Speech and language problems

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Chapter 40 SPEECH AND LANGUAGE PROBLEMS

Timothy J. Horita

General Discussion

Speech and language delay affects 5% to 8% of preschool children and often persists into the school years. As a child develops from newborn to infant to toddler, there is a significant change in how the child communicates. This development continues through adulthood, but this early period is considered very important, if not critical. Numerous different areas are involved with speech and language development, and problems occur in many different ways. To communicate with others, we need to be able to produce and receive speech and language. In addition, many layers of cognitive and social development need to be mastered. Speech (the production of sounds) and language (those rules which govern communication both verbal and nonverbal) develop very early. Some of the most complex and intricate aspects of communication are not learned, or detected, until later in development.

Speech refers to the mechanics of oral communication; language encompasses the understanding, processing, and production of communication. Speech problems may include stuttering or dysfluency, articulation disorders, or unusual voice quality. Language problems can involve difficulty with grammar, words or vocabulary, the rules and system for speech sound production, units of word meaning, and the use of language, particularly in social contexts. Speech and language problems can exist together or separately.

Parents who have concerns about their child’s development of speech and language should be taken very seriously. These concerns are usually expressed before 3 years of age. Many parents, especially those with multiple children, are able to detect these problems early on. A good familiarity with what is normal versus abnormal is very important. Several behavioral problems might be first interpreted as a speech or language disorder.

The distinction between delay versus disorder and expressive versus receptive problems is also important in the evaluation and management of children with potential problems. A delay is a slower than expected chronologic progression, whereas a disorder is a change in the actual ability to communicate in a specific area. Expressive problems are those involved with producing speech and language while receptive problems refer to the ability to receive and understand speech and language. Recognition of these problems can often provide clues to other developmental abnormalities and is important because early recognition and intervention can often be very beneficial. Although learning disorders can lead to speech and language disorders, the opposite is true as well.

A thorough developmental history is very important in making the appropriate diagnosis. Special attention should be paid to language milestones. The physician should be concerned if the child is not babbling by the age of 12 to 15 months, comprehending simple commands by 18 months of age, talking by 2 years of age, making sentences by 3 years of age, or telling a simple story by 4 to 5 years of age. Other items of concern include unintelligible speech after 3 years of age or speech that is more than a year late in comparison with normal patterns of speech development.

A basic knowledge of speech milestones is necessary to determine whether a child has speech delay. These speech milestones are presented in Table 40-1. Children’s speech and language can be evaluated at any age when there is a suspicion of delay or disorder. The most common referral is to a speech-language pathologist for an evaluation. If the speech-language service does not have audiology services, a referral should be made to an audiologist or an otologist for a hearing evaluation.

Table 40-1 Pattern of Speech Development

Age	Achievement
1-6 mo	Coos in response to voice
6-9 mo	Babbling
10-11 mo	Imitation of sounds; says “mama/dada” without meaning
12 mo	Says “mama/dada” with meaning; often imitates two- and three-syllable words
13-15 mo	Vocabulary of four to seven words in addition to jargon; <20% of speech understood by strangers
16-18 mo	Vocabulary of 10 words; some echolalia and extensive jargon; 20% to 25% of speech understood by strangers
19-21 mo	Vocabulary of 20 words; 50% of speech understood by strangers
22-24 mo	Vocabulary >50 words; two-word phrases; dropping out of jargon; 60% to 70% of speech understood by strangers
2 to 2 1/2 yr	Vocabulary of 400 words, including names; two- to three-word phrases; use of pronouns; diminishing echolalia; 75% of speech understood by strangers
2 1/2-3 yr	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
3-4 yr	Three to six words per sentence; asks questions, converses, relates experiences, tells stories; almost all speech understood by strangers
4-5 yr	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.)

Key Historical Features

Caregiver, family, or teacher concern about not meeting perceived milestones

Detailed history of developmental milestones at specific ages

Prenatal and birth history

• Maternal health status

• Maternal substance abuse

• Past use of ototoxic medications (aminoglycosides, diuretics, NSAIDs)

• Feeding difficulties

• Recurrent or persistent otitis media

• Seizures

• Severe jaundice

• Trauma

• Endocrine or metabolic disorders

Family history

• Speech or language problems

• Sensorineural hearing loss

Psychosocial history

Number of languages spoken to the child

Aptitude of verbal versus nonverbal communication

Level of intelligence in other areas

Motor development milestones

Language development milestones

Ability of child to communicate with close family members versus strangers or medical team

Suggested Work-Up

Early Language Milestone Scale	Used to assess language development in children younger than 3 years. Focuses on expressive, receptive, and visual language. Relies primarily on the parents’ report
Peabody Picture Vocabulary Test Revised	Used for children 2.5 to 18 years of age to screen for word comprehension. If the child is bilingual, performance on the test should be compared with that of other bilingual children of similar cultural and linguistic backgrounds
Denver Developmental Screening Test	Comprehensive developmental assessment to evaluate for a global intellectual impairment, which may manifest initially as a delay in speech development
Audiometry	Indicated for all children with speech delay
Tympanometry	To evaluate eardrum compliance
Complete blood count (CBC) and general chemistry panel	May be considered to screen for anemia or metabolic disorders

Additional Work-Up

Test of intelligence	For children whose results on the Denver Developmental Screening Test indicate an abnormal condition
Auditory brainstem response	Useful in infants and uncooperative children to evaluate for peripheral hearing loss
Karyotype for chromosomal abnormalities and a DNA test	For children who have the phenotypic appearance of fragile X syndrome
Electroencephalogram (EEG)	Should be considered for children with seizures or with significant receptive language disabilities
Thyroid-stimulating hormone (TSH)	If hypothyroidism is suspected
Referral to a pediatric neurologist	If a neurologic disorder is suspected
Referral to a developmental pediatrician	If a developmental delay is suspected or discovered on the Denver Developmental Screening Test