DELAY A MEDICAL APPROACH TO LANGUAGE DELAY

Communication is central to the personal development, social interaction and learning of a .

Speech, writing, art and body and sign language are all methods of communica- tion. Because is central to the development of a child, failure of a child to speak by the age of 2 years should be taken seriously. Language prob- lems interfere with a child’s ability to communicate effectively, both in the expres- sion and understanding of ideas. The outcome of such a delay may have wide- spread results ranging from academic to social problems.

The evaluation of development in a child requires a range of skills embodied in different specialists, making a team approach appropriate. Doctors need to understand the terminology used by speech therapists in order to facili- tate communication between team members. As language delay may be associat- ed with a wide variety of medical conditions and developmental problems the L JACKLIN doctor plays an important role in the team. MB ChB, MMed (Paed), FCP (Paed), MSc Child Health (Neurodevelopment) Boys are more likely to suffer from language problems. As there is also a strong Principal Specialist (Paediatrician) genetic predisposition, the presence of a family history is a useful indicator of the

Department of Paediatrics course the delay will follow. The prevalence of language delay is 7 - 10% and it is the most common developmental problem in preschool children. Although the Johannesburg Hospital and speech problem may decrease with age, language delay frequently persists as Memorial Institute for Child Health and an educational or social problem.1 Development Johannesburg NORMAL Lorna Jacklin is a registered neurodevelop- mental paediatrician. Her interest in child The doctor needs to understand normal communication milestones and language development extends into childhood dis- patterns (Table I). This will assist in detecting deviant language and in assessing abilities, particularly the child with a visual the seriousness of the problem. Parents, on the other hand, usually compare the child to a peer or sibling as a guide to normal language development. Fig. 1 impairment, and the interaction between shows the normal speech and language pathway as described by Reynell in child abuse and developmental delay. 1969.1

Experience of Feedback Opportunity for language verbal expression

Hearing of speech Articulated speech

Verbal comprehension/ Expressive language receptive language

Comprehension Concept formed Expression

Fig. 1. Pathway for normal speech and language development.

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Table I. Linguistic and auditory milestones

Language milestone Age (months) Language milestone Age (months)

Alerting 1 Two words 12 1 Social smile 1 /2 Three words 14 Cooing 3 One-step command (without gestures) 15 Orient to voice 4 Four to six words 15 Orient to bell (I) 5 Immature jargoning 15 ‘Ah-goo’ 5 Seven to 20 words 18 Razzing 5 Mature jargoning 18 6 One body part 18 Orient to bell (II) 7 Three body parts 21 ‘Dada/mama’ (inappropriately) 8 Two-word combinations 21 Gesture 9 Five body parts 23 Orient to bell (III) 10 50 words 24 ‘Dada/mama’ (appropriately) 10 Two-word sentences (noun-pronoun 24 One word 11 inappropriately and verb) One-step command (with gesture) 12 Pronouns (I, me, you, inappropriately) 24 Source: Capute AJ, Accardo PJ. Linguistic and auditory milestones during the first two years of life. Clin Pediatr 1978; 17: 847.

Table II. Landmarks in the development of communicative skills during the first 15 months of life1 (Extract)

Month Sound production Auditory perception Communication

0-1Reflexive sound production: Responses to instrumental Infant links mother's voice cry, discomfort sounds, music and speech are with her face and is vegetative sounds. These differentiated. Responses comforted when crying by sounds are either vocalic or show preference for human her voice. Infant responds consonantal. Pain and speech. Ability to turn differently to infant crying hunger cries are head in horizontal plane to and to adult speech. Infant differentiated in first week sound source in immediate stares intently at faces vicinity is present 2-3Consonantal sounds are Sucking and heart rate Social smiling and cooing produced at the back of the responses indicate vocalisations appear. mouth. Brief consonantal discrimination of different Infant is attentive to elements are superimposed CV syllables (ba v. da; da nodding, smiling adult and upon vocalic sounds v. ta) is likely to vocalise in response to adult. Turn- taking is managed chiefly by adults; mother and infant may vocalise in chorus

The speech of 5-year-old children is environmental factors and the ability infant to the information. This is a usually fluent; they are able to express to hear. Significant language delay in social interaction. The development of themselves adequately and understand a child with normal hearing is a pre- communication can therefore be divid- what is said in the everyday context. dictor of a learning disability, and ed into 3 areas, namely production, From this age speech will increase in such children should be referred to a understanding and communication complexity until adulthood. The rate speech and language therapist for (Table II). Delayed production but and extent of speech development is evaluation and intervention (Table I). good understanding and communica- widely variable. Some children with tion would have a better prognosis delayed speech will catch up while Language milestones in than a delay in all areas.1 others require intervention. The chal- infancy lenge is to decide when to intervene. In the infant language is the interac- Sound production is dependent on Factors to consider when a child has a tion between information received by motor control of the oral structures developmental delay are the familial a variety of means, e.g. vision, hear- such as the tongue, palate and jaw. pattern of language development, ing and touch, and the response of the Movement of the oral muscles has to

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Because communication is central to the development Processing of Processing of outgoing information incoming of a child, failure of a auditory child to speak by the age input Expressive Speech of 2 years should be taken (sounds, words, grammar) seriously. — interpretation — discrimination Grammar Vocabulary Articulation — memory (syntax) (semantics) discrimination The prevalence of lan- — sequencing guage delay is 7 - 10% — retrieval — understanding and it is the most common — attention Conversation Spelling — closure developmental problem in (pragmatics) — analysis/synthesis preschool children. — comprehension

The speech of 5-year-old Fig. 2. Areas where problems may arise in children with severe speech/language children is usually fluent; impairment. they are able to express ing a delay in all areas will have a The use of speech to communicate in themselves adequately and worse prognosis than one with a the social context is termed pragmat- understand what is said in delay in one area only. ics. The child learns how to use the everyday context. speech to establish and maintain in the social interest. This is done by linking second year to the needs of the partner. Children with language dif- In the second year language starts The child is aware of the need to sus- ficulties may demonstrate with sounds, later replaced with real tain a topic. This is achieved by turn words, accompanied by gestures. problems in self-regulation taking. Language is modified to the There is a rapid growth in vocabulary and are easily frustrated, context, e.g. more or less formal to about 50 words. Speech starts as impulsive and inattentive depending on the social context. The single-word utterances, progressing to child shows an awareness that lan- when activities related to multi-word phrases with a single mean- guage can be used to influence others. language are involved. ing (‘out the door’ meaning ‘out’) or In summary the child learns to have a multi-word with multi-function, e.g. ‘me conversation. — go — bye-bye’. Sentences will con- be co-ordinated with breathing and sist of a content word, e.g. baby, and The requirements for language acquisi- the larynx. The resulting pitch, hard- a function word which expresses rela- tion are the following: ness and timing of speech are referred tions, e.g. go, sleep, my, etc. The • Normal hearing, necessary to to as prosody. method of production and the use of gesture vary from child to child. develop the ability to perceive the The understanding of speech develops Language can be described by its elements of speech and to discrimi- from an awareness of the rhythm, form, content and use. Increasing com- nate between sounds. pitch, intensity and content of adult plexity occurs with the development of • Normal speech motor abilities and speech and the ability to discriminate grammatical form. The form of the sen- normal hearing, necessary for the sounds. An infant will respond to this tence is referred to as syntax, i.e. child to monitor the production of aspect of speech long before under- grammar. This is the structure of the sounds. sentence, which in English is depend- standing develops. • An environment where a child is ent on word order, and the endings of exposed to speech and is encour- words (pleural, possessives, tenses). Communication behaviour in the infant aged to express him/herself will The early understanding of speech is is seen as responsiveness to others support the learning of speech. situational, e.g. ‘give me the cup?’ and awareness of the response of oth- Language and cognitive develop- ers, as shown in vocal play behaviour when the child is sitting at the meal ment are closely related. between mothers and their babies. table. This request is usually accompa- • Language must be learnt in an envi- Infants soon learn that they are able to nied by gesture to assist understand- ronment that allows speech to influence interaction and to make ing. Parents naturally accommodate develop as a means of social inter- demands on the adult. Observation of the communication needs of a child by these three aspects of communication simplifying and slowing their speech. action. will give an indication of the serious- The meaning attached to a word is See Table III for referral guidelines. 2 ness of the problem. An infant show- referred to as semantics.

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Table III. Guidelines for referral of an infant for audiology, speech-language or psychological evaluation

Interaction-communication Expression-production Excessive crying after 3 months of age Failure to produce any consonantal sounds (raspberries, Lack of crying, or crying perceived as abnormal in nasals, and stops) in the first year of life infancy Failure to produce consonantal sounds towards front of Lack of eye contact or smiling after 3 months of age mouth in second 6 months of life Lack of cooing vocalisations or response to smiling at Failure to produce high front /v/, back /a/, and rounded adults from 3 to 6 months of age vowels /u/ by 15 months of age Expressions of dislike at being held (squirming, crying, Failure to produce prolonged vocalic or consonantal consistent tenseness relieved by placing child in infant sounds, to combine primitive consonantal and vocalic ele- seat) in first 6 months ments in a single segment, or to produce series of segments Failure of appearance of laughter or lack of laughter in or syllables in non-cry in the first 12 months of life interactive situations by 6 months of age Failure to produce reduplicated babbling by 9 - 10 months Failure to respond in interactive peek-a-boo and patty of age cake games by 1 year of age Lack or use of an excessive amount of expressive jargon Failure to indicate communicative intention non-verbally after 18 months of age by 1 year of age Failure to produce recognisable words by age 2 Failure to use several recognisable two-word combinations Reception-comprehension that combine two ideas by age 2 years, e.g. ‘more juice’ Failure to respond to environmental sounds Lack of multi-word utterances (phrases, sentences) by age 3 Failure to quiet to mother’s voice when infant is fussing or Lack of intelligible speech by age 3 crying and when mother is out of immediate line of sight Many initial consonants omitted at age 3. Lack of final con- and not in contact with infant sonants by age 4 Difficulty in localising a sound source correctly after 9 - 12 Continuing substitution of easy sounds for more difficult months sounds after age 5 Failure to respond to voices of family members in the sec- Persisting faults of speech articulation after age 7 ond 6 months of life when they return after an absence and Decrease in amount of speech produced, instead of steady are still out of immediate line of sight and not in contact increase, at any age from 3 to 7 years with infant Sentences that are poorly formed, confused, marked by Failure to understand common words or commands by age word reversals or telegraphic style by age 4 (dialectal varia- 18 months tions not to be considered in this category) Failure to indicate 1 or 2 familiar objects or people when Noticeable stuttering or other types of abnormality of rhythm these are named with gesture in the second year of life or rate (rapid speech, cluttering) after age 4 Failure to indicate 1 or 2 familiar objects or people when Monotonous, unusually loud, hoarse, harsh, or inaudible these are named (without accompanying gesture towards or voice gaze at object-person) early in the third year of life Pitch that is not appropriate to child’s age and sex Failure to understand simple discussions of past or future Noticeable hypernasality or lack of normal resonance events by age 3 years Embarrassment or disturbed feelings about speech on the Report that a child does not understand what is said, ‘takes part of the child at any age no notice’ of what is said, or ‘takes a long time to catch on’ to what is said in the third year of life

DISORDERS OF abnormality of the palate, velum or the management. Referral to an ENT COMMUNICATION pharynx, resulting in hyponasal or specialist, speech therapist, neurologist hypernasal speech. Referral to an ENT and/or psychologist may be necessary. Disorders of communication can be due specialist, speech pathologist, or dentist to abnormalities in expressive speech, is recommended. Disorders of fluency receptive speech or both together (Fig. Fluency is dependent on the rate and 2). Voice disorder rhythm of speech. Dysfluency is common The voice may be abnormal in quality, between 2 and 4 years and may DISORDERS OF EXPRESSIVE pitch or loudness. This may be caused progress into later life. Early referral is SPEECH by damage to the vocal cords or by needed to determine the nature of the allergy, or it may be neurogenic or psy- problem and underlying factors. It is Disorders of resonance chogenic in origin. In most cases, inde- important to provide the parents with There are due to interrupted oronasal pendent of the aetiology, voice training guidance on how to handle the problem sound balance, caused by anatomical will be necessary as part of and to monitor progress.

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Disorders of articulation • words and relationship expressed appropriate strategies to facilitate the This is a disorder in sound production, by a word, e.g. his, hers production of language consistent with i.e. consonants and vowels. Sound • sentences with different grammati- age, and academic and social needs. production is a learnt auditory motor cal structures and lengths PSYCHOLOGICAL ASPECTS OF act, which requires both hearing and • social conversations, idioms, LANGUAGE production. It requires intact oral, humour, explanations nasal and laryngeal co-ordination. • stories and lectures. Specific language impairment refers to Sounds are refined into grammatical a child who has normal hearing, nor- forms. Speech sounds are complete by Evaluation by a speech therapist mal cognitive function in certain 8 years. There is a variable rate of would involve an assessment of all areas, normal social interaction and acquisition. Articulation errors include these areas of difficulty measured no emotional cause for language substitution, omission, distortion or against the age expectations for the delay. The diagnosis of a specific lan- addition. Causes of poor articulation child. Children who have difficulties in guage disability is based on the are heterogeneous and include: comprehension may also have expres- assumption of normal intelligence. • hearing impairment sive language difficulties. Expressive Most of the intelligence tests rely on • structural abnormalities of the oral language is the means of representing language to determine intellectual cavity, jaw, palate thoughts and self in a social context. functioning. This places language- • neurological problems — central or Deficits are manifest by difficulties in disabled children at a disadvantage. peripheral, e.g. difficulties with co- age-appropriate syntax, morphology, These children will do better in the ordination, weakness or paralysis word-finding and ability to comment in non-verbal scales of such tests. It is of the vocal cords story-form or conversation. therefore recommended that tests • central nervous system problems — which rely less heavily on language, may cause an abnormality of voli- To assess expressive language the fol- such as the CASS or Hisky-Nebraska tion. These children have a normal lowing are looked at: Test of Learning Aptitude, be used. capacity for movement but lack the • analysis of the topic capacity to sequence the sounds • context of communication Children with language difficulties into speech. •intent of the child •principal means of communication may demonstrate problems in self-regu- Management of expressive • relationships expressed by the child lation and are easily frustrated, impul- speech disorders • sentence-building skills sive and inattentive when activities Children with a mild or moderate dis- • word-finding abilities related to language are involved. order respond to traditional speech • appropriateness of the sentence These children struggle with aggres- therapy. Severe disorders of communi- •organisation of narrative in conver- sion. This and poor communication cation require augmentative communi- sation. lead to difficulty with peer relation- cation techniques such as boards (Bliss ships. These children are therefore at Board), charts, sign language Parents complain that their children risk for psychiatric disorders including (Makaton), and computer-assisted com- have difficulty expressing ideas in anxiety and behavioural problems. munication systems. A thorough evalu- words or that they are unable to fol- Such problems frequently persist as ation of the child, environment and low the child’s conversation. The child self-regulation and academic prob- 2 financial constraints is needed before does not speak like other children and lems. Referral is recommended for a a decision on the form of assistance becomes frustrated if not understood, hearing test, to a speech therapist, can be made. and refuses to repeat. These children and to a psychologist. do not speak much and prefer to do LANGUAGE DISABILITY things for themselves, or will use ges- WHAT ROLE COULD A tures to communicate. They frequently DOCTOR PLAY IN This is a heterogeneous group of disor- exhibit tantrums or difficulty in control. PROMOTING LANGUAGE ders characterised by deficits in com- Management of language DEVELOPMENT IN THE prehension, production and use of lan- delay COMMUNITY? guage. The aetiologies range from hearing impairment, mental retarda- Therapy includes programmes that tion, to pervasive developmental disor- improve the cognitive forms represent- There is a strong association between der. All children who present with a ed in language. A modified teaching early language skills and academic language delay should have a hearing environment may be necessary which performance. It is therefore important assessment. Problems in comprehen- provides for organisation and lan- not only that early language delays be sion of language refer to difficulty in guage modification. Individual therapy identified and remediated, but that understanding the spoken language. will begin with what the child knows there is active prevention of language These children present with difficulty in and proceed developmentally, assist- delay. Factors that have been associat- understanding: ing the child in acquiring new and ed with good language development

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and subsequent good academic out- IN A NUTSHELL comes are good parent-child interac- tion and a good language environ- Communication is central to the per- A doctor must have some idea of 3-5 ment. It is therefore the responsibility sonal development, social interaction normal communication milestones of the medical practitioner to encour- and learning ability of a child. and language patterns. age parents to spend time talking to Development of communication can There is wide variability in the rate their children. The traditional bedtime therefore be divided into 3 areas, and extent of speech development. story does much to encourage both namely production, understanding bonding and an opportunity for lan- Factors to consider when a child has and communication. guage development. The ‘television a developmental delay are the famil- culture’ does little to encourage good A team should do the evaluation of a ial pattern of language development, language. Retaining the tradition of child who fails to communicate. environmental factors and ability to eating around the dinner table has To play a meaningful role in the hear. many elements that encourage both team it is important that the doctor Significant language delay in a child good communication and emotional understands the terminology used by who has normal hearing is a predic- stability. speech therapists. tor of a learning disability and such Language delay may be associated children should be referred to a References available on request. with a wide variety of medical condi- speech and language therapist for tions and developmental problems. evaluation and intervention.

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