Baby Center: Warning Signs of a Hearing Problem in Children 12 to 36 Months Old
Evaluation and Management of the Child with Speech Filibuster
Am Fam Physician. 1999 Jun ane;59(xi):3121-3128.
See related patient information handout on the child with speech filibuster, written by the authors of this article.
Article Sections
- Abstract
- Normal Speech Evolution
- Epidemiology
- Etiology
- Clinical Evaluation
- Management
- References
A delay in speech evolution may be a symptom of many disorders, including mental retardation, hearing loss, an expressive language disorder, psychosocial impecuniousness, autism, elective mutism, receptive aphasia and cognitive palsy. Voice communication delay may be secondary to maturation filibuster or bilingualism. Being familiar with the factors to expect for when taking the history and performing the concrete examination allows physicians to make a prompt diagnosis. Timely detection and early intervention may mitigate the emotional, social and cognitive deficits of this disability and ameliorate the outcome.
Speech is the motor act of communicating by articulating exact expression, whereas language is the noesis of a symbol arrangement used for interpersonal communication.1 In full general, a child is considered to have spoken communication delay if the child's speech development is significantly below the norm for children of the same age. A child with voice communication delay has speech evolution that is typical of a ordinarily developing child of a younger chronologic age; the speech-delayed child'southward skills are caused in a normal sequence, only at a slower-than-normal charge per unit.ii
Voice communication filibuster has long been a business organization of physicians who care for children. The concern is well founded, because a number of developmental bug accompany delayed onset of speech. In addition, spoken language filibuster may have a significant impact on personal, social, bookish and, later on, vocational life. Early on identification and appropriate intervention may mitigate the emotional, social and cognitive deficits of this disability and may improve the outcome.
Normal Oral communication Development
- Abstruse
- Normal Speech Development
- Epidemiology
- Etiology
- Clinical Evaluation
- Direction
- References
To determine whether a child has speech delay, the physician must have a basic knowledge of speech milestones. Normal speech progresses through stages of cooing, babbling, echolalia, jargon, words and give-and-take combinations, and judgement formation. The normal pattern of voice communication evolution is shown in Table ane.3
Tabular array one
Normal Blueprint of Speech communication Development
| Age | Accomplishment |
|---|---|
| 1 to six months | Coos in response to vocalization |
| 6 to 9 months | Babbling |
| 10 to 11 months | False of sounds; says "mama/dada" without meaning |
| 12 months | Says "mama/dada" with meaning; oft imitates 2- and three-syllable words |
| 13 to 15 months | Vocabulary of four to seven words in addition to jargon; < 20% of speech understood past strangers |
| 16 to xviii months | Vocabulary of x words; some echolalia and all-encompassing jargon; twenty% to 25% of speech understood by strangers |
| nineteen to 21 months | Vocabulary of 20 words; 50% of voice communication understood by strangers |
| 22 to 24 months | Vocabulary > 50 words; ii-word phrases; dropping out of jargon; lx% to lxx% of speech understood past strangers |
| 2 to ii ½ years | Vocabulary of 400 words, including names; two- to 3-word phrases; employ of pronouns; diminishing echolalia; 75% of speech understood past strangers |
| 2½ to three years | Use of plurals and by tense; knows historic period and sex; counts three objects correctly; iii to v words per sentence; 80% to xc% of speech understood by strangers |
| 3 to 4 years | Three to six words per judgement; asks questions, converses, relates experiences, tells stories; almost all spoken communication understood by strangers |
| 4 to five years | 6 to eight words per sentence; names four colors; counts 10 pennies correctly |
Epidemiology
- Abstract
- Normal Speech Evolution
- Epidemiology
- Etiology
- Clinical Evaluation
- Management
- References
Exact figures that would document the prevalence of speech delay in children are difficult to obtain because of dislocated terminology, differences in diagnostic criteria, unreliability of unconfirmed parental observations, lack of reliable diagnostic procedures and methodologic bug in sampling and information retrieval. Information technology can be said, however, that speech delay is a common childhood problem that affects three to 10 percent of children.4–6 The disorder is three to iv times more common in boys than in girls.5,seven
Etiology
- Abstract
- Normal Speech Evolution
- Epidemiology
- Etiology
- Clinical Evaluation
- Management
- References
Speech filibuster may exist a manifestation of numerous disorders. Causes of the problem are listed in Tabular array 2.
TABLE two
Causes of Speech Delay
| Mental retardation |
| Hearing loss |
| Maturation delay (developmental language delay) |
| Expressive linguistic communication disorder (developmental expressive aphasia) |
| Bilingualism |
| Psychosocial deprivation |
| Autism |
| Elective mutism |
| Receptive aphasia |
| Cerebral palsy |
MENTAL RETARDATION
Mental retardation is the well-nigh common crusade of voice communication delay, bookkeeping for more than 50 percent of cases.8 A mentally retarded child demonstrates global language delay and as well has delayed auditory comprehension and delayed utilize of gestures. In full general, the more severe the mental retardation, the slower the acquisition of communicative spoken communication. Speech evolution is relatively more delayed in mentally retarded children than are other fields of development.
In approximately xxx to 40 percent of children with mental retardation, the cause of the retardation cannot be determined, even subsequently extensive investigation.9 Known causes of mental retardation include genetic defects, intrauterine infection, placental insufficiency, maternal medication, trauma to the central nervous system, hypoxia, kernicterus, hypothyroidism, poisoning, meningitis or encephalitis, and metabolic disorders.9
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 development may lead to profound speech delay.
Hearing loss may be conductive or sensorineural. Conductive loss is unremarkably caused by otitis media with effusion.x Such hearing loss is intermittent and averages from 15 to 20 dB.11 Some studies take shown that children with conductive hearing loss associated with center ear fluid during the first few years of life are at gamble for speech filibuster.4,xi Withal, not all studies observe this association.12 Conductive hearing loss may as well be caused by malformations 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, intracranial hemorrhage, certain syndromes (e.g., Pendred syndrome, Waardenburg syndrome, Usher syndrome) and chromosomal abnormalities (due east.g., trisomy syndromes). 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 delay occurs in the maturation of the cardinal neurologic process required to produce voice communication. The condition is more common in boys, and a family history of "belatedly bloomers" is often nowadays.xiii The prognosis for these children is first-class, however; they ordinarily accept normal speech development by the age of school entry.14
EXPRESSIVE LANGUAGE DISORDER
Children with an expressive linguistic communication disorder (developmental expressive aphasia) neglect to develop the use of speech at the usual age. These children have normal intelligence, normal hearing, adept emotional relationships and normal articulation skills. The primary deficit appears to be a brain dysfunction that results in an inability to translate ideas into spoken communication. Comprehension of spoken communication is appropriate to the age of the child. These children may use gestures to supplement their limited verbal expression. While a late bloomer will eventually develop normal voice communication, the child with an expressive linguistic communication disorder will not practise so without intervention.13 It is sometimes hard, if non impossible, to distinguish at an early age a late bloomer from a child with an expressive linguistic communication disorder. Maturation delay, nevertheless, is a much more than mutual crusade of spoken communication delay than is expressive language disorder, which accounts for simply a small percentage of cases. A child with expressive linguistic communication disorder is at run a risk for language-based learning disabilities (dyslexia). Because this disorder is non 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'southward comprehension of the 2 languages is normal for a kid of the same age, nevertheless, and the child usually becomes proficient in both languages before the age of five years.
PSYCHOSOCIAL Deprivation
Concrete deprivation (eastward.yard., poverty, poor housing, malnutrition) and social deprivation (e.k., inadequate linguistic stimulation, parental absenteeism, emotional stress, kid neglect) have an adverse consequence on spoken language development. Driveling children who alive with their families do non seem to accept speech delay unless they are also subjected to fail.fifteen Because abusive parents are more likely than other parents to ignore their children and less probable to use verbal means to communicate with them, abused children have an increased incidence of speech delay.xvi
AUTISM
Autism is a neurologically based developmental disorder; onset occurs earlier the child reaches the age of 36 months. Autism is characterized by delayed and deviant language development, failure to develop the ability to relate to others and ritualistic and compulsive behaviors, including stereotyped repetitive motor activity. A variety of speech abnormalities have been described, such equally echolalia and pronoun reversal. The spoken language of some autistic children has an atonic, wooden or sing-song quality. Autistic children, in general, neglect to make eye contact, smile socially, respond to being hugged or use gestures to communicate. Autism is iii to four times more common in boys than in girls.
Constituent MUTISM
Elective mutism is a condition in which children do not speak because they do non want to. Typically, children with elective mutism will speak when they are on their own, with their friends and sometimes with their parents, simply they do non speak in school, in public situations or with strangers. The condition occurs somewhat more often in girls than in boys.17 A significant proportion of children with elective mutism also have articulatory or linguistic communication deficits.
The basis of mutism is ordinarily family psychopathology. Electively mute children unremarkably manifest other symptoms of poor adjustment, such every bit poor peer relationships or overdependence on their parents. By and large, these children are negativistic, shy, timid and withdrawn. The disorder can persist for months or years.
RECEPTIVE APHASIA
A deficit in the comprehension of spoken communication is the master problem in receptive aphasia; product difficulties and speech communication filibuster stem from this disability. Children with receptive aphasia testify normal responses to nonverbal auditory stimuli. Their parents often describe such children as "not listening" rather than "not hearing." The voice communication of these children is non only delayed but besides sparse, agrammatic and indistinct in articulation.18 Near children with receptive aphasia gradually learn a language of their own, understood only by those who are familiar with them.
CEREBRAL PALSY
Delay in speech is common in children with cerebral palsy. Speech delay occurs about oft in those with an athetoid type of cerebral palsy. The following factors, alone or in combination, may account for the speech delay: hearing loss, incoordination or spasticity of the muscles of the tongue, coexisting mental retardation or a defect in the cognitive cortex.
Clinical Evaluation
- Abstract
- Normal Speech Development
- Epidemiology
- Etiology
- Clinical Evaluation
- Management
- References
A history and physical examination are important in the evaluation of children with speech delay. The data obtained will help the physician select appropriate studies for farther evaluation (Tables 3 and 4).
Table three
Historical Information in the Evaluation of Speech Delay in Children
| Historical data | Possible etiology | |
|---|---|---|
| Developmental history | ||
| Delay in language milestones | Speech filibuster | |
| Delay in motor milestones | Cognitive palsy | |
| Generalized delay in developmental milestones | Mental retardation | |
| Maternal illness during pregnancy | ||
| Intrauterine infection (e.1000., rubella, toxoplasmosis, cytomegalovirus inclusion disease) | Hearing loss, mental retardation | |
| Maternal phenylketonuria | Mental retardation | |
| Maternal hypothyroidism | Mental retardation | |
| Maternal utilize of drugs (e.g., alcohol) | Mental retardation | |
| Placental insufficiency | Mental retardation, cerebral palsy | |
| Perinatal history | ||
| Prematurity | Cerebral palsy | |
| Hypoxia | Mental retardation, cerebral palsy, hearing loss | |
| Birth trauma | Cognitive palsy | |
| Intracranial hemorrhage | Mental retardation, hearing loss, cognitive palsy | |
| Kernicterus | Mental retardation, hearing loss, cerebral palsy | |
| 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 | |
| Caput trauma | Mental retardation, hearing loss | |
| Seizures | Cerebral palsy, mental retardation | |
| Use of medications | ||
| Ototoxic drugs | Hearing loss | |
| Psychosocial history | ||
| Psychosocial stress, family unit conflicts | Psychosocial deprivation, constituent mutism | |
| Aberrant social play, lack of empathy, disability to relate to others | Autism | |
| More than one language spoken to the child | Bilingualism | |
| Family history | ||
| Voice communication filibuster | Maturation filibuster, mental retardation | |
| Chromosomal abnormalities | Mental retardation | |
| Pendred syndrome, Waardenburg syndrome, Usher syndrome | Hearing loss | |
| Prader-Willi syndrome, Williams syndrome, Bardet-Biedl syndrome | Mental retardation | |
Table 4
Physical Examination Findings in the Evaluation of Children With Speech Filibuster
| Physical findings | Possible etiology |
|---|---|
| Short stature, obesity, hypogonadism | Prader-Willi syndrome |
| Microcephaly, macrocephaly | Mental retardation, cerebral palsy, hearing loss |
| 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's syndrome |
| Goiter | Pendred syndrome |
| Café 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, built cytomegalovirus |
| Lack of eye contact, stereotyped repetitive motor activity | Autism |
| Spasticity, hyperreflexia, clonus, extensor plantar response, contractures | Cerebral palsy |
| Athetosis, choreoathetosis, ataxia | Cognitive palsy |
| Dysarthria | Cerebral palsy |
HISTORY
A thorough developmental history, with special attending to language milestones, is extremely important in making the diagnosis. The doctor should be concerned if the child is not blathering by the age of 12 to xv months, not comprehending simple commands by the age of 18 months, not talking by ii years of historic period, non making sentences by three years of age, or is having difficulty telling a simple story by 4 to five years of age.4,18 The doctor should besides be concerned if the child's spoken communication is largely unintelligible later three years of age or if the child'due south speech is more a year belatedly in advent in comparison with normal patterns of speech development. Generalized delay in all aspects of developmental milestones suggests mental retardation as the crusade of a child's speech delay.
The medical history should include whatsoever maternal illnesses during the pregnancy, perinatal trauma, infections or asphyxia, gestational historic period at birth, nativity weight, past health, utilise of ototoxic drugs, psychosocial history, language(southward) spoken to the child, and family history of pregnant illness or voice communication filibuster.
Physical Exam AND SCREENING TESTS
A precise measurement of the child's superlative, weight and head circumference is necessary. A review of the advisable parameter on the growth chart also can aid in early identification of some types of speech communication delay. Any dysmorphic features or abnormal physical findings should exist noted. A complete neurologic examination should be performed and should include vision and hearing evaluations.
The Early Linguistic communication Milestone Scale (Figure one) is a simple tool that can be used to appraise language development in children who are younger than 3 years of age.xix The test focuses on expressive, receptive and visual language. Information technology relies primarily on the parents' report, with occasional testing of the child. The test can exist done in the physician's office and takes but a few minutes to administer.vii For children two and half to eighteen years of historic period, the Peabody Motion picture Vocabulary Test–Revised20 is a useful screening instrument for word comprehension. If the child is bilingual, it is important to compare the child'due south language performance with that of other bilingual children of similar cultural and linguistic backgrounds.
Figure ane.
Early Language Milestone Calibration.
Reprinted with permission from Coplan J. ELM calibration: the early language milestone scale. Austin, Tex.: Pro-Ed, 1987.
A comprehensive developmental cess is essential, considering a filibuster in speech communication evolution is the well-nigh common early manifestation of global intellectual harm. The Denver Developmental Screening Test is the most popular exam in clinical use for infants and young children.ix,21
Children whose results betoken an abnormal status crave more than definitive testing with one of the standardized and validated tests of intelligence. The most widely used intelligence tests for assessing the intellectual and adaptive functioning of a kid are the Stanford-Binet Intelligence Scale, the Bayley Scales of Babe Development, the Wechsler Intelligence Scale for Children–Revised (WISC–R), and the Wechsler Preschool and Primary Scale of Intelligence (WPPSI).
DIAGNOSTIC EVALUATION
All children with speech delay should exist referred for audiometry, regardless of how well the child seems to hear in an part setting and regardless of whether other disabilities seem to account for the speech delay.viii Special earphones that close out background dissonance may meliorate the study result. Tympanometry is a useful diagnostic tool. When coupled with results from pure-tone audiometry, measurement of eardrum compliance by means of a tympanometer helps to place a potential conductive component (e.m., middle ear effusion) that might otherwise be missed. An auditory encephalon-stalk response provides a definitive and quantitative physiologic means of ruling out peripheral hearing loss.22 It is especially useful in infants and uncooperative children.22 The auditory brain-stem response is not affected past sedation or full general anesthesia.
Boosted tests should exist ordered simply when they are indicated by the history or concrete examination. A karyotype for chromosomal abnormalities and a Dna exam should be considered in children who have the phenotypic appearance of fragile X syndrome. An electroencephalogram should exist considered in children with seizures or with significant receptive language disabilities. The latter may occasionally be related to subclinical seizure activities in the temporal lobe.4
Direction
- Abstract
- Normal Speech Development
- Epidemiology
- Etiology
- Clinical Evaluation
- Management
- References
The management of a child with spoken communication delay should exist individualized. The wellness intendance team might include the medico, a voice communication-language pathologist, an audiologist, a psychologist, an occupational therapist and a social worker. The doctor should provide the team with information almost the cause of the speech communication filibuster and be responsible for whatever medical handling that is available to correct or minimize the handicap.
A speech-language pathologist plays an essential function in the conception of handling plans and target goals. The main goal of linguistic communication remediation is to teach the kid strategies for comprehending spoken linguistic communication and producing advisable linguistic or communicative beliefs. The speech-linguistic communication pathologist tin help parents learn ways of encouraging and enhancing the child's chatty skills.
In children with hearing loss, such measures as hearing aids, auditory preparation, lip-reading teaching and myringotomy may exist indicated; occasionally, reconstruction of the external auditory canal, ossicular reconstruction and cochlear implantation may be necessary. The use of a high-risk registry too as universal hearing screening may help to identify hearing loss at an early historic period.
Psychotherapy is indicated for the child with elective mutism. It is also recommended when the speech communication delay is accompanied by undue anxiety or low. In autistic children, gains in speech conquering have been reported with beliefs therapy that includes operant workout.
Parents and caregivers who work with children with speech filibuster should exist made aware of the demand to adjust their speech to the level of the particular child. Teachers should consider the utilise of small group education for children with spoken language delay.23
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REFERENCES
bear witness all references
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3. Schwartz ER. Speech and language disorders. In: Schwartz MW, ed. Pediatric primary care: a problem oriented approach. St. Louis: Mosby, 1990: 696–700.
4. Shonkoff JP. Linguistic communication delay: tardily talking to communication disorder. In: Rudolph AM, Hoffman JI, Rudolph CD, eds. Rudolph'south pediatrics. London: Prentice-Hall, 1996:124–viii.
five. Silva PA, Williams S, McGee R. A longitudinal study of children with developmental language filibuster at historic period three: later intelligence, reading and behaviour problems. 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 clan with full general retardation. Dev Med Child 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 intendance of infants and children. St. 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 Southward, 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;v:29–35.
eleven. Schlieper A, Kisilevsky H, Mattingly S, Yorke L. Mild conductive hearing loss and linguistic communication development: a one yr follow-upwardly report. J Dev Behav Pediatr. 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 kid with language delay. Clin Pediatr. 1985;24:26–31.
14. McRae KM, Vickar E. Uncomplicated developmental spoken language delay: a follow-up study. Dev Med Child Neurol. 1991;33:868–74.
15. Davis H, Stroud A, Green L. The maternal language surround of children with language delay. Br J Disord Commun. 1988;23:253–66.
xvi. 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 Fifty, eds. Child and adolescent psychiatry. Oxford: Blackwell Science, 1994:546–68.
18. Denckla MB. Linguistic communication disorders. In: Downey JA, Low NL, eds. The child with disabling affliction: principles of rehabilitation. New York: Raven, 1982:175–202.
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, 1981.
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. Upshot of small-group instruction in linguistic communication-delayed preschoolers. Except Child. 1981;48:178–9.
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