadelphia: Lippincott, 1994:686?700.

3. Schwartz ER. Speech and language disorders. In: Schwartz MW, ed. Pediatric primary care: a problem oriented approach. St. Louis: M 4. Shonkoff JP. Language delay: late talking to communication disorder. In: Rudolph AM, Hoffman JI, Rudolph CD, eds. Rudolph's pediat

1996:124?8. 5. Silva PA, Williams S, McGee R. A longitudinal study of children with developmental language delay at age three: later intelligence, r

Dev Med Child Neurol. 1987;29:630?40. 6. Stevenson J, Richman N. The prevalence of language delay in a population of three-year-old children and its association with genera

Neurol. 1976;18:431?41. 7. Vessey JA. The child with cognitive, sensory, or communication impairment. In: Wong DL, Wilson D, eds. Whaley & Wong's nursing ca

Louis: Mosby, 1995:1006?47. 8. Coplan J. Evaluation of the child with delayed speech or language. Pediatr Ann. 1985;14:203?8. 9. Leung AK, Robson WL, Fagan J, Chopra S, Lim SH. Mental retardation. J R Soc Health. 1995;115:31?9. 10. Leung AK, Robson WL. Otitis media in infants and children. Drug Protocol. 1990;5:29?35. 11. Schlieper A, Kisilevsky H, Mattingly S, Yorke L. Mild conductive hearing loss and language development: a one year follow-up stud

1985;6:65?8. 12. Allen DV, Robinson DO. Middle ear status and language development in preschool children. ASHA. 1984;26:33?7. 13. Whitman RL, Schwartz ER. The pediatrician's approach to the preschool child with language delay. Clin Pediatr. 1985;24:26?31. 14. McRae KM, Vickar E. Simple developmental speech delay: a follow-up study. Dev Med Child Neurol. 1991;33:868?74. 15. Davis H, Stroud A, Green L. The maternal language environment of children with language delay. Br J Disord Commun. 1988;23: 16. Allen R, Wasserman GA. Origins of language delay in abused infants. Child Abuse Negl. 1985;9:335?40. 17. Bishop DV. Developmental disorders of speech and language. In: Rutter M, Taylor E, Hersov L, eds. Child and adolescent psychiatry

1994:546?68. 18. Denckla MB. Language disorders. In: Downey JA, Low NL, eds. The child with disabling illness: principles of rehabilitation. New York 19. Coplan J. ELM scale: the early language milestone scale. Austin, Tex.: Pro-Ed, 1987. 20. Dunn LM, Dunn LM. The Peabody Picture Vocabulary Test?Revised (PPVT?R). Circle Pines, Minn.: American Guidance Services, 19 21. Avery ME, First LR, eds. Pediatric medicine. Baltimore: Williams & Wilkins, 1989:42?50. 22. Resnick TJ, Allen DA, Rapin I. Disorders of language development: diagnosis and intervention. Pediatr Rev. 1984;6:85?92. 23. Lowenthal B. Effect of small-group instruction in language-delayed preschoolers. Except Child. 1981;48:178?9.

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