Expressive and receptive language characteristics in three-year-old preterm children with extremely low birth weight.

Van Lierde KM, Roeyers H, Boerjan S, De Groote I.

Department of Otorhinolaryngology, Head and Neck Surgery and Speech and Language Pathology, Ghent University Hospital, Ghent University, Ghent, Belgium. kristiane.vanlierde@ugent.be

Supported By

CHILDREN SPEECH CLINIC

CLINIC FOR CHILDREN Yudhasmara Foundation

Office ; JL Taman Bendungan Asahan 5 Jakarta Indonesia 10210  phone : 62(021) 70081995 – 5703646 email : judarwanto@gmail.com, http://childrenclinic.wordpress.com/ 

Clinic and Editor in Chief :

Dr WIDODO JUDARWANTO

phone : 62(021) 70081995 – 62(021) 5703646, mobile : 0817171764

email : judarwanto@gmail.com 

curriculum vitae

Copyright © 2010, Children Speech Clinic  Information Education Network. All rights reserved

Faktor lingkungan sangat berpengaruh dalam tumbuh dan berkembangannya anak. Selain faktor genetik dan host, perkembangan bahasa dan gangguan bicara dan bahasa sangat dipengaruhi berbagai faktor lingkungan.

• Lingkungan verbal mempengaruhi proses belajar bahasa anak. Anak di lingkungan keluarga profesional akan belajar kata-kata tiga kali lebih banyak dalam seminggu dibandingkan anak yang dibesarkan dalam keluarga dengan kemampuan verbal lebih rendah.
• Studi lain juga melaporkan ibu dengan tingkat pendidikan rendah merupakan faktor risiko keterlambatan bahasa pada anaknya.
• Chouhury dan beberapa peneliti lainnya mengungkapkan bahwa jumlah anak dalam keluarga mempengaruhi perkembangan bahasa seorang anak, berhubugan dengan intensitas komunikasi antara orang tua dan anak.
• Menurut Gore Eckenrode, McLoyd, McLoyd Wilson, masalah kemiskinan dapat menjadi penyebab meningkatnya risiko berbagai masalah dalam rumah tangga. Kemiskinan secara signifikan mempertinggi risiko terpaparnya masalah kesehatan seperti asma, malnutrisi, gangguan kesehatan mental kurang perhatian dan ketidak-teraturan perawatan dari orang tua, defisit dalam perkembangan kognisi dan pencapaian keberhasilan.
• Beberapa penelitian yang dilaporkan Attar Guerra, Brooks-Gunn, Liaw  Brooks-Gunn dan McLoyd menjelaskan bahwa keluarga yang bermasalah, terpapar lebih besar faktor-faktor risiko daripada keluarga yang tidak berada dibawah tingkat kemiskinan, dan konsekuensi dari faktor-faktor risiko ini dapat lebih berat pada anak dalam keluarga ini.
• Anak yang terpapar berbagai faktor risiko, memiliki risiko mengalami gangguan perkembangan yang semakin meningkat. Salah satu yang termasuk gangguan perkembangan anak tersebut adalah specific language impairment (SLI). Hal ini telah dilaporkan oleh Spitz dan Tallal Flax, mereka menjelaskan secara umum tentang pencapaian yang buruk dalam berbahasa pada anak meskipun anak tersebut memiliki pendengaran dan intelegensi nonverbal yang normal.
• Penelitian Fazio, Naremore dan Connell, lebih mengkhususkan hal ini bahwa dapat diartikan suatu kondisi yang menyebabkan seorang anak memiliki penilaian spesifik dibawah rata-rata standar tes bahasa, tetapi berada pada level rata-rata untuk tes intelegensi nonverbal. Dengan demikian, pencegahan SLI dapat dengan mengidentifikasi faktor resiko anak sebelum diagnosis formal dibuat.
•  Beberapa penelitian mengungkapkan faktor-faktor risiko biologi untuk SLI dan penempatan-penempatan faktor lain dengan melihat “outcome” anak-anak sekolah yang ditempatkan di neonatal intensive care units (NICUs) setelah lahir dengan segera. Anak-anak dari populasi ini diketahui memiliki risiko untuk keterlambatan kognisi dan kesulitan akademik karena mereka biasanya lahir prematur, berat badan lahir rendah (kurang dari 2500 g) atau mengalami respiratori distres.
• Menurut Resnick, Rice, Spitz O’Brien dan  Siegel Tomblin, sebagian besar literatur menyatakan bahwa meskipun anak-anak dari NICU lebih berisiko mengalami kesulitan kognisi seperti retardasi mental dan gangguan belajar, mereka tidak memiliki risiko yang meningkat untuk masalah spesifik bahasa, khususnya saat angka penilaian disesuaikan karena prematuritasnya.
• Beberapa penelitian yang dilakukan Beitchman, Hood Inglis, Spitz, Tallal Ross, Tomblin telah memperlihatkan bahwa gangguan bahasa umumnya memiliki kecenderungan dalam suatu keluarga berkisar antara 40% hingga 70%. Hampir separuh dari keluarga yang anak-anaknya mengalami gangguan bahasa, minimal satu dari anggota keluarganya memiliki problem bahasa. Dengan demikian orang tua yang berpengaruh pada keturunan ini mungkin bertanggung jawab terhadap faktor-faktor genetik. Mungkin tidak diketahui berapa banyak transmisi intergenerasi gangguan-gangguan bahasa tersebut disebabkan oleh kurangnya dukungan lingkungan terhadap bahasa.
• Kondisi lingkungan merupakan hal yang penting menyangkut hasil perkembangan seorang anak. Beberapa anak yang datang dari keluarga yang tidak stabil dan kurangnya perhatian, perawatan, dan kurang memadainya kebutuhan nutrisi dan perawatan kesehatan, dapat membentuk level stress lingkungan yang merugikan bagi perkembangan anak termasuk bahasa. Risiko dari problem-problem bahasa juga dikaitkan dengan faktor sosioekonomi dan rendahnya status ekonomi.
• Peneliti-peneliti lain mendiskusikan beberapa variabel-variabel lingkungan yang tampak lebih dapat diprediksi. Seperti yang dilaporkan Hoff-Ginsberg, Neils Aram, Pine,  Tallal, Tomblin, Tomblin dan Hardy faktor permintaan cara persalinan ternyata termasuk faktor risiko gangguan perkembangan bicara pada anak. Sedangkan menurut Paul, Rice, Tomblin dan Tomblin menunjukkan pendidikan ibu yang rendah termasuk salah satu faktor risiko gangguan bahasa yang terjadi pada anak.  Orang tua tunggal menurut Andrews, Goldberg, Wellen, Goldberg McLaughlin dan Miller Moore juga merupakan faktor risiko yang harus diperhitungkan.
• Menurut Sameroff dan Barocas, tersusunnya model risiko perkembangan dapat digunakan untuk memprediksi dengan lebih akurat, dengan mengkombinasi satu atau lebih faktor-faktor risiko tersebut adalah efek komulatif dari risiko yang multipel.
• Dalam suatu model penelitian dari Sameroff menunjukkan beberapa faktor risiko sosial dan keluarga diantaranya adalah: masalah-masalah kesehatan mental ibu, kecemasan ibu, sikap otoriter ibu dalam mengasuh anak, hubungan ibu-anak yang buruk, pendidikan ibu yang kurang dari menengah atas, orang tua yang kurang atau tidak memiliki ketrampilan dalam pekerjaan, status etnik minoritas, tidak ada bapak, beberapa tekanan kehidupan tahun terdahulu, dan ukuran keluarga yang besar.
• Dilaporkan bahwa semua faktor tersebut adalah rangkaian individu yang berkaitan dengan nilai IQ anak-anak pada usia 4 tahun dan sebagian besar mayoritas masih berhubungan dengan IQ pada usia 13 tahun. Selain itu, jumlah faktor risiko sebagaimana didefinisikan oleh risiko kumulatif dalam, adalah prediktor kuat IQ pada usia 4 tahun dengan 58% dan pada umur 13 dengan varians 61%.
• Sebuah penelitian yang dilakukan oleh Hooper, Burchinal, Roberts, Zeisel dan Neebe juga menyajikan fakta-fakta yang menggunakan model risiko komulatif untuk memprediksi kemampuan kognitif dan bahasa pada bayi yang lebih dipengaruhi oleh status sosioekonomi yang rendah pada populasi Afrika Amerika. Hooper  mengidentifikasi satu perangkat dari 10 faktor-faktor risiko sosial dan keluarga berdasarkan pada model risiko dari Sameroff berupa status kemiskinan, pendidikan ibu kurang dari sekolah menengah atas, ukuran keluarga yang besar, ibu yang tidak menikah, hidup yang penuh tekanan, dampak dari ibu yang depresi, interaksi ibu-anak yang buruk, IQ ibu, kualitas lingkungan rumah, dan kualitas perawatan sehari-hari.
• Seluruh faktor risiko sosial dan keluarga dimasukkan ke dalam studi, saat bayi berusia 6 sampai 12 bulan. Peneliti-peneliti menemukan bahwa 9 dari 10 faktor-faktor risiko (tekanan hidup merupakan pengecualian) terkait dengan keberhasilan kognisi dan bahasa pada bayi. Komulatif indeks risiko dihubungkan dengan pengukuran bahasa dengan varians sekitar 12% sampai 17% tetapi bukan pengukuran kognisi.
• Evans dan English menyajikan fakta-fakta bahwa anak-anak dengan orang tua berpenghasilan rendah terpapar faktor-faktor risiko lingkungan dalam jumlah yang lebih besar daripada yang berpenghasilan menengah. Mereka memperkenalkan tiga penyebab stress psikososial (kekerasan, pertengkaran keluarga, perpisahan anak dengan keluarga) dan tiga penyebab stress fisik (kekacauan, kegaduhan, kualitas rumah yang rendah) merupakan faktor risiko yang memberikan pengaruh negatif.
• Dalam penelitiannya tentang lingkungan yang miskin, mereka menemukan hanya 20% anak-anak yang hidup dalam keluarga dengan penghasilan yang rendah tidak terpapar satupun faktor risiko. Sebaliknya, 61% keluarga dengan penghasilan menengah tidak terpapar faktor risiko. Temuan ini menyatakan bahwa mayoritas anak-anak dari keluarga berpenghasilan rendah terpapar lebih banyak masalah kemelaratan daripada kelompok berpenghasilan menengah dan disfungsi kognitif, prilaku, atau sosial akan meningkat.
• Sampai saat ini penelitian-penelitian terus mempelajari tentang perbedaan perkembangan bahasa anak yang diambil dari budaya dan latar-belakang sosioekonomi yang berbeda dan pengaruh dari perbedaan-perbedaan ini terhadap pencapaian akademik selanjutnya.
• Robertson membandingkan kemampuan fonologi anak TK dari keluarga dengan kemampuan bahasa tinggi dan rendah dan menemukan bahwa anak-anak dari kemampuan bahasa rendah secara signifikan lebih buruk pada rangkaian pengukuran kognisi, linguistik, pra-baca. Dua tahun pemantauan terlihat bahwa anak-anak ini tidak mengejar anak-anak dari keluarga kemampuan bahasa baik.
• Burt, Holm, and Dodd juga menemukan hubungan antara prestasi yang buruk dengan kemampuan bahasa yang rendah dengan menilai prestasi anak-anak pada beberapa tugas-tugas fonologi. Suatu usaha untuk menjelaskan keterkaitan antara kelemahan dan kegagalan sekolah.
• Hart and Risley mempelajari perbedaan antara kualitas bahasa ditujukan pada anak-anak dengan latar belakang kemampuan bahasa yang berbeda pada 2¹/2 tahun pertama kehidupan mereka. Mereka melaporkan bahwa anak-anak dari latar belakang kemampuan bahasa yang rendah berada dalam kelemahan karena orang tua mereka atau pengasuh sangat jarang mengajak berbicara; akibatnya mereka miskin perbendaharaan kata dan kemampuan komunikasi dibanding kelompok dengan kemampuan bahasa yang lebih tinggi.

 Daftar Pustaka :

• Tina L. Stanton-Chapman, Derek A. Chapman, Ann P. Kaiser, Terry B. Hancock .Cumulative Risk and Low-Income Children’s Language Development. Topics in Early Childhood Special Education, 2004, Vol. 24, No. 4, 227-237
• Adams, C. D., Hillman, N., & Gaydos, G. R. Behavioral diffi­culties in toddlers: Impact of sociocultural and biological risk factors. Journal of Clinical Child Psychology, 1994. 23, 373–381.
• Brooks-Gunn, J., Klebanov, P., & Liaw, F. The learning, physi­cal, and emotional environment of the home in the context of pov­erty: The infant health and development program. Children and Youth Services Review, 1995. 17, 251–276.
• Duncan, G., Klebanov, P., & Brooks-Gunn, J. Economic depri­vation and early childhood development. Child Development, 1994; 65; 296–318.
• Evans, G. W., & English, K. (2002). The environment of poverty: Multiple stressor exposure, psychophysiological stress, and socioe-motional adjustment. Child Development, 73, 1238–1248.
• Fazio, B. B., Naremore, R. C., & Connell, P. J. (1996). Tracking chil­dren from poverty at-risk for specific language impairment: A 3-year longitudinal study. Journal of Speech and Hearing Research, 39, 611–624.
• Halpern, R. (2000). Early childhood intervention for low-income chil­dren and families. In J. P. Shonkoff & S. J. Meisels (Eds.), Handbook of early childhood intervention (2nd ed., pp. 361–386). Cambridge, England: Cambridge University Press.
• Hoff-Ginsberg, E. (1998). The relation of birth order and socioeco-nomic status to children’s language experience and language devel­opment. Applied Psycholinguistics, 19, 603–629.

Supported By

CHILDREN SPEECH CLINIC

CLINIC FOR CHILDREN Yudhasmara Foundation

Office ; JL Taman Bendungan Asahan 5 Jakarta Indonesia 10210  phone : 62(021) 70081995 – 5703646 email : judarwanto@gmail.com, http://childrenclinic.wordpress.com/ 

Clinic and Editor in Chief :

Dr WIDODO JUDARWANTO

phone : 62(021) 70081995 – 62(021) 5703646, mobile : 0817171764

email : judarwanto@gmail.com 

curriculum vitae

Copyright © 2010, Children Speech Clinic  Information Education Network. All rights reserved

Anak dengan jenis kelamin laki-laki  lebih rentan terhadap keterlambatan perkembangan bahasa dibanding anak perempuan. Secara teori hormon estrogen sebagai hormon sexual pada anak perempuan sangat berperan selama perkembangan otak, dimana hormon estrogen ini mempercepat proses myelinisasi serabut syaraf otak.

Data Gurian and Stevens (2005) dalam Vesna Nikolic (2008) menyatakan bahwa 80% masalah kedisiplinan pada anak dilakukan oleh anak laki-laki, 70% anak yang terdiagnosis gangguan belajar adalah anak laki-laki dan 80% anak laki-laki dari tahun ke tahun, berada separuh di belakang anak perempuan untuk ketrampilan matematika dan membacanya.

Guardian dan Stevens menjelaskan bahwa terdapat beberapa perbedaan antara otak anak laki-laki dengan anak perempuan :

1. Pada anak laki-laki lebih banyak dopamin di aliran darahnya, sehingga meningkatkan risiko perilaku impulsif, dampaknya anak laki-laki kurang mampu belajar dengan duduk tenang, mereka memerlukan aktivitas fisik untuk mengembangkan otak mereka, dan lebih cendrung membuat keputusan yang impulsif.
2. Amigdala (pusat marah dan agresi) pada anak laki-laki secara signifikan memiliki volume lebih tinggi, akibatnya anak laki-laki cendrung bereaksi dari pada memberi respon, sehingga dikatakan lebih berisiko memiliki masalah-masalah kedisiplinan.
3. Pada anak laki-laki juga ter-setting untuk recharge diantara tugas-tugasnya, anak perempuan lebih mampu mempertahankan konsentrasi, meskipun dalam keadan istirahat otak mereka masih tetap aktif. Corpus callosum (serabut penghubung antara hemispaer kiri dan kanan) juga memiliki ukuran yang berbeda dibanding anak perempuan, sehingga anak perempuan dapat menjalani berbagai tugas-tugasnya dengan lebih baik, sementara anak laki-laki lebih fokus pada suatu aktivitas pada saat itu saja.
4. Anak perempuan memiliki neuronal connections yang lebih kuat di lobus temporalnya sehingga mereka dapat berperan sebagai pendengar yang lebih baik sementara anak laki-laki lebih sedikit menangkap stimuli yang berkenaan dengan suara di sekitar mereka, khususnya saat di sampaikan melalui kata-kata.

^{Daftar Pustaka}

• Data Gurian and Stevens (2005) dalam Vesna Nikolic (2008), Fascinated by the Brain (November 2008) DPCDSB, vesna.nikolic@dpcdsb.org 

Supported By

CHILDREN SPEECH CLINIC

CLINIC FOR CHILDREN Yudhasmara Foundation

Office ; JL Taman Bendungan Asahan 5 Jakarta Indonesia 10210  phone : 62(021) 70081995 – 5703646 email : judarwanto@gmail.com, http://childrenclinic.wordpress.com/ 

Clinic and Editor in Chief :

Dr WIDODO JUDARWANTO

phone : 62(021) 70081995 – 62(021) 5703646, mobile : 0817171764

email : judarwanto@gmail.com 

curriculum vitae

Copyright © 2010, Children Speech Clinic  Information Education Network. All rights reserved

Sensitivity of the Denver Developmental Screening Test in Speech and Language Screening

PEDIATRICS Vol. 78 No. 6 December 1986, pp. 1075-1078

Kathleen C. Borowitz MS, CCC-SLP¹, Frances P. Glascoe PhD¹

¹ From the Comprehensive Developmental Evaluation Center, Department of Pediatrics, Vanderbilt University, Nashville
A retrospective study was undertaken to determine whether the Denver Developmental Screening Test (DDST) language sector is a sensitive screen of speech and language development. Seventy-one children between 18 and 66 months of age with suspected developmental problems were referred to screening clinics conducted by a child evaluation team. Each child was screened using the DDST (revised) and another screening measure of speech and language development. Statistically significant differences were found between the DDST language sector and the speech-language screening in identification of expressive language and articulation problems. No significant difference was found with receptive language. The DDST failed to identify more than one half of the children with expressive language and/or articulation problems. These results demonstrate that the DDST may fail to identify children with speech and language impairment. Professionals involved in developmental screening need to be advised of alternative speech and language screening measures. 

Key Words: Denver Developmental Screening Test • speech and language development  

Supported By

 CHILDREN SPEECH CLINIC Yudhasmara Foundation

 Office ; JL Taman Bendungan Asahan 5 Jakarta Indonesia 10210 

 phone : 62(021) 70081995 – 5703646 email : judarwanto@gmail.com, http://clinicalpediatric.wordpress.com/  

Clinic and Editor in Chief : Dr WIDODO JUDARWANTO  

phone : 62(021) 70081995 – 62(021) 5703646, mobile : 0817171764

email : judarwanto@gmail.com  curriculum vitae  

Copyright © 2010, Children Speech Clinic  Information Education Network. All rights reserved

The Effects of Literate Narrative Intervention on Children With Neurologically Based Language Impairments: An Early Stage Study

Douglas B. Petersen
University of Wyoming, Laramie

Sandra Laing Gillam
Trina Spencer
Ronald B. Gillam
Utah State University, Logan Contact author: Douglas B. Petersen, College of Health Sciences, Division of Communication Disorders, University of Wyoming, Department 3311, 1000 East University Avenue, Laramie, WY 82071. E-mail: dpeter39@uwyo.edu

Purpose: This study investigated the effect of a literate narrative intervention on the macrostructural and microstructural language features of the oral narratives of 3 children with neuromuscular impairment and co-morbid receptive and expressive language impairment.

Method: Three children, ages 6-8 years, participated in a multiple baseline across participants and language features study. The 3 participants engaged in 10 individual literate narrative intervention sessions following staggered baseline trials. Assessment probes eliciting picture- and verbally prompted narratives were recorded and analyzed.

Results: All three children demonstrated gains in the use of story grammar (macrostructure) and causality (microstructure), with moderate to large effect sizes based on percentage of nonoverlapping data points. Gains were seen in both picture-prompted narratives that were the direct focus of intervention and in verbally prompted narratives that served as a measure of generalization. Other features of microstructure not explicitly targeted during intervention increased in the narratives produced by the participants. Additionally, follow-up data collected 8 months after intervention indicated the maintenance of some skills over time.

Conclusion: The results of this study suggest that literate narrative intervention may be useful for improving children’s functional use of narrative macrostructure and microstructure, including literate language.

KEY WORDS: language impairment, narrative intervention, literate language, storytelling 

Supported By

 CHILDREN SPEECH CLINIC Yudhasmara Foundation

 Office ; JL Taman Bendungan Asahan 5 Jakarta Indonesia 10210 

 phone : 62(021) 70081995 – 5703646 email : judarwanto@gmail.com, http://clinicalpediatric.wordpress.com/  

Clinic and Editor in Chief : Dr WIDODO JUDARWANTO  

phone : 62(021) 70081995 – 62(021) 5703646, mobile : 0817171764

email : judarwanto@gmail.com  curriculum vitae  

Copyright © 2010, Children Speech Clinic  Information Education Network. All rights reserved

Evidence That a Motor Timing Deficit Is a Factor in the Development of Stuttering

Journal of Speech, Language, and Hearing Research Vol.53 898-907 August 2010. doi:10.1044/1092-4388(2009/09-0048)
© American Speech-Language-Hearing Association

Lindsey Olander
Anne Smith
Howard N. Zelaznik
Purdue University, West Lafayette, IN

Contact author: Anne Smith, Department of Speech, Language, and Hearing Sciences, Purdue University, 1353 Heavilon Hall, 500 Oval Drive, West Lafayette, IN 47907-2038. E-mail: asmith@purdue.edu

Purpose:

To determine whether young children who stutter have a basic motor timing and/or a coordination deficit.

Method:

Between-hands coordination and variability of rhythmic motor timing were assessed in 17 children who stutter (4–6 years of age) and 13 age-matched controls. Children clapped in rhythm with a metronome with a 600-ms interbeat interval and then attempted to continue to match this target rate for 32 unpaced claps.

Results:

 Children who stutter did not significantly differ from children who were typically developing on mean clapping rate or number of usable trials produced; however, they produced remarkably higher variability levels of interclap interval. Of particular interest was the bimodal distribution of the stuttering children on clapping variability. One subgroup of children who stutter clustered within the normal range, but 60% of the children who stutter exhibited timing variability that was greater than the poorest performing nonstuttering child. Children who stutter were not more variable in measures of coordination between the 2 hands (mean and median phase difference between hands).

Conclusion:

We infer that there is a subgroup of young stuttering children who exhibit a nonspeech motor timing deficit, and we discuss this result as it pertains to recovery or persistence of stuttering.

KEY WORDS: stuttering, motor timing, development of stuttering, bimanual motor control, nonspeech task
 

Supported By

 CHILDREN SPEECH CLINIC Yudhasmara Foundation

 Office ; JL Taman Bendungan Asahan 5 Jakarta Indonesia 10210 

 phone : 62(021) 70081995 – 5703646 email : judarwanto@gmail.com, http://clinicalpediatric.wordpress.com/  

Clinic and Editor in Chief : Dr WIDODO JUDARWANTO  

phone : 62(021) 70081995 – 62(021) 5703646, mobile : 0817171764

email : judarwanto@gmail.com  curriculum vitae  

Copyright © 2010, Children Speech Clinic  Information Education Network. All rights reserved

The Impact of Object and Gesture Imitation Training on Language Use in Children With Autism Spectrum Disorder

Journal of Speech, Language, and Hearing Research Vol.53 1040-1051 August 2010. doi:10.1044/1092-4388(2009/09-0043)
© American Speech-Language-Hearing Association

Brooke Ingersoll
Katherine Lalonde
Michigan State University, East Lansing

Contact author: Brooke Ingersoll, 105B Psychology Building, Michigan State University, East Lansing, MI 48824. E-mail: ingers19@msu.edu

Purpose:

Reciprocal imitation training (RIT) is a naturalistic behavioral intervention that teaches imitation to children with autism spectrum disorder (ASD) within a social–communicative context. RIT has been shown to be effective at teaching spontaneous, generalized object and gesture imitation. In addition, improvements in imitation are associated with increases in verbal imitation and spontaneous language.

Method: This study used a modified multiple-baseline design across 4 children to examine whether adding gesture imitation training improves the overall rate of appropriate language use in children with ASD who have already been participating in object imitation training.

Results: Three of the 4 children showed greater improvements in their use of appropriate language after gesture imitation was begun. Further, the children were more likely to use verbal imitation during gesture imitation training than during object imitation training.

Conclusion: These findings suggest that adding gesture imitation training to object imitation training can lead to greater gains in rate of language use than object imitation alone. Implications for both language development and early intervention are discussed.

KEY WORDS: autism spectrum disorder, imitation, language, gesture

Supported By

 CHILDREN SPEECH CLINIC Yudhasmara Foundation

 Office ; JL Taman Bendungan Asahan 5 Jakarta Indonesia 10210 

 phone : 62(021) 70081995 – 5703646 email : judarwanto@gmail.com, http://clinicalpediatric.wordpress.com/  

Clinic and Editor in Chief : Dr WIDODO JUDARWANTO  

phone : 62(021) 70081995 – 62(021) 5703646, mobile : 0817171764

email : judarwanto@gmail.com  curriculum vitae  

Copyright © 2010, Children Speech Clinic  Information Education Network. All rights reserved

Voice technology “could help detect autism”, BBC News has reported. The BBC website said that a new US study found that the early speech of 86% of infants with autism differed from that of unaffected children. In the study researchers recorded the speech of three groups of children aged 10-48 months: 106 ‘typically-developing’ young children, 49 children with language delay and 77 children diagnosed with autism. Their fully automated recording devices were able to determine differences in speech between the groups and accurately predict which children were from each group. The technique also follows the child in their natural home setting, providing the opportunity for efficient and effective speech assessment in a familiar environment.

This research is still in the early stages, and further study will determine how this system could work alongside other developmental assessment methods. So far, the system has not been investigated as a method for diagnosing new cases of language or developmental delay. Before it is introduced into practice, the uses and feasibility of this novel approach will need to be explored.

Where did the story come from?

The study was carried out by researchers from the Universities of Memphis, Chicago and Kansas and was funded by the Plough Foundation at the University of Memphis. It was published in the peer-reviewed scientific journal Proceedings of the National Academy of Sciences USA. 

What kind of research was this?

This was an observational study that attempted to further the techniques used in researching speech and language development. The aim was to investigate an automated method for assessing young children’s speech development on a large scale by carrying out extended recordings in the homes of infants and young children. The main goal of the research was to isolate each child’s vocalisations from other voices and background noise on candid recordings and automatically identify significant features that could be useful predictors of the child’s developmental level. 

What did the research involve?

To gather audio samples, the researchers provided parents with a battery-powered recorder that was then attached to their child’s clothing, recording the child in their natural environment all day. The children recorded were drawn from three different groups: those whose parents self-reported them to be typically-developing, those reported to have language delay and those reported to have autism.

Language delay was confirmed by checking for documentation in medical records or by assessment with a speech and language clinician, and autism was confirmed by checking medical records of the diagnosis. The final sample recorded featured a total of 232 children:

• 106 ‘typically-developing’ children aged 10-48 months
• 49 children with language delay aged 10-44 months
• 77 children with autism aged 16-48 months
• The researchers carried out a total of 1,486 all-day recordings across the groups over the three years of the study, which provided a total of 23,716 hours of audio and captured a total of 3.1 million child utterances.

The recording devices were able reliably to differentiate between the child’s vocalisations and other sounds, allowing the researchers to carry out an in-depth analysis of the 12 parameters of speech known to have a role in speech development. These parameters included how the child was able to articulate each syllable, speech rhythm, pitch, their vocal characteristics and duration of speech.

The researchers looked at the relationship between a child’s overall vocalisations and the number of the 12 parameters that were as expected according to their age.
 
What were the basic results?

• The researchers found that the automated analysis was able to predict development.
• In the typically-developing group all 12 of the parameters of speech were as expected according to their age.
• In the language-delayed group 7 of 12 parameters were as expected for their age.
• In the autism group few of the 12 parameters of speech were as expected according to age.

The study also found that in the typically-developing group certain vocal tendencies diminished with age, while this was not seen in the other groups. They also noted that children with autism tended to have quite unpredictable patterns of development, suggesting that they had different vocalisation from both typically-developing children and those with language delay.

Overall, the test correctly identified 90% of children who were in the ‘typically-developing’ group, 80% of those with autism and 62% of those with language delay.

How did the researchers interpret the results?

The researchers considered this research to be a ‘proof of concept’, a type of developmental project designed to test how well a conceptual method translates into real-world use. They demonstrated that their method of automated assessment was able to track children’s development on acoustic parameters known to play key roles in speech, and was also able to differentiate the vocalisations of children with autism or language delay from those of typically-developing children.

They conclude that their study of ‘automated analysis’ has the potential to advance research in speech and language development. 

Conclusion
This was valuable research that has carried out extensive all-day recordings of children and found that the automated analyses of their vocalisations could distinguish between children with normal development, language delay and autism.

The advantage of this method is that it is completely automated, requiring no human intervention. As it follows the child in their home, it provides the opportunity for efficient and effective speech assessment in a familiar environment.

This research is still in the developmental stages. Further study will be needed to see how this recording system could supplement developmental assessment of children by health professionals and the standard screening and diagnostic procedures used.

So far, the system has only been used to detect previously-diagnosed conditions, and has not yet been tested as a means of identifying undiagnosed linguistic or developmental delay. This means the accuracy of the test needs further testing. Additionally, there are likely to be many other considerations to be addressed before this could be brought into practice, including the costs and feasibility of distributing recorders on a large scale and then having trained personnel available to interpret the data from these in-depth recordings.

As the researchers say, the ability to study linguistic development in natural home environments could provide a completely objective way of detecting speech-related disorders in early childhood. Such an advance would be a highly valuable medical tool for speech and language therapists.

Source : NHS choice

Apakah tontonan televisi dapat menstimulasi dan meningkatkan perkembangan bicara pada anak?  Sebuah penelitian yang dilakukan oleh Dimitri A. Christakis dari Seattle Children’s Research Institute, University of Washington, AS menunjukkan bahwa vokalisasi, kosakata, dan percakapan yang dilakukan oleh pendamping anak seperti orangtua, pengasuh  berkurang secara bermakna selama ia menonton televisi.

Penelitian tersebut juga menunjukkan bahwa anak-anak 8 – 16 bulan yang menonton video-video “edukasi” tersebut selama 1 jam setiap hari memiliki penurunan 6 – 8 kosa kata dibandingkan dengan anak-anak yang tidak menonton.

Penelitian tersebut dilakukan pada 329 anak berusia antara 2 bulan hingga 4 tahun yang masing-masing menggunakan alat perekam digital kecil pada hari-hari tertentu yang dipilih secara acak setiap bulannya selama 2 tahun. Sebuah rompi didesain khusus dengan saku dada tempat menempelkan alat perekam  yang akan menangkap setiap kata yang diucapkan maupun didengarkan oleh anak selama periode 12-16 jam. Yang menjadi parameter dalam studi ini antara lain adalah jumlah kata yang diucapkan oleh pendamping anak, vokalisasi anak, dan interaksi verbal anak dalam percakapan (suatu keadaan di mana pendamping memberikan respon vokal terhadap vokalisasi anak, atau sebaliknya, dalam 5 detik).

Ternyata terdapat pengurangan jumlah dan lama vokalisasi anak, serta interaksi dalam percakapan secara bermakna (jumlah kata dapat berkurang sekitar 770 dari 1000 kata yang seharusnya didengar anak dari pendampingnya selama sesi rekaman). Hal ini penting untuk diperhatikan mengingat stimulasi merupakan faktor yang sangat penting dalam mendukung perkembangan anak. Setiap anak perlu mendapat stimulasi rutin sedini mungkin secara bertahap dan terus menerus pada setiap kesempatan.

Disney’s Baby Einstein Program

Ketika penelitian tersebut dimuat dalam jurnal Pediatrics, salah satu CEO Disney, Robert Iger, menuntut para peneliti untuk menarik pengumuman persnya. Terkait pembentukan opini publik terhadap program acara Disney’s Baby Einstein yang terlampau membuat bayi-bayi tidak aktif berbicara selama program mereka diputar di televisi. Karena tendensi dari hasil penelitian tersebut dirasa ‘menyerang’ keberlangsungan Baby Einstein.

Namun sekarang setelah penelitian terbukti, Disney justru menawarkan dana kompensasi pengganti bagi orang tua yang telah membeli DVD-DVD program edukasi Baby Einstein.

Rekomendasi

American Academy of Pediatrics merekomendasikan sebaiknya anak di bawah dua tahun tidak diajak menonton televisi. Dengan menonton TV, tentunya anak tidak mendapatkan pengalaman linguistik yang sama seperti ketika berinteraksi langsung dengan orangtua mereka. Anak justru pasif, asyik menatap layar kaca. Hal ini tentunya berpengaruh pada pengembangan kreativitas anak.

Tips yang direkomendasikan oleh Christakis bagi orangtua dan para pengasuh, yaitu:

Untuk anak berusia di bawah 2 tahun:

• Hindari kebiasaan menonton televisi, dan pilihlah aktivitas yang dapat membantu perkembangan bahasa dan pertumbuhan otak anak seperti berbicara, membaca, menyanyi, bermain, mendengarkan musik, dsb.

Untuk anak berusia di atas 2 tahun:

• Jauhkan televisi dari kamar tidur anak Anda.
• Batasi penggunaan televisi maksimal 2 jam dalam sehari.
• Jika Anda memperbolehkan anak Anda menonton, pilihlah program yang sesuai dengan usianya. Berhati-hatilah dengan tontonan anak Anda. Bahkan film kartun untuk anak saja dapat menunjukkan perilaku yang kasar dan tidak patut ditiru. Untuk itu, dampingilah anak Anda selama menonton sambil membicarakan mengenai acara yang sedang ditonton.
• Matikan televisi saat makan, dan saat program yang dipilih telah berakhir.
• Jangan pernah menggunakan televisi sebagai imbalan atas apa yang telah dilakukan oleh anak Anda.

Sumber:
Christakis et al. Audible television and decreased adult words, infant vocalizations, and conversational turns: a population-based study. Archives of Pediatrics and Adolescent Medicine, 2009; 163 (6): 554

Signs of autism may appear during infancy and the disorder is usually diagnosed by the age of 3. Sometimes the child’s development appears normal until about 2 years old and then regresses rapidly. Symptoms of autism occur in various combinations, from mild to severe.

Infants with the disorder often display abnormal reactions to sensory stimuli (i.e., senses may be over- or underactive). Touches may be experienced as painful, smells may be overwhelmingly unpleasant, and ordinary daily noises may be painful. Loud noises (e.g., motorcycle going by, vacuum cleaner) and bright lights may cause inconsolable crying.Other signs of the disorder in infants include the following:

• Appears indifferent to surroundings
• Appears content to be alone, happier to play alone
• Displays lack of interest in toys
• Displays lack of response to others
• Does not point out objects of interest to others (called protodeclarative pointing)
• Marked reduction or increase in activity level
• Resists cuddling

Young children with autism usually have impaired language development. They often have difficulty expressing needs (i.e., use gestures instead of words) and may laugh, cry, or show distress for unknown reasons. Some autistic patients develop rudimentary language skills that do not serve as an effective form of communication. They may develop abnormal patterns of speech that lack intonation and expression and may repeat words or phrases repetitively (called echolalia). Some children with autism learn to read. 

Supported By

 CHILDREN SPEECH CLINIC Yudhasmara Foundation

 Office ; JL Taman Bendungan Asahan 5 Jakarta Indonesia 10210 

 phone : 62(021) 70081995 – 5703646 email : judarwanto@gmail.com, http://clinicalpediatric.wordpress.com/  

Clinic and Editor in Chief : Dr WIDODO JUDARWANTO  

phone : 62(021) 70081995 – 62(021) 5703646, mobile : 0817171764

email : judarwanto@gmail.com  curriculum vitae  

Copyright © 2010, Children Speech Clinic  Information Education Network. All rights reserved

Speech Therapy focuses on receptive language, or the ability to understand words spoken to you, and expressive language, or the ability to use words to express yourself. It also deals with the mechanics of producing words, such as articulation, pitch, fluency, and volume. 

Speech therapy in children, it generally involves pursuing milestones that have been delayed. Some children only need help with language, others have the most problems with the mechanics of speech, and some need every kind of speech help there is. The professional in charge of your child’s speech therapy — called a speech-language pathologist, speech therapist, speech teacher, or whatever combination of these words your school district pastes together — will work to find fun activities to strengthen your child in areas of weakness. For mechanics, this might involve exercises to strengthen the tongue and lips, such as blowing on whistles or licking up Cheerios. For language, this might involve games to stimulate word retrieval, comprehension or conversation.

Supported By

 CHILDREN SPEECH CLINIC Yudhasmara Foundation

 Office ; JL Taman Bendungan Asahan 5 Jakarta Indonesia 10210 

 phone : 62(021) 70081995 – 5703646 email : judarwanto@gmail.com, http://clinicalpediatric.wordpress.com/  

Clinic and Editor in Chief : Dr WIDODO JUDARWANTO  

phone : 62(021) 70081995 – 62(021) 5703646, mobile : 0817171764

email : judarwanto@gmail.com  curriculum vitae  

Copyright © 2010, Children Speech Clinic  Information Education Network. All rights reserved

Motor Profile of Children With Developmental Speech and Language Disorders

Chris Visscher, PhD^a,b, Suzanne Houwen, MSc^a,b, Erik J.A. Scherder, PhD^a, Ben Moolenaar, BEd^c, Esther Hartman, PhD^a   

^a Center for Human Movement Sciences
^b University Center for Sport, Movement, and Health, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
^c Hanze Institute for Sports Studies, Hanze University Groningen, Groningen, Netherlands

	ABSTRACT

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
OBJECTIVES. The purpose of this study was to investigate the motor profile of 125 children with developmental speech and language disorders and to test for differences, if any, in motor profile among subgroups of children with developmental speech and language disorders.   

METHODS. The participants were 125 children with developmental speech and language disorders aged 6 to 9 years from 2 special schools for children with communication problems in the northern Netherlands. They were tested with the Movement Assessment Battery for Children. The children were classified by the schools’ speech and language therapists into 3 subgroups on the basis of language tests, oral motor tests, and clinical examinations: children with speech disorders (n = 14), language disorders (n = 46), or both (n = 65).   

RESULTS. Compared with the norms of the Movement Assessment Battery for Children, children with developmental speech and language disorders performed significantly less well. Results showed that 51% of the children with developmental speech and language disorders had borderline or definite motor problems. Children with language disorders had significantly lower scores (ie, better performance) on the ball-skills subtest and the total test than children with speech disorders and children with both speech and language disorders. Furthermore, children with language disorders had significantly better performance on the balance subtest than children with both speech and language disorders.   

CONCLUSIONS. The findings of this study support the idea that developmental speech and language disorders are frequently associated with motor problems and that the kind of developmental speech and language disorders affects motor performance differently. Speech and language disorders seem to have more impact on motor performance than only language disorders, and it seems that when speech production is affected, motor problems are more pronounced. The findings support the need to give early and more attention to the motor skills of children with developmental speech and language disorders in the educational and home setting, with special attention to children whose speech is affected.   

Key Words: motor development • language development disorders • children  

Abbreviations: DSLD—developmental speech and language disorder • ABC—Assessment Battery for Children • DCD—developmental coordination disorder  

Developmental speech and language disorders (DSLDs) are characterized by delays in speech and language development in the absence of mental or physical handicap, hearing loss, emotional disorder, or environmental deprivation. The clinical picture is quite varied; many children have speech as well as language disorders, others may have pure speech disorders or pure language disorders. The prevalence of DSLDs varies from 1.3% to 7.4%, depending on the definition used.   

Although most attention has been paid to the communication profile of children with DSLDs, it has been shown that motor problems are not uncommon in this population. The co-occurrence of motor problems and DSLDs may be explained by both factors within the child, such as a genetic risk or neurologic deficits, and environmental factors, such as communication difficulties negatively influencing social acceptance and participation in play and sports activities.  

The majority of studies concerning motor problems in children with DSLDs mainly focused on fine motor tasks.Studies indicate that these children are significantly slower than regular children on tasks that mainly challenge eye-hand coordination (ie, pegboard, threading beads, fastening buttons, and tapping). Of note is that motor problems seem to not be restricted to tasks involving time constraints. For gross motor skills, it has been observed that skills like stepping, running, stair climbing, muscle tone, standing on 1 leg, hopping on 1 leg, toe gait, heel gait, and skills that involve object control or locomotor activity of children with language problems were poor relative to regular children. Moreover, balancing on 1 leg proved to be 1 of the most discriminating measures between children with specific language impairment and regular children. In contrast, results of an early study found no difference between children with specific language impairment and regular children in duration of balance.  

Quite clearly there is strong evidence of clinically significant overlap between DSLDs and motor problems; however, 2 things are of note. First, hardly any attention has been paid to ball skills of children with DSLDs, although these skills explicitly may challenge eye-hand coordination, depend on balance control, and importantly contribute to the child’s social interaction with peers.  Because children with DSLDs may already have problems with social acceptance,because of their communication difficulties,  inadequate ball skills may further restrict the child’s capacity to interact socially and physically with peers. Within this scope, it is noteworthy that recent epidemiologic studies emphasize the value of a social and physical active lifestyle, particularly when started early in life. One of the major effects of such a lifestyle is reducing the risk for cognitive impairment later in life.  

Second, research examining the motor performance of subgroups of children with DSLDs is limited. Hill suggested that subgroups of children with DSLDs differ in their performance on fine motor tasks. Bishop  addressed the issue of subtype-specific differences in relation to motor performance and found some interesting results. In 2 twin studies where 1 or both twins had speech/language impairment along with a control group of unaffected children, she found that children with combined speech and language impairments obtained poorer scores on a pegboard and tapping task than unaffected children. Furthermore, she concluded that the link between speech/language impairments and motor problems was stronger for speech than for language impairments. It is important to gain insight in the performance profile of subgroups of children with DSLDs, because this information may provide clues for effective intervention.   

Specifically, this study had 2 aims. The first aim was to investigate the motor profile of children with DSLDs with respect to manual dexterity, ball skills, and balance. The second aim was to test for differences, if any, in motor profile among 3 subgroups of children with DSLDs: children with speech disorders, children with language disorders, and children with both speech and language disorders.  References  

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19. Noterdaeme M, Mildenberger K, Minow F, Amorosa H. Evaluation of neuromotor deficits in children with autism and children with a specific speech and language disorder. Eur Child Adolesc Psychiatry. 2002;11 :219 –225[CrossRef][Web of Science][Medline]  

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Supported By CHILDREN SPEECH CLINIC Yudhasmara Foundation Office ; JL Taman Bendungan Asahan 5 Jakarta Indonesia 10210  phone : 62(021) 70081995 – 5703646 email : judarwanto@gmail.com, http://clinicalpediatric.wordpress.com/  Clinic and Editor in Chief : Dr WIDODO JUDARWANTO  phone : 62(021) 70081995 – 62(021) 5703646, mobile : 0817171764 email : judarwanto@gmail.com  curriculum vitae  

Copyright © 2010, Children Speech Clinic  Information Education Network. All rights reserved

ARTICLES

Unilateral Hearing Loss Is Associated With Worse Speech-Language Scores in Children

Judith E. C. Lieu, MD^a, Nancy Tye-Murray, PhD^a, Roanne K. Karzon, PhD^a,b, Jay F. Piccirillo, MD^a

^a Department of Otolaryngology—Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri; and
^b Center for Communication Disorders, St Louis Children’s Hospital, St Louis, Missouri

 PEDIATRICS Vol. 125 No. 6 June 2010, pp. e1348-e1355 (doi:10.1542/peds.2009-2448)

ABSTRACT

OBJECTIVE To determine whether children with unilateral hearing loss (UHL) demonstrate worse language skills than their siblings with normal hearing, and whether children with UHL are more likely to receive extra assistance at school.

PATIENTS AND METHODS We conducted a case-control study of 6- to 12-year-old children with UHL compared with sibling controls (74 pairs, n = 148). Scores on the oral portion of the Oral and Written Language Scales (OWLS) were the primary outcome measure. Multivariable analysis was used to determine whether UHL independently predicted OWLS scores after we controlled for potential confounding variables. RESULTS Children with UHL had worse scores than their siblings on language comprehension (91 vs 98; P = .003), oral expression (94 vs 101; P = .007), and oral composite (90 vs 99; P < .001). UHL independently predicted these OWLS scores when multivariable regression was used with moderate effect sizes of 0.3 to 0.7. Family income and maternal education were also independent predictors of oral expression and oral composite scores. No differences were found between children with right- or left-ear UHL or with varying severity of hearing loss. Children with UHL were more likely to have an individualized education plan (odds ratio: 4.4 [95% confidence interval: 2.0–9.5]) and to have received speech-language therapy (odds ratio: 2.6 [95% confidence interval: 1.3–5.4]). CONCLUSIONS School-aged children with UHL demonstrated worse oral language scores than did their siblings with normal hearing. These findings suggest that the common practice of withholding hearing-related accommodations from children with UHL should be reconsidered and studied, and that parents and educators should be informed about the deleterious effects of UHL on oral language skills.

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21. Weschler D. Wechsler Abbreviated Scale of Intelligence (WASI). 1999. Available at: www.pearsonassess.com/haiweb/cultures/en-us/productdetail.htm?pid=015-8981-502. Accessed May 15, 2009

22. Hosmer DW, Lemeshow S. Applied Logistic Regression. 2nd ed. New York, NY: John Wiley & Sons Inc; 2000

23. American Academy of Pediatrics,Joint Committee on Infant Hearing.Joint Committee on Infant Hearing 1994 position statement. Pediatrics. 1995;95(1):152–156[Abstract/Free Full Text]

24. Prathanee B, Thinkhamrop B, Dechongkit S. Factors associated with specific language impairment and later language development during early life: a literature review. Clin Pediatr (Phila). 2007;46(1):22–29[Abstract/Free Full Text]

25. Morton CC, Nance WE. Newborn screening: a silent revolution. N Engl J Med. 2006;354(20):2151–2164[Free Full Text]

26. Bamiou DE, Savy L, O’Mahoney C, Phelps P, Sirimanna T. Unilateral sensorineural hearing loss and its aetiology in childhood: the contribution of computerised tomography in aetiological diagnosis and management. Int J Pediatr Otorhinolaryngol. 1999;51(2):91–99[CrossRef][Web of Science][Medline]

27. Neary W, Kent S, Yeong C, Coyne L. The role of audiological testing and computed tomography in the aetiological investigation of children with permanent unilateral hearing loss. Audiol Med. 2003;1(4):215–223[CrossRef]

28. Simons JP, Mandell DL, Arjmand EM. Computed tomography and magnetic resonance imaging in pediatric unilateral and asymmetric sensorineural hearing loss. Arch Otolaryngol Head Neck Surg. 2006;132(2):186–192[Abstract/Free Full Text]

29. Dikkers FG, Verheij JBCM, van Mechelen M. Hereditary congenital unilateral deafness: a new disorder? Ann Otol Rhinol Laryngol. 2005;114(4):332–337[Web of Science][Medline]

30. Dodson KM, Kamei T, Sismanis A, Nance WE. Familial unilateral deafness and delayed endolymphatic hydrops. Am J Med Genet A. 2007;143A(14):1661–1665

31. Patel N, Oghalai JS. Familial unilateral cochlear nerve aplasia. Otol Neurotol. 2006;27(3):443–444[CrossRef][Web of Science][Medline]

32. Tharpe AM, Sladen DP. Causation of permanent unilateral and mild bilateral hearing loss in children. Trends Amplif. 2008;12(1):17–25[Abstract/Free Full Text]

33. Priwin C, Jonsson R, Hultcrantz M, Granstrom G. BAHA in children and adolescents with unilateral or bilateral conductive hearing loss: a study of outcome. Int J Pediatr Otorhinolaryngol. 2007;71(1):135–145[CrossRef][Web of Science][Medline]

34. McDermott AL, Williams J, Kuo M, Reid A, Proops D. Quality of life in children fitted with a bone-anchored hearing aid. Otol Neurotol. 2009;30(3):344–349[CrossRef][Web of Science][Medline]

35. Kunst SJW, Leijendeckers JM, Mylanus EAM, Hol MKS, Snik AFM, Cremers CWRJ. Bone-anchored hearing aid system application for unilateral congenital conductive hearing impairment: audiometric results. Otol Neurotol. 2008;29(1):2–7[CrossRef][Web of Science][Medline]

36. Arkebauer HJ, Mencher GT, McCall C. Modification of speech discrimination in patients with binaural asymmetrical hearing loss. J Speech Hear Disord. 1971;36(2):208–212[Abstract/Free Full Text]

37. Nabelek AK, Mason D. Effect of noise and reverberation on binaural and monaural word identification by subjects with various audiograms. J Speech Hear Res. 1981;24(3):375–383[Web of Science][Medline]

38. Noble W, Gatehouse S. Interaural asymmetry of hearing loss, Speech, Spatial and Qualities of Hearing Scale (SSQ) disabilities, and handicap. Int J Audiol. 2004;43(2):100–114[CrossRef][Web of Science][Medline]

39. Rothpletz AM, Tharpe AM, Grantham DW. The effect of asymmetrical signal degradation on binaural speech recognition in children and adults. J Speech Lang Hear Res. 2004;47(2):269–280[Abstract/Free Full Text]

40. National Center for Hearing Assessment and Management.State EHDI/UNHS mandates: summary table. 2008. Available at: www.infanthearing.org/legislative/summary/index.html. Accessed May 24, 2009

41. National Center for Hearing Assessment and Management.Part C early intervention eligibility for infants and toddlers with hearing loss. 2003. Available at: www.infanthearing.org/earlyintervention/eligibility.pdf. Accessed May 24, 2009

42. Holstrum WJ, Gaffney M, Gravel JS, Oyler RF, Ross DS. Early intervention for children with unilateral and mild bilateral degrees of hearing loss. Trends Amplif. 2008;12(1):35–41[Abstract/Free Full Text]

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44. Swanson HL, Rosston K, Gerber M, Solari E. Influence of oral language and phonological awareness on children’s bilingual reading. J Sch Psychol. 2008;46(4):413–429[CrossRef][Web of Science][Medline]

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46. Schuele CM. The impact of developmental speech and language impairments on the acquisition of literacy skills. Ment Retard Dev Disabil Res Rev. 2004;10(3):176–183[CrossRef][Web of Science][Medline]

Supported By

 CHILDREN SPEECH CLINIC Yudhasmara Foundation

Office ; JL Taman Bendungan Asahan 5 Jakarta Indonesia 10210  phone : 62(021) 70081995 – 5703646 email : judarwanto@gmail.com, http://clinicalpediatric.wordpress.com/ 

Clinic and Editor in Chief : Dr WIDODO JUDARWANTO

 phone : 62(021) 70081995 – 62(021) 5703646, mobile : 0817171764 email : judarwanto@gmail.com  curriculum vitae

Copyright © 2010, Children Speech Clinic  Information Education Network. All rights reserved

The Relationship Between Different Measures of Oral Reading Fluency and Reading Comprehension in Second-Grade Students Who Evidence Different Oral Reading Fluency Difficulties

Language, Speech, and Hearing Services in Schools Vol.41 340-348 July 2010. doi:10.1044/0161-1461(2009/08-0093)
© American Speech-Language-Hearing Association

Justin C. Wise
Rose A. Sevcik
Robin D. Morris
Georgia State University, Atlanta

Maureen W. Lovett
Hospital for Sick Children/University of Toronto, Canada Maryanne Wolf
Tufts University, Medford, MA Melanie Kuhn
Rutgers University, New Brunswick, NJ Beth Meisinger
University of Memphis, TN Paula Schwanenflugel
University of Georgia, Athens Contact author: Justin Wise, Department of Psychology, P.O. Box 5010, Georgia State University, Atlanta, GA 30302. E-mail: psyjcwx@langate.gsu.edu // <![CDATA[
var u = "psyjcwx", d = "langate.gsu.edu"; document.getElementById("em0").innerHTML = '' + u + '@' + d + ''
// ]]>.Purpose: The purpose of this study was to examine whether different measures of oral reading fluency relate differentially to reading comprehension performance in two samples of second-grade students: (a) students who evidenced difficulties with nonsense-word oral reading fluency, real-word oral reading fluency, and oral reading fluency of connected text (ORFD), and (b) students who evidenced difficulties only with oral reading fluency of connected text (CTD). Method: Participants (ORFD, n = 146 and CTD, n = 949) were second-grade students who were recruited for participation in different reading intervention studies. Data analyzed were from measures of nonsense-word oral reading fluency, real-word oral reading fluency, oral reading fluency of connected text, and reading comprehension that were collected at the pre-intervention time point. Results: Correlational and path analyses indicated that real-word oral reading fluency was the strongest predictor of reading comprehension performance in both samples and across average and poor reading comprehension abilities. Conclusion: Results of this study indicate that real-word oral reading fluency was the strongest predictor of reading comprehension and suggest that real-word oral reading fluency may be an efficient method for identifying potential reading comprehension difficulties. KEY WORDS: oral reading fluency, reading comprehension, oral reading fluency difficulties, elementary school–age students 

Office ; JL Taman Bendungan Asahan 5 Jakarta Indonesia 10210  phone : 62(021) 70081995 – 5703646 email : judarwanto@gmail.com, http://clinicalpediatric.wordpress.com/ 

Clinic and Editor in Chief : Dr WIDODO JUDARWANTO

 phone : 62(021) 70081995 – 62(021) 5703646, mobile : 0817171764 email : judarwanto@gmail.com  curriculum vitae

Copyright © 2010, Children Speech Clinic  Information Education Network. All rights reserved

Impact of Chromosome 4p- Syndrome on Communication and Expressive Language Skills: A Preliminary Investigation

Language, Speech, and Hearing Services in Schools Vol.41 265-276 July 2010. doi:10.1044/0161-1461(2009/08-0098)
© American Speech-Language-Hearing Association

Althea T. Marshall
Southern Connecticut State University, New Haven

Contact author: Althea T. Marshall, Southern Connecticut State University, Department of Communication Disorders, Davis Hall Room 012 L 501, Crescent Street, New Haven, CT 06515. E-mail: marshalla1@southernct.edu // <![CDATA[
var u = "marshalla1", d = "southernct.edu"; document.getElementById("em0").innerHTML = '' + u + '@' + d + ''
// ]]>.Purpose: The purpose of this investigation was to examine the impact of Chromosome 4p- syndrome on the communication and expressive language phenotype of a large cross-cultural population of children, adolescents, and adults. Method: A large-scale survey study was conducted and a descriptive research design was used to analyze quantitative and qualitative data regarding the communication and expressive language manifestations of 200 children, youth, and adults from 16 countries and Puerto Rico who had been diagnosed with 4p conditions, including Wolf-Hirschhorn syndrome (WHS), Pitt-Rogers-Danks syndrome (PRDS), Proximal 4p Deletion syndrome, and complex chromosomal rearrangements associated with 4p-. Results: Individuals with Chromosome 4p- syndrome represent a heterogeneous population with complex phenotypic profiles. The majority of the participants exhibited communication and expressive language skills below the 36-month developmental functioning level. A relatively small cohort of the study population exhibited advanced expressive language skills, a finding not reported in the professional literature. Conclusion: Results broaden the spectrum of expressive language skills associated with Chromosome 4p- syndrome and highlight the communication potential of a subset of individuals with 4p abnormalities for development of advanced language structures. It is hypothesized that the largest 4p deletion, which includes the 4p16.3 band and contiguous gene regions, results in the most severely affected expressive language phenotype. KEY WORDS: language, developmental disabilities, genetics 

Office ; JL Taman Bendungan Asahan 5 Jakarta Indonesia 10210  phone : 62(021) 70081995 – 5703646 email : judarwanto@gmail.com, http://clinicalpediatric.wordpress.com/ 

Clinic and Editor in Chief : Dr WIDODO JUDARWANTO

 phone : 62(021) 70081995 – 62(021) 5703646, mobile : 0817171764 email : judarwanto@gmail.com  curriculum vitae

Copyright © 2010, Children Speech Clinic  Information Education Network. All rights reserved

Evidence-Based Systematic Review: Effects of Different Service Delivery Models on Communication Outcomes for Elementary School–Age Children

Language, Speech, and Hearing Services in Schools Vol.41 233-264 July 2010. doi:10.1044/0161-1461(2009/08-0128)
© American Speech-Language-Hearing Association

Frank M. Cirrin
Minneapolis Public Schools, MN

Tracy L. Schooling
National Center for Evidence-Based Practice in Communication Disorders, Rockville, MD

Nickola W. Nelson
Western Michigan University, Kalamazoo

Sylvia F. Diehl
University of South Florida, Tampa

Perry F. Flynn
North Carolina Department of Public Instruction, Raleigh
The University of North Carolina at Greensboro

Maureen Staskowski
Macomb Intermediate School District, Clinton Township, MI

T. Zoann Torrey
Kansas State Department of Education (Retired), Topeka

Deborah F. Adamczyk
American Speech-Language-Hearing Association, Rockville, MD

Contact author: Frank M. Cirrin, Minneapolis Public Schools/Special Education, 425 5^th Street, NE, Minneapolis, MN 55413. E-mail: fcirrin@mpls.k12.mn.us .

Purpose: The purpose of this investigation was to conduct an evidence-based systematic review (EBSR) of peer-reviewed articles from the last 30 years about the effect of different service delivery models on speech-language intervention outcomes for elementary school–age students.

Method: A computer search of electronic databases was conducted to identify studies that addressed any of 16 research questions. Structured review procedures were used to select and evaluate data-based studies that used experimental designs of the following types: randomized clinical trial, nonrandomized comparison study, and single-subject design study.

Results: The EBSR revealed a total of 5 studies that met the review criteria and addressed questions of the effectiveness of pullout, classroom-based, and indirect–consultative service delivery models with elementary school–age children. Some evidence suggests that classroom-based direct services are at least as effective as pullout intervention for some intervention goals, and that highly trained speech-language pathology assistants, using manuals prepared by speech-language pathologists to guide intervention, can provide effective services for some children with language problems.

Conclusion: Lacking adequate research-based evidence, clinicians must rely on reason-based practice and their own data until more data become available concerning which service delivery models are most effective. Recommendations are made for an expanded research agenda.

KEY WORDS: service delivery models, pullout, classroom based, indirect–consultative, evidence-based practice

Supported By

 CHILDREN SPEECH CLINIC Yudhasmara Foundation

Office ; JL Taman Bendungan Asahan 5 Jakarta Indonesia 10210  phone : 62(021) 70081995 – 5703646 email : judarwanto@gmail.com, http://clinicalpediatric.wordpress.com/ 

Clinic and Editor in Chief : Dr WIDODO JUDARWANTO

 phone : 62(021) 70081995 – 62(021) 5703646, mobile : 0817171764 email : judarwanto@gmail.com  curriculum vitae

Copyright © 2010, Children Speech Clinic  Information Education Network. All rights reserved

Ternyata, satu dari sepuluh orang didiagnosa memiliki kecenderungan Disleksi. Berasal dari kata Yunani, disleksia berarti ‘kesulitan dengan kata-kata’. Artinya, penderita ini memiliki kesulitan untuk mengenali huruf atau kata. Hal itu terjadi karena kelemahan otak dalam memproses informasi. Akibatnya, anak yang menderita disleksia susah untuk membaca, mengeja, menulis, hingga tak bisa mengerti masalah matematika. Ini menyebabkan sang anak merasa malu dan tak percaya diri untuk hadir di antara teman-teman di kelasnya.

Disleksia (bahasa Inggris: dyslexia) adalah sebuah kondisi ketidakmampuan belajar pada seseorang yang disebabkan oleh kesulitan pada orang tersebut dalam melakukan aktifitas membaca dan menulis. Perkataan disleksia berasal dari bahasa Yunani δυς- dys- (”kesulitan untuk”) dan λέξις lexis (”huruf” atau “leksikal”). 

Pada umumnya keterbatasan ini hanya ditujukan pada kesulitan seseorang dalam membaca dan menulis, akan tetapi tidak terbatas dalam perkembangan kemampuan standar yang lain seperti kecerdasan, kemampuan menganalisa dan juga daya sensorik pada indera perasa.

Terminologi disleksia juga digunakan untuk merujuk kepada kehilangan kemampuan membaca pada seseorang dikarenakan akibat kerusakan pada otak. Disleksia pada tipe ini sering disebut sebagai “Alexia”. Selain mempengaruhi kemampuan membaca dan menulis, disleksia juga ditenggarai juga mempengaruhi kemampuan berbicara pada beberapa pengidapnya. Disleksia tidak hanya terbatas pada ketidakmampuan seseorang untuk menyusun atau membaca kalimat dalam urutan terbalik tetapi juga dalam berbagai macam urutan, termasuk dari atas ke bawah. Para peneliti menemukan disfungsi ini disebabkan oleh kondisi dari biokimia otak yang tidak stabil dan juga dalam beberapa hal akibat bawaan keturunan dari orang tua.

Pada umumnya keterbatasan ini hanya ditujukan pada kesulitan seseorang dalam membaca dan menulis, akan tetapi tidak terbatas dalam perkembangan kemampuan standar yang lain seperti kecerdasan, kemampuan menganalisa dan juga daya sensorik pada indera perasa.Gambar pada tulisan ini merupakan contoh seorang yang menderita Disleksia ketika menirukan suatu tulisan “The owl was a bird” menjadi “Teh owl saw a brid.” Terminologi disleksia juga digunakan untuk merujuk kepada kehilangan kemampuan membaca pada seseorang dikarenakan akibat kerusakan pada otak. Disleksia pada tipe ini sering disebut sebagai “Alexia”. Selain mempengaruhi kemampuan membaca dan menulis, disleksia juga ditenggarai juga mempengaruhi kemampuan berbicara pada beberapa pengidapnya.Disleksia tidak hanya terbatas pada ketidakmampuan seseorang untuk menyusun atau membaca kalimat dalam urutan terbalik tetapi juga dalam berbagai macam urutan, termasuk dari atas ke bawah. Para peneliti menemukan disfungsi ini disebabkan oleh kondisi dari biokimia otak yang tidak stabil dan juga dalam beberapa hal akibat bawaan keturunan dari orang tua.

Peluang disleksia untuk dijumpai pada anak laki-laki dan perempuan sama besarnya. Disleksia merupakan kelainan yang bisa diturunkan ke generasi berikutnya.  Bila orang tua disleksia, anaknya berpeluang untuk mengalaminya sekitar 50 persen.

Diagnosa disleksia biasanya dilakukan pada usia 7-8 tahun. Namun, sebenarnya bila cermat gejala disleksia bisa dikenali sejak usia 3-4 tahun.

Tanda-tanda disleksia pada usia pra sekolah antara lain:

• Suka mencampur adukkan kata-kata dan frasa
• Kesulitan mempelajari rima (pengulangan bunyi) dan ritme (irama)
• Sulit mengingat nama atau sebuah obyek
• Perkembangan kemampuan berbahasa yang terlambat
• Senang dibacakan buku, tapi tak tertarik pada huruf atau kata-kata
• Sulit untuk berpakaian

Adapun tanda-tanda disleksia di usia sekolah dasar:

• Sulit membaca dan mengeja
• Sering tertukar huruf dan angka 
• Sulit mengingat alfabet atau mempelajari tabel
• Sulit mengerti tulisan yang ia baca
• Lambat dalam menulis
• Sulit konsentrasi
• Susah membedakan kanan dan kiri, atau urutan hari dalam sepekan
• Percaya diri yang rendah
• Masih tetap kesulitan dalam berpakaian

Bila seorang anak didiagnosa disleksia, ia harus mendapat dukungan ekstra di sekolahnya dari seorang guru spesialis. Biasanya ini bisa dilakukan dengan bantuan intens dalam pelajaran membaca dan menulis.

Tapi disleksia tak harus menghentikan anak-anak untuk terus belajar. Ia tak akan menimbulkan efek pada intelijensinya, karena otak mereka bekerja dengan cara yang berbeda.

Bahkan beberapa penderita disleksia memiliki kreativitas yang tinggi, kemampuan berbicara yang baik, pemikir inovatif atau pencari solusi yang intuitif.

Yang dapat dilakukan orang tua di rumah adalah:

• Usahakan agar benar-benar aktif dalam mendampinginya dari waktu ke waktu. Penderita disleksia setiap saat akan menemukan kesulitan-kesulitan. Dan bila kita biarkan mereka mencari jawabannya sendiri,maka ketika menemukan kegagalan demi kegagalan,si penderita justru akan menjadi semakin bodoh. Keadaan tersebut akan memperburuk penyimpangannya.
• Memberikan dorongan sedemikian rupa untuk mengembalikan kepercayaan dirinya. Penderita disleksia akan cenderung  menghabiskan waktunya untuk mencari cara dalam usahanya untuk menguasai sejumlah materi pelajaran seperti,membaca,menulis dan hitungan-hitungan. Perjuangan ini hanya akan tetap bertahan apabila kepercayaan dirinya terus terjaga
• Buatlah semenarik mungkin ketika mengajarinya membaca. Hampir semua anak penderita disleksia tidak suka pelajaran membaca,karena membaca adalah pekerjaan yang paling berat bagi dirinya. Carilah isi bacaan yang disukai oleh subjek,sehingga hal tersebut akan menjadi menarik bagi subjek untuk terus mambacanya walaupun sulit.
• Berikan model peran ,seperti orang-orang sukses yang disleksia. Model peran  sangat penting mereka untuk meningkatkan semangatnya, dan tidak selalu harus Albert Einstein, karena mungkin itu terlalu kuno. Ambilah misalnya Orlando Bloom,Jackie Chan,Mc Dreamy,Patrick Dempsey (ini adalah tokoh-tokoh pria sukses yang disleksia). Untuk wanita bisa diberikan tokoh: Selma Hayek,Jewel,Whoopi Goldberg yang tentu akan membangkitkan semangat dan harapan kesembuhan pada dirinya.
• Bantu mereka dengan teknologi  yang membantu. Memberikan komputer saja untuk anak-anak disleksia  tidak akan sangat membantu. Berikan mereka software seperti Dragon Naturally Speaking atau Kurzweil 3000 . Biarkan mereka belajar sampai ia benar-benar menguasainya .
• Gunakan Metode Pendekatan Multi-Sensori. Wilson Reading System. Orton-Gillingham, dan Slingerland Approach merupakan pendekatan pengajaran Multi-sensori. Mengajar mereka dengan pendekatan multi-sensori akan sangat membantu proses recoverynya.Ke enam cara ini bisa anda gunakan untuk bisa membantu mereka.

Bila si kecil mengalami kesulitan membaca secara teknis, seperti sering terbolak-balik membaca kata atau bingung dengan huruf yang bentuknya mirip, Anda bisa membantunya dengan cara :

• Mulailah melatihnya dengan mengenalkan huruf, suku kata, lalu berlanjut dengan kata yang terdiri dari dua suku kata, dan seterusnya. Anda juga bisa membuatkan huruf dari lilin warna-warni agar ia lebih bersemangat untuk belajar.
• Lakukan metode dikte. Cobalah Anda mendiktekan suatu kata atau kalimat kepadanya dan biarkan ia menuliskannya. Atau lakukan sebaliknya, biarkan si kecil mendikte dan Anda yang menulis. Lalu minta ia membacakannya kembali.
• Ajak si kecil untuk membaca suatu wacana yang sumbernya bisa dari buku bacaan atau buku cerita bergambar. Kemudian lakukan tanya-jawab mengenai wacana tersebut.
• Berikan tugas yang melatih rangsang visualnya.

Latihan Khusus Yang Bisa diberikan

Ajarkan Si Kecil Menulis

• Sebagian anak yang menderita disleksia memiliki tulisan yang kurang bagus. Ini disebabkan kontrol motoriknya yang tidak berfungsi dengan baik. Langkah yang bisa dilakukan antara lain:
• Berikan Ia sebuah buku bergambar dengan pola titik-titik. Ajarkan Ia untuk menghubungkan titik-titik tersebut hingga menjadi sebuah gambar. Ini berfungsi untuk melatih kemampuan motorik halusnya.
• Latihlah terus si kecil untuk menulis halus, berupa pola ataupun kalimat. Berikan pensil yang tebal (misalnya pensil 2B) bila tekanan menulis si anak terlalu lemah dan pensil yang tipis (pensil H) pada anak yang tekanan pada kertasnya terlalu kuat.

Ajak Si Kecil Bermain angka dan Melatih Ingatan Untuk membantunya mengingat urutan hari dalam satu minggu, bulan dalam satu tahun ataupun sejumlah deretan angka, Anda bisa membantunya dengan cara berikut :

• Jangan pernah lupa untuk mengingatkan ia setiap hari tentang tanggal ataupun hari saat ini.
• Lakukan permainan yang melatih kemampuannya dalam mengurutkan, seperti permainan menyusun angka, kalimat dan sebagainya.
• Di waktu luang, mintalah ia menceritakan kembali secara berurutan suatu kejadian yang Ia alami dalam satu hari atau sebuah film pendek yang baru saja ditontonnya.
• Bila si kecil sulit memahami matematika, seperti salah menempatkan angka dan sulit menghitung mundur atau memahami simbol. Gunakan kertas berpetak untuk melakukan penjumlahan atau pengurangan. Ganti lambang-lambang yang sulit dimengerti dengan istilah yang mudah dipahami.

Ajak Si kecil Untuk Memahami orientasi

Kesulitan lain yang dialami anak disleksia adalah sering kali ragu memahami orientasi ruang seperti kanan-kiri, depan-belakang, ataupun atas-bawah. Tak jarang pula dari mereka yang tidak mengerti waktu dan tempat di mana mereka berada. Untuk meningkatkan kemampuan orientasinya, langkah berikut bisa Anda terapkan:

• Ajak si kecil untuk mengikuti permainan baris-berbaris atau permainan “Pegang telinga kiri dengan tangan kananmu!”. Ini berfungsi untuk melatih kemampuan orientasinya
• Jika si kecil benar-benar sulit membedakan mana tangan kanan dan kiri, berilah tanda seperti gelang pada salah satu tangannya.
• Bacakan buku dan bantu mereka saat hendak membaca buku sendiri
• Untuk usia pra sekolah, ajarkan rima, bermain game kata-kata dan puzzle juga akan membantu.
• Ajarkan dan latih bersama bagaimana mengenakan pakaian
• Jangan memfokuskan pada kelemahannya, dukung kegiatan yang disenangi
• Bantu untuk mengerjakan PR
• Tingkatkan kepercayaan diri mereka

Tokoh-tokoh terkenal yang diketahui mempunyai disfungsi dyslexia adalah Albert Einstein, Tom Cruise, Orlando Bloom, Whoopi Goldberg, dan Vanessa Amorosi, Orlando Bloom, Cher, Steve Jobs, Walt Disney, Erin Brockovitch , Thomas Edison, Tracey Gold, General George Patton, Salma Hayek, Nelson Rockefeller, Jewel, Pablo Picasso, Keira Knightley,  Hans Christian Anderson, Leonardo da Vinci,  John Lennon, Alexander Graham Bell, Thomas Jefferson, John F. Kennedy, George Washington, Mohammad Ali, Steven Spielberg

Dr Widodo judarwanto

Children Speech Clinic

Jl Taman Bendungan Asahan 5 Jakarta PusatPhone : (021) 70081995 – 5703646

email : judarwanto@gmail.com

http://korananakindonesia.wordpress.com/

Copyright © 2010, hildren Speech ClinicC  Network  Information Education Network. All rights reserved

A team of American and British researchers studying 2-year-old twins has found that genetics, not the environment, plays the major role in the delayed acquisition of language among children who are having the most difficulty learning to speak.

The study, which looked at more than 3,000 pairs of twins born in England and Wales, was headed by Robert Plomin, research professor of psychology at the Institute of Psychiatry in London and Philip Dale, University of Washington psychology professor. It focused on both the entire range of normal variation among children and on children who ranked in the bottom 5 percent in acquiring language.

The researchers found that twins, whether identical or fraternal, generally scored very similarly in language at age 2. But the results from the children in the bottom 5 percent told a different story. If one identical twin ranked in the lowest 5 percent there was an 81 percent chance that his or her twin also would fall into that group. But if the twin was a fraternal there was only a 42 percent chance of the other being in the bottom 5 percent.

“This points to a genetic influence since identical twins have the same genetic makeup while fraternal twins are only 50 percent the same genetically,” said Dale. “For the broad range of children, environment or nurture appears to be more important. With fast, average and even moderately slow language development genetics or nature doesn’t seem to matter as much as environment, though it does play some role. But what happens to children at the low or very slow end of language development is strikingly different. With these children, genetics is important and that’s why it makes a whopping difference what kind of twin they are.”

There’s further suggestion for the effects of genetics among this group of children, according to Dale, if you assume fraternal and identical twins are treated similarly in the way parents talk and read to them.

“If fraternal twins are more different from each other than identical twins it is because they are genetically different,” he said. “If the treatment is the same for identical twins and they both have low scores again the reason primarily must be genetic.” In addition, because same-sex and opposite-sex fraternal twins have the same 42 percent chance of being at the low end of language development scale, it appears that boys and girls aren’t being treated differently. This also suggests a genetic rather than an environmental influence, according to Dale.

Despite this apparent genetic link to a delay in learning language for some children, Dale emphasized that environment and the way parents relate to their youngsters is vital.

“For kids in general, environment really matters. The amount and the way parents talk to children is very important and influences how well they will learn language.”

To examine language acquisition, the Dale-Plomin team was able to enlist the help of parents of 3,039 pairs of twins who are part of the Twins Early Development Study which is looking at all 7,756 pairs born in England and Wales in 1994. Their study consisted of 1,044 pairs of identical twins, 1,006-same sex fraternal twins and 989 opposite-sex twins. The parents were given a list of 100 words, representative of a larger inventory of common words that 2-year-olds use. Parents were asked to check off specific words that their twins use.

Children at age 2 have a huge variety in their vocabulary, ranging from those who speak no recognizable words to those who already use all 100 on the list. The average number of words produced from the list was 48 for the entire sample of twins, but just 4.2 words for the lowest 5 percent. Sixty-one children produced no recognizable words.

Dale said that an early delay in language acquisition doesn’t necessarily mean a child will have language or reading problems later in life.

“We know half of them won’t have problems and will catch up with their peers. The other half will have problems and we would like to know how to identify those who won’t catch up. From this study, we know that part of the reason is genetic and we would like to look for specific genetic markers of both temporary and more enduring delay in future research.”

Dale said the researchers are following the twins in their study to find which children do and don’t catch up. So far, they have found no relationship between delayed language acquisition and other abilities such as spatial and non-verbal skills.

The study, which was published in the journal “Nature Neuroscience,” reaffirmed known gender differences in language delay: more boys than girls have this problem. Analysis of data indicated that parents are not treating boys and girls differently.

“Boys are more at risk for this, just as they are for just about everything else,” he said.

Other members of the research team include Emily Simonoff, Thalia Eley, Bonny Oliver, Thomas Price and Shaun Purcell of the Institute of Psychiatry in London; Dorothy Bishop of MRC Cognition and Brain Science Unit in Cambridge, England; and Jim Stevenson of the Centre for Research into Psychological Development at the University of Southampton.

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The motor theory of speech perception is the hypothesis that people perceive spoken words by identifying the vocal tract gestures with which they are pronounced rather than by identifying the sound patterns that speech generates. It originally claimed that speech perception is done through a specialized module that is innate and human-specific. Though the idea of a module has been qualified in more recent versions of the theory, the idea remains that the role of the speech motor system is not only to produce speech articulations but also to detect them.

The hypothesis has gained more interest outside the field of speech perception than inside. This has increased particularly since the discovery of mirror neurons that link the production and perception of motor movements, including those made by the vocal tract. An alternative interpretation of research linking speech perception to speech production, however, is that it links to speech imitation rather than speech perception.

The theory was initially proposed in the Haskins Laboratories in the 1950s by Alvin Liberman and Franklin S. Cooper, and developed further by Donald Shankweiler, Michael Studdert-Kennedy, Ignatius Mattingly, Carol Fowler and Douglas Whalen

Origins and development

The hypothesis has its origins in research using pattern playback to create reading machines for the blind that would substitute sounds for orthographic letters.[7] This led to a close examination of how spoken sounds correspond to the acoustic spectrogram of them as a sequence of auditory sounds. This found that successive consonants and vowels overlap in time with one another (a phenomenon known as coarticulation). This suggested that speech is not heard like an acoustic “alphabet” or “cipher,” but as a “code” of overlapping speech gestures.

Associationist approach

Initially, the theory was associationist: infants mimic the speech they hear and that this leads to behavioristic associations between articulation and its sensory consequences. Later, this overt mimicry would be short-circuited and become speech perception. This aspect of the theory was dropped, however, with the discovery that prelinguistic infants could already detect most of the phonetic contrasts used to separate different speech sounds.

Cognitivist approach

The behavioristic approach was replaced by a cognitivist one in which there was a speech module. The module detected speech in terms of hidden distal objects rather than at the proximal or immediate level of their input. The evidence for this was the research finding that speech processing was special such as duplex perception.

Changing distal objects

Initially, speech perception was assumed to link to speech objects that were both

the invariant movements of speech articulators

the invariant motor commands sent to muscles to move the vocal tract articulators

This was later revised to include the phonetic gestures rather than motor commands,[1] and then the gestures intended by the speaker at a prevocal, linguistic level, rather than actual movements.

Modern revision

The “speech is special” claim has been dropped,[5] as it was found that speech perception could occur for nonspeech sounds (for example, slamming doors for duplex perception).

Mirror neurons

The discovery of mirror neurons has led to renewed interest in the motor theory of speech perception, and the theory still has its advocates,[5] although there are also critics.

Support

Nonauditory gesture information

If speech is identified in terms of how it is physically made, then nonauditory information should be incorporated into speech percepts even if it is still subjectively heard as “sounds”. This is, in fact, the case.

The McGurk effect shows that seeing the production of a spoken syllable that differs from one an auditory one synchronized with it affects the perception of the auditory one. In other words, if someone hears “ba” but sees a video of someone pronouncing “ga”, what they hear is different—some people believe they hear “da”.

People find it easier to hear speech in noise if they can see the speaker.

People can hear syllables better when their production can be felt haptically.

Categorical perception

Using a speech synthesizer, speech sounds can be varied in place of articulation along a continuum from /bɑ/ to /dɑ/ to /ɡɑ/, or in voice onset time on a continuum from /dɑ/ to /tɑ/ (for example). When listeners to discriminate between two different sounds, they perceive sounds as belonging to discrete categories, even though the sounds vary continuously. In other words, 10 sounds (with the sound on one extreme being /dɑ/ and the sound on the other extreme being /tɑ/, and the ones in the middle varying on a scale) may all be acoustically different from one another, but the listener will hear all of them as either /dɑ/ or /tɑ/. Likewise, the English consonant /d/ may vary in its acoustic details across different phonetic contexts (the /d/ in /du/ does not technically sound the same as the one in /di/, for example), but all /d/’s as perceived by a listener fall within one category (voiced alveolar stop) and that is because “linguistic representations are abstract, canonical, phonetic segments or the gestures that underlie these segments.”[18] This suggests that humans identify speech using categorical perception, and thus that a specialized module, such as that proposed by the motor theory of speech perception, may be on the right track.

Speech imitation

If people can hear the gestures in speech, then the imitation of speech should be very fast, as in when words are repeated that are heard in headphones as in speech shadowing. People can repeat heard syllables more quickly than they would be able to produce them normally.
Speech production

Hearing speech actives vocal tract muscles,[22] and the motor cortex[23] and premotor cortex.[24] The integration of auditory and visual input in speech perception also involves such areas.

Disrupting the premotor cortex disrupts the perception of speech units such as stop consonants.

The activation of the motor areas occurs in terms of the phonemic features which link with the vocal track articulators that create speech gestures.

The perception of a speech sound is aided by pre-emptively stimulating the motor representation of the articulators responsible for its pronunciation .

Perception-action meshing

The evidence exits that perception and production are generally coupled in the motor system. This is supported by the existence of mirror neurons that are activated both by seeing (or hearing) an action and when that action is carried out. Another source of evidence is that for common coding theory between the representations used for perception and action.

Criticisms

The motor theory of speech perception has not had much success. As three of its advocates have noted, “it has few proponents within the field of speech perception, and many authors cite it primarily to offer critical commentary p. 361 Several critiques of it exist.

Multiple sources

Speech perception is affected by nonproduction sources of information, such as context. Individual words are hard to understand in isolation but easy when heard in sentence context. It therefore seems that speech perception uses multiple sources that are integrated together in an optimal way.

Production

The motor theory of speech perception would predict that speech motor abilities in infants predict their speech perception abilities, but in actuality it is the other way around. It would also predict that defects in speech production would impair speech perception, but they do not.

Speech moduls

Several sources of evidence for a specialized speech module have failed to be supported.

Duplex perception can be observed with door slams.

The McGurk effect can also be achieved with nonlinguistic stimuli, such as showing someone a video of a basketball bouncing but playing the sound of a ping-pong ball bouncing.

As for categorical perception, listeners can be sensitive to acoustic differences within single phonetic categories.

As a result, this part of the theory has been dropped.

Sublexical tasks

The evidence provided for the motor theory of speech perception is limited to tasks such as syllable discrimination that use speech units not full spoken words or spoken sentences. As a result, “speech perception is sometimes interpreted as referring to the perception of speech at the sublexical level. However, the ultimate goal of these studies is presumably to understand the neural processes supporting the ability to process speech sounds under ecologically valid conditions, that is, situations in which successful speech sound processing ultimately leads to contact with the mental lexicon and auditory comprehension.” This however creates the problem of ” a tenuous connection to their implicitt target of investigation, speech recognition”.

Imitation

The motor theory of speech perception faces the problem that the research linking speech perception to speech production is also consistent with the brain processing speech to imitate spoken words. The brain must have a means to do this if language is to exist, since a child’s vocabulary expansion requires a means to learn novel spoken words, as does an adult’s picking up of new names.[6] Imitation has to be initiated for all vocalizations since a word’s novelty cannot be known until after it is heard, and so after when the information needed to identify its articulation gestures and motor goals has gone. As result vocal imitation needs to be initiated by default into short term memory for every heard spoken vocalizations. If speech perception uses multiple sources of information, this default imitation processing would provide as a secondary use an extra source for word perception. Since imitation will be most needed for vocalizations that are not proper words, this could explain why sublexical tasks that do not use proper words so strongly link to processing of motor gestures

Gan

A person with an expressive language disorder (as opposed to a mixed receptive/expressive language disorder) understands language better than he/she is able to communicate. In speech-language therapy terms, the person’s receptive language (understanding of language) is better than his/her expressive language (use of language). This type of language disorder is often a component in developmental language delay (see section on this disorder). Expressive language disorders can also be acquired (occurring as a result of brain damage/injury), as in aphasia (see section on aphasia). The developmental type is more common in children, whereas the acquired type is more common in the elderly. An expressive language disorder could occur in a child of normal intelligence, or it could be a component of a condition affecting mental functioning more broadly (i.e. mental retardation, autism).

Definition
Expressive Language Disorder is a learning disability affecting communication of thoughts using spoken and sometimes basic written language and expressive written language. This disorder involves difficulty with language processing centers of the brain. Expressive language disorders can result from inherited conditions or may be caused by brain injuries or stroke.

Characteristics :

Children with expressive language delays often do not talk much or often, although they generally understand language addressed to them. For example, a 2 year old may be able to follow 2-step commands, but he/she cannot name body parts. A 4 year old may understand stories read to him/her, but he/she may not be able to describe the story even in a simple narrative. Imaginative play and social uses of language (i.e. manners, conversation) may also be impaired by expressive language limitations, causing difficulty in playing with peers. These are children who may have a lot to say, but are unable to retrieve the words they need. Some children may have no problem in simple expression, but have difficulties retrieving and organizing words and sentences when expressing more complicated thoughts and ideas. This may occur when they are trying to describe, define, or explain information or retell an event or activity.

In school-aged children, expressive language difficulties may be evident in writing as well. These children may have difficulties with spelling, using words correctly, composing sentences, performing written composition, etc. They may express frustration because they recognize that they cannot express the idea they wish to communicate. These children may become withdrawn socially because they cannot use language to relate to peers.
People with expressive language disorders may understand what is said to them or written in passages, but they have substantial difficulty communicating. They have difficulty with language processing and the connection between words and ideas they represent. Some people may also have problems with pronunciation of words.

Some students with expressive language disorders may also have difficulty with receptive language.

In a more severely affected child, delays may be evident in early milestones. For example, in typically developing children, a vocabulary of first words is emerging between the ages of 10-18 months, two-word phrases are produced around the ages of 18-24 months, with 2-3 word phrases emerging in their second year of life, and around the age of 3 years, children speak in 3-4 word sentences, engage in simple conversation, and begin asking questions in more adult-like ways (i.e. “Can we go?” instead of “Me go?”).

In more mildly impaired children, delays may not be evident until school begins. Issues may be seen in academics or in oral expression for more complicated language tasks. He may begin to have difficulties as schoolwork becomes more difficult (i.e. writing sentences or short stories, summarizing information, answering questions in class). Older children (i.e. middle, high school) face difficulties with the challenges of their more advanced school work (i.e. taking notes, written or oral reports/essays, etc.).

As mentioned in the section on developmental language disorders, these children may act out in school, or in later school years and reject learning completely without help. Also, as mentioned in the section on developmental language disorders, expressive language disorders do not disappear with time. A speech-language pathologist can best diagnose an expressive language disorder. Parents and classroom teachers are in key positions to help in the evaluation as well as in the planning and implementation of treatment. Other professionals involved in assessment and treatment, especially as related to academics, include educational therapists, resource specialists, and tutors.

Treatment

Evaluation can provide information to help educators develop effective strategies. Typical strategies focus on language therapy to develop the important concepts necessary to communicate. Vocabulary development, rehearsal, and practice of using language in social situations are often helpful therapeutic methods.

Students with substantial communication disorders may require extensive specially designed instruction on their IEPs. Language processing disorders may play a role in dyslexia and autism.

Myths

People with Expressive Language Disorder may appear less capable than they really are because they cannot effectively express themselves. Except in rare cases, their understanding of language and subjects in school is often as well-developed as that of other learners their age.

Assessment :

Diagnostic writing and speech/language tests can be used to determine what specific types of language difficulty are affecting the learner’s communication skills. Through observations, analyzing student work, cognitive assessment, and occupational therapy evaluations, speech pathologists and teachers can develop individualized therapy and education programs that will help the student learn.

What To Do Next:

Expressive Language Disorders – If you believe you or your child has an Expressive Language Disorder and may have a learning disability that requires special education, contact your school principal or counselor for information on how to request an assessment. For students in college and vocational programs, their school’s advising office can assist with finding resources to help ensure their success. Students with expressive language deficits and other learning disabilities will need to develop self-advocacy skills.

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email : judarwanto@gmail.com,

Copyright © 2010, Children Speech Clinic Information Education Network. All rights reserved.

For the past few weeks we’ve been faced with our youngest son having a serious speech issue. At first we just thought his speech was delayed because he was the second born or because his brother talks so much he never gets a chance to. I never really worried about it and figured he would catch up eventually. But right before his second birthday I noticed that his speech didn’t seem to be progressing. The words he used were almost his own language. I could usually figure out what he was saying, but no one else could understand him.

At his 2 year well child appointment his pediatrician seemed very concerned. She said that he should have around 10-20 words and be able to start string words together into “sentences.” We were given referrals for a hearing and balance test as well as speech therapy. I was in shock. Does that mean he can’t hear? Does that mean he can’t learn to speak? Does that mean something could be wrong with him?

The hearing test was inconclusive. I believe the test results read, “possible 20% hearing loss in at least one ear. Possibly due to fluid in middle ear.” We were told to come back in 6 months to have him retested. The doctor recommended find a good speech therapist…that if it wasn’t hearing loss it would most likely be apraxia. She explained that apraxia is when the muscles in the mouth can’t form the words the brain wants it to say. It was like being punched in the gut hearing that description. It’s exactly what I see when I watch our son struggle to communicate with us, but only the same sounds come out over and over. When we ask him, “Can you say dog?”, instead of saying some 2-year-old version of dog, he shakes his head and says, “Uh-uh.”

Tomorrow we meet with a speech therapist. She is going to come to our home, which is really comforting. But I can’t help but worry and be nervous. I’ve done a little research on apraxia. Apparently some kids need to be in speech therapy every week for several years. For some it’s a lifelong struggle to learn to speak correctly. Don’t get me wrong…I’m thankful everyday that my children are healthy, happy and with me every day. But any time your child has to struggle it’s heartbreaking. I’m hoping tomorrow will bring some good information, a plan of action and most of all, hope.

Source : Raising Healthy Kids, Katie_G

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Clinical and Editor in Chief :

DR WIDODO JUDARWANTO, pediatrician

email : judarwanto@gmail.com,

Copyright © 2010, Children Speech Clinic Information Education Network. All rights reserved.

Supported by

CHILDREN SPEECH CLINIC

CHILDREN SPEECH CLINIC online

JL Taman Bendungan Asahan 5 Jakarta Pusat, Indonesia 10210

PHONE :62 (021) 70081995 – 5703646

Email : judarwanto@gmail.com

http://childrenspeechclinic.wordpress.com/

Clinical and Editor in Chief :

DR WIDODO JUDARWANTO, pediatrician

email : judarwanto@gmail.com,

Copyright © 2010, Children Speech Clinic Information Education Network. All rights reserved.

If you’re concerned about your child’s speech and language development, there are some things to watch for.

An infant who isn’t responding to sound or who isn’t vocalizing is of particular concern. Between 12 and 24 months, reasons for concern include a child who:

isn’t using gestures, such as pointing or waving bye-bye by 12 months

prefers gestures over vocalizations to communicate by 18 months

has trouble imitating sounds by 18 months

has difficulty understanding simple verbal requests

Seek an evaluation if a child over 2 years old:

can only imitate speech or actions and doesn’t produce words or phrases spontaneously

says only certain sounds or words repeatedly and can’t use oral language to communicate more than his or her immediate needs

can’t follow simple directions

has an unusual tone of voice (such as raspy or nasal sounding)

is more difficult to understand than expected for his or her age. Parents and regular caregivers should understand about half of a child’s speech at 2 years and about three quarters at 3 years. By 4 years old, a child should be mostly understood, even by people who don’t know the child.

With reasons being unknown about the cause of stuttering, there is a theory going around which states the connection between food allergies and stuttering. According to this notion, the allergy to certain foods causes the sympathetic nervous system to be activated rather than the para-sympathetic nervous system. As a result, what follows is an increase in the level of anxiousness in the stutterer stimulating the stutter and worsening it.

There has been no conclusive evidence to show that certain foods worsen or aggravate the stutter in a person when he is already a stutterer. But there have been instances where stutterers have felt remarkable improvement in their stuttering with the elimination of certain items from their diet. Most stutterers are unaware of the connection between stuttering and food. This link cannot be assumed to exist in all stutterers but there is a possibility that some stutterers maybe experiencing their stutter because of their diet. It is advisable that stutterers check with a gastroenterologist to ensure that their food intake is not a possible reason for their stutter.

The most common food allergy prevalent in stutterers is that of gluten which has been found to aggravate the stutter. Gluten is a substance found in wheat and hence is present in most of the bread varieties. The consumption of gluten by the stutterer worsens his stutter, sometimes aggravating it to such an extent that the stutterer is not even able to put in a complete sentence. The slurring and stuttering become extremely bad with the intake of gluten. Once the stutterer ceases to take in gluten in any form, his stuttering is back to its normal level. But this gluten aversion could also be because of some other bigger disorders like Celiac and should immediately be checked with a doctor.

Also, food rich in dopamine cause stutterers to experience extreme stuttering and hence must be avoided. One such item rich in dopamine is caffeine and this along with sugary foods should not be included in a stutterer’s diet. Some people develop a temporary stutter because of their allergy towards certain food varieties; allergy to peanut butter causes stuttering in some people. Such stutters can be avoided by keeping away from the allergic food items. The same goes for stutterers who are experiencing food allergies too but since they already stutter in their speech, it is better to be cautious and stay away from such items.

Cause of Stuttering is generally unknown. But few researchers have claimed about the connection between food allergies and stuttering. A particular food allergy can activate our Sympathetic Nervous System instead of the Para-sympathetic Nervous System. Thus, our levels of anxiousness increases. This condition stimulates stuttering.

Sympathetic Nervous System is a type of nervous system present in our body, which operates on its own. It becomes more active when our body is under stress. It follows the mechanism of ‘Fight-or-Flight’. Para-sympathetic Nervous System also performs on it own. It follows the mechanism of ‘Rest and Digest’ and hence opposite in action to Sympathetic Nervous System.

Till now no scientific evidence is available. So most stutterers are unaware of this. But certain instances are convincing where stutterers have felt improvement by avoiding certain food items. These instances increase our intesrest in finding details on how certain food can worsen the stuttering conditions in a stutterer. So we advise all stutterers to consult a gastroenterologist to ensure if any food allergic reaction is making you stutter more. All stutterers may not be suffering from food allergic-stuttering but few may experience.

Most common food allergen which can cause stuttering is found to be ‘Gluten’. Gluten is found in wheat, so present in most bakery items like – bread. When a stutterer is allergic to gluten, can experience high level of stuttering. The stutterer may not be able to complete even a sentence. His stuttering condition can get normal once he stops consuming products having gluten.

Sometimes, foods rich in Dopamine can also cause extreme stuttering in stutterers. Dopamine is present in caffeine. Some may also be allergic to peanut butter or sugar. The allergic products are needed to be identified properly and should not be included in the diet. Extreme stuttering caused due to food allergy can be checked only by avoiding the foods in your diet that cause allergy. Cautious Living can make your life better.

ScienceDaily (Nov. 27, 2003) — OAK BROOK, Ill. – Children with unusually delayed speech tend to listen with the right side of the brain rather than the left side of the brain, according to a study published in the December issue of the journal Radiology. Preliminary study results were presented at the Radiological Society of North America’s (RSNA) Annual Meeting in 2002.

The research represents the first time functional magnetic resonance imaging (fMRI) has been used to investigate brain activity associated with speech delay. “With the advent of neuroimaging, we saw a new way of looking at language disorders,” said Nolan R. Altman, M.D., co-author of the study and chief of radiology at Miami Children’s Hospital.

The researchers completed fMRI studies on 17 abnormally speech-delayed children and 35 age-matched children without delayed speech to compare the brain activation patterns between the two groups. To study the brain’s reaction to passive language, the children’s brains were imaged as they listened to audiotapes of their mothers. The children were between ages 2 and 8 with a mean age of approximately 4 ½ years.

The findings indicated that children with seriously delayed speech have higher levels of right brain lobe activity than children without delayed speech, who tend to use the left side of their brains when they listen. They also found that language-delayed children age 4 and older had less total brain activation than the children in the control group, potentially indicating that speech-delayed children are less receptive to language as they age.

Children typically say their first words by age 1 and advance to simple sentences by age 2 ½ or 3. If a 1-year-old child has not made verbal sounds, or if his or her speech is extremely unclear compared with that of children of similar age, then it may be advisable for parents to consult their family physician or a speech pathologist to determine if the child has a language disorder, according to the researchers.

“The overall ramifications of our early research augment the accepted importance of early intervention for children with language disorders,” Dr. Altman explained. “With fMRI, radiologists may be able to help diagnose, guide and monitor treatment of children with these complex disorders.” According to the American Speech-Language Hearing Association (ASHA), an estimated 2 percent of children have a condition that may cause speech delay, including emotional or behavioral disabilities, birth complications, cleft lip or palate, developmental disabilities, hearing loss or lack of environmental stimulation.

Dr. Altman said the next step is to expand the study and develop a reliable test to diagnose language delay. He emphasized the importance of early identification of children with speech-delayed brain activation patterns, so that interventions can be started early, when they are most effective.

“A valid test identifying language delay would be valuable to both the practitioner and the child,” Dr. Altman said. “Alternatively, after the child goes through speech therapy or another intervention, we can re-scan to see if the brain appears more normal.”

Radiology is a monthly scientific journal devoted to clinical radiology and allied sciences. The journal is edited by Anthony V. Proto, M.D., School of Medicine, Virginia Commonwealth University, Richmond, Virginia. Radiology is owned and published by the Radiological Society of North America Inc. (http://radiology.rsnajnls.org).

RSNA is an association of more than 35,000 radiologists, radiation oncologists and related scientists committed to promoting excellence in radiology through education and by fostering research, with the ultimate goal of improving patient care. The Society is based in Oak Brook, Ill. (http://www.rsna.org).

“Speech-Delayed Children: An FMRI Study.” Collaborating with Dr. Altman on this paper was Byron Bernal, M.D.

ALEXANDER K.C. LEUNG, M.B.B.S.

Alberta Children’s Hospital and University of Calgary, Alberta, Canada

C. PION KAO, M.D.,

Alberta Children’s Hospital, Calgary, Alberta, Canada

A delay in speech development may be a symptom of many disorders, including mental retardation, hearing loss, an expressive language disorder, psychosocial deprivation, autism, elective mutism, receptive aphasia and cerebral palsy. Speech delay may be secondary to maturation delay or bilingualism. Being familiar with the factors to look for when taking the history and performing the physical 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 improve the outcome.

Speech is the motor act of communicating by articulating verbal expression, whereas language is the knowledge of a symbol system used for interpersonal communication.1 In general, a child is considered to have speech delay if the child’s speech development is significantly below the norm for children of the same age. A child with speech delay has speech development that is typical of a normally developing child of a younger chronologic age; the speech-delayed child’s skills are acquired in a normal sequence, but at a slower-than-normal rate.

Speech delay has long been a concern of physicians who care for children. The concern is well founded, because a number of developmental problems accompany delayed onset of speech. In addition, speech delay may have a significant impact on personal, social, academic and, later on, vocational life. Early identification and appropriate intervention may mitigate the emotional, social and cognitive deficits of this disability and may improve the outcome.

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 data retrieval. It can be said, however, that speech delay is a common childhood problem that affects 3 to 10 percent of children.4-6 The disorder is three to four times more common in boys than in girls.

Etiology

Mental Retardation
Mental retardation is the most common cause of speech delay, accounting for more than 50 percent of cases.8 A mentally retarded child demonstrates global language delay and also has delayed auditory comprehension and delayed use of gestures. In general, the more severe the mental retardation, the slower the acquisition of communicative speech. Speech development is relatively more delayed in mentally retarded children than are other fields of development.

In approximately 30 to 40 percent of children with mental retardation, the cause of the retardation cannot be determined, even after 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 commonly caused by otitis media with effusion.10 Such hearing loss is intermittent and averages from 15 to 20 dB.11 Some studies have shown that children with conductive hearing loss associated with middle ear fluid during the first few years of life are at risk for speech delay.4,11 However, not all studies find this association.12 Conductive hearing loss may also 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 (e.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 central neurologic process required to produce speech. The condition is more common in boys, and a family history of “late bloomers” is often present.13 The prognosis for these children is excellent, however; they usually have normal speech development by the age of school entry.14

Expressive Language Disorder
Children with an expressive language disorder (developmental expressive aphasia) fail to develop the use of speech at the usual age. These children have normal intelligence, normal hearing, good emotional relationships and normal articulation skills. The primary deficit appears to be a brain dysfunction that results in an inability to translate ideas into speech. Comprehension of speech 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 speech, the child with an expressive language disorder will not do so without intervention.13 It is sometimes difficult, if not impossible, to distinguish at an early age a late bloomer from a child with an expressive language disorder. Maturation delay, however, is a much more common cause of speech delay than is expressive language disorder, which accounts for only a small percentage of cases. A child with expressive language disorder is at risk for language-based learning disabilities (dyslexia). 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 comprehension of the two languages is normal for a child of the same age, however, and the child usually becomes proficient in both languages before the age of five years.

Psychosocial Deprivation
Physical deprivation (e.g., poverty, poor housing, malnutrition) and social deprivation (e.g., inadequate linguistic stimulation, parental absenteeism, emotional stress, child neglect) have an adverse effect on speech development. Abused children who live with their families do not seem to have speech delay unless they are also subjected to neglect.15 Because abusive parents are more likely than other parents to ignore their children and less likely to use verbal means to communicate with them, abused children have an increased incidence of speech delay.16

Autism
Autism is a neurologically based developmental disorder; onset occurs before 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 as echolalia and pronoun reversal. The speech of some autistic children has an atonic, wooden or sing-song quality. Autistic children, in general, fail to make eye contact, smile socially, respond to being hugged or use gestures to communicate. Autism is three to four times more common in boys than in girls.

Management

The management of a child with speech delay should be individualized. The health care team might include the physician, a speech-language pathologist, an audiologist, a psychologist, an occupational therapist and a social worker. The physician should provide the team with information about the cause of 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 goal of language remediation is to teach the child strategies for comprehending spoken language and producing appropriate linguistic or communicative behavior. The speech-language 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 may be indicated; occasionally, reconstruction of the external auditory canal, ossicular reconstruction and cochlear implantation may be necessary. The use of a high-risk registry as well 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 accompanied by undue anxiety or depression. In autistic children, gains in speech acquisition have been reported with behavior therapy that includes operant conditioning.

Parents and caregivers who work with children with speech delay should be made aware of the need to adjust their speech to the level of the particular child. Teachers should consider the use of small group instruction for children with speech delay.

REFERENCES

Blum NJ, Baron MA. Speech and language disorders. In: Schwartz MW, ed. Pediatric primary care: a problem oriented approach. St. Louis: Mosby, 1997:845-9.

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

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

Shonkoff JP. Language delay: late talking to communication disorder. In: Rudolph AM, Hoffman JI, Rudolph CD, eds. Rudolph’s pediatrics. London: Prentice-Hall, 1996:124-8.

Silva PA, Williams S, McGee R. A longitudinal study of children with developmental language delay at age three: later intelligence, reading and behaviour problems. Dev Med Child Neurol 1987;29:630-40.

Stevenson J, Richman N. The prevalence of language delay in a population of three-year-old children and its association with general retardation. Dev Med Child Neurol 1976;18:431-41.

Vessey JA. The child with cognitive, sensory, or communication impairment. In: Wong DL, Wilson D, eds. Whaley & Wong’s nursing care of infants and children. St. Louis: Mosby, 1995:1006-47.

Coplan J. Evaluation of the child with delayed speech or language. Pediatr Ann 1985;14:203-8.

Leung AK, Robson WL, Fagan J, Chopra S, Lim SH. Mental retardation. J R Soc Health 1995;115:31-9.

Leung AK, Robson WL. Otitis media in infants and children. Drug Protocol 1990;5:29-35.

Schlieper A, Kisilevsky H, Mattingly S, Yorke L. Mild conductive hearing loss and language development: a one year follow-up study. J Dev Behav Pediatr 1985;6:65-8.

Allen DV, Robinson DO. Middle ear status and language development in preschool children. ASHA 1984;26:33-7.

Whitman RL, Schwartz ER. The pediatrician’s approach to the preschool child with language delay. Clin Pediatr 1985;24:26-31.

McRae KM, Vickar E. Simple developmental speech delay: a follow-up study. Dev Med Child Neurol 1991;33:868-74.

Davis H, Stroud A, Green L. The maternal language environment of children with language delay. Br J Disord Commun 1988;23:253-66.

Allen R, Wasserman GA. Origins of language delay in abused infants. Child Abuse Negl 1985;9:335-40.

Bishop DV. Developmental disorders of speech and language. In: Rutter M, Taylor E, Hersov L, eds. Child and adolescent psychiatry. Oxford: Blackwell Science, 1994:546-68.

Denckla MB. Language disorders. In: Downey JA, Low NL, eds. The child with disabling illness: principles of rehabilitation. New York: Raven, 1982:175-202.

Coplan J. ELM scale: the early language milestone scale. Austin, Tex.: Pro-Ed, 1987.

Dunn LM, Dunn LM. The Peabody Picture Vocabulary Test­Revised (PPVT­R). Circle Pines, Minn.: American Guidance Services, 1981.

Avery ME, First LR, eds. Pediatric medicine. Baltimore: Williams & Wilkins, 1989:42-50.

Resnick TJ, Allen DA, Rapin I. Disorders of language development: diagnosis and intervention. Pediatr Rev 1984;6:85-92.

Lowenthal B. Effect of small-group instruction in language-delayed preschoolers. Except Child 1981;48:178-9.

Developmental phonological disorders

Developmental Phonological Disorders or “phonological disorder”, are a group of language disorders, whose cause is unclear, that affect children’s ability to develop easily understood speech patterns by the time they are four years old. Developmental phonological disorders can also affect children’s ability to learn to read and spell.
Developmental phonological disorders are known by many names including ‘phonological disorder’ and ‘phonological delay’, and ‘phonological impairment’. 

There are two terms that are not included in the list of synonyms. They are “phonological processing disorder” and “phonological processes disorder”. Despite their wide usage, these incorrect (and misleading) terms are not synonyms for developmental phonological disorder. Neither are they names for closely related speech sound disorders. They are “made up” terms that have somehow crept into listservs and discussions. Even SLPs sometimes use them!

A phonological disorder was termed a ‘functional articulation disorder’, and the relationship between it and learning basic school work (like reading and spelling) was not well recognised. Children were just thought to have difficulty in articulating the sounds of speech. Traditional articulation therapy was used to rectify the problem. 

Different name
‘Developmental phonological disorder’ is not simply a new name for an old problem. The term reflects the influence of psycholinguistic theory on the way speech-language pathologists now understand phonological disorders. Nowadays, the traditional diagnostic classification of ‘functional articulation disorder’ is falling into disuse. 

Children with phonological disability are usually able to use, or can be quickly taught to use, all the sounds needed for clear speech – thus demonstrating that they do not have a problem with articulation as such. In other words, we now know that the problem is not a motor speech disorder. 

Just to complicate matters, however, some children with developmental phonological disorders also have difficulties with fine motor control and/or motor planning for speech.

Traditional articulation therapy
There is no single definition of traditional articulation therapy. It is a term that is applied to a number of therapy approaches that focus on the motor aspects of speech production, with or without auditory discrimination training. 

In essence, traditional articulation therapy involves behavioural techniques, focused on teaching children new sounds in place of error-sounds or omitted sounds, one at a time, and then gradually introducing them (new sounds that is) into longer and longer utterances, and eventually into normal conversational speech.

Traditional therapy techniques, using the format outlined above, have withstood the test of time, and can still be very suitable for children with functional speech disorders.

Children with just a few speech-sound difficulties such as lisping (saying ‘th’ in place of ‘s’ and ‘z’), or problems saying ‘r’, ‘l’ or ‘th’ are usually described as having functional speech disorders. But, you guessed it! There are synonyms for this too. Functional speech disorders are often referred to as ‘mild articulation disorders’ or ‘functional articulation disorders’. Examples include:

The word super pronounced as thooper.
The word zebra pronounced as thebra.
The word rivers pronounced as wivvers.
The word leave pronounced as weave.
The word thing pronounced as fing.
The word those pronounced as vose.

NOTE: 
Some of these sound changes are acceptable in a number of English dialects.

Traditional articulation therapy
The traditional approach is unsuitable for children with developmental phonological disorders. SLP’s who include phonological principles in their theory of intervention believe that a ‘phonological approach’ should be used with children with phonological disorders. Phonological approaches to intervention, of which there are several, are called ‘phonological therapy’.

Therapy
The term phonological therapy refers to the application of phonological principles to the treatment of children with phonological disability. Phonological therapy:

1. is based on the systematic nature of phonology;
2. is characterised by conceptual, rather than motoric, activities;
3. aims to facilitate age-appropriate phonological patterns through activities that encourage and nurture the development of the appropriate cognitive organisation of the child’s underlying phonological system; and,
4. has generalisation as its ultimate goal.

In essence, the child with a developmental phonological disorder has a language difficulty affecting their ability to learn and organise their speech sounds into a system of ‘sound patterns’ or ‘sound contrasts’. The problem is at a linguistic level, and there is no impairment to the child’s larynx, lips, tongue, palate or jaw.

Unfortunately, no. Children with “dyspraxia” (Childhood Apraxia of Speech) or a dysarthria have articulation disorders (or motor speech disorders). Children with anatomical (structural) differences such as cleft lip and palate, tongue-tie or other cranio-facial anomalies may also have articulation disorders.

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phone : 62(021) 70081995 – 62(021) 5703646, mobile : 0817171764

email : judarwanto@gmail.com 

Copyright © 2010, Children Speech Clinic  Information Education Network. All rights reserved

Childhood Apraxia of Speech is a childhood speech disorder. It is NOT the same as “Apraxia” or “Dyspraxia” in adults who have had strokes or head injuries. Children with dyspraxia (or apraxia – both terms are as “correct” as any of the others listed below) have the capacity to say speech sounds but have a problem with motor planning. They have difficulty making the movements needed for speech, voluntarily. 

Dyspraxia can be mild, moderate or severe. It can apparently resolve with appropriate therapy, in that the person’s speech sounds acceptable, though the underlying deficit probably remains forever. Alternatively, it can persist for a lifetime, in the form of very little speech and / or very difficult to understand speech, despite a great deal of appropriate therapy.

Different names

Dyspraxia in children is known by various names:

apraxia
apraxia of speech
developmental apraxia of speech [DAS]
childhood apraxia of speech [CAS]
suspected childhood apraxia of speech [sCAS]
developmental verbal dyspraxia [DVD]
developmental articulatory dyspraxia [DAD]

On close reading of the literature, all the CAS ‘names’ seem to mean the same thing when it comes to looking at the actual symptoms or features of the child’s speech production, mouth movements and slow progress acquiring speech. The most commonly used names for it are probably: developmental apraxia of speech [DAS], developmental articulatory dyspraxia [DAD], and developmental verbal dyspraxia [DVD]. Childhood Apraxia of Speech [CAS] is an insurance friendly newcomer that has rapidly currency in the United States in recent years, and in the contemporary research literature where the terms CAS and sCAS are used and preferred.

In general each of these terms refer to children who have the capacity (the neuro-muscular wherewithal, if you like) to say speech sounds but who have a problem with motor planning. Messages from the brain, intended to tell the speech mechanism (larynx, lips, tongue, palate and jaw) what movements to make to produce speech, do not occur easily for children with dyspraxia. This difficulty comprises both a motor planning problem AND a difficulty ‘retrieving’ speech sounds and patterns when they are required.

The characteristic speech of such children includes differences in the rhythm and timing (prosody or ‘melody’) of speech and inconsistent speech sound errors. The distinguishing characteristic of apraxia of speech is that it is a problem with motor speech planning and programming, with NO weakness, paralysis or poor co-ordination of the speech mechanism.

It is probably safe to say that that whether researchers or clinicians call the disorder DAS/CAS/sCAS, DAD or DVD, they would ALL agree that the features outlined above are characteristic of the speech problem they are studying, assessing or treating.

It is also probably true to say that whatever term is being used to name the problem, experienced clinicians at the ‘grass roots’ level will be drawing on a very similar range of therapy techniques and activities.

All of which begs the question: so why call the problem by different names? There are at least five main THEORIES that attempt to explain the basis of developmental apraxia. 

(1) It is due to an auditory processing problem 
(2) It is a very specific ‘specific language impairment’ affecting language acquisition at the sound-syllable-prosody level 
(3) It is due to an organisational problem with sequencing the movements required for speech  
(4) It is due to a difficulty with making volitional (pre-planned, if you like) movements for speech production 
(5) It is due to various combinations of these factors.

Importantly, these are THEORIES that are currently being formulated and tested by speech scientists. The fact is, we do not yet have a watertight explanation for dyspraxia.

Many clinicians and researchers actually working with children in the “apraxia population” who use the terms DAS and DAD tend to be those who veer towards the “motor based” explanation. 

Those who use the term DVD tend towards a “language based” explanation. Some clinicians use the terms DAS and DVD interchangeably. Some, who embrace the probability that the problem might be “linguistic” and “motor” in origin use DVD/DAS. 

Those who use the term CAS are probably au fait with the current research literature and current thinking about the disorder.

Then again, there are clinicians who use terms such as these because they have dropped into their clinical vernacular, in which case the term used does not reflect a particular theoretical orientation

The characteristics of Childhood Apraxia of Speech
To recapitulate, the distinguishing characteristic of childhood apraxia of speech is that it is a problem with motor speech planning and programming, with NO weakness, paralysis or poor co-ordination of the speech mechanism.

Some authorities believe that the primary difficulty children with dyspraxia have is with volitional (voluntary) movements of the speech production mechanism.

Children with CAS, if they are able to talk, usually make very variable articulation errors, their speech is slow, it seems very effortful to an onlooker, and there is a lot of ‘trial and error’ involved in trying to make particular sounds. The rhythm of speech usually seems wrong to the listener, and the child seems to put the emphasis in all the wrong spots (that is, there is something obviously unusual about their prosody).

The key features that alert a speech-language pathologist to the possibility of a CAS diagnosis in a young child are these:

1. The child may have no words, very few words, or up to 100 to 200 words in their vocabulary. They are unlikely to be attempting to make more than a handful of 2-word combinations.
2. Some give the impression of struggling to talk, exhibiting trial and error attempts to say words, accompanied by great frustration.
3. Many use self-taught signs and gestures to augment communication, which may include a lot of ingenious body language and facial expression. They MAY use a lot of mime and gesture to communicate. Some augment signs and gestures with a repertoire of sound-effects (car noises, and the like) to good effect.
4. Their speech has several of these characteristics:
   1. Words, in general, are not clearly spoken, though there may be remarkable exceptions such as a very clear (and useful!) ‘no’. Examples of this lack of clarity might include ‘ball’ being pronounced as ‘or’ and ‘knee’ being pronounced as ‘dee’.
   2. Speech errors affect vowels as well as consonants. For instance, ‘milk’ might be pronounced ‘mih’, ‘muh’ or ‘meh’.
   3. Inconsistency is evident, with the same word being pronounced in several different ways (e.g., ‘me’ pronounced as ‘ee’, ‘dee’, ‘bee’ ‘nee’, or ‘mee’). This is called token-to-token variability.
   4. Sounds that are used in some words are omitted from other words. I knew a child who could say ‘p’ TWICE in the word ‘Poppi’ (her grandfather) but who pronounced both ‘happy’ and ‘puppy’ as ‘huh-ee’.
   5. When asked to imitate speech sounds, sound effects (e.g., car noises: brm-brm etc) or words, the child does not seem to know where to start.
   6. They may have unusual intonation, pausing and stress patterns.
   7. They may not seem to know where to “put” nasal resonance.
       
5. Many of these children can UNDERSTAND LANGUAGE at a more advanced level than their limited speech would suggest. This is sometimes called the Receptive-Expressive gap.
6. They MAY not be able to easily copy mouth movements (i.e., non-speech movements) as well as their age-peers, and they may be (understandably!) reluctant to imitate speech movements and words.

Referred to as a ‘controversial’ diagnosis
Having said that CAS or sCAS is a motor speech disorder, it is important to note that it is a somewhat controversial diagnosis, with some authorities seeing it as a purely motor speech disorder with no ‘language’ (linguistic) component; others seeing it as a linguistically based disorder; others seeing it as a combination of these two; with yet another group doubting its very existence as a diagnostic entity!

My own position is that childhood apraxia of speech does exist, as a complex disorder and that no two children with it will be precisely the same. It can range from mild to severe. Some children with CAS appear to have a motor planning / programming problem with little or no accompanying language component. In my clinical experience this is a rarity. Most appear to have a motor planning / programming difficulty combined with associated linguistic difficulties, particularly phonological problems and difficulties with expressive grammar and syntax. I do not see these language difficulties as part of the CAS, but as difficulties that commonly occur alongside the CAS.

While the idea of a purely linguistic, or phonological basis (that is, no motor planning component) for DVD is intriguing, to date there is no convincing research data to support such a view.

Diagnosis
There is no actual AGE at which CAS can be diagnosed for sure. It is more to do with STAGE than age.

SLP’s often have CAS on their ‘short-list’ of probable diagnoses for children who are late talkers with difficult-to-understand-speech (especially if they have feeding difficulties and sensory integration issues too) but we cannot be really sure until the child has plenty to say, or, at the very least, is making many speech attempts.

Ideally, the SLP has to be in a position to do a detailed speech and language assessment that includes analysing speech movements, speech sounds, speech patterns and speech rhythms. To be able to do this the child has to be attempting to say lots of words.

SLP colleagues and I have made diagnoses of CAS in children who had vocabularies of between 100 and 200 words, and who ranged in age from 2;3 to 4;6. We also know of several children for whom a clear diagnosis of DAS was not possible until after the age of 7.

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Dr WIDODO JUDARWANTO

phone : 62(021) 70081995 – 62(021) 5703646, mobile : 0817171764

email : judarwanto@gmail.com 

Copyright © 2010, Children Speech Clinic  Information Education Network. All rights reserved

Dysarthrias have many causes and characteristics. Children with the various types of dysarthria have a neuromuscular impairment. That is, the speech mechanism (larynx, lips, tongue, palate and jaw) may be paralysed, weak or poorly co-ordinated. Dysarthrias can affect ALL motor speech processes: breathing, producing sounds in the larynx, articulation, resonance, and the ‘prosody’ or rhythm of speech.

Phonetic disorders, phonological disorders, dyspraxia and the dysarthrias co-occur
The disorders can occur, in varying degrees, in the same individual. For example, a child might have a severe developmental phonological disorder with mild dyspraxic features. Another child might have dyspraxia with mild dysarthria.

Occur with OTHER communication disorders
Specific language impairment (SLI), semantic-pragmatic language disorder (SPLD), stuttering, voice disorders and other communication disorders can occur in the same child, alongside phonological disorders, dyspraxia and dysarthria.

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CHILDREN SPEECH CLINIC Yudhasmara Foundation

Office ; JL Taman Bendungan Asahan 5 Jakarta Indonesia 10210  phone : 62(021) 70081995 – 5703646 email : judarwanto@gmail.com, http://clinicalpediatric.wordpress.com/ 

Clinic and Editor in Chief :

Dr WIDODO JUDARWANTO

phone : 62(021) 70081995 – 62(021) 5703646, mobile : 0817171764

email : judarwanto@gmail.com 

Copyright © 2010, Children Speech Clinic  Information Education Network. All rights reserved

Diagnosis yang tepat terhadap gangguan bicara dan bahasa pada anak, sangat berpengaruh terhadap perbaikan dan perkembangan kemampuan bicara dan bahasa. Terapi sebaiknya dimulai saat diagnosis ditegakkan, namun hal ini menjadi sebuah dilema, diagnosis sering terlambat karena adanya variasi perkembangan normal atau orang tua baru mengeluhkan gangguan ini kepada dokter saat mencurigai adanya kelainan pada anaknya, sehingga para dokter lebih sering dihadapkan pada aspek kuratif dan rehabilitatif dibandingkan preventif. Tata laksana dini terhadap gangguan ini akan membantu anak-anak dan orang tua untuk menghindari atau memperkecil kelainan di masa sekolah

Gangguan bicara dan bahasa pada anak cenderung membaik seiring pertambahan usia, dan pada dasarnya perkembangan bahasa dilatarbelakangi perawatan primer orang tua dan keluarga terhadap anak. Usaha preventif pada masa neonatus, bayi dan balita dapat dilakukan dengan memberi pujian dan respon terhadap segala usaha anak untuk mengeluarkan suara, serta member tanda terhadap semua benda dan kata yang menggambarkan kehidupan sehari-hari. Pola intonasi suara dapat diperbaiki sejalan dengan respon anak yang semakin mendekati pola orang dewasa.

Secara umum, anak akan berusaha untuk lebih baik saat orang dewasa merespon apa yang diucapkannya tanpa menekan anak untuk mengucapkan suara atau kata tertentu. Sebagai motivasi ketika seorang anak berbicara satu kata secara jelas, pendengan sebaiknya merespon tanpa paksaan dengan memperluas hingga dua kata.

Tindakan kuratif penatalaksanaan gangguan bicara dan bahasa pada anak disesuaikan dengan penyebab kelainan tersebut. Penatalaksanaan dapat melibatkan multi disiplin ilmu dan terapi ini dilakukan oleh suatu tim khusus yang terdiri dari fisioterapis, dokter, guru dan orang tua pasien. Beberapa jenis gangguan bicara dapat diterapi dengan terapi wicara, tetapi hal ini membutuhkan perhatian medis seorang dokter. Anak-anak usia sekolah yang memiliki gangguan bicara dapat diberikan pendidikan program khusus. Beberapa sekolah tertentu menyediakan terapi wicara kepada para murid selama jam sekolah, meskipun menambah hari belajar.

Konsultasi dengan psikoterapis anak diperlukan jika gangguan bicara dan bahasa diikuti oleh gangguan tingkah laku, sedangkan gangguan bicaranya dievaluasi oleh ahli terapi wicara.

Supported By

CHILDREN SPEECH CLINIC Yudhasmara Foundation

Office ; JL Taman Bendungan Asahan 5 Jakarta Indonesia 10210  phone : 62(021) 70081995 – 5703646 email : judarwanto@gmail.com, http://clinicalpediatric.wordpress.com/ 

Clinic and Editor in Chief :

Dr WIDODO JUDARWANTO

phone : 62(021) 70081995 – 62(021) 5703646, mobile : 0817171764

email : judarwanto@gmail.com 

Copyright © 2010, Children Speech Clinic  Information Education Network. All rights reserved

Supported By

CHILDREN SPEECH CLINIC Yudhasmara Foundation

Office ; JL Taman Bendungan Asahan 5 Jakarta Indonesia 10210  phone : 62(021) 70081995 – 5703646 email : judarwanto@gmail.com, http://clinicalpediatric.wordpress.com/ 

Clinic and Editor in Chief :

Dr WIDODO JUDARWANTO

phone : 62(021) 70081995 – 62(021) 5703646, mobile : 0817171764

email : judarwanto@gmail.com 

Copyright © 2010, Children Speech Clinic  Information Education Network. All rights reserved

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curriculum vitae

Copyright © 2010, Children Speech Clinic  Information Education Network. All rights reserved

Penyebab gangguan perkembangan bahasa sangat banyak dan luas, semua gangguan mulai dari proses pendengaran, penerusan impuls ke otak, otak, otot atau organ pembuat suara. Adapun beberapa penyebab gangguan atau keterlambatan bicara adalah gangguan pendengaran, kelainan organ bicara, retardasi mental, kelainan genetik atau kromosom, autis, mutism selektif, keterlambatan fungsional, afasia reseptif dan deprivasi lingkungan. Deprivasi lingkungan terdiri dari lingkungan sepi, status ekonomi sosial, tehnik pengajaran salah, sikap orangtua. Gangguan bicara pada anak dapat disebabkan karena kelainan organik yang mengganggu beberapa sistem tubuh seperti otak, pendengaran dan fungsi motorik lainnya.

Beberapa penelitian menunjukkan penyebab ganguan bicara adalah adanya gangguan hemisfer dominan. Penyimpangan ini biasanya merujuk ke otak kiri. Beberapa anak juga ditemukan penyimpangan belahan otak kanan, korpus kalosum dan lintasan pendengaran yang saling berhubungan. Hal lain  dapat juga di sebabkan karena diluar organ tubuh seperti lingkungan yang kurang mendapatkan stimulasi yang cukup atau pemakaian dua bahasa. Bila penyebabnya karena lingkungan biasanya keterlambatan yang terjadi tidak terlalu berat.

Terdapat tiga penyebab keterlambatan bicara terbanyak diantaranya adalah retardasi mental, gangguan pendengaran dan keterlambatan maturasi. Keterlambatan maturasi ini sering juga disebut keterlambatan bicara fungsional.

Keterlambatan bicara fungsional merupakan penyebab yang cukup sering  dialami oleh sebagian anak. Keterlambatan bicara fungsional sering juga diistilahkan keterlambatan maturasi atau keterlambatan perkembangan bahasa. Keterlambatan bicara golongan ini disebabkan karena keterlambatan maturitas (kematangan) dari proses saraf pusat yang dibutuhkan untuk memproduksi kemampuan bicara pada anak. Gangguan seperti ini sering dialami oleh laki-laki dan sering terdapat riwayat keterlambatan bicara pada keluarga. Biasanya hal ini merupakan keterlambatan bicara yang ringan dan prognosisnya baik. Pada umumnya kemampuan bicara akan tampak membaik setelah memasuki usia 2 tahun. Terdapat penelitian yang melaporkan penderita dengan keterlambatan ini, kemampuan bicara saat masuk usia sekolah akan normal seperti anak lainnya.

Dalam keadaan ini biasanya fungsi reseptif sangat baik dan kemampuan pemecahan masalah visuo-motor anak dalam keadaan normal. Anak hanya mengalami gangguan perkembangan ringan dalam fungsi ekspresif. Ciri khas lain adalah anak tidak menunjukkan kelainan neurologis, gangguan pendengaran, gangguan kecerdasan dan gangguan psikologis lainnya.

Faktor Internal

Berbagai faktor internal atau faktor biologis tubuh seperti faktor persepsi, kognisi dan prematuritas dianggap sebagai faktor penyebab keterlambatan bicara pada anak.

Persepsi

Kemampuan membedakan informasi yang masuk  disebut persepsi. Persepsi berkembang dalam 4 aspek : pertumbuhan, termasuk perkembangan sel saraf dan keseluruhan sistem; stimulasi, berupa masukan dari lingkungan  meliputi seluruh aspek sensori, kebiasaan, yang merupakan hasil dari skema yang sering terbentuk. Kebiasaan, habituasi, menjadikan bayi mendapat stimulasi baru yang kemudian akan tersimpan dan selanjutnya dikeluarkan dalam  proses belajar bahasa anak. Secara bertahap anak akan mempelajari stimulasi-stimulasi baru mulai dari raba, rasa, penciuman kemudian penglihatan dan pendengaran.

Pada usia balita, kemampuan persepsi auditori mulai terbentuk pada usia 6 atau 12 bulan, dapat memprediksi ukuran kosa kata dan kerumitan pembentukan pada usia 23 bulan.   Telinga sebagai organ sensori auditori berperan penting dalam perkembangan bahasa. Beberapa studi menemukan gangguan pendengaran karena otitis media pada anak akan mengganggu perkembangan bahasa.³⁷     

Sel saraf bayi baru lahir relatif belum terorganisir dan belum spesifik. Dalam perkembangannya, anak mulai membangun peta auditori dari fonem, pemetaan terbentuk saat fonem terdengar. Pengaruh bahasa ucapan berhubungan langsung terhadap jumlah kata-kata yang didengar anak selama masa awal perkembangan sampai akhir umur pra sekolah.

Kognisi

Anak pada usia ini sangat aktif mengatur pengalamannya ke dalam kelompok umum maupun konsep yang lebih besar. Anak belajar mewakilkan, melambangkan ide dan konsep. Kemampuan ini merupakan kemampuan kognisi dasar untuk pemberolehan bahasa anak.

Beberapa teori  yang menjelaskan hubungan antara kognisi dan bahasa :

1. Bahasa berdasarkan dan ditentukan oleh pikiran (cognitive determinism)
2. 2.      Kualitas pikiran ditentukan oleh bahasa (linguistic determinism)
3. Pada awalnya pikiran memproses bahasa tapi selanjutnya pikiran dipengaruhi oleh bahasa.
4. Bahasa dan pikiran adalah faktor bebas tapi kemampuan yang berkaitan.

Sesuai dengan teori-teori tersebut maka kognisi bertanggung jawab pada pemerolehan bahasa dan pengetahuan kognisi merupakan dasar pemahaman kata.

Prematuritas

Weindrich menemukan adanya faktor-faktor yang berhubungan dengan prematuritas yang mempengaruhi perkembangan bahasa anak, seperti berat badan lahir, Apgar score, lama perawatan di rumah sakit, bayi yang iritatif, dan kondisi saat keluar rumah sakit.

Beitchman, Hood, & Inglis, 1990; Spitz et al., 1997; Tallal, Ross, & Curtiss, 1989; Tomblin, Smith, & Zhang, 1997, melaporkan bahwa gangguan bahasa sekitar 40% dan 70% merupakan kecendrungan dalam suatu keluarga. Separuh keluarga yang memiliki anak dengan gangguan bahasa, minimal satu dari anggota keluarganya memiliki problem bahasa. Orang tua yang berpengaruh pada keturunan ini mungkin bertanggung jawab terhadap faktor-faktor genetik. Mungkin sulit mengetahui berapa banyak transmisi intergenerasi gangguan-gangguan bahasa tersebut, disebabkan oleh kurangnya dukungan lingkungan terhadap bahasa.

Faktor Eksternal (Faktor Lingkungan)

Riwayat keluarga

Demikian pula dengan anak dalam keluarga yang mempunyai riwayat keterlambatan atau gangguan bahasa beresiko mengalami keterlambatan bahasa pula.  Riwayat keluarga yang dimaksud antara lain anggota keluarga yang mengalami keterlambatan berbicara, memiliki gangguan bahasa, gangguan bicara atau masalah belajar.

Pola asuh

Law dkk juga menemukan bahwa anak yang menerima contoh berbahasa yang tidak adekuat dari keluarga, yang tidak memiliki pasangan komunikasi yang cukup dan juga yang kurang memiliki kesempatan untuk berinteraksi akan memiliki kemampuan bahasa yang rendah.

Lingkungan verbal

Lingkungan verbal mempengaruhi proses belajar bahasa anak. Anak di lingkungan keluarga profesional akan belajar kata-kata tiga kali lebih banyak dalam seminggu dibandingkan anak yang dibesarkan dalam keluarga dengan kemampuan verbal lebih rendah.

Pendidikan

Studi lain melaporkan juga ibu dengan tingkat pendidikan rendah merupakan faktor resiko keterlambatan bahasa pada anaknya.

Jumlah anak

Chouhury dan beberapa peneliti lainnya mengungkapkan bahwa jumlah anak dalam keluarga mempengaruhi perkembangan bahasa seorang anak, berhubugan dengan intensitas komunikasi antara orang tua dan anak.^38,39

Kemiskinan menempatkan anak pada resiko meningkatnya problem-problem rumah tangga (Halpern, 2000). Kemiskinan secara signifikan mempertinggi resiko terpaparnya masalah kesehatan seperti asma, malnutrisi (Klerman, 1991); gangguan kesehatan mental (Gore & Eckenrode, 1996; McLoyd, 1990; McLoyd & Wilson, 1991); kurang perhatian dan ketidak-teraturan perawatan dari orang tua (Halpern, 1993); dan defisit dalam perkembangan kognisi dan pencapaian keberhasilan (Duncan, Klebanov, & Brooks-Gunn, 1994; Levin, 1991). Beberapa penelitian menjelaskan bahwa keluarga yang bermasalah, terpapar lebih besar faktor-faktor resiko daripada keluarga yang  tidak berada dibawah level kemiskinan, dan konsekuensi dari faktor-faktor resiko ini dapat lebih berat pada anak-anak dalam keluarga ini (Attar, Guerra, & Tolan, 1994; Brooks-Gunn, Kleba-nov, & Liaw, 1995; Liaw & Brooks-Gunn, 1994; McLoyd, 1990).

Anak-anak yang terpapar berbagai faktor resiko, maka resiko untuk berkembang menjadi disabilitas akan meningkat. Salah satu yang termasuk disabilitas adalah specific language impairment (SLI), yang secara umum dijelaskan sebagai pencapaian yang buruk dalam berbahasa meskipun memiliki pendengaran dan intelegensi nonverbal normal (Spitz, Tallal, Flax, & Benasich, 1997). Lebih khusus hal ini dapat diartikan suatu kondisi yang menyebabkan seorang anak memiliki penilaian spesifik dibawah rata-rata standar tes bahasa, tetapi berada pada level rata-rata untuk tes intelegensi nonverbal (Fazio, Naremore, & Connell, 1996). Dengan demikian, pencegahan SLI dapat dengan mengidentifikasi faktor resiko anak sebelum diagnosis formal dibuat.

 Beberapa penelitian meneliti faktor-faktor resiko biologi untuk SLI dan penempatan-penempatan faktor lain dengan melihat “outcome” anak-anak sekolah yang ditempatkan di neonatal intensive care units (NICUs) setelah lahir dengan segera. Anak-anak dari populasi ini diketahui memiliki resiko untuk keterlambatan kognisi dan kesulitan akademik karena mereka biasanya lahir prematur, berat badan lahir rendah (kurang dari 2500 g) atau respiratori distres. Sebagian besar literatur menyatakan bahwa meskipun anak-anak dari NICU lebih beresiko mengalami kesulitan kognisi (seperti retardasi mental dan gangguan belajar), mereka tidak memiliki resiko yang meningkat untuk masalah spesifik bahasa, khususnya saat angka penilaian disesuaikan karena prematuritasnya (Resnick et al., 1998; Rice, Spitz, & O’Brien, 1999; Siegel et al., 1982; Tomblin, Smith, & Zhang, 1997).

Beberapa penelitian memperlihatkan bahwa gangguan bahasa umumnya terdapat kecenderungan dalam suatu keluarga berkisar antara 40% dan 70% (Beitchman, Hood, & Inglis, 1990; Spitz et al., 1997; Tallal, Ross, & Curtiss, 1989; Tomblin, Smith, & Zhang, 1997). Hampir separuh dari keluarga yang anak-anaknya mengalami gangguan bahasa, minimal satu dari anggota keluarganya memiliki problem bahasa. Dengan demikian orang tua yang berpengaruh pada keturunan ini mungkin bertanggung jawab terhadap faktor-faktor genetik. Mungkin tidak diketahui berapa banyak transmisi intergenerasi gangguan-gangguan bahasa tersebut disebabkan oleh kurangnya dukungan lingkungan terhadap bahasa.

Kondisi lingkungan merupakan hal yang penting menyangkut hasil perkembangan seorang anak. Beberapa anak yang datang dari keluarga yang tidak stabil dan kurangnya perhatian, perawatan, dan kurang memadainya kebutuhan nutrisi dan perawatan kesehatan, dapat membentuk level stress lingkungan yang merugikan bagi perkembangan anak termasuk bahasa (Wells, 1980). Untuk alasan ini, resiko dari problem-problem bahasa dikaitkan dengan faktor sosioekonomi dan kelemahan ekonomi. Peneliti-peneliti lain mendiskusikan beberapa variabel-variabel lingkungan yang tampak lebih dapat diprediksi:

1. higher birth order (Hoff-Ginsberg, 1998; Neils & Aram, 1986; Pine, 1995; Tallal et al., 1989; Tomblin, 1989, 1990; Tomblin, Hardy, & Hein, 1991);
2. Pendidikan ibu yang rendah (Paul, 1991; Rice et al., 1999; Tomblin, Records, et al., 1997; Tomblin, Smith, & Zhang, 1997); and
3. Orang tua tunggal (Andrews, Goldberg, Wellen, Pittman, & Struening, 1995; Goldberg, McLaughlin, Grossi, Tytun, & Blum, 1992; Miller & Moore, 1990).

Tersusunnya model resiko perkembangan dapat digunakan untuk memprediksi dengan lebih akurat, dengan mengkombinasi satu atau lebih faktor-faktor resiko tersebut (Sameroff, Seifer, Baldwin, & Baldwin, 1993; Sameroff, Seifer, Barocas, Zax, & Greenspan, 1987). Pernyataan-pernyataan yang diambil ini adalah efek komulatif dari resiko yang multipel,

Dalam suatu model penelitian dari Sameroff (1993) menunjukkan beberapa faktor resiko sosial dan keluarga diantaranya adalah : masalah-masalah kesehatan mental ibu, kecemasan ibu, maternal authoritarian childrearing attitudes, hubungan ibu-anak yang buruk, pendidikan ibu yang kurang dari menengah atas, orang tua yang kurang atau tidak memiliki ketrampilan dalam pekerjaan head of the household has a semiskilled or an unskilled occupation, status etnik minoritas, tidak ada bapak, beberapa tekanan kehidupan tahun terdahulu, dan ukuran keluarga yang besar.

Sebuah studi oleh Hooper, Burchinal, Roberts, Zeisel, and Neebe (1998) juga menyajikan fakta-fakta yang menggunakan model resiko komulatif untuk memprediksi kemampuan kognitif dan bahasa pada bayi yang lebih dipengaruhi oleh status sosioekonomi yang rendah pada populasi Afrika Amerika. Hooper  mengidentifikasi satu perangkat dari 10 faktor-faktor resiko sosial dan keluarga berdasarkan pada model resiko dari Sameroff berupa status kemiskinan, pendidikan ibu kurang dari sekolah menengah atas, ukuran keluarga yang besar, ibu yang tidak menikah, hidup yang penuh tekanan, dampak dari ibu yang depresi, interaksi ibu-anak yang buruk, IQ ibu, kualitas lingkungan rumah, dan kualitas perawatan sehari-hari.

Seluruh faktor resiko sosial dan keluarga dimasukkan ke dalam studi, saat bayi berusia 6 sampai 12 bulan. Peneliti-peneliti menemukan bahwa 9 dari 10 faktor-faktor resiko (tekanan hidup merupakan pengecualian) terkait dengan keberhasilan kognisi dan bahasa dari infan-infan. Komulatif indeks resiko dihubungkan dengan pengukuran bahasa (sekitar 12% sampai 17% dari varian) tetapi bukan pengukuran kognisi

Evans dan English (2002) menyajikan fakta-fakta bahwa anak-anak dengan orang tua berpenghasilan rendah terpapar faktor-faktor resiko lingkungan dalam jumlah yang lebih besar daripada yang berpenghasilan menengah. Mereka memperkenalkan tiga penyebab stress psikososial  (kekerasan, pertengkaran keluarga, perpisahan anak dengan keluarga) dan tiga penyebab stress fisik  (kekacauan, kegaduhan, kualitas rumah yang rendah) merupakan faktor resiko yang memberikan pengaruh negatif. Dalam penelitiannya tentang lingkungan yang miskin, mereka menemukan hanya 20% anak-anak yang hidup dalam keluarga dengan penghasilan yang rendah tidak terpapar satupun faktor resiko. Sebaliknya, 61% keluarga dengan penghasilan menengah tidak terpapar faktor resiko. Temuan ini menyatakan bahwa mayoritas anak-anak dari keluarga berpenghasilan rendah terpapar lebih banyak masalah kemelaratan daripada kelompok berpenghasilan menengah dan disfungsi kognitif, prilaku, atau sosial akan meningkat.

Sampai saat ini penelitian-penelitian terus mempelajari tentang perbedaan perkembangan bahasa anak yang diambil dari kultur dan latar-belakang sosioekonomi yang berbeda dan pengaruh dari perbedaan-perbedaan ini terhadap pencapaian akademik selajutnya. Robertson (1998) membandingkan kemampuan fonologi anak TK dari keluarga dengan SES tinggi dan rendah dan menemukan bahwa anak-anak dari SES rendah secara signifikan lebih buruk pada rangkaian pengukuran kognisi, linguistik, pra-baca. Dua tahun pemantauan terlihat bahwa anak-anak ini tidak mengejar anak-anak dari keluarga high-SES. Burt, Holm, and Dodd (1999) juga menemukan hubungan antara prestasi yang buruk dengan SES yang rendah dengan menilai prestasi anak-anak pada beberapa tugas-tugas fonologi. Suatu usaha untuk menjelaskan keterkaitan antara  kelemahan dan kegagalan sekolah, In an attempt to explain the link between disadvantage and school failure, maka Hart and Risley (1995) mempelajari perbedaan antara kualitas bahasa ditujukan pada anak-anak dengan latar belakang SES yang berbeda pada 2¹/2 tahun pertama kehidupan mereka. Mereka melaporkan bahwa anak-anak dari latar belakang SES yang rendah berada dalamkelemahan karena orang tua mereka atau pengasuh sangat jarang mengajak berbicara; akibatnya mereka miskin perbendaharaan kata dan kemampuan komunikasi dibanding kelompok SES yang lebih tinggi. 

Genetik

Laporan-laporan kasus sering memperlihatkan riwayat keluarga positif pada gangguan komunikasi. Antara 28% and 60% dari anak-anak dengan gangguan bicara dan bahasa mempunyai saudara kandung dan/atau orang tua yang juga mengalami kesulitan bicara dan bahasa. (e.g. Bishop and Edmundson 1986, Tallal et al. 1989, Whitehurst et al. 1991, Lewis 1992). Anggota keluarga laki-laki lebih berpengaruh dari pada wanita (Tallal et al. 1989, Lewis and Freebairn 1997). Bagaimanapun, data terbanyak memperlihatkan anak-anak dengan hanya gangguan bahasa saja dan tidak pada anak dengan gangguan bicara terpisah (isolated speech disorders). Lewis and Freebairn (1997) berhipotesa bahwa anak-anak dengan riwayat keluarga positif terhadap gangguan bicara akan membentuk grup spesifik ke dalam populasi gangguan bicara. Penemuan mereka tidak mendukung hipotesa karena tidak ada perbedaan signifikan yang ditemukan pada pengukuran artikulasi, fonologi, bahasa, kemampuan-kemampuan oral-motor atau kemampuan membaca dan menulis diantara anak-anak yang memiliki riwayat keluarga dengan gangguan bicara dibanding yang bukan. Akan tetapi disimpulkan bahwa riwayat keluarga yang positif masih bisa “dipertimbangkan sebagai faktor resiko yang bisa digunakan untuk identifikasi awal sehingga memungkinkan dilakukan intervensi dini bagi anak-anak yang keluarganya memperlihatkan gangguan ini (Lewis and Freebairn 1997: 398).

Otitis media

Sekitar 80% dari seluruh anak prasekolah mengalami satu atau lebih episode otitis media Akut (OMA) atau otitis media effusion (OME) (Grievink et al. 1993). Selama episode ini, anak-anak mengalami fluktuasi kehilangan pendengaran, biasanya antara 20 dB dan 50 dB (Gravel and Nozza 1997 for a review), mempengaruhi jumlah dan kualitas bicara dan bahasa yang didengar. Banyak studi yang melaporkan kemungkinan ada hubungan antara otitis media dengan atau tanpa efusi dan keterlambatan perkembangan bicara dan bahasa. Lima artikel membahas khusus tentang hal ini (Roberts et al. 1991, 1997, Pagel Paden 1994, Roberts and Clarke-Klein 1994, Schwartz et al. 1997). Artikel-artikel ini menyimpulkan bahwa banyak, tetapi tidak semua anak yang mengalami episode infeksi telinga tengah mempunyai gangguan bicara dan bahasa, dan tidak semua anak yang mempunyai gangguan bicara dan bahasa mengalami infeksi telinga tengah.

Pre dan perinatal

Penyebab spesifik berhubungan antara kesulitan pre dan perinatal dengan gangguan bicara dan bahasa juga telah dibuktikan. Infeksi selama kehamilan, imaturitas dan berat badan lahir rendah dilaporkan mempunyai efek negatif pada perkembangan bicara dan bahasa (Byers-Brown and Edwards 1989, Tomblin et al. 1991, 1997, Peters et al. 1997, Gerber 1998). Bagaimanapun, Bax and Stevenson (1982) and Menyuk et al. (1986) menemukan perbedaan yang tidak signifikan sejumlah kejadian antara imaturitas dan berat badan lahir rendah anak dan kontrolnya.  Saat paling banyak studi-studi terfokus pada anak-anak dengan gangguan bahasa, Byers-Brown et al. (1986) melaporkan secara signifikan keterlambatan proses pengeluaran suara dalam bicara pada anak imatur. Lebih jauh diperlukan penelitian yang mengkhususkan pada anak-anak dengan gangguan bicara terpisah.

Sucking habits

Gangguan bicara mungkin dihubungkan dengan kebiasaan-kebiasan mengisap pada anak. Dianggap bahwa mengisap yang berlebihan dengan menggunakan jempol dan botol berperan sebagai pengaman (pacifier) pada gangguan myofunction, menurunnya oral awareness, menurunnya kemampuan motorik oral (Garliner 1971, Hahn 1988, Hensel and Splieth 1998). Gangguan fungsi otot sering dihubungkan dengan kesulitan-kesulitan bicara. Terpisah dari ditegakkannya hubungan antara /s/ distorsi dan gangguan fungsi otot (e.g. Hahn 1988, Hensel and Splieth 1998) ada fakta-fakta yang tidak memperlihatkan adanya hubungan antara kebiasaan mengisap, kemampuan motorik oral dan gangguan bicara.

Ringkasnya, hubungan antara faktor-faktor resiko dengan perkembangan bicara dan bahasa masih belum jelas. Terbanyak studi-studi focus pada anak-anak dengan kombinasi bicara dan bahasa atau hanya gangguan bahasa terpisah yang mungkin tidak menggambarkan anak-anak dengan gangguan bicara terpisah.

Daftar Pustaka

1. Delgado, Christine E. F.; Vagi, Sara J.; Scott, Keith G.Early Risk Factors for Speech and Language Impairments. Exceptionality, v13 n3 p173-191 2005
2. Margaret Snowling ^a1c1, D. V. M. Bishop ^a2 and Susan E. Stothard ^a3Is Preschool Language Impairment a Risk Factor for Dyslexia in Adolescence? Journal of Child Psychology and Psychiatry (2000), 41:5:587-600
3. Fox A. V.¹; Dodd B.¹; Howard D.¹Risk factors for speech disorders in children. International Journal of Language & Communication Disorders, Volume 37, Number 2, 1 April 2002 , pp. 117-131(15)
4. J. G. Barry*^,†, I. Yasin ^† D. V. M. Bishop Heritable risk factors associated with language impairments
5. Brant LJ, Gordon-Salant S, Pearson JD, Klein LL, Morrell CH, Metter EJ, Fozard JL. Risk factors related to age-associated hearing loss in the speech frequencies. J Am Acad Audiol. 1996 Jun;7(3):152-60
6. Fox A V; Dodd Barbara; Howard David. Risk factors for speech disorders in children. International journal of language & communication disorders / Royal College of Speech & Language Therapists 2002;37(2):117-31.
7. McGrath Lauren M; Hutaff-Lee Christa; Scott Ashley; Boada Richard; Shriberg Lawrence D; Pennington Bruce F. Children with comorbid speech sound disorder and specific language impairment are at increased risk for attention-deficit/hyperactivity disorder.Journal of abnormal child psychology 2008;36(2):151-63.
8. Salameh E.¹; Nettelbladt U.¹; Gullberg B.¹Risk factors for language impairment in Swedish bilingual and monolingual children relative to severity. Acta Paediatrica, Volume 91, Number 12, 2002 , pp. 1379-1384(6)
9. Kisilevsky BS, Hains SM, Brown CA, Lee CT, Cowperthwaite B, Stutzman SS, Swansburg ML, Lee K, Xie X, Huang H, Ye HH, Zhang K, Wang Z. Fetal sensitivity to properties of maternal speech and language. Infant Behav Dev. 2009 Jan;32(1):59-71. Epub 2008 Dec 5.
10. von Kries R, von Suchodoletz W, Stränger J, Toschke AM. Television in a child’s bedroom–a possible risk factor for expressive language impairment in 5- and 6-year-old children. Gesundheitswesen. 2006 Oct;68(10):613-7
11. O’Callaghan, Michael, Williams, Gail M.Andersen, Margaret J.
    Bor, William Najman, Jake M. Social and Biological Risk Factors for Mild and Borderline Impairment of Language Comprehension in a Cohort of Five-Year-Old Children. Developmental Medicine and Child Neurology. 1995-01-01;37,12,1051-1061
12. Tina L. Stanton-Chapman, Derek A. Chapman, Ann P. Kaiser, Terry B. Hancock .Cumulative Risk and Low-Income Children’s Language Development. Topics in Early Childhood Special Education, Vol. 24, No. 4, 227-237 (2004)

Supported By

CHILDREN SPEECH CLINIC Yudhasmara Foundation

Office ; JL Taman Bendungan Asahan 5 Jakarta Indonesia 10210  phone : 62(021) 70081995 – 5703646 email : judarwanto@gmail.com, http://clinicalpediatric.wordpress.com/ 

Clinic and Editor in Chief :

Dr WIDODO JUDARWANTO

phone : 62(021) 70081995 – 62(021) 5703646, mobile : 0817171764

email : judarwanto@gmail.com 

curriculum vitae

Copyright © 2010, Children Speech Clinic  Information Education Network. All rights reserved

Myklebust membagi tahap perkembangan bahasa berdasarkan komponen ekspresif dan reseptif sebagai berikut :

1. Lahir – 9 bulan : anak mulai mendengar dan mengerti, kemudian berkembanglah pengertian konseptual yang sebagian besar nonverbal.
2. Sampai 12 bulan : anak berbahasa reseptif auditorik, belajar mengerti apa yang dikatakan, pada umur 9 bulan belajar meniru kata-kata spesifik misalnya dada, muh, kemudian menjadi mama, papa.
3. Sampai 7 tahun : anak berbahasa ekspresif auditorik termasuk persepsi auditorik kata-kata dan menirukan suara. Pada masa ini terjadi perkembangan bicara dan penguasaan pasif kosa kata sekitar 3000 buah.
4. Umur 6 tahun dan seterusnya : anak berbahasa reseptif visual (membaca). Pada saat masuk sekolah ia belajar membandingkan bentuk tulisan dan bunyi perkataan.
5. Umur 6 tahun dan seterusnya : anak berbahasa ekspresif visual (mengeja dan menulis).

 Daftar pustaka

• Myklebust M. Prelinguistic Communication. In: Yule W, Rutter M,eds.  Language development and disorders; Clinics in developmental medicine. 1968.

Supported By

CHILDREN SPEECH CLINIC Yudhasmara Foundation

Office ; JL Taman Bendungan Asahan 5 Jakarta Indonesia 10210  phone : 62(021) 70081995 – 5703646 email : judarwanto@gmail.com, http://clinicalpediatric.wordpress.com/ 

Clinic and Editor in Chief :

Dr WIDODO JUDARWANTO

phone : 62(021) 70081995 – 62(021) 5703646, mobile : 0817171764

email : judarwanto@gmail.com 

curriculum vitae

Copyright © 2010, Children Speech Clinic  Information Education Network. All rights reserved

Perkembangan Pragmatik

Perkembangan komunikasi anak sesungguhnya sudah dimulai sejak dini, pertama-tama dari tangisannya bila bayi merasa tidak nyaman, misalnya karena lapar, popok basah. Dari sini bayi akan belajar bahwa ia akan mendapat perhatian ibunya atau orang lain saat ia menangis sehingga kemudian bayi akan  menangis bila meminta orang dewasa melakukan sesuatu buatnya.

Usia 3 minggu bayi tersenyum saat ada rangsangan dari luar, misalnya wajah seseorang, tatapan mata, suara dan gelitikan. Ini disebut senyum sosial. Usia 12 minggu mulai dengan pola dialog sederhana berupa suara balasan bila ibunya memberi tanggapan. Usia 2 bulan bayi mulai menanggapi ajakan komunikasi ibunya. Usia 5 bulan bayi mulai meniru gerak-gerik orang, mempelajari bentuk ekspresi wajah. Pada usia 6 bulan bayi mulai tertarik dengan benda-benda sehinga komunikasi menjadi komunikasi ibu, bayi dan benda-benda. Usia 7-12 bulan anak menunjuk sesuatu untuk  menyatakan keinginannya. Gerak-gerik ini akan berkembang disertai dengan  bunyi-bunyi tertentu yang mulai konsisten. Pada masa ini sampai sekitar 18 bulan, peran gerak-gerik lebih menonjol dengan penggunaan satu suku kata. Usia 2 tahun anak kemudian memasuki tahap sintaksis  dengan mampu merangkai kalimat 2 kata, bereaksi terhadap pasangan bicaranya dan masuk dalam dialog singkat. Anak mulai memperkenalkan atau merubah topik dan mulai belajar memelihara alur percakapan dan menangkap persepsi pendengar. Perilaku ibu yang fasilitatif akan membantu anaknya dalam memperkenalkan topik baru. Lewat umur 3 tahun anak mulai berdialog lebih lama sampai beberapa kali giliran. Lewat umur ini, anak mulai mampu mempertahankan topik yang selanjutnya mulai membuat topik baru. Hampir 50 persen anak 5 tahun dapat mempertahankan topik melalui 12 kali giliran.

Sekitar 36 bulan, terjadi peningkatan dalam keaktifan berbicara dan anak memperoleh  kesadaran sosial dalam percakapan. Ucapan yang ditujukan pada pasangan bicara  menjadi jelas, tersusun baik dan teradaptasi baik untuk pendengar.²  Sebagian besar pasangan berkomunikasi anak adalah orang dewasa, biasanya orang tua. Saat anak mulai membangun jaringan sosial melibatkan orang di luar keluarga, mereka akan memodifikasi pemahaman diri dan bayangan diri dan menjadi lebih sadar akan standar sosial. Lingkungan linguistik memiliki pengaruh bermakna pada proses belajar berbahasa. Ibu memegang kontrol dalam membangun dan mempertahankan dialog yang benar. Ini berlangsung sepanjang usia pra sekolah.

Anak berada pada fase mono dialog, percakapan sendiri dengan kemauan untuk melibatkan orang lain. Monolog kaya akan lagu, suara, kata-kata tak bermakna, fantasi verbal dan ekspresi perasaan.

Perkembangan Semantik

Karena faktor lingkungan sangat berperan dalam perkembangan semantik, maka pada umur 6-9 bulan anak telah mengenal orang atau benda yang berada di sekitarnya. Leksikal dan pemerolehan konsep berkembang pesat pada masa pra sekolah. Terdapat indikasi bahwa anak dengan kosa kata lebih banyak akan lebih popular di kalangan teman-temannya. Diperkirakan terjadi penambahan 5 kata perhari di usia 1,5  sampai 6 tahun.² Pemahaman kata bertambah tanpa pengajaran langsung orang dewasa.  Terjadi strategi pemetaan yang cepat di usia ini sehingga anak dapat menghubungkan suatu kata dengan rujukannya. Pemetaan yang cepat adalah  langkah awal  dalam proses pemerolehan leksikal. Selanjutnya  secara bertahap anak akan mengartikan lagi informasi-informasi baru yang diterima.

Definisi kata benda anak usia pra sekolah meliputi properti fisik seperti bentuk, ukuran dan warna, properti fungsi, properti pemakaian dan lokasi. Definisi kata kerja anak pra sekolah juga berbeda dari kata kerja orang dewasa atau anak yang lebih besar. Anak pra sekolah dapat menjelaskan  siapa, apa, kapan, di mana, untuk apa, untuk siapa, dengan apa, tapi biasanya mereka belum memahami pertanyaan bagaimana dan mengapa atau menjelaskan proses.⁴ 

Anak akan mengembangkan kosa katanya melalui cerita yang dibacakan orang tuanya. Begitu kosa kata berkembang, kebutuhan untuk mengorganisasikan kosa kata akan lebih  meningkat, dan beberapa jaringan semantik atau antar relasi akan terbentuk.

Perkembangan Sintaksis

Susunan sintaksis paling awal terlihat pada usia kira-kira 18 bulan walaupun pada beberapa anak terlihat pada usia 1 tahun bahkan lebih dari 2 tahun. Awalnya berupa kalimat dua kata. Rangkaian dua kata, berbeda dengan masa “kalimat satu kata” sebelumnya yang disebut masa holofrastis.³⁰ Kalimat satu kata bisa ditafsirkan dengan mempertimbangkan konteks penggunaannya. Hanya mempertimbangkan arti kata semata-mata tidaklah mungkin kita menangkap makna dari kalimat satu kata tersebut.

Peralihan dari satu kata menjadi kalimat yang merupakan rangkaian kata terjadi secara bertahap. Pada waktu kalimat pertama terbentuk yaitu penggabugan dua kata menjadi kalimat, rangkaian kata tersebut berada pada jalinan intonasi. Jika kalimat dua kata tersebut memberi makna lebih dari satu maka anak membedakannya dengan menggunakan pola intonasi yang berbeda.

Perkembangan pemerolehan sintaksis meningkat pesat pada waktu anak menjalani usia 2 tahun, yang mencapai puncaknya pada akhir usia 2 tahun.

Supported By

CHILDREN SPEECH CLINIC Yudhasmara Foundation

Office ; JL Taman Bendungan Asahan 5 Jakarta Indonesia 10210  phone : 62(021) 70081995 – 5703646 email : judarwanto@gmail.com, http://clinicalpediatric.wordpress.com/ 

Clinic and Editor in Chief :

Dr WIDODO JUDARWANTO

phone : 62(021) 70081995 – 62(021) 5703646, mobile : 0817171764

email : judarwanto@gmail.com 

curriculum vitae

Copyright © 2010, Children Speech Clinic  Information Education Network. All rights reserved

Pada sebagian besar manusia area bahasa terletak pada hemisfer serebri kiri. Terdapat empat area bahasa secara konvensional yaitu dua area bahasa reseptif dan dua lainnya adalah eksekutif  yang menghasilkan bahasa. Dua area reseptif berhubungan erat dengan zona bahasa sentral. Area reseptif berfungsi mengatur persepsi  bahasa  yang diucapkan, yaitu area 22 posterior yang disebut area Wernicke dan girus Heschls (area 41 dan 42). Area yang mengatur persepsi bahasa tulisan menempati girus angulus (area 39) pada lobus parietal inferior anterior terhadap area reseptif visual. Girus supra marginal yang terletak di antara pusat bahasa auditori dan visual dan area temporal inferior yang terletak di anterior korteks asosiasi visual kemungkinan adalah bagian dari zona bahasa sentral juga. Area-area ini terletak pada pusat integrasi untuk fungsi bahasa visual dan auditori.

Area Broadman 44 dan 45 disebut area Broca dan merupakan bagian eksekutif utama yang bertanggung jawab terhadap aspek motorik bicara. Secara visual kata-kata yang diterima diekspresikan dalam bentuk tulisan  melalui area tulisan Exner. Area sensori dan motori terhubungkan satu dengan yang lain melalui fasikulus arkuatum yang melewati ismus lobus temporal kemudian memutari ujung posterior fisura silvii, sambungan lainnya melalui kapsula eksterna nukleus lentikular.²⁷         

Area penerimaan visual dan somatosensori terintegrasi pada lobus parietal, sedangkan penerimaan auditori terletak di lobus temporal. Serat  pendek, menghubungkan area Broca dengan korteks rolandi bawah yang menginervasi  organ bicara, otot  bibir, lidah, farings dan  larings. Area menulis Exner juga terintegrasi dengan organ motor untuk otot tangan. Area bahasa perisylvian juga terhubungkan  dengan striata dan thalamus dan area korespondensi pada hemisfer non dominan melalui korpus kalosum dan komisura anterior.

Tiga fungsi dasar otak adalah fungsi pengaturan, proses dan formulasi.Fungsi pengaturan bertanggungjawab untuk tingkat energi dan tonus korteks secara keseluruhan. Fungsi proses berlokasi di belakang korteks, mengontrol analisa informasi, pengkodean dan penyimpanan. Korteks yang lebih tinggi bertanggung jawab untuk memproses rangsangan sensori seperti rangsangan optik, akustik dan olfaktori. Data dari tiap sumber digabungkan dengan sumber sensori lainnya untuk dianalisa dan diformulasikan. Proses formulasi berlokasi pada lobus frontal, bertanggung jawab untuk formasi intensi dan perilaku. Fungsi utamanya adalah untuk mengaktifkan otak untuk pengaturan atensi dan konsentrasi.

Meskipun hemisfer kiri dan kanan simetris untuk proses motorik dan sensoris, namun terdapat juga ketidaksimetrisan untuk fungsi khusus tertentu seperti bahasa. Dengan demikian, meskipun fungsinya berbeda, kedua hemisfer tersebut saling berintegrasi dan memberi informasi melalui korpus kalosum dan subkortikal lainnya. Fungsi yang menonjol dari hemisfer serebri kiri adalah sebagai fungsi dasar untuk bahasa. Teori yang paling umum mengatakan traktus kortikospinal berasal dari hemisfer kiri yang berisi lebih banyak serat dan menyilang lebih tinggi dibanding hemifer kanan. Belajar juga merupakan suatu faktor, terjadi banyak pergeseran dari kiri ke kanan (shifted sinistral). Pada sebagian anak terjadi pergeseran  ke kanan hemisfer di usia muda, dan menjadi bertangan kidal.

Daftar Pustaka

1. Victor M, Ropper AH. Priciples of Neurology Adams and Victor’s, seventh edition. McGraw-Hill.2001.

Supported  by CHILDREN SPEECH CLINIC Yudhasmara Foundation

Office ; JL Taman Bendungan Asahan 5 Jakarta Indonesia 10210  phone : 62(021) 70081995 – 5703646 email : judarwanto@gmail.com, http://clinicalpediatric.wordpress.com/ 

Clinic and Editor in Chief :

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phone : 62(021) 70081995 – 62(021) 5703646, mobile : 0817171764

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curriculum vitae

Copyright © 2010, Children Speech Clinic  Information Education Network. All rights reserved

Tahap perkembangan bahasa menurut Bzoch yang membagi perkembangan bahasa anak dari lahir sampai usia 3 tahun dalam empat stadium.

1. Perkembangan bahasa bayi sebagai komunikasi prelinguistik. 0-3 bulan.  Periode lahir sampai akhir tahun pertama.  Bayi baru lahir belum bisa menggabungkan elemen bahasa baik isi, bentuk dan pemakaian bahasa. Selain belum berkembangnya bentuk bahasa konvensional, kemampuan kognitif bayi juga belum berkembang. Komunikasi lebih bersifat reflektif daripada terencana. Periode ini disebut prelinguistik. Meskipun bayi belum mengerti dan belum bisa mengungkapkan bentuk bahasa konvensional, mereka mengamati dan memproduksi suara dengan cara yang unik. Klinisi harus menentukan apakah bayi mengamati atau bereaksi terhadap suara. Bila tidak, ini merupakan indikasi untuk evaluasi fisik dan audiologi. Selanjutnya intervensi direncanakan untuk membangun lingkungan yang menyediakan banyak kesempatan untuk mengamati dan bereaksi terhadap suara.
2. Kata-kata pertama : transisi ke bahasa anak. 3-9 bulan. Salah satu perkembangan bahasa utama milestone adalah pengucapan kata-kata pertama yang terjadi pada akhir tahun pertama, berlanjut sampai satu setengah tahun saat pertumbuhan kosa kata berlangsung cepat, juga tanda dimulainya pembetukan kalimat awal.  Berkembangnya kemampuan kognitif, adanya kontrol dan interpretasi emosional di periode ini akan memberi arti pada kata-kata pertama anak. Arti kata-kata pertama mereka dapat merujuk ke benda, orang, tempat, dan kejadian-kejadian di seputar lingkungan awal anak.
3. Perkembangan kosa kata yang cepat-Pembentukan kalimat awal. 9-18 bulan.  Bentuk kata-kata pertama menjadi banyak, dan dimulainya produksi kalimat. Perkembangan komprehensif dan produksi kata-kata berlangsung cepat pada sekitar 18 bulan. Anak mulai bisa menggabungkan kata benda dengan kata kerja yang kemudian menghasilkan sintaks. Melalui interaksinya dengan orang dewasa, anak mulai belajar mengkonsolidasikan isi, bentuk dan pemakaian bahasa dalam percakapannya. Dengan semakin berkembangnya kognisi dan pengalaman afektif, anak mulai bisa berbicara memakai kata-kata yang tersimpan dalam memorinya.  Terjadi pergeseran dari pemakaian kalimat satu kata menjadi bentuk kata benda dan kata kerja.
4. Dari percakapan bayi menjadi registrasi anak pra sekolah yang menyerupai orang dewasa. 18-36 bulan. Anak dengan mobilitas yang mulai meningkat memiliki akses ke jaringan sosial yang lebih luas dan perkembangan kognitif menjadi semakin dalam.  Anak mulai berpikir konseptual, mengkategorikan benda, orang dan peristiwa serta dapat  menyelesaikan masalah fisik Anak terus mengembangkan pemakaian bentuk fonem dewasa.

Supported  by CHILDREN SPEECH CLINIC Yudhasmara Foundation

Office ; JL Taman Bendungan Asahan 5 Jakarta Indonesia 10210  phone : 62(021) 70081995 – 5703646 email : judarwanto@gmail.com, http://clinicalpediatric.wordpress.com/ 

Clinic and Editor in Chief :

Dr WIDODO JUDARWANTO

phone : 62(021) 70081995 – 62(021) 5703646, mobile : 0817171764

email : judarwanto@gmail.com 

curriculum vitae

Copyright © 2010, Children Speech Clinic  Information Education Network. All rights reserved

Komunikasi adalah suatu alat yang digunakan oleh manusia untuk berinteraksi satu dengan yang lainnya dalam bentuk bahasa. Komunikasi tersebut terjadi baik secara verbal maupun non verbal yaitu dengan tulisan, bacaan dan tanda atau simbol.⁵ Berbahasa itu sendiri merupakan proses yang kompleks dan tidak terjadi begitu saja. Setiap individu berkomunikasi lewat bahasa memerlukan suatu proses yang berkembang dalam tahap-tahap usianya. Bagaimana bahasa bisa digunakan untuk berkomunikasi selalu menjadi pertanyaan yang menarik untuk dibahas sehingga memunculkan banyak teori tentang pemerolehan bahasa.^1,12

Bahasa adalah bentuk aturan atau sistem lambang yang digunakan anak dalam berkomunikasi dan beradaptasi dengan lingkungannya yang dilakukan untuk bertukar gagasan, pikiran dan emosi. Bahasa bisa diekspresikan melalui bicara yang mengacu pada simbol verbal. Selain itu bahasa  dapat juga diekspresikan melalui  tulisan, tanda gestural dan musik. Bahasa juga dapat mencakup aspek komunikasi nonverbal seperti gestikulasi, gestural atau pantomim. Gestikulasi adalah ekspresi gerakan tangan dan lengan untuk menekankan makna wicara. Pantomim adalah sebuah cara komunikasi yang mengubah komunikasi verbal dengan aksi yang mencakup beberapa gestural (ekspresi gerakan yang menggunakan setiap bagian tubuh) dengan makna yang berbeda beda.¹

Gangguan bicara dan bahasa adalah salah satu penyebab gangguan perkembangan yang paling sering ditemukan pada anak. Keterlambatan bicara adalah keluhan utama yang sering dicemaskan dan dikeluhkan orang tua kepada dokter. Gangguan ini semakin hari tampak semakin meningkat pesat. Beberapa laporan menyebutkan angka kejadian gangguan bicara dan bahasa berkisar 5 – 10% pada anak sekolah.¹²

Penyebab keterlambatan bicara sangat  banyak dan luas, gangguan tersebut ada yang ringan sampai yang berat, mulai dari yang bisa membaik hingga yang sulit untuk membaik. Keterlambatan bicara fungsional merupakan penyebab yang sering  dialami oleh sebagian anak. Keterlambatan bicara golongan ini biasanya ringan dan hanya merupakan ketidakmatangan fungsi bicara pada anak. Pada usia tertentu terutama setelah usia 2 tahun akan membaik. Bila keterlambatan bicara tersebut bukan karena proses fungsional maka gangguan tersebut harus lebih diwaspadai karena bukan sesuatu yang ringan.

Semakin dini mendeteksi keterlambatan bicara, maka semakin baik kemungkinan pemulihan gangguan tersebut. Bila keterlambatan bicara tersebut nonfungsional maka harus cepat dilakukan stimulasi dan intervensi pada anak tersebut. Deteksi dini keterlambatan bicara harus dilakukan oleh semua individu yang terlibat dalam penanganan anak. Kegiatan deteksi dini ini melibatkan orang tua, keluarga, dokter kandungan yang merawat sejak kehamilan dan dokter anak yang merawat anak tersebut.¹

DEFINISI

Kata bahasa berasal dari bahasa latin “lingua” yang berarti lidah. Awalnya pengertiannya hanya merujuk pada bicara, namun selanjutnya digunakan sebagai bentuk sistem konvensional dari simbol-simbol yang dipakai dalam komunikasi.¹²

American Speech-Language Hearing Association Committee on Language mendefinisikan bahasa sebagai : suatu sistem lambang konvensional yang kompleks dan dinamis yang dipakai dalam berbagai cara berpikir dan berkomunikasi.¹³

Dalam Kamus  Bahasa Indonesia, bahasa didefinisikan sebagai : suatu sistem lambang bunyi yang  arbitrer, yang digunakan oleh suatu anggota masyarakat untuk bekerja bersama, berinteraksi dan  mengidentifikasikan diri.^14,15 Kamus bahasa Inggris juga memberi definisi yang sama tentang bahasa.¹⁶ 

Terdapat perbedaan mendasar antara bicara dan bahasa. Bicara adalah pengucapan yang menunjukkan ketrampilan seseorang mengucapkan suara dalam suatu kata. Bahasa berarti menyatakan dan menerima informasi dalam suatu cara tertentu. Bahasa merupakan salah satu cara berkomunikasi. Bahasa reseptif adalah kemampuan untuk mengerti apa yang dilihat dan apa yang didengar. Bahasa ekspresif adalah kemampuan untuk berkomunikasi secara simbolis baik visual (menulis, memberi tanda) atau auditorik.^14,16

Seorang anak yang mengalami gangguan berbahasa mungkin saja ia dapat mengucapkan satu kata dengan jelas tetapi tidak dapat menyusun dua kata dengan baik, atau sebaliknya seorang anak mungkin saja dapat mengucapkan sebuah kata yang sedikit sulit untuk dimengerti tetapi ia dapat menyusun kata-kata tersebut dengan benar untuk menyatakan keinginannya.¹⁷  

Masalah bicara dan bahasa sebenarnya berbeda tetapi kedua masalah ini sering kali tumpang tindih.¹⁷  Gangguan bicara dan bahasa terdiri dari masalah artikulasi, suara, kelancaran bicara (gagap), afasia (kesulitan dalam menggunakan kata-kata, biasanya akibat cedera otak) serta keterlambatan dalam bicara atau bahasa. Keterlambatan bicara dan bahasa dapat disebabkan oleh berbagai faktor termasuk faktor lingkungan atau hilangnya pendengaran. Gangguan bicara dan bahasa juga berhubungan erat dengan area lain yang mendukung proses tersebut seperti fungsi otot mulut dan fungsi pendengaran. Keterlambatan dan gangguan bisa mulai dari bentuk yang sederhana seperti bunyi suara yang “tidak normal” (sengau, serak) sampai dengan ketidakmampuan untuk mengerti atau menggunakan bahasa, atau ketidakmampuan mekanisme motorik oral dalam fungsinya untuk bicara dan makan.¹⁸

Gangguan perkembangan artikulasi meliputi kegagalan mengucapkan satu huruf sampai beberapa huruf, sering terjadi penghilangan atau penggantian bunyi huruf tersebut sehingga menimbulkan kesan cara bicaranya seperti anak kecil. Selain itu juga dapat berupa gangguan dalam pitch, volume atau kualitas suara.¹⁸

Afasia yaitu kehilangan kemampuan untuk membentuk kata-kata atau kehilangan kemampuan untuk menangkap arti kata-kata sehingga pembicaraan tidak dapat berlangsung dengan baik. Anak-anak dengan afasia didapat memiliki riwayat perkembangan bahasa awal yang normal, dan memiliki onset setelah trauma kepala atau gangguan neurologis lain (contohnya kejang).^18-20

Gagap adalah gangguan kelancaran atau abnormalitas dalam kecepatan atau irama bicara. Terdapat pengulangan suara, suku kata atau kata atau suatu bloking yang spasmodik, bisa terjadi spasme tonik dari otot-otot bicara seperti lidah, bibir dan laring. Terdapat kecendrungan adanya riwayat gagap dalam keluarga. Selain itu, gagap juga dapat disebabkan oleh tekanan dari orang tua agar anak bicara dengan jelas, gangguan lateralisasi, rasa tidak aman, dan kepribadian anak.^18,19

Epidemiologi

Gangguan bicara dan bahasa dialami oleh 8% anak usia prasekolah. Hampir sebanyak 20% dari anak berumur 2 tahun mempunyai gangguan keterlambatan bicara. Keterlambatan bicara paling sering terjadi pada usia 3-16 tahun. ^1,21

Pada anak-anak usia 5 tahun, 19% diidentifikasi memiliki gangguan bicara dan bahasa (6,4% keterlambatan berbicara, 4,6% keterlambatan bicara dan bahasa, dan 6% keterlambatan bahasa). Gagap terjadi 4-5% pada usia 3-5 tahun dan 1% pada usia remaja. Laki-laki diidentifikasi memiliki gangguan bicara dan bahasa hampir dua kali lebih banyak daripada wanita. Sekitar 3-6% anak usia sekolah memiliki gangguan bicara dan bahasa tanpa gejala neurologi, sedangkan pada usia prasekolah prevalensinya lebih tinggi yaitu sekitar 15%. Menurut penelitian anak dengan riwayat sosial ekonomi yang lemah memiliki insiden gangguan bicara dan bahasa yang lebih tinggi daripada anak dengan riwayat sosial ekonomi menengah ke atas.^1,21

  Studi Cochrane terakhir telah melaporkan data keterlambatan bicara, bahasa dan gabungan keduanya pada anak usia prasekolah dan usia sekolah. Prevalensi keterlambatan perkembangan bahasa dan bicara pada anak usia 2 sampai 4,5 tahun adalah 5-8%, prevalensi keterlambatan bahasa adalah 2,3-19%.²² Sebagian besar studi melaporkan prevalensi dari 40% sampai 60%.^7,22,23 

Prevalensi keterlambatan perkembangan berbahasa di Indonesia belum pernah diteliti secara luas.^1,24 Kendalanya dalam menentukan kriteria keterlambatan perkembangan berbahasa. Data di Departemen Rehabilitasi Medik RSCM tahun 2006, dari 1125 jumlah kunjungan pasien anak terdapat 10,13% anak terdiagnosis keterlambatan bicara dan bahasa.²⁵  Penelitian Wahjuni tahun 1998 di salah satu kelurahan di Jakarta Pusat menemukan prevalensi keterlambatan bahasa sebesar 9,3% dari 214 anak yang berusia bawah tiga tahun.²⁶

Daftar Pustaka

1. Soetjiningsih. Perkembangan anak dan permasalahannya. Dalam:Narendra MB,Sularyo TS, Soetjiningsih, Suyitno H, 

Ranuh IG, penyunting. Buku Ajar Tumbuh Kembang Anak dan Remaja; Edisi I. Jakarta : Ikatan Dokter Anak Indonesia. Jakarta, Sagung Seto, 2002; 91

1. Busari JO, Weggelaar NM. How to investigate and manage the child who is slow to speak. BMJ 2004; 328:272­ 276
2. Parker S, Zuckerman B, Augustyn M. Developmental and behavioral Pediatrics (2nd ed): Language Delays. Philadelphia : Lippincott Williams & Wilkins, 2005
3. Owens RE. Language Development an Introduction, 5th edition. New York:Allyn and Bacon; 2001.
4. Smith C, Hill J, Language Development and Disorders of Communication and Oral Motor Function. In : Molnar GE, Alexander MA,editors. Pediatric Rehabilitation. Philadelphia: Hanley and Belfus;1999.p. 57-79.
5. Rydz D, Srour M, Oskoui M, Marget N, Shiller M, Majnemer A, et.al. Screening for developmental delay in the setting of a community pediatr clinic: A Prospective assessment of parent-Report questionnaires. Pediatrics 2006;118;e1178-e1186.
6. Silva PA, Williams SM, McGee R. A longitudinal study of children with developmental language delay at age three; later intelligence , reading and behavior problems. Dev Med Child Neurol 1987;29;630-640.
7. Chris V, Suzanne H, Erik JA, Scherder, Ben M, Esther H. Motor Profile of Children With Development Speech and Language Disoreders. Pediatris, v0l 120 no 1 July, pp.e158-e163.
8. K. Alcock. Oral movements and language. Down Syndrome Research and Practice 11(1), 1-8. © 2006 The Down Syndrome Educational Trust. All Rights Reserved. ISSN: 0968-7912. Diunduh dari http://information. downsed. Org/ dsrp/11/01
9. Moore CA, Ruark JL. (1996). Does speech emerge from earlier appearing oral motor behaviors? Journal of Speech and Hearing Research 1996;39(5), 1034-1047.
10. Dworkin JP, Culatta RA . Oral structural and neuromuscular characteristics in children with normal and disordered articulation. Journal of Speech and HearingmDisorders 1985;50(2), 150-156.
11. Chaer A, Psiokolinguistik Kajian Teoritik. Jakarta: Rineka Abdi.. 2003
12. Owens RE. Language Development an Introduction, 5th edition. New York:Allyn and Bacon; 2001.
13. Salim P, Salim Y, Kamus Bahasa Indonesia Kontemporer, Edisi kedua.Jakarta: Modern English Press;1995.
14. Alwi H, Sugono D, Adiwinata SS. Kamus Besar Bahasa Indonesia, edisi ketiga, Departement Pendidikan Nasional. Jakarta: Balai pustaka;2005.
15. Oxford Learner’s Dictionary, New Ediition. Oxford University Press. 2003
16. Coplan, James. Normal speech and language development : Pediatric In Review1995; 91­99
17. Markum, AH. Gangguan perkembangan berbahasa. Dalam : Markum, Ismael S, Alatas H, Akib A, Firmansyah A, Sastroasmoro S, editor. Buku ajar ilmu kesehatan anak. Jilid I. Jakarta : Balai Penerbit FKUI, 1991; 56­69
18. Virginia W, Meredith G, Dalam : Adam, boeis highler. Gangguan bicara dan bahasa. Buku ajar penyakit telinga, hidung, tenggorok. Edisi 6. Jakarta : EGC, 1997 ; 397­410.
19. Kaplan,   Harold   I.   Gangguan   komunikasi.   Dalam   :   I   Made   Wiguna,   editor. Sinopsis  psikiatri  :  Bina  Rupa  Aksara, 1997 ; 766­82
20. British medical journal. Language disorders: a 10 year  research  update  review.  Bmj ; 2000.
21. Council on Children with Disabilities, Section on Developmental Behavioral Pediatrics, Bright Futures Steering committee and Medical Home Initiatives for Children with special needs Project Advisory Committee.  Identifying infants and young children with  developmental disorders in the Medical Home: An algorithm for developmental surveillance and screening. Pediatrics 2006;118;405-420.
22. Law J, Bowle J, Harris F, Harkness A, Nye C., Screening for speech and language delay; a systematic review of literature, In: Health Technology Assessment 1998 Vol2(9).
23. Sidiarto L. Berbagai gangguan berbahasa pada anak. Proceedings of Pertemuan Linguistik Lembaga Bahasa Atma Jaya Keempat. Jakarta: Penerbit Kanisius; 1991.
24. Departemen Rehabilitasi Medik. Buku laporan pasien rawat jalan. Jakarta. 2006
25. Wahjuni S. Pemeriksaan Penyaring Keterlambatan Perkembangan Bahasa pada Anak Batita dengan Early Language Milestone Scale di Kelurahan Paseban Jakarta Pusat. Jakarta. FKUI. 1998

Supported  by

CHILDREN SPEECH CLINIC  Yudhasmara Foundation

Office ; JL Taman Bendungan Asahan 5 Jakarta Indonesia 10210   phone : 62(021) 70081995 – 5703646

email : judarwanto@gmail.com, 

http://clinicalpediatric.wordpress.com/ 

Clinic and Editor in Chief :

Dr WIDODO JUDARWANTO

phone : 62(021) 70081995 – 62(021) 5703646, mobile : 0817171764

email : judarwanto@gmail.com 

curriculum vitae

Copyright © 2010, Children Speech Clinic  Information Education Network. All rights reserved

Clarita Barbosa1 , Sandra Vasquez1 , Mary A Parada2 , Juan Carlos Velez Gonzalez1 , Chanaye Jackson2 , N David Yanez2,3 , Bizu Gelaye2  and Annette L Fitzpatrick2,4 

1 

Corporacion de Rehabilitacion Club De Leones Cruz Del Sur, Punta Arenas, Chile

2 

Multidisciplinary International Research Training Program, University of Washington, School of Public Health, Seattle, Washington, USA

3 

Department of Biostatistics, University of Washington, School of Public Health, Seattle, Washington, USA

4 

Departments of Epidemiology and Global Health, University of Washington, School of Public Health, Seattle, Washington, USA

author email⁠ corresponding author email⁠

BMC Pediatrics 2009, 9:66⁠doi:10.1186/1471-2431-9-66

The electronic version of this article is the complete one and can be found online at: http://www.biomedcentral.com/1471-2431/9/66

Received:

Accepted:

Published:

© 2009 Barbosa et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background

Previous studies have shown that children’s nonnutritive sucking habits may lead to delayed development of their oral anatomy and functioning. However, these findings were inconsistent. We investigated associations between use of bottles, pacifiers, and other sucking behaviors with speech disorders in children attending three preschools in Punta Arenas (Patagonia), Chile.

Methods

Information on infant feeding and sucking behaviors, age starting and stopping breast- and bottle-feeding, pacifier use, and other sucking behaviors, was collected from self-administered questionnaires completed by parents. Evaluation of speech problems was conducted at preschools with subsequent scoring by a licensed speech pathologist using age-normative standards.

Results

A total of 128 three- to five-year olds were assessed, 46% girls and 54% boys. Children were breastfed for an average of 25.2 (SD 9.6) months and used a bottle 24.4 (SD 15.2) months. Fifty-three children (41.7%) had or currently used a pacifier for an average of 11.4 (SD 17.3) months; 23 children (18.3%) were reported to have sucked their fingers. Delayed use of a bottle until after 9 months appeared to be protective for subsequent speech disorders. There was less than a one-third lower relative odds of subsequent speech disorders for children with a delayed use of a bottle compared to children without a delayed use of a bottle (OR: 0.32, 95% CI: 0.10-0.98). A three-fold increase in relative odds of speech disorder was found for finger-sucking behavior (OR: 2.99, 95% CI: 1.10-8.00) and for use of a pacifier for 3 or more years (OR: 3.42, 95% CI: 1.08-10.81).

Conclusion

The results suggest extended use of sucking outside of breastfeeding may have detrimental effects on speech development in young children.

Background

It has been suggested that children in the Chilean Patagonia use milk bottles and pacifiers far beyond recommendations of health personnel. Of primary importance is answering the question, what type of feeding, breast or bottle, is better for oral cavity architecture and the influence on the acquisition of early speech. The development of oral motor structures is reflected on craniofacial development and dentition [1]. To identify potential risk factors for speech disorders in children, there is a need to better understand the association between early life feeding and sucking behaviors and subsequent speech development.

The relationships between children’s sucking habits and the impact on the development of their oral anatomy and functioning have been described in the literature. Agurto et al studied 1,110 Chilean children between the ages of 3 to 6 years of age. They reported bad oral habits were associated with development of dentomaxilar anomalies [2]. Linder and Modeer studied 76 four year old children to investigate the relationship between sucking habits (dummy or fingers) and dental characteristics in children with unilateral cross bite. The results indicated that duration and intensity of sucking habits may adversely influence dental characteristics by reducing the transverse width of the maxillary arch [3].

Duncan et al studied a cohort of 867 children using a family questionnaire on sucking habits at 15, 24, and 36 months of age and a dental examination at 31, 43, and 61 months of age. The results indicated that at 15 months, 63% of children had a sucking habit, 38% used just a dummy and 23% used a digit. By 36 months, sucking had reduced to 40% with similar prevalence of dummy and digit sucking. Both habits had effects on developing dentition, most notably on upper labial segment alignment and the development of anterior open bites and posterior cross bites [4]. In one study [5] involving 108 children, a significant association between children who were bottle fed and presence of anteroposterior malocclusion was reported. Breastfeeding was also found to decrease the risk of getting this type of malocclusion. The investigators noted that when bottle feeding occurs, only the buccinator muscles and the orbicular muscle(s) of the mouth are exerted without stimulating other muscles. They concluded sucking only during breastfeeding promotes correct muscle activity, and thus proper development of the oral motor structures [5].

Broad performed a study in 1972 in Putaruru, New Zealand that examined the effects of infant feeding on speech quality [6]. Broad investigated clarity of articulation, tonal quality, confidence, and reading ability in 5 and 6 year old children. There was a significant association between clarity of speech and breastfed males but not females, and breastfeeding was associated with improved tonal quality and reading ability of both males and females [6]. Breastfeeding has been found to be beneficial in other studies of linguistic and cognitive development [7]. The development of coordinated breathing, chewing, swallowing and speech articulation has also been shown to be associated with breastfeeding. It is believed that breastfeeding promotes mobility, strength, and posture of the speech organs. Such speech organs include: lips, tongue, maxilla, mandible, cheeks, soft palate, hard palate, dental arch, floor of mouth, and more. In order for speech development to occur, the child must suck with consistent rhythm and strength. Movements while sucking can cause absorption of the sucking pads and growth of the mandible. As a result, the intra-oral space increases [1]. Moreover, studies have shown that breastfeeding protects normal dentition [8-10].

Fox et al in their study of German children with speech-disorders reported a significantly higher incidence of bottle and pacifier use compared to normal children [11]. Children of industrialized western countries are more likely to use pacifiers and to feed using a bottle than children in developing countries. Over the last few decades, use of bottles and pacifiers has increased approximately 75% to 79% in the West [12-14]. In non-industrialized countries such as Tanzania and Zimbabwe, pacifier use and finger sucking are less common or non-existent [14]. This has also been found in families with lower social economic status. A study conducted in Santiago, Chile by Olguin and Quintana reported 28% of breastfed and 52% of non-breastfed children used pacifiers [15]. They also found that mothers (88% of the time) were more likely to use of pacifiers without a specific reason for their use [15]. It is reasonable to conclude that whether a child is breast or bottle fed depends on both cultural and economic factors.

From the above it is apparent that feeding-sucking behaviors and speech-oral anatomy development have positive and negative impacts on speech. In the current study we intended to move beyond assessment of oral musculature to the speech disorder that may impair communication and literacy [16]. We describe an observational study designed to evaluate risk factors among pre-school Chilean Patagonia children focusing on past and present sucking behaviors as reported by their parents. We also sought to see the extent to which early feeding and sucking patterns might influence speech disorders.

Methods

Data were collected on 128 children aged 37 to 70 months old attending three local public kindergartens in Punta Arenas (Patagonia), Chile, during the school years of 2006 and 2007. Information was gathered utilizing parent questionnaires, child speech evaluations and physical examinations of the children’s mouths conducted by a pediatrician. Parental informed consent and assent from the participating children were received prior to conduct of the study. This project was reviewed by and received approval from the local Institutional Review Board governing this research (Centro de Rehabilitacion Club de Leones Cruz del Sur, Punta Arenas, Chile). Before analysis, personal identifiers were removed from each data set. The Human Subjects Division of the University of Washington, USA granted approval to use the de-identified and anonymised data set for analysis.

Parent Questionnaires

Parent questionnaires [Additional File 1] consisted of 79 questions intended to collect information on each child’s feeding history, demographics, and social economic status. To investigate the effect of oral development from feeding, the questionnaire asked parents to answer the following questions: whether or not the child drank from a bottle and if yes, how often; in what position, and when the child stopped bottle feeding (if not still using one). Similar questions were asked about use of a pacifier, use of a security blanket (it is often common for children in Chile to suck the blanket while going to sleep), and whether the child sucked their fingers. Parental (mother and father) education, income, and parental perceptions about the child’s ability to communicate were also surveyed.

Speech Evaluation

A standard phonological evaluation used by Chilean speech therapists, TEPROSIF (test to evaluate simplified phonological processes) was utilized to determine the type and number of errors in the child-age related phonological processes. TEPROSIF is based on the natural phonology theory from the classical work of Stampe [17] and Ingram [18]. This theory proposes that during development, children produce words in a simplified manner using a group of simplification strategies known as phonological processes. The TEPROSIF test was validated among 620 normal Chilean children between the ages of 3 and 7 years old [19]. The validation study was conducted in 5 different regions of the country. The study findings indicated that the TEPROSIF test had high degree of reliability (Cronbach alpha = 0.9). Another study done among children with specific language disorders and a control group showed that children with speech language disorders produced phonological processes more often than the normal controls (p < 0.005) [19].

To perform this test, an evaluator first shows a child a series of black and white drawings from a test booklet. Then the examiner tells him/her a standardized phrase that includes the name of the figure and the child is asked to imitate the production. If the child does not complete the phrase, the examiner repeats the name of the figure and asks the child to repeat it. The responses are used to determine child's ability to produce particular speech sounds. These responses are written down, phonetically transcribed by a licensed speech therapist. Common errors are determined including changes of syllable structure, substitution, and assimilation. Categories scores were determined using procedures previously described by Maggiolo and Pavez [16]. Those with mean for age +/- 1 standard deviations (SD) were categorized as normal; those with less than -1SD were grouped as below normal, and those with greater than 1SD were categorized as above normal.

Statistical Analysis

Descriptive statistics were calculated using cross-tabulations for categorical variables and grouped means and standard deviations for continuously measured variables. In Tables 1 and 2, chi-square tests were used to compare the age categories and categorical characteristics; regression analysis was used to compare continuous characteristics to age. In Table 3, chi-square tests were used to compare categorical characteristics to the TEPROSIF classifications. The p-values are omnibus tests of association between the two variables. Multivarible logistic regression was used to investigate the associations between potential risk factors and speech disorder outcomes. Both unadjusted models and adjusted models (adjusting for gender and age) were fitted to obtain estimated odds ratios (ORs) and 95% confidence intervals (CIs). Wald test statistics were used in all hypothesis tests. All p-values are two-sided. These analyses were conducted using the SPSS (version 13.0) statistical package.

Results

Descriptive Analyses

Table 1 provides a summary of selected characteristics and children's ages in our study sample in this study. Of 128 children total, there were 58 three year olds (45%), 49 four year olds (31%) and 21 five year olds (13%). Twenty-six percent of mothers were younger than 20 years, approximately 50% of the mothers had high school education, and 30% were college educated. Approximately 75% of mothers had a normal gestation period, although 19 births (15%) occurred in less than 38 weeks of gestation. Approximately 16% babies had low birth weight (< 2500 grams).

In Table 2, we present summaries on breastfeeding and other sucking behaviors versus children's age. Five children (4%) were not breastfed, 30% were breastfed for more than one year. Almost all (85%) children were bottle fed more than 18 months; almost half of children were bottle fed more than three years (47%). Forty two percent of the children used a pacifier and approximately 33% of these children used them for more than 3 years. Only 23 children (18.3%) were reported to have sucked their fingers for comfort.

Association with phonological processes

Table 3 shows sucking behavior according to the evaluated level of phonological processes. In these bivariate summaries only one behavior, having ever sucked their finger, was significantly associated with the three speech processing classifications (p = .02). Several other variables showed higher percentages of children with below normal speech processing classifications and high levels of sucking behaviors. These associations, however, were not statistically significant. Children with below normal occurrence of speech phonological processes were breastfed for a shorter period of time; only 26% were breastfed for 12 months or longer, compared to 35.7% and 32.0% with normal or above normal phonological processes respectively. More than twice as many children with below normal phonological processes used a pacifier for more than three years compared to those without speech problems.

Logistic regression was used to evaluate associations between feeding/sucking behaviors and the level of phonological processes categorized as below normal versus normal. The unadjusted and adjusted (gender and age) results are shown in Table 4. The results indicate children born pre-term had an increased risk of developmental problems with speech; children with gestational age less than 38 weeks had three times higher odds of having an abnormal score on the TEPROSIF compared to those of normal gestation group (OR: 3.27, 95% CI: 1.0 – 10.2). Adjusted for age and gender, delayed use of a bottle until after 9 months appears to be protective from subsequent speech disorders by less than one-third relative odds (OR: 0.32, 95% CI: 0.10-0.98). A three-fold increase in relative odds of speech disorder was found with any finger-sucking behavior (OR: 2.99, 95% CI: 1.10 – 8.00). Those who used a pacifier for 3 or more years were so found to have a three-fold an increased relative odds of speech disorders (OR: 3.4, 95% CI: 1.08-10.81).

Discussion

Results of this study indicate that finger sucking behaviors and prolonged use of a pacifier for 3 years or more may be detrimental to optimal speech development in young children. There was less than a one-third lower relative odds of subsequent speech disorders for children with a delayed use of a bottle compared to children without a delayed use of a bottle (OR: 0.32, 95% CI: 0.10-0.98). A three-fold increase in relative odds of speech disorder was found for finger-sucking behavior (OR: 2.99, 95% CI: 1.10, 8.00) and for use of a pacifier for 3 or more years (OR: 3.42, 95% CI: 1.08, 10.81).

While our study findings indicate that habits of longer durations (longer than three years) may provide the greatest risk of speech disorders, others have found that nonnutritive sucking habits of shorter durations may affect oral development as well. Warren et al [10] studied dental arch and occlusal conditions of 4 to 5 years old children with a variety of different nonnutritive sucking habit durations. They found that children with nonnutritive sucking habits past the age of 48 months, compared to children with a shorter duration of nonnutritive sucking habits, were more likely to have narrower maxillary arch widths, greater overjet, higher prevalence of open bite, and posterior crossbite. They concluded that while habits continuing past 48 months produced the greatest changes in dental arch and occlusal characteristics, there are also detectable differences between children that have had shorter sucking durations and minimal sucking durations [20]. It has been proposed, however, that these effects may be reversible. Verrastro et al evaluated occlusal and orafacial myofunctional characteristics of twenty seven 3 to 5 year old-children. They reported that removal of pacifier sucking habit was significantly associated with a reduction of 2 mm on anterior bite (P < .001), an improvement of lip posture (P = .03), favored nasal breathing (P = . 008), and a reduction in the occurrence of tongue interposition while swallowing (P = .008) [21].

In Brazil, Tomita et al examined the effect of oral habits and speech problems on dental occlusion in a cross-sectional study of 2,139 children between the ages 3 to 5 years. They found that habit of sucking a pacifier was a greater risk factor for malocclusion (OR = 5.46) followed by habit of finger sucking (OR 1.54). They also reported found that speech did not show any influence in malocclusion occurrence [22].

Our study involved a number of strengths as well as limitations. Strengths included a larger sample size compared to other studies, the use of a standardized test to evaluate the children's speech and the use of a speech pathologist to score the tests. There are limitations to this study. First, due to the observational nature of the study design, confounding factors could adversely impact our findings. Second, the parent's survey data were collected by self-reports and there is the possibility of measurement error and recall biases. Measurement error tends to bias the observed results to the null and one might reasonably assume the associations would be stronger if more precisely measured variables were collected. It may also be a challenge to generalize these results to a wider population of children. At last, the fact that some of the sample children were born prematurely, being them at greater risk per se for speech delays.

Conclusion

These results suggest that sucking habits such as pacifier use, finger sucking and bottle feeding are associated with speech disorders in preschool children. The age at which the child started bottle feeding was separated into three categories, less than three months, three to nine months, and more than nine months. Starting bottle feeding after 9 months was found to be better for the suppression of phonological processes, since it is protective against obtaining an abnormal classification on the Test for classifying these processes. Finger sucking, on the other hand, proved to be harmful to the development of these processes. This is reflected on the finding that children who suck their fingers were about three times more likely to obtain an abnormal classification on the TEPROSIF evaluation of simplified phonological processes. Pacifier use was also shown to negatively impact the development of speech alterations if used for more than three years while less was not found to be harmful. Although results of this study provide further evidence for the benefits of longer duration of breastfeeding of infants, they should be interpreted with caution as these data are observational. Further investigation of larger studies and clinical trials are needed to confirm these findings.

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

CB, SV, and JCV conceived the study, participated in the design of the study, carried out data collection, and drafted the manuscript. MP and CJ participated in data analysis, interpretation and drafted the manuscript. AF supervised the study and the students for this project and led the analysis, participated in interpretation, drafting and critical review of the manuscript. NDY participated in data analysis, interpretation, contributed towards drafting and provided critical review of the manuscript. BG participated in critical review and format of the manuscript. All authors read and approved the final manuscript

Acknowledgements

This research was completed while Ms. Mary Parada and Ms. Chanaye Jackson were research training fellows with the Multidisciplinary International Research Training (MIRT) Program of the University of Washington, School of Public Health. The MIRT Program is supported by an award from the National Institutes of Health, National Center on Minority Health and Health Disparities (T37-MD001449). The authors wish to thank Corporación de Rehabilitación Club de Leones Cruz del Sur, Punta Arenas, Chile for providing facilities and logistics support throughout the research process and Junta Nacional de Jardines Infantiles de Chile (JUNJI) for granting access to conduct the study.

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CHILDREN SPEECH CLINI

http://childrenspeechclinic.wordpress.com

Dorman, Michael F.; Loizou, Philipos C.; Kemp, Lauren L.; Iler Kirk, and Karen

Ear and Hearing . 21(6):590-596, December 2000.

Abstract

Objective: The aims of this study were 1) to determine the number of channels of stimulation needed by normal-hearing adults and children to achieve a high level of word recognition and 2) to compare the performance of normal-hearing children and adults listening to speech processed into 6 to 20 channels of stimulation with the performance of children who use the Nucleus 22 cochlear implant.

Design: In E-periment 1, the words from the Multisyllabic Le-ical Neighborhood Test (MLNT) were processed into 6 to 20 channels and output as the sum of sine waves at the center frequency of the analysis bands. The signals were presented to normal-hearing adults and children for identification. In E-periment 2, the wideband recordings of the MLNT words were presented to early-implanted and late-implanted children who used the Nucleus 22 cochlear implant.

Results: E-periment 1: Normal-hearing children needed more channels of stimulation than adults to recognize words. Ten channels allowed 99% correct word recognition for adults; 12 channels allowed 92% correct word recognition for children. E-periment 2: The average level of intelligibility for both early- and late-implanted children was equivalent to that found for normal-hearing adults listening to four to si- channels of stimulation. The best intelligibility for implanted children was equivalent to that found for normal-hearing adults listening to si- channels of stimulation. The distribution of scores for early- and late-implanted children differed. Nineteen percent of the late-implanted children achieved scores below that allowed by a 6-channel processor. None of the early-implanted children fell into this category.

Conclusions: The average implanted child must deal with a signal that is significantly degraded. This is likely to prolong the period of language acquisition. The period could be significantly shortened if implants were able to deliver at least eight functional channels of stimulation. Twelve functional channels of stimulation would provide signals near the intelligibility of wideband signals in quiet.

CHILDREN SPEECH CLINIC

http://childrenspeechclinic.wordpress.com

Nature 387, 176 – 178 (08 May 1997); doi:10.1038/387176a0



Beverly A. Wright*†, Linda J. Lombardino‡, Wayne M. King‡, Cynthia S. Puranik‡, Christiana M. Leonard§ & Michael M. Merzenich*

* Keck Center for Integrative Neurosdence, Box 0732, University of California, San Francisco, California 94143-0732, USA
‡ Department of Communication Processes and Disorders, § Department of Neurosdence and University of Florida Brain Institute, University of Florida, Gainesville, Florida 32611, USA
†Present address: Audiology and Hearing Sciences Program, Northwestern University, 2299 North Campus Drive, Evanston, Illinois 60208-3550, USA.

Between 3 and 6 per cent of children who are otherwise unimpaired have extreme difficulties producing and understanding spoken language1. This disorder is typically labelled specific language impairment. Children diagnosed with specific language impairment often have accompanying reading difficulties (dyslexia)2, but not all children with reading difficulties have specific language impairment3. Some researchers claim that language impairment arises from failures specific to language or cognitive processing4–6. Others hold that language impairment results from a more elemental problem that makes affected children unable to hear the acoustic distinctions among successive brief sounds in speech7–11. Here we report the results of psycho-physical tests employing simple tones and noises showing that children with specific language impairment have severe auditory perceptual deficits for brief but not long tones in particular sound contexts. Our data support the view that language difficulties result from problems in auditory perception, and provide further information about the nature of these perceptual problems that should contribute to improving the diagnosis and treatment of language impairment and related disorders.

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CHILDREN SPEECH CLINIC

http://childrenspeechclinic.wordpress.com

Tova Most and Miriam Peled

Tel-Aviv University, Israel

Correspondence should be addressed to Tova Most, School of Education, Tel Aviv University, Israel 69978 (e-mail: tovam{at}post.tau.ac.il).

Received October 26, 2006.

Revision received March 1, 2007.

Accepted March 7, 2007.

Abstract

This study assessed perception of suprasegmental features of speech by 30 prelingual children with sensorineural hearing loss. Ten children had cochlear implants (CIs), and 20 children wore hearing aids (HA): 10 with severe hearing loss and 10 with profound hearing loss. Perception of intonation, syllable stress, word emphasis, and word pattern was assessed. Results revealed that the two HA groups significantly outperformed the CI group in perceiving both intonation and stress. Within each group, word pattern was perceived best, and then intonation and emphasis, with syllable stress perceived poorest. No significant correlation emerged between age at implantation and perception of the various suprasegmental features, possibly due to participants’ relatively late age at implantation. Results indicated that CI use did not show an advantage over HA use in the perception of suprasegmental features of speech. Future research should continue to explore variables that might improve this perception.

CHILDREN SPEECH CLINIC

http://childrenspeechclinic.wordpress.com

BMJ. 2000 October 14; 321(7266): 908–909.

Copyright © 2000, BMJ

James Law, reader

Language and Communication Sciences, City University, London EC1V 0HB

Gina Conti-Ramsden, professor of child language and learning

School of Education, University of Manchester, Manchester M13 9PL


About 5-8% of children under the age of 5 have developmental impairments of speech and language. This proportion is higher than that for any other neurodevelopmental condition occurring at that age.1 Parents are concerned about these impairments, and the number of children being referred to speech and language therapy services is increasing.2

These impairments are characterised by a low level of speech and language skills. Such difficulties may occur secondary to disabilities such as cerebral palsy, sensorineural hearing loss, or autism. Impairment may also be the main symptom in a constellation of comorbid difficulties, such as challenging behaviour or otitis media.3

Although spontaneous remission of symptoms in primary speech and language disorders sometimes occurs many children will experience long term effects from these disorders. Studies of samples of children from different communities show that children who are at the extreme ends of the distribution of speech and language impairment are at risk of developing problems that can persist into adulthood.4–6 The inability to communicate with peers can have a marked effect on wellbeing.

Given what we know about the stability of speech and language impairments across time, what role can intervention play? There is evidence to suggest that some interventions can modify intelligence,7 and the literature about the Head Start programmes in the United States has shown that preschool programmes have a long term impact in terms of social outcomes (for example, in reducing the incidence of teenage pregnancy or incarceration).8 Clinical experience suggests that speech (whether difficulties involve dyspraxic—that is, neuromotor—or phonological presentations) and vocabulary can be modified but that it is much more difficult to change elements of syntax and verbal comprehension.

At first glance the picture painted by Glogowska et al in this issue of the BMJ (p923) is gloomy.9 Interventions for speech and language impairments do not seem to work. However, there are some features of this study that should be interpreted cautiously. On average the children spent just six hours with their speech and language therapist in 12 months. How long would it take most people to change their speech and language behaviours? More than six hours, we would argue, even if clients were highly motivated. It is particularly important to note that both groups of children in the study (those who were given therapy and those who were not) continued to have marked language difficulties.

This study also needs to be set against a recent systematic review of studies of speech and language impairments that identified effect sizes for randomised and quasi-experimental study designs on the order of one standard deviation.10 This corresponds to a shift from the 25th to the 5th centile: a good improvement by any standard. These studies all included children of comparable ages and levels of language impairment. The source of the difference provides a potential explanation for the findings of Glogowska and colleagues. All of the studies in the review offered more treatment. In many cases the studies were carried out in university clinics and could best be described as efficacy rather than effectiveness studies. On the other hand, Glogowska et al’s project is a study of the routine clinical services that are currently available to children in the United Kingdom.

Taken together the data indicate that offering limited amounts of speech and language therapy is not a tenable solution to the problem. The six hours provided did not necessarily reflect the choice of the speech and language therapists in the study but rather a constraint imposed on them by the “package of care” model of service delivery. The data suggest that such a simplistic model is not helpful and that the practitioners and their managers should be able to offer a more flexible package of interventions. This is likely to require a reorganisation of speech and language therapy services, but this is the point of practising evidence based medicine: when you fill the evidence gap you need to act.

Notes

Papers p 923

References

1. Drillien C, Drummond M. Developmental screening and the child with special needs. London: Heinemann; 1983.

2. Reid J, Millar S, Tait L, Donaldson ML, Dean EC, Thomason GOB, et al. The role of speech and language therapists in the education of pupils with special educational needs. Edinburgh: Edinburgh Centre for Research in Child Development; 1996.

3. Bax M, Hart H, Jenkins S. Child development and child health. Oxford: Oxford University Press; 1990.

4. Johnson CJ, Beitchman JH, Young A, Escobar M, Atkinson L, Wilson B, et al. Fourteen-year follow-up of children with and without speech/language impairments: speech/language stability and outcomes. J Speech Lang Hear Res. 1999;42:744–760. [PubMed]

5. Stothard SE, Snowling MJ, Bishop DVM, Chipchase BB, Kaplan CA. Language-impaired preschoolers: a follow-up into adolescence. J Speech Lang Hear Res. 1998;41:407–418. [PubMed]

6. Clegg J, Hollis C, Rutter M. Life sentence: what happens to children with developmental language disorders in later life? Bull R Coll Speech Lang Therapists. 1999;571:16–18.

7. Howe MJA. IQ in question: the truth about intelligence. London: Sage; 1997.

8. Campbell FA, Ramey CT. Effects of early intervention on intellectual and academic achievement: a follow-up study of children from low-income families. Child Dev. 1994;65:684–698. [PubMed]

9. Glogowska M, Roulstone S, Enderby P, Peters TJ. Randomised controlled trial of community based speech and language therapy for preschool children. BMJ. 2000;321:923–926. [PubMed]

10. Law J, Boyle J, Harris F, Harkness A, Nye C. Screening for speech and language delay: a systematic review of the literature. Health Technol Assess. 1998;2:1–184. [PubMed]

Dr Widodo Judarwanto Spa
CHILDREN SPEECH CLINIC

http://childrenspechhclinic.wordpress.com

J Appl Behav Anal. 2007 Fall; 40(3): 431–445.
doi: 10.1901/jaba.2007.40-431.

Copyright Society for the Experimental Analysis of Behavior, Inc.

Michael E Kelley

MARCUS INSTITUTE AND EMORY UNIVERSITY SCHOOL OF MEDICINE

M Alice Shillingsburg, M Jicel Castro, and Laura R Addison

MARCUS INSTITUTE

Robert H LaRue, Jr

DOUGLASS DEVELOPMENTAL DISABILITIES CENTER AND RUTGERS, THE STATE UNIVERSITY OF NEW JERSEY

John Northup, Action Editor

Requests for reprints should be sent to M Alice Shillingsburg, Marcus Institute, 1920 Briarcliff Road, Atlanta, Georgia 30329, e-mail: shillingsburg/at/marcus.org

Abstract

The conceptual basis for many effective language-training programs are based on Skinner’s (1957) analysis of verbal behavior. Skinner described several elementary verbal operants including mands, tacts, intraverbals, and echoics. According to Skinner, responses that are the same topography may actually be functionally independent. Previous research has supported Skinner’s assertion of functional independence (e.g., Hall & Sundberg, 1987; Lamarre & Holland, 1985), and some research has suggested that specific programming must be incorporated to achieve generalization across verbal operants (e.g., Sigafoos, Reichle, & Doss, 1990). The present study provides further analysis of the independence of verbal operants when teaching language to children with autism and other developmental disabilities. In the current study, 3 participants’ vocal responses were first assessed as mands or tacts. Generalization for each verbal operant across alternate conditions was then assessed and subsequent training provided as needed. Results indicated that generalization across verbal operants occurred across some, but not all, vocal responses. These results are discussed relative to the functional independence of verbal operants as described by Skinner.

Keywords: autism, communication training, developmental disabilities, generalization, language, speech, verbal behavior

References

American Psychiatric Association. Diagnostic and statistical manual of mental disorders. (4th ed. rev.). Washington, DC: Author; 2003.

Bourret J, Vollmer T.R, Rapp J.T. Evaluation of a vocal mand assessment and vocal mand training procedures. Journal of Applied Behavior Analysis. 2004;37:129–144. [PubMed]

Carr E.G, Durand V.M. Reducing behavior problems through functional communication training. Journal of Applied Behavior Analysis. 1985;18:111–126. [PubMed]

Durand V.M, Crimmins D.B. Assessment and treatment of psychotic speech in an autistic child. Journal of Autism and Developmental Disorders. 1987;17:17–28. [PubMed]

Fisher W, Piazza C.C, Bowman L.G, Hagopian L.P, Owens J.C, Slevin I. A comparison of two approaches for identifying reinforcers for persons with severe and profound disabilities. Journal of Applied Behavior Analysis. 1992;25:491–498. [PubMed]

Fisher W, Piazza C, Cataldo M, Harrell R, Jefferson G, Conner R. Functional communication training with and without extinction and punishment. Journal of Applied Behavior Analysis. 1993;26:23–36. [PubMed]

Gillberg C. Outcome in autism and autistic-like conditions. Journal of the American Academy of Child and Adolescent Psychiatry. 1991;30:375–382. [PubMed]

Hall G, Sundberg M.L. Teaching mands by manipulating conditioned establishing operations. The Analysis of Verbal Behavior. 1987;5:41–53.

Handleman J.S, Harris S.L. Preschool education programs for children with autism (2nd ed.). Austin, TX: Pro-Ed; 2001.

Horner R.D, Baer D.M. Multiple-probe technique: A variation of the multiple baseline. Journal of Applied Behavior Analysis. 1978;11:189–196. [PubMed]

Kelley M.E, Lerman D.C, Van Camp C.M. The effects of competing reinforcement schedules on the acquisition of functional communication. Journal of Applied Behavior Analysis. 2002;35:59–63. [PubMed]

Kelley M.E, Shillingsburg M.A, Castro M.J, Addison L.R, LaRue R.H, Martins M.P. Assessment of the functions of vocal behavior in children with developmental disabilities: A replication. Journal of Applied Behavior Analysis. 2007;40:571–576.

Lamarre J, Holland J.G. The functional independence of mands and tacts. Journal of the Experimental Analysis of Behavior. 1985;43:5–19. [PubMed]

Laraway S, Snycerski S, Michael J, Poling A. Motivating operations and terms to describe them: Some further refinements. Journal of Applied Behavior Analysis. 2003;36:407–414. [PubMed]

Leaf R, McEachin J, editors. Behavior management strategies and a curriculum for intensive behavioral treatment of autism. New York: DRL Books; 1999.

Lerman D.C, Parten M, Addison L.R, Vorndran C.M, Volkert V.M, Kodak T. A methodology for assessing the functions of emerging speech in children with developmental disabilities. Journal of Applied Behavior Analysis. 2005;38:303–316. [PubMed]

Miguel C.F, Carr J.E, Michael J. The effects of a stimulus-stimulus pairing procedure on the vocal behavior of children diagnosed with autism. The Analysis of Verbal Behavior. 2002;18:3–13.

Miguel C.F, Petursdottir A.I, Carr J.E. The effects of multiple-tact training and receptive-discrimination training on the acquisition of intraverbal behavior. The Analysis of Verbal Behavior. 2005;21:27–41.

Normand M.P, Knoll M.L. The effects of a stimulus-stimulus pairing procedure on the unprompted vocalizations of a young child diagnosed with autism. The Analysis of Verbal Behavior. 2006;22:81–85.

Nuzzolo-Gomez R, Greer R.D. Emergence of untaught mands and tacts of novel adjective-object pairs as a function of instructional history. The Analysis of Verbal Behavior. 2004;20:63–76.

Petursdottir A.I, Carr J.E, Michael J. Emergence of mands and tacts of novel objects among preschool children. The Analysis of Verbal Behavior. 2005;21:59–74.

Reichle J, Barrett C, Tetlie R.R, McQuarter R.J. The effect of prior intervention to establish generalized requesting on the acquisition of object labels. Augmentative and Alternative Communication. 1987;3:3–11.

Shirley M.J, Iwata B.A, Kahng S, Mazaleski J.L, Lerman D.C. Does functional communication training compete with ongoing contingencies of reinforcement? An analysis during response acquisition and maintenance. Journal of Applied Behavior Analysis. 1997;30:93–104. [PubMed]

Sigafoos J, Reichle J, Doss S. “Spontaneous” transfer of stimulus control from tact to mand contingencies. Research in Developmental Disabilities. 1990;11:165–176. [PubMed]

Skinner B.F. Verbal behavior. Englewood Cliffs, NJ: Prentice Hall; 1957.

Sundberg M.L, Michael J. The benefits of Skinner’s analysis of verbal behavior for children with autism. Behavior Modification. 2001;25:698–724. [PubMed]

Sundberg M.L, Partington J.W. Teaching language to children with autism or other developmental disabilities. Pleasant Hill, CA: Behavior Analysts, Inc; 1998.

Twyman J.S. The functional independence of impure mands and tacts of abstract stimulus properties. The Analysis of Verbal Behavior. 1996;13:1–19.

Venter A, Lord C, Schopler E. A follow-up study of high-functioning autistic children. Journal of Child Psychology and Psychiatry. 1993;33:489–507. [PubMed]

Wacker D.P, Steege M.W, Northup J, Sasso G, Berg W, Reimers T, et al. A component analysis of functional communication training across three topographies of severe behavior problems. Journal of Applied Behavior Analysis. 1990;23:417–429. [PubMed]

Worsdell A.S, Iwata B.A, Hanley G.P, Thompson R.H, Kahng S. Effects of continuous and intermittent reinforcement for problem behavior during functional communication training. Journal of Applied Behavior Analysis. 2000;33:167–179. [PubMed]

Yoon S, Bennett G.M. Effects of a stimulus-stimulus pairing procedure on conditioning vocal sounds as reinforcers. The Analysis of Verbal Behavior. 2000;17:75–88.

Dr Widodo Judarwanto SpA
CHILREN SPEECH CLINIC

http://childrenspeechclinic.wordpress.com

Rehabilitation Intervention For Development Delayed in Children with Down Syndrome

Narulita Dewi, Jakarta Indonesia

Introduction

Historical background

In1866, John Langdon Down, a British physician working in an institution for children with mental retardation, recognized patients with similar characteristics as previously described by Esquirol and Séguin: flat face, round cheeks, epicanthal folds, thick tongue, and small nose. He also noted that these children had language difficulties, a short life expectancy, and humorous personalities. He referred to these children as “Mongoloids” based on their similar appearance to people from Mongolia. The term “mongolism” was commonly used to describe these individuals; however, this was replaced by Down syndrome (DS) when the Mongolian People’s Republic pointed out the inappropriateness of the term. It was not until 1959 that DS was found to be due to the presence of an extra chromosome 21, or trisomy 21.¹

The extra chromosome 21 is considered the direct cause of Down syndrome; the indirect causes responsible for the extra chromosome are yet to be identified. However, Down syndrome is not caused by something the mother does (or does not do) during pregnancy. Trisomy 21 can occur in one of three forms:²

Incidence

Down syndrome is a relatively common genetic disorder, occurring in about one of every 800 to 1,000 live births. The chance of having a baby with Down syndrome increases significantly with the mother’s increasing age. For example, at age 35 (mother’s age), the risk of having a child with Down syndrome is one in 400; at age 40, the risk is one in 110; at age 45, the risk is approximately one in 35 (National Down Syndrome Society). The risk of having a second child with Down syndrome is higher. If a parent is a balanced translocation carrier, the risk of having a child with Down syndrome may be as high as one in ten.²

Mortality and morbidity

Approximately 75% of concepti with trisomy 21 die in embryonic or fetal life. Approximately 85% of infants survive to age 1 year, and 50% can be expected to live longer than age 50 years. Congenital heart disease is the most important factor that determines survival. In addition, esophageal atresia with or without transesophageal (TE) fistula, Hirschsprung disease, duodenal atresia, and leukemia contribute to mortality. The high mortality rate later in life may be the result of premature aging. Individuals with Down syndrome have a greatly increased morbidity rate, primarily because of infections involving impaired immune response. Large tonsils and adenoids, lingual tonsils, choanal stenosis, or glossoptosis can obstruct the upper airway. Airway obstruction can cause serous otitis media, alveolar hypoventilation, arterial hypoxemia, cerebral hypoxia, and pulmonary arterial hypertension with resulting cor pulmonale and heart failure. A delay in recognizing atlantoaxial and atlanto-occipital instability may result in irreversible spinal-cord damage. Visual and hearing impairments in addition to mental retardation may further limit the child’s overall function and may prevent him or her from participating in important learning processes and developing appropriate language and interpersonal skills. Unrecognized thyroid dysfunction may further compromise CNS function.³

Diagnosis

A diagnosis of Down syndrome is confirmed by chromosome analysis. Diagnosis in the newborn or older individual is accomplished by chromosome analysis of lymphocytes (white blood cells) obtained from a blood sample. Prenatal diagnosis involves examination using fetal cells floating in the amniotic fluid (obtained by amniocentesis) or of cells taken from the placenta (chorionic villus sampling). Prenatal testing is usually performed when there is an increased risk of the fetus having Down syndrome. An increased risk might be indicated by increased maternal age, a prior family history of Down syndrome or a chromosome abnormality in the parent, or by abnormal levels of certain biochemical markers found on maternal blood screening.³

Physical and developmental characteristics

The most common physical and developmental features of children with Down syndrome include:²

Physical characteristics 

• Diminished rate of growth and physical development. Most people with Down syndrome do not reach average adult height 
• An atypical head shape. The head may be smaller than average (microcephaly), with a flat area at the back (occiput)
• Eyes that slant upward toward the edge of the face (upslanting palpebral fissures) and an excess fold of skin over the inner corner of the eyes (epicanthal folds)
• White (Brushfield) spots in the colored part of the eyes
• Small or overfolded ears, a flat nasal bridge, and a small mouth with low oral muscle tone and a protruding tongue
• Short, broad hands with short fingers and a single crease spanning the width of the palm (single palmar crease)
• Decreased muscle tone

In addition to the general developmental delays that are characteristic of most children with Down syndrome, there may also be qualitative differences between the development of children with Down syndrome and typically developing children. Furthermore, within a population of children with Down syndrome, as within any group of children, there will be considerable individual variability of development. It is important to recognize that all children with Down syndrome will have distinguishing strengths and talents as well as limitations.

Medical Problems

Children with Down syndrome are at risk for:^4,5

• Short stature.
• Congenital heart disease. More than 40 percent of children born with Down syndrome will have a congenital heart malformation.
• Frequent ear infections and other respiratory tract infections.
• Hearing loss. Infants and children may have a conductive loss as a result of middle ear effusion or structural abnormalities of the ear, a sensorineural loss, or both. Some people with Down syndrome may begin to develop hearing loss after 10 years of age. If undetected, this may significantly impact on all areas of development.
• Eye problems including refractive errors, strabismus, nystagmus, and cataracts. Congenital cataracts can lead to vision loss if not treated.
• Dental anomalies and gum disease.
• Thyroid function abnormalities (hypo- or hyperthyroidism) occur more frequently among individuals with Down syndrome.
• Obstructive airway disease. Symptoms include snoring, unusual sleeping positions, excessive fatigue or napping during the day, inattention and distractibility, or behavior changes.
• Increased mobility of the cervical spine between the first and second vertebrae (atlantoaxial instability). This condition is found by x-ray in approximately 14 percent of individuals with Down syndrome. Symptoms, occurring in about 1-2 percent of individuals with Down syndrome, include neck pain, unusual posturing of the head and neck, change in gait, loss of upper body strength, abnormal neurologic reflexes, and change in bowel/bladder function (Cohen 1996).
• Congenital defects of the gastrointestinal tract. These include duodenal atresia, an obstruction of the first segment of the small intestine.
• Higher incidence (but still only about 1 percent) of acute lymphoblastic leukemia than in the general population. In this condition, abnormally dividing white blood cells replace normal blood marrow elements, leaving the affected child susceptible to anemia, bleeding, and infection. Symptoms may include excessive bleeding and bruising, pinpoint red spots (petechiae), bone or joint pain, and enlarged lymphnodes.
• A tendency toward obesity.

The development of children with Down syndrome^7,8,9

Children with Down syndrome make progress in all areas of development, in the same way as other children but usually at a slower pace. Some areas of their development are usually more delayed than others, leading many researchers to now describe a specific profile of strengths and weaknesses.^[1,2]

However, before describing this profile in more detail, it is important to stress that any group of 100 infants or preschool children with Down syndrome will vary as widely in abilities, behaviour, personality characteristics, size and appearance as any group of 100 ‘typically developing’ preschoolers. Their development is influenced by their biology and by their social and learning opportunities, like all other children.

The effect of the extra chromosome on the foetal development of babies with Down syndrome is not the same for all the infants. For example, nearly half are born with congenital heart defects but the other half have no heart abnormalities, and while some children have bowel abnormalities, most do not. It is clear that the effects on physical development vary, for reasons not yet fully understood, and it can be predicted that the effects on brain development and learning abilities also vary between children. Some of the individual differences in rates of progress are therefore due to biological differences at birth. Some children with Down syndrome will have a greater degree of disability than others, however good their family care and stimulation, their therapy and school services. It is important to stress this point, as many parents wrongly blame themselves when their child makes slow progress.

The progress of most children with Down syndrome is also influenced by the stimulation and love provided in the family, the opportunity to be included in all aspects of community life and by better quality education. As a group, children with Down syndrome are progressing faster and achieving more than they did 25 years ago.

Children with Down syndrome are individuals^8,9

Children with Down syndrome are all individuals. The conventional stereotypes are inaccurate and unhelpful. In physical appearance, they look like their parents and brothers and sisters, just like all other children. They do have some physical characteristics as a result of having Down syndrome but they do not all look alike and neither do the ‘Down syndrome’ features dominate their appearance. Similarly, children with Down syndrome vary widely in personality, from being extroverted, friendly and sociable to being introverted and shy. Some children are always calm, others are anxious. Some children are flexible and adaptable, others find change difficult and may have a tendency to be obsessional in their behaviours. Some children are easy to manage, are happy to be co-operative and to conform at home and in school, while other children are difficult to manage and like to have their own way, or to be in control, at home and at school.

Similarly, in all areas of development, children with Down syndrome vary in their progress. Some children will be fairly slow to achieve the motor milestones of reaching, sitting and walking and others will show little motor delay, and some children with Down syndrome will have more difficulty learning to talk than others.

The reasons for these differences will be partly influenced by genetic makeup and partly influenced by the way in which parents, carers and teachers have been able to help the child to adapt to the demands of growing up. If a child with Down syndrome is more severely delayed than is typical, it is particularly important that his or her parents have extra help and support from services and from parent support groups.

Each baby and child with Down syndrome is an individual and he or she has the same needs as any other child plus some specific needs, and it is important that everyone concerned with a child with Down syndrome remembers this. It is helpful to know about the specific needs that are usually associated with Down syndrome and these are described in the next section, but having Down syndrome does not define any individual child.

It is also important to remember that a child with Down syndrome may have additional difficulties, like any other child. A small number of children with Down syndrome have additional medical complications, like seizures or other illnesses, which may affect their development. Similarly, a small number of children have autistic spectrum difficulties, attention deficit or hyperactivity. These additional difficulties affect less than 10% of children with Down syndrome but they should be recognised and treated in their own right when they do occur. These difficulties are discussed in a little more detail later in this module.

Most children with Down syndrome can achieve a number of the same developmental goals at 5 years of age as other children. Most five-year-olds are walking, toilet trained, able to feed themselves and put on at least some of their own clothes.

Most 5-year-olds are able to be part of an age-appropriate group and can conform to the social expectations in the classroom. They are able to sit at a table, listen to the story and follow the teacher’s instruction – with some needing no help to do this and others needing some support. Most children can control their own behaviour and are not anti-social. They have appropriate understanding of the emotions of others, for example, when they are happy, sad or hurt.

Therefore motor skills, social progress and behaviour are strengths. However, most 5-year-olds with Down syndrome will have significant delays in spoken language – typically talking in 2 or 3-word phrases, and the words may be difficult to understand. Some children will have a knowledge of the maths concepts needed in the classroom, and be starting to count, despite general language delay. Some children will be reading a sight word vocabulary and know their letter names and sounds, despite having general language delay.

The specific developmental profile associated with Down syndrome

Children with Down syndrome are all individuals and vary in their rates of progress – however, they tend to have a specific profile of strengths and weaknesses ^7,8,9 :

• Social development and social learning are strengths, right from infancy – the children enjoy and learn from social interaction with adults and peers
• Motor development is usually delayed and may hold back progress in self-help skills, handling toys in play and in writing, though the use of gesture to communicate is a strength
• Speech and language development is usually the children’s area of most significant delay – it is more delayed than non-verbal abilities. Most children understand more than they can say and signing is an important bridge to speaking. Speech intelligibility is usually a difficulty. A high incidence of hearing difficulties is contributing to speech and language delay.
• Working memory development is specifically delayed relative to non-verbal abilities, particularly the verbal short-term memory component – so that learning from listening is difficult for the children. Working memory also supports thinking, problem solving and reasoning. Visual and spatial processing and memory are relative strengths – so that the children learn effectively from visual information – they can be thought of as visual learners.
• Social behaviour- the children have strengths in social skills and in developing age-appropriate social behaviour, if this is encouraged and expected. However, their good social understanding and empathy leads them to pick up on non-verbal emotional cues, such as those for anxiety or disapproval, very quickly. They are therefore sensitive to failure and may use behavioural strategies to avoid difficult situations.

Over the last 15 to 20 years, researchers have made progress in understanding the effects of having Down syndrome on development, though there is still much more to learn in order to fully understand how to help the children. Research has identified a specific profile of developmental strengths and weaknesses. However, while this profile is typically associated with Down syndrome, the degree to which any individual with Down syndrome shows this pattern will vary. It is helpful as a guide to understanding any child’s developmental needs and learning profile, but it should be treated as a checklist for any individual child, as he or she may have all or none of these characteristics and if he or she does have some, the degree to which they show any strength or weakness will need to be assessed in order to develop an appropriate therapy, early intervention or teaching programme⁸.

While children with Down syndrome experience some delays in all areas of development, the extent of the delay is not the same across all areas of development.⁹

Social understanding and social interactive skills are a relative strength and less delayed than speech and language skills. Most children with Down syndrome make eye-contact, smile and interact by cooing and babbling from the first months of life, and show little delay in social interactive skills. They are socially sensitive and understand the non-verbal cues to emotions, such as facial expression, tones of voice and body postures, from the first year of life.⁸

Motor skills, including reaching, sitting and walking, are delayed but the main milestones are steadily achieved and most children become mobile and independent in self-help skills, such as feeding and dressing, which require motor skills.

Speech and language skills are more delayed than the children’s non-verbal understanding and reasoning abilities. This is a pattern of specific language impairment. Most children with Down syndrome understand more language than they can use as a result of specific speech production difficulties. For this reason, learning to sign will help the majority of children to communicate, to show their understanding and reduce their frustration. Hearing difficulties, usually due to ‘glue ear’ are common and contribute to speech and language difficulties.⁸

For most children with Down syndrome, the most serious delay that they experience is in learning to talk. This is not only frustrating but it has serious consequences for all other aspects of their social and cognitive development. As children learn to talk, each new word that they learn is a new concept or piece of information about their world. Once they can string words together, speech becomes a powerful tool for learning and for communicating with everyone in their world, and it also becomes a tool for thinking, remembering and reasoning. We carry out these mental activities using silent speech in our minds. While we can also use visual imagery to imagine and recall events, reasoning with the use of language is considerably more powerful. It follows that a serious delay in learning to understand and to use language will lead to delay in all aspects of mental or cognitive development. Conversely, if we can improve the rate at which children learn language, this should benefit all areas of their social and cognitive development.⁷

Working memory development, particularly verbal short-term memory, seems to be specifically impaired – again not progressing as fast as would be expected for non-verbal abilities – and this has consequences for the children’s ability to process information.⁷

Visual memory and visual processing are relative strengths, while auditory processing and auditory memory are more impaired. This means that children with Down syndrome should be thought of as visual learners and all teaching supported with visual materials.⁷

Reading ability is often a strength from as early as two years of age, perhaps because it builds on visual memory skills, and reading activities can be used to teach spoken language from this time.^7,8

Number seems to be relatively more difficult for children with Down syndrome and their number skills delayed relative to reading skills.⁸

Social behaviour is a strength as children with Down syndrome are less likely to develop difficult behaviours than other children with similar levels of cognitive delay. However, children with Down syndrome are, as a group, more likely to develop difficult behaviours than non-disabled children of their age.^7,8

Treatment

Because it is a problem with the chromosomes, there are no cures for Down syndrome. Therefore, treatment for the condition focuses on controlling symptoms and any medical conditions that result because of Down syndrome. Treatment for Down syndrome can include: regular checkups for health screening and prevention, medications, surgery, counseling and support.^{5, 6}

Children with Down syndrome are at greater risk for some illnesses and for hearing and visual difficulties. Any child’s developmental progress will be influenced by illness or sensory difficulties, so that it is important that all healthcare issues are understood and addressed.⁵

Health Conseling

Family physicians can help patients with Down syndrome develop good communication and social skills that will enhance their ability to live independently, have a job and interact with others. Although the foundation for these skills starts before adulthood, there are still ways to help an adult with Down syndrome function more effectively. Speech and language therapy may improve intelligibility of language. Vocational training and job coaches also are helpful.^5,6

A local parent-support group is a valuable resource for information on relationship and sexuality training, abuse prevention, estate planning and independent and group living. Local groups can be found in the telephone book or obtained from national organizations, such as the National Down Syndrome Society.

An adult with Down syndrome is considered competent to make medical decisions unless declared otherwise. The issue of whether or not guardianship is appropriate should be addressed early. When guardianship is not appropriate, the question of advanced directives, especially power of attorney for health care and finance, should be addressed.^5,6,7

Frequently, independent living with supervision is appropriate but not available. Group homes are not appropriate for everyone, and some behavior problems that occur in group homes may be due to the stress of people living together who do not like one another. Some parents have tried to alleviate this problem by buying houses or duplex apartments to better control the living arrangements. Independent but supervised housing is important long-term planning. Parents may die or become incapacitated, and other family members cannot always step in.^5,6

Local parent groups can also provide information about estate planning for the family. Frequently, supplemental trusts are used to handle money inherited by the adult with Down syndrome.⁷

Physicians and family members should anticipate stresses that may overwhelm the adult with Down syndrome. Planning can ensure a successful transition, such as those from home to apartment or from one job to another. Anticipatory planning can also lessen the impact of the loss of access to a friend or family member. The physician should monitor these patients for loss of independence, loss of living skills or function, depression and behavior changes at least annually.⁸

CASE REPORT

The patient is 5 years and 4 months old girl. She was referred to PM&R department by pediatric department

A. ANAMNESIS

Chief complaint is speech delayed

History of present illness

The patient with Down syndrome, patient’s mother knew her child had feature Down syndrome from a doctor since born, but she did not know what the problem of her baby in the future. In this age the patient can’t speech fluently. If she wants something, sometime she talks “suffix of the word”. Sometime with pull hand’s mother or point it. The patient can do a simple instruction. She can refuse if she doesn’t like something and she can choice that she likes. The patient also was difficult imitate a word that her mother talking, especially vowel “ i ”.

 The acuity of patient’s visual is minus 9 for right eye and minus 8 for left eye. She often refuse for use her glasses, may be not comfortable.

For activity daily living, the patient every Monday to Thursday she goes to PAUD and every Wednesday in the evening she learn dancing, every Saturday morning she goes to Gymnastic/exercise sport club, before exercise she should be run around field and she can around field 3 time. The patient every Monday goes to Dentist in the RSCM for maintain her teeth.

The patient can eat with using spoon and can chew but for defecation and urinary the patient using pampers, although sometime she can talk it (toileting) before that. The patient can dressing and undressing with supervision but she didn’t know distinguishing front and back of clothing, she can doff her shoes, but can’t don.

History of past Illness :

The patient ever hospitalize in the St Carolus hospital cause of fever, diarrhea, and bronchopneumonia in the 2 years old.

History of Family Illness:

No history of family illness

Psychpsocial Status            :

The patient is second child, she only has 1 older brother, healthy and normal. The patient was taken care by her mother. She lived in the grandmother’s house (200 meter square) with her uncle’s family. Her father selling stall in the front of house, and her mother is housewife. In this house her parents only expenses telephone, for PLN and PAM expensed by her uncle (brother of mother). The income of the patient’s parents is 150,000-200,000 rupiah per day. Her medical expenses are from SKTM.

Pre, peri, post natal history

• Pre-natal        : her mother age was 42 years old when pregnant, antenatal care regular to a midwife. In this period no problem with mother and the baby (there was no history of fever or bleeding and no drug history).
• Peri-natal       : the patient was a term, Spontaneous parturition help by a doctor, crying inadequate, there was mild cyanosis and jaundice, cyanotic disappear around in 3 months old. The patient birth weight was 3900 gram and her birth length was 46 cm.
• Post-natal      : the patient had no history of seizures. She had basic vaccination.

Development History

• Head lift at 3 months old
• Move from supine to prone at 3 months old.
• Sitting at 1 year and 5 months old
• Standing at 2 years old
• Walking at 2 years and 8 months old
• Babbling at 10 months old

B. Physical Examination (conduct on 24^th October 2009)

General Examination

Patient came to clinic being carried by her mother

Consciousness             : Compos mentis, Mental             : no irritability

General appearance : Down syndrome’s profile

Vital sign: temperature : no fever, respiration rate:20x/minute,pulse: 90x /minute

Nutritional status: body weight: 16 kg (normoweight), body height       : 98 cm (normoheight)

Gait                                :           wide base

Skin                               :           Normal color and normal turgor, hyperkeratosis (-)

Head and neck                     :

Head                                          :           circumference 46 cm, microcephaly

head neck control (+) adequate

Neck                              :           Midline position.

Eyes                               :           Up-slanting palpebral fissures, bilateral epicanthal

folds, refractive errors: myopi OD/OS:9/8, strabismus divergen/convergen (-/-), conjungtiva anemia (-/-),  sclera icteric (-/-) Direct/ indirect light reflexes (+/+).

Ear                                 :           small with an overfolded helix. Response to     

                                           auditory

stimulus (+/+)

Nose                              :           Hypoplastic nasal bone and flat nasal bridge (+)

Mouth and teeth          :           open mouth, tongue protrusion, mouth breathing

                                            with drooling (-), malformed teeth and caries dentis

                                             (+), high palatum arch, pharynx not hyperemic, arch

                                           of pharynx symmetrical, no deviation of uvula.

Thorax                                                :

Cor                                 :           normal heart sound, no murmur, no gallop

Pulmo                            :           symmetric movement of the chest wall during

respiration, sound of breath is vesicular, no

wheezing, no ronkhi

Abdomen                              :           normal bowel sound.

Back                                       :           vertebral alignment straight, shoulder and

                                                  Scapulae symmetrical, postural tone hipotonus

Neuromuscular

Nervi cranialis              :           there is no paralise of nervi cranialis.

In sitting/erect Position:

Neck                              :           Head lifting adequate. Head neck control adequate

Trunk                             :         trunk control adequate, sitting/standing balance

                                           adequate

Upper Extremities    :

Look               :           no deformity, no inflammation, no atrophy

Feel                :           hypotonus (+/+), no tightness

Move              :           ligamentum laxity (+) in the wrist bilateral, ROM

full/full (see details on the table 1), MMT impression normal, physiologic reflex BTR ++/++, pathologic reflex Hofmann Trommer -/-, no spasticity, no rigidity.

Lower Extremities

Look               :           no deformity, no inflammation, no atrophy, genu

valgus, ankle instability, flat feet.

Feel              :           hypotonus, slightly tightness hamstring

Move            :           spasticity (-/-), regidity (-/-), clonus (-/-) ligament

laxity (+) in the hip, knee, and ankle bilateral, ROM full/full, MMT impression normal, physiological reflex KPR +/+, pathologic reflex Babinsky -/-.

Special test:

Popliteal angle 0⁰/0⁰

Ortolani test (-), Barlow test (-)

Milestone                     :

Gross Motor               :           equal to 3 years old (runs well, walks up stairs with

alternating feet)

Fine Motor                 :           equal to 2 years (place pencil shaft between thumb

                                        And fingers, draws with arm and wrist action)

Personal social        :           equal to 2 years (use spoon well, opens door

                                        Turning knob)

Speech-language    :           equal to 18 months (points to named body part)

Cognitive                   :           equal to 18 months (capable of insight; problem

solving by mental combinations, not physical

groping)

C. Supporting Finding

1. BERA examination (5^nd February 2007) : Impression : Ambang dengar AS =

    30 dB (normal) Ambang dengar AD = 30 dB (normal)

2. IQ test: Moderate MR (Wechs = 50)

D. Summary

A girl with Down syndrome, 5 years and 4 months old, was come to PM and R department with chief complaint speech delayed . The other problems is a motor delayed, mental retardation and refraction error in correction.

From physical examination, the patient is normal weight but she has microcephaly. She also has severe myopia (OD/OS = 9/8) in correction but not adequate, has small nose, flat nasal bridge (+), caries dental (+), high palatal arch (+). In UE & LE bilateral: hypotonic, slight genu valgus, ligament laxity, small finger, hypo reflexes.

From supported finding, Berra test is normal limit, the result of IQ test is Moderate MR (Wechs = 50)

E. Diagnosis

Medical Diagnosis               :           Down Syndrome with development delayed

Rehabilitation Diagnosis    :           speech and language impairment, motor

development delayed, general hypotonic, ligament

laxity.

ICF:

1. Body function

• b117 Intellectual functions
• b147 Psychomotor functions
• b167 Mental functions of language
• b210 Seeing functions
• b310 Voice functions
• b730 Muscle power functions
• b220 Structure of eyeball
• s750 structure of the lower extremity
• b130 Copying
• d330 Speaking
• d440 fine hand use
• d445 hand and arm use

1. Body structure

F. Problem Inventory

Medical problems                : mental retardation, delayed development and refraction error

Rehabilitation problem       :

1. Speech and language impairment
2. Delayed gross motor development
3. Delayed fine motor development
4. Visual impairment (correction inadequate)
5. General hypotonic
6. Ligament laxity.
7. Slight genu valgus
8. Slight ankle instability
9. Flat feet

10.  Financial problem.

G .Goal

Short term

1. Improve speech and language especially expressive
2. Improve hand function and dexterity
3. Improve visual function with always use comfortable glasses
4. Maintain strength trunk and limb muscle
5. Maintain body weight and nutritional status

Long term

1. Independence in personal care
2. Able to communication and interaction in peer or community
3. Prevent all medically problem linked Down syndrome.
4. Maintain good nutritional status.

Goals for speech and language therapists working with 5-11 year olds with Down syndrome

1. to have up-to-date knowledge of the specific research literature on speech and language development, working memory and effective therapies for children with Down syndrome
2. to understand the significance of the specific impairment in the phonological loop component of working memory for the speech and language profile associated with Down syndrome
3. to understand the importance of reading work to support the development of vocabulary, grammar and speech clarity, using strengths in visual memory
4. to understand the importance of auditory discrimination for speech sounds, phonics activities, phonological awareness training and speech work for improving working memory function
5. to have clear targets for 4 areas of work, speech, vocabulary, grammar and communication skills and to keep detailed records of progress
6. for vocabulary and grammar, to have separate targets for comprehension and for production, as comprehension in both domains is typically significantly ahead of production
7. for speech work, separate targets may be needed for articulation, phonology and intelligibility (pacing, voice etc)
8. to review oral-motor function, feeding, chewing and drinking patterns and advise accordingly
9. all targets should be shared with parents, teachers and assistants

10. children with Down syndrome should be seen at least monthly in school, targets reviewed and activities set for parents, teachers and assistants to include in their daily routines

11. these activities should be modelled with the child by the speech and language therapist, if parents and assistants are expected to deliver therapy

12. ideally, all children with Down syndrome of primary school age should have weekly individual or group sessions of speech and language therapy with a therapist who has specialist knowledge and the skills to address their profile of difficulties, particularly for speech and intelligibility work.

Goals for teachers of 5-11 year olds with Down syndrome

1. to involve the child in all aspects of school life and school routines
2. to support social independence in school and the development of friendships with peers
3. to support the development of play skills and inclusion with peers in break and lunchtimes
4. to encourage, model and expect age-appropriate, socially acceptable behaviour at all times
5. to be familiar with the research findings which demonstrate a specific cognitive profile associated with Down syndrome and to adapt teaching methods appropriately
6. to provide access to all areas of the school curriculum at a level appropriate for the individual child
7. to recognise the importance of teaching reading and writing daily, to develop speech, language and working memory skills as well as literacy skills
8. to have clear targets for speech and language work for each child, and identify how these can be absorbed into all aspects of the curriculum
9. to facilitate independent learning and the ability to work and to learn as part of a group

10. to make full use of computer aided learning, with appropriate software for individual and group work

Goals for occupational therapists and physiotherapists

1. to provide programmes of activity to develop gross motor skills and spatial awareness
2. to advise on adaptations and specific activities to enable children to participate in the school PE and games curriculum
3. to advise parents on suitable sporting, dance or gymnastics activities and any adaptations necessary to enable their child to participate
4. to advise teachers and parents on suitable seating and posture in the classroom and at home
5. to provide activities and adaptations to develop fine motor skills, fine motor co-ordination and handwriting
6. to review progress with independent drinking, feeding, toileting and dressing, if necessary, and advise on any adaptations needed

H. PROGNOSIS

Ad vitam                    :           dubia ad bonam

Ad functional                        :           dubia ad bonam

Ad sanationam         :           dubia

I. PROGRAM

Medical problem

1. Education for parent or family about all problem that linked with Down syndrome
2. Preschool and School Services may include special education provided by a certified teacher and focused on the needs of the child.
3. Periodic counseling for health screening and prevention

Rehabilitation problem

1. Speech and language therapy:
   1. Non-verbal skill: smiling, eye-contact, initiating a conversation, maintaining the topic (pragmatic)
   2. Vocabulary : stimulation to build a dictionary of single word and their meanings (lexicon and semantic)
   3. Grammar:  stimulation to learn the word ending rules for plurals, tenses, word order rules for questions, negatives, (morphology and syntax)
   4. Speech/motor skills: stimulation to make speech sounds, produce clear words with correct stress and intonation (articulation, phonology and prosody)
   5. Oral motor exercise for improve oral muscle strenght.
   6. Occupational therapy: hand training

                                          i.    Training hand functions: reaching, carrying, release, hand eye coordination ( precision) and bilateral integration

                                        ii.    Training hand skill: three jaw chuck, pinch, grasp

1.  
   1. General hypotonic :

                                          i.    Exercise for maintain strength upper and lower extremity muscle.

                                        ii.    Exercise for maintain strength extensor trunk and abdominal muscle.

                                       iii.    Cardio respiration endurance.

1. Special shoes for supported limb

J. CASE ANALYSIS

A patient could be suspected Down syndrome since born from physical examination. The extra chromosome 21 is considered the direct cause of Down syndrome, as we know if mother has age 40 then the risk of Down syndrome is one in 110; if age 45, the risk is approximately one in 35 (National Down Syndrome Society). In this case, known the patient’s mother is 42 years old when pregnant of her.

In this patient found dysmophic features like Down syndrome such as head circumference 46 cm, (microcephal). Eyes up-slanting palpebral fissures, bilateral epicanthal folds, refractive errors: myopi OD/OS:9/8, ear small, nose hypoplastic nasal bone and flat nasal bridge (+) and mouth and teeth open mouth, tongue protrusion, malformed teeth and caries dentis (+), high palatum arch, hypotonic oral muscle. All above condition, addition hypotonic oral muscle and microcephaly (the brain is abnormally rounded and short with a decreased anterior-posterior /AP diameter) with mental retardation cause difficult of speech and language.

In this patient also is found, mental retardation and delayed development. Known that overall brain weight in individuals with Down syndrome is 76% of normal, with combined weight of the cerebellum and brainstem being even smaller: 66% of normal, the number of sulci is decreased, and cytologic in brains of children with Down syndrome found small neurons, decrease synaptogenesis owing to altered synaptic morphology, also there are abnormalities of structure dendritic spines in the pyramidal tracts of the motor cortex and lack of myelination as well as delay in the completion of myelination between 2 month and 6 years.

The patient also has refraction error (visual acuity problem) that may affect eye hand coordination (can’t move together for fine motor tasks) and has smaller hand and finger, also she has general hypotonic and ligament laxity, in the children with Down syndrome that cause of collagen deficit and all of this problem is a major contributing factor to developmental motor delay.

Children progress significantly in all areas of their development during this period from 5 to 11 years and success in these years builds their self-esteem and confidence. Conversely, difficulties in any of the areas of progress discussed can have a significant negative effect on any child’s confidence and self-esteem.⁷

Children’s progress varies widely, even within the range considered to be ‘typical development’ and these differences will be in part explained by inherited individual differences in abilities and aptitudes but it will also be powerfully influenced by the family support and educational opportunities that they receive.⁸

Between 5 and 11 years, typically developing children make significant progress in all areas of their development and we have tried to illustrate the significant changes that take place in figure 1. There is a wide range of individual differences in achievements in all these areas, with some children being more socially confident than others, some children making faster academic progress than others and some children having more difficulty with behaviour control than others.⁷

Perhaps the biggest challenge for children at the start of this age period is settling into school. Children start full-time school at different ages in different countries but most children will be spending part or all of each day in a kindergarten or school class by 5 years of age. In the UK, full-time school starts in the year a child reaches their fifth birthday and formal instruction in reading, writing and number begins in that school year (Reception class).^7,8

Figure 1. An overview of developmental progress from five to eleven years in typically developing children⁷

Childhood can be seen as a period of preparation for adult life. In preschool years, children are largely sheltered in their family world and parents determine friendships and social experiences. Joining full-time school is a big step into the wider community and it provides important opportunities for children to learn about the wider community, and to mix with a wider variety of children and adults. Children’s strengths and weaknesses will become more apparent as they leave the support of their families and have to cope in these larger communities. If children are going to have some difficulties socially, emotionally or academically, these will become apparent when they meet the challenges of the typical school environment.

Going to school – social and academic demands⁸

The classroom environment places demands on children’s social skills as well as their language and learning abilities.The children are part of a large group of children in the classroom, and will have to be able to cope socially with a range of different children. They have to communicate with one another in the classroom and the playground. They are beginning to learn about how to get on with others and how to make and keep friends. These are very important skills for teenage and adult life. They will meet children whose behaviour and attitudes are different from their own as they experience a wide range of children in their community from different backgrounds and social circumstances. These experiences are very important for helping children to develop their social skills.^7,9

During the preschool years, children will have had quite a high level of individual support for learning in their families but in the full-time school classroom they have to be able to be part of a large group and to follow the teacher’s instructions to the whole group. They may also have many opportunities for small group work and activities, but they will not be able to have much one-to-one support for their learning in most typical school classrooms. In their first years in the school system, children are expected to learn to read, write and count, and some will find this easier than others. The abilities and the aptitudes of children will begin to become apparent to their parents, teachers and themselves. Children will also develop their learning skills and become increasingly independent learners.⁹

Speech and language skills

The school environment places a heavy demand on children’s speech, language and communication abilities. Most of the classroom and school instruction is through spoken language. When typically developing 5 year olds enter school they do not all have the same spoken language skills. Some children will be much more competent talkers than others, with larger vocabularies and more advanced grammar and some will be more able listeners than others. Some children will have difficulty listening to and remembering all the spoken instructions and information given by their teachers. Studies show that children with delayed speech and language for their age have difficulty in the classroom and tend to fall behind with their academic progress. Children’s language abilities and learning abilities are also influenced by their working memory skills. Recent research has shown that children with poorer working memory skills when they enter school have difficulty keeping up with the academic work.⁷

Children’s spoken language skills develop a great deal during the period from 5 to 11 years. Most typically developing 5 year olds come to school talking in sentences. They have several thousand words in their vocabulary and they have mastered most of the grammar of their native language. They do learn some more complex and formal grammar during these school years and they learn a great deal of new vocabulary (as many as 3000 new words each year from 7 to 16 years). This progress in vocabulary and grammar has been shown to be influenced by the children’s reading progress. Children who have reading difficulties, and fall behind their peers on reading progress, do not make typical progress on language or working memory measures. Children also develop their ability to enter into conversations, to initiate conversations with other children and adults and to tell stories or describe events they have taken part in, during this period.^8.9

Academic progress

During the primary school years, typically developing children are expected to achieve at least a basic level of competence in reading, writing and mathematics. Most 5 year olds are beginners, usually starting school unable to read though they may know some sight words and some letter names and sounds, and they may be able to write their name and to count to 20. Most children make steady progress over the next six years and by the age of 11 years can write and spell well enough to record classroom work and to write a short story. Most will be able to read books for information and for pleasure. Most will be able to calculate using numbers at least to one thousand, tell the time and calculate money accurately. Most children will be able to weigh and measure adequately for everyday applications. Some typically developing children will be more advanced than this, but a significant number of typically developing children (20-25%) will not have achieved these levels by 11 years of age.⁸

Children will be studying a wide range of subjects on the school curriculum such as science, geography and history but their literacy skills will influence their progress across all aspects of the curriculum. Children will also be enjoying music and creative arts, and these areas, along with sport and music, will not be as influenced by success with literacy. Musical and sporting abilities will be developing and some children will discover that they have particular abilities in these areas or in creative arts, including painting, dance and drama.^7,8

Out of school – social and practical independence

In the years from 5 to 11, children will be experiencing a wider range of leisure and community activities. They will be able to join clubs and activities for their age group and they will become more involved in family tasks such as shopping. Children will begin to establish a wider range of friendships and visit with friends at their homes to play. They will be invited to parties and outings with friends and their families.

By the end of this age period, children may be walking to school without parent support and walking to local shops or to friend’s homes. They may also be learning to use buses independently or with friends by 11 years of age. They will have watches and be able to tell the time. They will know their names and addresses and know what to do if they have a difficulty when out on their own. They will be able to use the telephone.^9,9

At home – personal independence

At home children will begin to take care of their personal needs over this period. At 5 most children will still be helped to wash, bath and choose appropriate clothes for the day’s activities and weather. By 11 years, most children will be achieving independence in self-care, able to run a bath or shower at the right temperature, learning to wash their own hair and cut their own finger and toe nails. They will choose their own clothes. They will not yet be expected to do their own laundry, although they may be expected to keep their own rooms clean and tidy.⁷

Most 11 year olds can make simple snacks such as toast and hot drinks, using kettles, toasters, microwave ovens and possibly cookers and ovens safely for simple meals. Many parents will be beginning to leave children of this age unsupervised at home for short periods and be confident that they know what to do in the event of an emergency i.e. they can use the phone and know when to call a neighbour or phone for a doctor, ambulance, fire engine or policeman.⁸

All of above problem cause the patient need the rehabilitation program include physical therapy, occupational therapy, speech therapy. Routine evaluation should be done by physiatrist and pediatrician to prevent all of medicine problem linked Down syndrome.

REFERENCE

1. Smith DS. M.D, Health Care Management of Adults with Down Syndrome a peer review-journal of the American Academy of family Physicians September 15, 2001
2. Chen H, MD, MS, FAAP, FACMG, Down Syndrome Departments of Pediatrics, Obstetrics and Gynecology, and Pathology, Director of Genetic Laboratory Services, Louisiana State University Medical Center Contributor Information and Disclosures Updated: Jun 15, 2009
3. Bruni M, BSc OT(C), Fine Motor Skill in Children with Down Syndrome: a guide for parents and profesionals, 1998
4. Clinical Practice Guideline Report of the Recommendations Down Syndrome Assessment and Intervention for Young Children, New York State Departement of Health Division of Family health Bureau of Early Intervention. www.hes.org
5. Lemieux BG, Chromosome-linked disorder in Swaiman KF, Pediatric Neurology Principle and Practice Ed 2, 1994; 25; 390-394
6. Buckley SJ. Speech, language and communication for individuals with Down syndrome — An overview. Down Syndrome Issues and Information. 2000.
7. Freeman, S.F.N. and Hodapp, R.M. (2000). Educating children with Down syndrome: linking behavioral characteristics to promising intervention strategies. Down Syndrome Quarterly, 5(1), 1-9.
8. Chapman, R.S. and Hesketh, L.J. (2000). Behavioural phenotype of individuals with Down syndrome. Mental Retardation and Developmental Disability Research Reviews, 6, 84-95.
9. Rynders, J., Abery, B.H., Spiker, D., Olive, M.L., Sheran, C.P., and Zajac, R.J. (1997). Improving educational programming for individuals with Down syndrome : Engaging the fuller competence. Down Syndrome Quarterly, 2(1), 1-11.

Supported  by

CHILDREN SPEECH CLINIC

Yudhasmara Foundation

Office ; JL Taman Bendungan Asahan 5 Jakarta Indonesia 10210

phone : 62(021) 70081995 – 5703646

email : judarwanto@gmail.com,

http://speechclinic.wordpress.com/

Clinic and Editor in Chief :

Dr WIDODO JUDARWANTO

email : judarwanto@gmail.com

curriculum vitae

Copyright © 2009, Children Speech Clinic  Information Education Network. All rights reserved

dr Ida Narulita dewi

Pendahuluan

Perkembangan adalah bertambahnya kemampuan dalam  struktur dan fungsi tubuh yang lebih kompleks dalam pola yang teratur dan dapat diramalkan, sebagai hasil dari proses pematangan. Disini menyangkut adanya proses diferensiasi dari sel-sel tubuh, jaringan tubuh, organ-organ dan sistem organ yang berkembang sedemikian rupa sehingga masing-masing dapat memenuhi fungsinya. Termasuk juga perkembangan emosi, intelektual dan tingkah laku sebagai hasil interaksi dengan lingkungannya.¹

Gangguan bicara dan bahasa adalah salah satu penyebab gangguan perkembangan yang paling sering ditemukan pada anak.  Keterlambatan bicara adalah keluhan utama yang sering dicemaskan dan dikeluhkan orang tua kepada dokter.² Gangguan ini semakin hari tampak semakin meningkat pesat. Beberapa laporan menyebutkan angka kejadian gangguan bicara dan bahasa berkisar 5 – 10% pada anak sekolah. Kemampuan motorik dan kognisi  berkembang sesuai tingkat usia anak, demikian juga pemerolehan bahasa bertambah melalui proses perkembangan mulai dari bahasa pertama, usia pra sekolah dan usia sekolah di mana bahasa berperan sangat penting dalam pencapaian akademik anak.^2,3

Perkembangan bahasa, pada usia bawah lima tahun (balita) akan berkembang sangat aktif dan pesat. Keterlambatan bahasa pada periode ini, dapat menimbulkan berbagai masalah dalam proses belajar di usia sekolah.⁴ Anak yang mengalami keterlambatan bicara dan bahasa beresiko mengalami kesulitan belajar, kesulitan membaca dan menulis dan akan menyebabkan pencapaian akademik yang kurang secara menyeluruh, hal ini dapat berlanjut sampai usia dewasa muda. Selanjutnya orang dewasa dengan pencapaian akademik yang rendah akibat keterlambatan bicara dan bahasa, akan mengalami masalah perilaku dan penyesuaian psikososial.⁵

Melihat sedemikian besar dampak yang timbul akibat keterlambatan bahasa pada anak usia pra sekolah maka sangatlah penting untuk mengoptimalkan proses perkembangan bahasa pada periode ini. Deteksi dini keterlambatan dan gangguan bicara usia prasekolah adalah tindakan yang terpenting untuk menilai tingkat perkembangan bahasa anak, sehingga dapat meminimalkan kesulitan dalam proses belajar anak tersebut saat memasuki usia sekolah. Beberapa ahli menyimpulkan perkembangan bicara dan bahasa dapat dipakai sebagai indikator perkembangan anak secara keseluruhan, termasuk kemampuan kognisi dan kesuksesan dalam proses belajar di sekolah.⁶ Hasil studi longitudinal menunjukkan bahwa keterlambatan perkembangan bahasa berkaitan dengan intelegensi dan membaca di kemudian hari.⁷

Gangguan bicara pada usia prasekolah, diperkirakankan 5% dari populasi normal dan 70% dari kasus tersebut ditangani oleh terapis (Weiss et al. 1987). Gangguan perkembangan bicara sangat bervariasi dan masih banyak timbul kontroversi khususnya mengenai penentuan klasifikasi sesuai dengan etiologi atau manifestasi klinisnya. Hal penting yang menjadi perhatian para klinisi adalah mengenai faktor resiko yang mempengaruhi perkembangan bicara dan bahasa. Faktor resiko yang paling sering dilaporkan adalah riwayat keluarga yang positif, gangguan pendengaran, pre dan perinatal problem meliputi kelahiran preterm dan berat badan lahir rendah serta faktor psikososial.  

 Faktor resiko yang dipengaruhi oleh kondisi biologi dan lingkungan ini meningkatkan kemungkinan terjadinya gangguan perkembangan (Brooks-Gunn, 1990). Mengenali berbagai faktor resiko yang berkaitan dengan disabilitas perkembangan menjadi perhatian utama, terutama faktor-faktor yang diyakini dipengaruhi oleh kondisi biologis dan lingkungan pada fase awal dari suatu proses perkembangan. Faktor biologis yang beresiko negatif pada perkembangan adalah prematuritas, berat badan lahir rendah, komplikasi perinatal. Sedangkan faktor resiko dari lingkungan meliputi status sosioekonomi yang rendah, hubungan tetangga yang buruk, psikopatologi orang tua.     Mengenali lebih dini faktor resiko pada anak merupakan faktor penting untuk menjamin bahwa mereka ditempatkan dalam bentuk program remedial yang tepat untuk meminimalkan atau mengurangi dampak dari faktor resiko tersebut. Peran utama penelitian tersebut adalah melakukan intervensi dini dan pendidikan khusus yang memperlihatkan bagaimana pendekatan suatu epidemiologi perkembangan sehingga dapat memberikan informasi bagi upaya pencegahan.

Deteksi dini dan penanganan awal terhadap emosi, kognitif atau masalah fisik adalah hal yang sangat penting. Orang-orang dewasa ini khususnya orang tua, perawat anak sehari-hari, atau dokter anak sering kali gagal menemukan indikator awal dari disabilitas.  Beberapa anak tidak memperoleh penanganan dengan baik sampai masalah perkembangan itu menjadi sesuatu yang tidak dapat ditangani atau berdampak secara signifikan terhadap hal-hal lain.

Epidemiologi perkembangan adalah suatu metodologi pendekatan yang bisa sangat membantu mengidentifikasi faktor-faktor resiko dini untuk masalah-masalah anak, seperti menentukan angka prevalensi dari masalah kesehatan di masyarakat. Beberapa penelitian menggunakan epidemiologi perkembangan untuk mengenali anak pada saat lahir, siapa yang paling beresiko nantinya mengalami gangguan perkembangan. Berbagai penelitian tersebut memperkenalkan faktor-faktor spesifik yang dapat meningkatkan resiko seorang anak mengalami gangguan perkembangan, tetapi penelitian tersebut tidak meneliti outcome pada anak-anak prasekolah atau tidak menggunakan skore penilaian bahasa yang standart untuk mengidentifikasi anak-anak yang beresiko.

Bicara dan bahasa pada Anak

Komunikasi adalah suatu alat yang digunakan oleh manusia untuk berinteraksi satu dengan yang lainnya dalam bentuk bahasa. Komunikasi tersebut terjadi baik secara verbal maupun non verbal yaitu dengan tulisan, bacaan dan tanda atau simbol.⁵ Berbahasa itu sendiri merupakan proses yang kompleks dan tidak terjadi begitu saja. Setiap individu berkomunikasi lewat bahasa memerlukan suatu proses yang berkembang dalam tahap-tahap usianya. Bagaimana bahasa bisa digunakan untuk berkomunikasi selalu menjadi pertanyaan yang menarik untuk dibahas sehingga memunculkan banyak teori tentang pemerolehan bahasa.^{1, 12}

Bahasa adalah bentuk aturan atau sistem lambang yang digunakan anak dalam berkomunikasi dan beradaptasi dengan lingkungannya yang dilakukan untuk bertukar gagasan, pikiran dan emosi. Bahasa bisa diekspresikan melalui bicara yang mengacu pada simbol verbal. Selain itu bahasa  dapat juga diekspresikan melalui  tulisan, tanda gestural dan musik. Bahasa juga dapat mencakup aspek komunikasi nonverbal seperti gestikulasi, gestural atau pantomim. Gestikulasi adalah ekspresi gerakan tangan dan lengan untuk menekankan makna wicara. Pantomim adalah sebuah cara komunikasi yang mengubah komunikasi verbal dengan aksi yang mencakup beberapa gestural (ekspresi gerakan yang menggunakan setiap bagian tubuh) dengan makna yang berbeda beda.¹

Gangguan bicara dan bahasa adalah salah satu penyebab gangguan perkembangan yang paling sering ditemukan pada anak. Keterlambatan bicara adalah keluhan utama yang sering dicemaskan dan dikeluhkan orang tua kepada dokter. Gangguan ini semakin hari tampak semakin meningkat pesat. Beberapa laporan menyebutkan angka kejadian gangguan bicara dan bahasa berkisar 5 – 10% pada anak sekolah.¹²

Penyebab keterlambatan bicara sangat  banyak dan luas, gangguan tersebut ada yang ringan sampai yang berat, mulai dari yang bisa membaik hingga yang sulit untuk membaik. Keterlambatan bicara fungsional merupakan penyebab yang sering  dialami oleh sebagian anak. Keterlambatan bicara golongan ini biasanya ringan dan hanya merupakan ketidakmatangan fungsi bicara pada anak. Pada usia tertentu terutama setelah usia 2 tahun akan membaik. Bila keterlambatan bicara tersebut bukan karena proses fungsional maka gangguan tersebut harus lebih diwaspadai karena bukan sesuatu yang ringan.

Semakin dini mendeteksi keterlambatan bicara, maka semakin baik kemungkinan pemulihan gangguan tersebut. Bila keterlambatan bicara tersebut nonfungsional maka harus cepat dilakukan stimulasi dan intervensi pada anak tersebut. Deteksi dini keterlambatan bicara harus dilakukan oleh semua individu yang terlibat dalam penanganan anak. Kegiatan deteksi dini ini melibatkan orang tua, keluarga, dokter kandungan yang merawat sejak kehamilan dan dokter anak yang merawat anak tersebut.¹

Definisi

Kata bahasa berasal dari bahasa latin “lingua” yang berarti lidah. Awalnya pengertiannya hanya merujuk pada bicara, namun selanjutnya digunakan sebagai bentuk sistem konvensional dari simbol-simbol yang dipakai dalam komunikasi.¹²

American Speech-Language Hearing Association Committee on Language mendefinisikan bahasa sebagai : suatu sistem lambang konvensional yang kompleks dan dinamis yang dipakai dalam berbagai cara berpikir dan berkomunikasi.¹³

Dalam Kamus Bahasa Indonesia, bahasa didefinisikan sebagai : suatu sistem lambang bunyi yang  arbitrer, yang digunakan oleh suatu anggota masyarakat untuk bekerja bersama, berinteraksi dan  mengidentifikasikan diri.^14,15 Kamus bahasa Inggris juga memberi definisi yang sama tentang bahasa.¹⁶ 

Terdapat perbedaan mendasar antara bicara dan bahasa. Bicara adalah pengucapan yang menunjukkan ketrampilan seseorang mengucapkan suara dalam suatu kata. Bahasa berarti menyatakan dan menerima informasi dalam suatu cara tertentu. Bahasa merupakan salah satu cara berkomunikasi. Bahasa reseptif adalah kemampuan untuk mengerti apa yang dilihat dan apa yang didengar. Bahasa ekspresif adalah kemampuan untuk berkomunikasi secara simbolis baik visual (menulis, memberi tanda) atau auditorik.^14,16

Seorang anak yang mengalami gangguan berbahasa mungkin saja ia dapat mengucapkan satu kata dengan jelas tetapi tidak dapat menyusun dua kata dengan baik, atau sebaliknya seorang anak mungkin saja dapat mengucapkan sebuah kata yang sedikit sulit untuk dimengerti tetapi ia dapat menyusun kata-kata tersebut dengan benar untuk menyatakan keinginannya.¹⁷  

Masalah bicara dan bahasa sebenarnya berbeda tetapi kedua masalah ini sering kali tumpang tindih.¹⁷  Gangguan bicara dan bahasa terdiri dari masalah artikulasi, suara, kelancaran bicara (gagap), afasia (kesulitan dalam menggunakan kata-kata, biasanya akibat cedera otak) serta keterlambatan dalam bicara atau bahasa. Keterlambatan bicara dan bahasa dapat disebabkan oleh berbagai faktor termasuk faktor lingkungan atau hilangnya pendengaran. Gangguan bicara dan bahasa juga berhubungan erat dengan area lain yang mendukung proses tersebut seperti fungsi otot mulut dan fungsi pendengaran. Keterlambatan dan gangguan bisa mulai dari bentuk yang sederhana seperti bunyi suara yang “tidak normal” (sengau, serak) sampai dengan ketidakmampuan untuk mengerti atau menggunakan bahasa, atau ketidakmampuan mekanisme motorik oral dalam fungsinya untuk bicara dan makan.¹⁸

Gangguan perkembangan artikulasi meliputi kegagalan mengucapkan satu huruf sampai beberapa huruf, sering terjadi penghilangan atau penggantian bunyi huruf tersebut sehingga menimbulkan kesan cara bicaranya seperti anak kecil. Selain itu juga dapat berupa gangguan dalam pitch, volume atau kualitas suara.¹⁸

Afasia yaitu kehilangan kemampuan untuk membentuk kata-kata atau kehilangan kemampuan untuk menangkap arti kata-kata sehingga pembicaraan tidak dapat berlangsung dengan baik. Anak-anak dengan afasia didapat memiliki riwayat perkembangan bahasa awal yang normal, dan memiliki onset setelah trauma kepala atau gangguan neurologis lain (contohnya kejang).^18-20

Gagap adalah gangguan kelancaran atau abnormalitas dalam kecepatan atau irama bicara. Terdapat pengulangan suara, suku kata atau kata atau suatu bloking yang spasmodik, bisa terjadi spasme tonik dari otot-otot bicara seperti lidah, bibir dan laring. Terdapat kecendrungan adanya riwayat gagap dalam keluarga. Selain itu, gagap juga dapat disebabkan oleh tekanan dari orang tua agar anak bicara dengan jelas, gangguan lateralisasi, rasa tidak aman, dan kepribadian anak.^18,19

Epidemiologi

Gangguan bicara dan bahasa dialami oleh 8% anak usia prasekolah. Hampir sebanyak 20% dari anak berumur 2 tahun mempunyai gangguan keterlambatan bicara. Keterlambatan bicara paling sering terjadi pada usia 3-16 tahun. ^1,21

Pada anak-anak usia 5 tahun, 19% diidentifikasi memiliki gangguan bicara dan bahasa (6,4% keterlambatan berbicara, 4,6% keterlambatan bicara dan bahasa, dan 6% keterlambatan bahasa). Gagap terjadi 4-5% pada usia 3-5 tahun dan 1% pada usia remaja. Laki-laki diidentifikasi memiliki gangguan bicara dan bahasa hampir dua kali lebih banyak daripada wanita. Sekitar 3-6% anak usia sekolah memiliki gangguan bicara dan bahasa tanpa gejala neurologi, sedangkan pada usia prasekolah prevalensinya lebih tinggi yaitu sekitar 15%. Menurut penelitian anak dengan riwayat sosial ekonomi yang lemah memiliki insiden gangguan bicara dan bahasa yang lebih tinggi daripada anak dengan riwayat sosial ekonomi menengah ke atas.^1,21

  Studi Cochrane terakhir telah melaporkan data keterlambatan bicara, bahasa dan gabungan keduanya pada anak usia prasekolah dan usia sekolah. Prevalensi keterlambatan perkembangan bahasa dan bicara pada anak usia 2 sampai 4,5 tahun adalah 5-8%, prevalensi keterlambatan bahasa adalah 2,3-19%.²² Sebagian besar studi melaporkan prevalensi dari 40% sampai 60%.^7,22,23 

Prevalensi keterlambatan perkembangan berbahasa di Indonesia belum pernah diteliti secara luas.^1,24 Kendalanya dalam menentukan kriteria keterlambatan perkembangan berbahasa. Data di Departemen Rehabilitasi Medik RSCM tahun 2006, dari 1125 jumlah kunjungan pasien anak terdapat 10,13% anak terdiagnosis keterlambatan bicara dan bahasa.²⁵  Penelitian Wahjuni tahun 1998 di salah satu kelurahan di Jakarta Pusat menemukan prevalensi keterlambatan bahasa sebesar 9,3% dari 214 anak yang berusia bawah tiga tahun.²⁶

Neurolinguistik         

Sistem Saraf Pusat

Pada sebagian besar manusia area bahasa terletak pada hemisfer serebri kiri. Terdapat empat area bahasa secara konvensional yaitu dua area bahasa reseptif dan dua lainnya adalah eksekutif yang menghasilkan bahasa. Dua area reseptif berhubungan erat dengan zona bahasa sentral. Area reseptif berfungsi mengatur persepsi bahasa  yang diucapkan, yaitu area 22 posterior yang disebut area Wernicke dan girus Heschls (area 41 dan 42). Area yang mengatur persepsi bahasa tulisan menempati girus angulus (area 39) pada lobus parietal inferior anterior terhadap area reseptif visual. Girus supra marginal yang terletak di antara pusat bahasa auditori dan visual dan area temporal inferior yang terletak di anterior korteks asosiasi visual kemungkinan adalah bagian dari zona bahasa sentral juga. Area-area ini terletak pada pusat integrasi untuk fungsi bahasa visual dan auditori.²⁷

Area Broadman 44 dan 45 disebut area Broca dan merupakan bagian eksekutif utama yang bertanggung jawab terhadap aspek motorik bicara. Secara visual kata-kata yang diterima diekspresikan dalam bentuk tulisan  melalui area tulisan Exner.²⁷ Area sensori dan motori terhubungkan satu dengan yang lain melalui fasikulus arkuatum yang melewati ismus lobus temporal kemudian memutari ujung posterior fisura silvii, sambungan lainnya melalui kapsula eksterna nukleus lentikular.²⁷         

Area penerimaan visual dan somatosensori terintegrasi pada lobus parietal, sedangkan penerimaan auditori terletak di lobus temporal. Serat pendek, menghubungkan area Broca dengan korteks rolandi bawah yang menginervasi organ bicara, otot bibir, lidah, farings dan larings. Area menulis Exner juga terintegrasi dengan organ motor untuk otot tangan. Area bahasa perisylvian juga terhubungkan dengan striata dan thalamus dan area korespondensi pada hemisfer non dominan melalui korpus kalosum dan komisura anterior.²⁷

Tiga fungsi dasar otak adalah fungsi pengaturan, proses dan formulasi.Fungsi pengaturan bertanggung-jawab untuk tingkat energi dan tonus korteks secara keseluruhan. Fungsi proses berlokasi di belakang korteks, mengontrol analisa informasi, pengkodean dan penyimpanan. Korteks yang lebih tinggi bertanggung jawab untuk memproses rangsangan sensori seperti rangsangan optik, akustik dan olfaktori. Data dari tiap sumber digabungkan dengan sumber sensori lainnya untuk dianalisa dan diformulasikan. Proses formulasi berlokasi pada lobus frontal, bertanggung jawab untuk formasi intensi dan perilaku. Fungsi utamanya adalah untuk mengaktifkan otak untuk pengaturan atensi dan konsentrasi.²⁷

Meskipun hemisfer kiri dan kanan simetris untuk proses motorik dan sensoris, namun terdapat juga ketidaksimetrisan untuk fungsi khusus tertentu seperti bahasa. Dengan demikian, meskipun fungsinya berbeda, kedua hemisfer tersebut saling berintegrasi dan memberi informasi melalui korpus kalosum dan subkortikal lainnya. Fungsi yang menonjol dari hemisfer serebri kiri adalah sebagai fungsi dasar untuk bahasa. Teori yang paling umum mengatakan traktus kortikospinal berasal dari hemisfer kiri yang berisi lebih banyak serat dan menyilang lebih tinggi dibanding hemifer kanan. Belajar juga merupakan suatu faktor, terjadi banyak pergeseran dari kiri ke kanan (shifted sinistral). Pada sebagian anak terjadi pergeseran  ke kanan hemisfer di usia muda, dan menjadi bertangan kidal.²⁸

Proses fisiologi bicara 

Menurut beberapa ahli komunikasi, bicara adalah kemampuan anak untuk berkomunikasi dengan bahasa oral (mulut) yang membutuhkan kombinasi yang serasi dari sistem neuromuskular untuk mengeluarkan fonasi dan artikulasi suara. Proses bicara melibatkan beberapa sistem dan fungsi tubuh, melibatkan sistem pernapasan, pusat khusus pengatur bicara di otak dalam korteks serebri, pusat respirasi di dalam batang otak dan struktur artikulasi, resonansi dari mulut serta rongga hidung.²⁹

Terdapat 2 hal proses terjadinya bicara, yaitu proses sensoris dan motoris. Aspek sensoris meliputi pendengaran, penglihatan, dan rasa raba berfungsi untuk memahami apa yang didengar, dilihat dan dirasa. Aspek motorik yaitu mengatur laring, alat-alat untuk artikulasi, tindakan artikulasi dan laring yang bertanggung jawab untuk pengeluaran suara.^27,29

Pada hemisfer dominan otak atau sistem susunan saraf pusat terdapat pusat-pusat yang mengatur mekanisme berbahasa yakni dua pusat bahasa reseptif area 41 dan 42 (area wernick), merupakan pusat persepsi auditori-leksik yaitu mengurus pengenalan dan pengertian segala sesuatu yang berkaitan dengan bahasa lisan (verbal). Area 39 broadman  adalah pusat persepsi visuo-leksik yang mengurus pengenalan dan pengertian segala sesuatu yang bersangkutan dengan bahasa tulis. Sedangkan area Broca adalah pusat bahasa ekspresif. Pusat-pusat tersebut berhubungan satu sama lain melalui serabut asosiasi.²⁷

Saat mendengar pembicaraan maka getaran udara yang ditimbulkan akan masuk melalui lubang telinga luar kemudian menimbulkan getaran pada membran timpani. Dari sini rangsangan diteruskan oleh ketiga tulang kecil dalam telinga tengah ke telinga bagian dalam. Di telinga bagian dalam terdapat reseptor sensoris untuk pendengaran yang disebut Coclea. Saat gelombang suara mencapai coclea maka impuls ini diteruskan oleh saraf VIII ke area pendengaran primer di otak diteruskan ke area wernick. Kemudian jawaban diformulasikan dan disalurkan  dalam bentuk artikulasi, diteruskan ke area motorik di otak yang mengontrol gerakan bicara. Selanjutnya proses bicara dihasilkan oleh getaran vibrasi dari pita suara yang dibantu oleh aliran udara dari paru-paru, sedangkan bunyi dibentuk oleh gerakan bibir, lidah dan palatum (langit-langit). Jadi untuk proses bicara diperlukan koordinasi sistem saraf motoris dan sensoris dimana organ pendengaran sangat penting.^27,29

Proses reseptif – Proses dekode    

Segera saat rangsangan auditori diterima, formasi retikulum pada batang otak akan menyusun tonus untuk otak dan menentukan modalitas dan rangsang mana yang akan diterima otak. Rangsang tersebut ditangkap oleh talamus dan selanjutnya diteruskan ke area korteks auditori pada girus Heschls, dimana sebagian besar signal yang diterima oleh girus ini berasal dari sisi telinga yang berlawanan.^27,29

Girus dan area asosiasi auditori akan memilah informasi bermakna yang masuk. Selanjutnya masukan linguistik yang sudah dikode, dikirim ke lobus temporal kiri untuk diproses. Sementara masukan paralinguistik berupa intonasi, tekanan, irama dan kecepatan masuk ke lobus temporal kanan. Analisa linguistik dilakukan pada area Wernicke di lobus temporal kiri. Girus angular dan supramarginal membantu proses integrasi informasi visual, auditori dan raba serta perwakilan linguistik. Proses dekode dimulai dengan dekode fonologi berupa penerimaan unit suara melalui telinga, dilanjutkan dengan dekode gramatika. Proses berakhir pada dekode semantik dengan pemahaman konsep atau ide yang disampaikan lewat pengkodean tersebut.²⁷

Proses ekspresif – Proses encode

Proses produksi berlokasi pada area yang sama pada otak. Struktur untuk pesan yang masuk ini diatur pada area Wernicke, pesan diteruskan melalui fasikulus arkuatum ke area Broca untuk penguraian dan koordinasi verbalisasi pesan tersebut. Signal kemudian melewati korteks motorik yang mengaktifkan otot-otot respirasi, fonasi, resonansi dan artikulasi. Ini merupakan proses aktif pemilihan lambang dan formulasi pesan. Proses enkode dimulai dengan enkode semantik yang dilanjutkan dengan enkode gramatika dan berakhir pada enkode fonologi. Keseluruhan proses enkode ini terjadi di otak/pusat pembicara.^{27, 29}

Di antara proses dekode dan enkode terdapat proses transmisi, yaitu pemindahan atau penyampaian kode atau disebut kode bahasa. Transmisi ini terjadi antara mulut pembicara dan telinga pendengar.^27,29-31 Proses decode-encode diatas disimpulkan sebagai proses komunikasi. Dalam proses perkembangan bahasa, kemampuan menggunakan bahasa reseptif dan ekspresif harus berkembang dengan baik.^29-31

Perkembangan bahasa pada anak usia di bawah 3 tahun 

Perkembangan bahasa sangat berhubungan erat dengan maturasi otak. Secara keseluruhan terlihat dengan berat kasar otak yang berubah sangat cepat dalam 2 tahun pertama kehidupan. Hal ini disebabkan karena mielinisasi atau pembentukan selubung sistem saraf.  Proses mielinisasi ini dikontrol oleh hormon seksual, khususnya estrogen. Hal ini menjelaskan kenapa proses perkembangan bahasa lebih cepat pada anak perempuan.^30-32 

Pada usia sekitar 2 bulan, korteks motorik di lobus frontal menjadi lebih aktif. Anak memperoleh lebih banyak kontrol dalam perilaku motor volusional. Korteks visual menjadi lebih aktif pada usia 3 bulan, jadi anak menjadi lebih fokus pada benda yang dekat maupun yang jauh. Selama separuh periode tahun pertama korteks frontal dan hipokampus menjadi lebih aktif. Hal ini menyebabkan peningkatan kemampuan untuk mengingat stimulasi dan hubungan awal antara kata dan keseluruhan. Pengalaman dan interaksi bayi akan membantu anak  mengatur kerangka kerja otak.³²  

Diferensiasi otak fetus dimulai pada minggu ke-16 gestasi. Selanjutnya maturasi otak berbeda dan terefleksikan pada perilaku bayi saat lahir. Selama masa prenatal batang otak, korteks primer dan korteks somatosensori bertumbuh dengan cepat. Sesudah lahir serebelum dan hemisfer serebri juga tumbuh bertambah cepat terutama area reseptor visual. Ini menjelaskan bahwa maturasi visual terjadi relatif lebih awal dibandingkan auditori. Traktus asosiasi yang mengatur bicara dan bahasa belum sepenuhnya matur sampai periode akhir usia pra sekolah.² Pada neonatus, vokalisasi dikontrol oleh batang otak dan pons. Reduplikasi babbling menandakan maturasi bagian wajah dan area laring pada korteks motor. Maturasi jalur asosiasi auditorik seperti fasikulus arkuatum yang menghubungkan area auditori dan area motor korteks tidak tercapai sampai awal tahun kedua kehidupan sehingga menjadi keterbatasan dalam intonasi bunyi dan bicara.^31,32  Pengaruh hormon estrogen pada maturasi otak akan mempengaruhi kecepatan perkembangan bunyi dan bicara pada anak perempuan.³²

Tabel 1. Milestones Normal Perkembangan Bicara dan Bahasa pada Anak.³³

Umur              Kemampuan Reseptif                                   Kemampuan Ekspresif

Lahir                      Melirik ke sumber suara                                          Menangis

                                    Memperlihatkan ketertarikan 

                                   terhadap suara­suara

2 – 4 bulan                                                                                             Tertawa dan mengoceh tanpa arti                           

6 bulan                   Memberi respon jika namanya                                Mengeluarkan suara yang 

                                      dipanggil                                                               merupakan kombinasi huruf 

                              hidup (vowel) dan huruf mati 

                                                                                                                                                (konsonan)

9 bulan                   Mengerti dengan kata ­kata yang                              Mengucapkan “ma­ma”, “da­da”

rutin (da­da)             

12 bulan                 Memahami dan menuruti                                         Bergumam

perintah sederhana                                                   Mengucapkan satu kata

15 bulan                 Menunjuk anggota tubuh                                        Mempelajari kata-­kata dengan 

perlahan

18 – 24 bulan         Mengerti kalimat                                                     Menggunakan/merangkai dua 

kata

24 – 36 bulan         Menjawab pertanyan                                               Frase 50% dapat dimengerti

Mengikuti 2 langkah perintah                                  Membentuk 3 (atau lebih) kalimat

Menanyakan “apa”

36 – 48 bulan         Mengerti banyak apa yang                                      Menanyakan “mengapa”

Diucapkan                                                               Kalimat 75% dapat dimengerti,                                                                                                               bahasa sudah mulai jelas, 

menggunakan lebih dari 4 kata 

dalam satu kalimat

48 – 60 bulan         Mengerti banyak apa yang                                      Menyusun kalimat dengan baik

dikatakan, sepadan dengan                                      Bercerita

fungsi kognitif                                                         100% kalimat dapat dimengerti

6 tahun                                                                                                   Pengucapan bahasa lebih jelas

Lundsteen membagi perkembangan bahasa dalam 3 tahap ³² :

1. Tahap pralinguistik

-               0-3 bulan, bunyinya di dalam (meruku) dan berasal dari tenggorok.

-               3-12 bulan, meleter, banyak memakai bibir dan langit-langit, misalnya ma, da, ba.

1. Tahap protolinguitik

-               12 bulan-2 tahun, anak sudah mengerti dan menunjukkan alat-alat tubuh. Ia mulai berbicara beberapa patah kata (kosa katanya dapat mencapai 200-300).

1. Tahap linguistik

-               2-6 tahun atau lebih, pada tahap ini ia mulai belajar tata bahasa dan perkembangan kosa katanya mencapai 3000 buah.

Tahap perkembangan bahasa di atas hampir sama dengan pembagian menurut Bzoch yang membagi perkembangan bahasa anak dari lahir sampai usia 3 tahun dalam empat stadium.³⁴

1. Perkembangan bahasa bayi sebagai komunikasi prelinguistik. 0-3 bulan.  Periode lahir sampai akhir tahun pertama.  Bayi baru lahir belum bisa menggabungkan elemen bahasa baik isi, bentuk dan pemakaian bahasa. Selain belum berkembangnya bentuk bahasa konvensional, kemampuan kognitif bayi juga belum berkembang. Komunikasi lebih bersifat reflektif daripada terencana. Periode ini disebut prelinguistik. Meskipun bayi belum mengerti dan belum bisa mengungkapkan bentuk bahasa konvensional, mereka mengamati dan memproduksi suara dengan cara yang unik. Klinisi harus menentukan apakah bayi mengamati atau bereaksi terhadap suara. Bila tidak, ini merupakan indikasi untuk evaluasi fisik dan audiologi. Selanjutnya intervensi direncanakan untuk membangun lingkungan yang menyediakan banyak kesempatan untuk mengamati dan bereaksi terhadap suara.³⁴
2. Kata-kata pertama : transisi ke bahasa anak. 3-9 bulan. Salah satu perkembangan bahasa utama milestone adalah pengucapan kata-kata pertama yang terjadi pada akhir tahun pertama, berlanjut sampai satu setengah tahun saat pertumbuhan kosa kata berlangsung cepat, juga tanda dimulainya pembetukan kalimat awal.  Berkembangnya kemampuan kognitif, adanya kontrol dan interpretasi emosional di periode ini akan memberi arti pada kata-kata pertama anak. Arti kata-kata pertama mereka dapat merujuk ke benda, orang, tempat, dan kejadian-kejadian di seputar lingkungan awal anak.³⁴
3. Perkembangan kosa kata yang cepat-Pembentukan kalimat awal. 9-18 bulan.  Bentuk kata-kata pertama menjadi banyak, dan dimulainya produksi kalimat. Perkembangan komprehensif dan produksi kata-kata berlangsung cepat pada sekitar 18 bulan. Anak mulai bisa menggabungkan kata benda dengan kata kerja yang kemudian menghasilkan sintaks. Melalui interaksinya dengan orang dewasa, anak mulai belajar mengkonsolidasikan isi, bentuk dan pemakaian bahasa dalam percakapannya. Dengan semakin berkembangnya kognisi dan pengalaman afektif, anak mulai bisa berbicara memakai kata-kata yang tersimpan dalam memorinya.  Terjadi pergeseran dari pemakaian kalimat satu kata menjadi bentuk kata benda dan kata kerja.³⁴
4. Dari percakapan bayi menjadi registrasi anak pra sekolah yang menyerupai orang dewasa. 18-36 bulan. Anak dengan mobilitas yang mulai meningkat memiliki akses ke jaringan sosial yang lebih luas dan perkembangan kognitif menjadi semakin dalam.  Anak mulai berpikir konseptual, mengkategorikan benda, orang dan peristiwa serta dapat  menyelesaikan masalah fisik Anak terus mengembangkan pemakaian bentuk fonem dewasa.³⁴

Perkembangan bahasa anak dapat dilihat juga dari pemerolehan bahasa menurut komponen-komponennya.

Perkembangan Pragmatik

Perkembangan komunikasi anak sesungguhnya sudah dimulai sejak dini, pertama-tama dari tangisannya bila bayi merasa tidak nyaman, misalnya karena lapar, popok basah. Dari sini bayi akan belajar bahwa ia akan mendapat perhatian ibunya atau orang lain saat ia menangis sehingga kemudian bayi akan menangis bila meminta orang dewasa melakukan sesuatu buatnya. ³⁴

Usia 3 minggu bayi tersenyum saat ada rangsangan dari luar, misalnya wajah seseorang, tatapan mata, suara dan gelitikan. Ini disebut senyum sosial. Usia 12 minggu mulai dengan pola dialog sederhana berupa suara balasan bila ibunya memberi tanggapan. Usia 2 bulan bayi mulai menanggapi ajakan komunikasi ibunya. Usia 5 bulan bayi mulai meniru gerak-gerik orang, mempelajari bentuk ekspresi wajah. Pada usia 6 bulan bayi mulai tertarik dengan benda-benda sehinga komunikasi menjadi komunikasi ibu, bayi dan benda-benda. Usia 7-12 bulan anak menunjuk sesuatu untuk menyatakan keinginannya. Gerak-gerik ini akan berkembang disertai dengan bunyi-bunyi tertentu yang mulai konsisten. Pada masa ini sampai sekitar 18 bulan, peran gerak-gerik lebih menonjol dengan penggunaan satu suku kata. Usia 2 tahun anak kemudian memasuki tahap sintaksis dengan mampu merangkai kalimat 2 kata, bereaksi terhadap pasangan bicaranya dan masuk dalam dialog singkat. Anak mulai memperkenalkan atau merubah topik dan mulai belajar memelihara alur percakapan dan menangkap persepsi pendengar. Perilaku ibu yang fasilitatif akan membantu anaknya dalam memperkenalkan topik baru. Lewat umur 3 tahun anak mulai berdialog lebih lama sampai beberapa kali giliran. Lewat umur ini, anak mulai mampu mempertahankan topik yang selanjutnya mulai membuat topik baru. Hampir 50 persen anak 5 tahun dapat mempertahankan topik melalui 12 kali giliran. ^4,34

Sekitar 36 bulan, terjadi peningkatan dalam keaktifan berbicara dan anak memperoleh  kesadaran sosial dalam percakapan. Ucapan yang ditujukan pada pasangan bicara  menjadi jelas, tersusun baik dan teradaptasi baik untuk pendengar.²  Sebagian besar pasangan berkomunikasi anak adalah orang dewasa, biasanya orang tua. Saat anak mulai membangun jaringan sosial melibatkan orang di luar keluarga, mereka akan memodifikasi pemahaman diri dan bayangan diri dan menjadi lebih sadar akan standar sosial. Lingkungan linguistik memiliki pengaruh bermakna pada proses belajar berbahasa. Ibu memegang kontrol dalam membangun dan mempertahankan dialog yang benar. Ini berlangsung sepanjang usia pra sekolah. ^4,34

Anak berada pada fase mono dialog, percakapan sendiri dengan kemauan untuk melibatkan orang lain. Monolog kaya akan lagu, suara, kata-kata tak bermakna, fantasi verbal dan ekspresi perasaan. ⁴

Perkembangan Semantik

Karena faktor lingkungan sangat berperan dalam perkembangan semantik, maka pada umur 6-9 bulan anak telah mengenal orang atau benda yang berada di sekitarnya. Leksikal dan pemerolehan konsep berkembang pesat pada masa pra sekolah. Terdapat indikasi bahwa anak dengan kosa kata lebih banyak akan lebih popular di kalangan teman-temannya. Diperkirakan terjadi penambahan 5 kata perhari di usia 18 bulan sampai 6 tahun.² Pemahaman kata bertambah tanpa pengajaran langsung orang dewasa.  Terjadi strategi pemetaan yang cepat di usia ini sehingga anak dapat menghubungkan suatu kata dengan rujukannya. Pemetaan yang cepat adalahlangkah awal dalam proses pemerolehan leksikal. Selanjutnya secara bertahap anak akan mengartikan lagi informasi-informasi baru yang diterima.⁴ 

Definisi kata benda anak usia pra sekolah meliputi properti fisik seperti bentuk, ukuran dan warna, properti fungsi, properti pemakaian dan lokasi. Definisi kata kerja anak pra sekolah juga berbeda dari kata kerja orang dewasa atau anak yang lebih besar. Anak pra sekolah dapat menjelaskan siapa, apa, kapan, di mana, untuk apa, untuk siapa, dengan apa, tapi biasanya mereka belum memahami pertanyaan bagaimana dan mengapa atau menjelaskan proses.⁴ 

Anak akan mengembangkan kosa katanya melalui cerita yang dibacakan orang tuanya. Begitu kosa kata berkembang, kebutuhan untuk mengorganisasikan kosa kata akan lebih meningkat, dan beberapa jaringan semantik atau antar relasi akan terbentuk.⁴

Perkembangan Sintaksis

Susunan sintaksis paling awal terlihat pada usia kira-kira 18 bulan walaupun pada beberapa anak terlihat pada usia 1 tahun bahkan lebih dari 2 tahun. Awalnya berupa kalimat dua kata. Rangkaian dua kata, berbeda dengan masa “kalimat satu kata” sebelumnya yang disebut masa holofrastis.³⁰ Kalimat satu kata bisa ditafsirkan dengan mempertimbangkan konteks penggunaannya. Hanya mempertimbangkan arti kata semata-mata tidaklah mungkin kita menangkap makna dari kalimat satu kata tersebut.^4,34

Peralihan dari satu kata menjadi kalimat yang merupakan rangkaian kata terjadi secara bertahap. Pada waktu kalimat pertama terbentuk yaitu penggabugan dua kata menjadi kalimat, rangkaian kata tersebut berada pada jalinan intonasi. Jika kalimat dua kata tersebut memberi makna lebih dari satu maka anak membedakannya dengan menggunakan pola intonasi yang berbeda.^4,34

Perkembangan pemerolehan sintaksis meningkat pesat pada waktu anak menjalani usia 2 tahun, yang mencapai puncaknya pada akhir usia 2 tahun.

Tahap perkembangan sintaksis secara singkat terbagi dalam ³⁴:

1. Masa pra-lingual, sampai usia 1 tahun
2. Kalimat satu kata, 1-1,5 tahun
3. Kalimat rangkaian kata, 1,5-2 tahun
4. Konstruksi sederhana dan kompleks, 3 tahun.

Lewat usia 3 tahun anak mulai menanyakan hal-hal yang abstrak dengan kata tanya “mengapa”,”kapan”. Pemakaian kalimat kompleks dimulai setelah anak menguasai kalimat empat kata sekitar usia 4 tahun.³⁴

Perkembangan Morfologi

Periode perkembangan ditandai dengan peningkatan panjang ucapan rata-rata, yang diukur dalam morfem. Panjang rata-rata ucapan, mean length of utterance (MLU) adalah alat prediksi kompleksitas bahasa pada anak yang berbahasa Inggris. MLU sangat erat berhubungan dengan usia dan merupakan prediktor yang baik untuk perkembangan bahasa.⁴

Dari usia 18 bulan sampai 5 tahun MLU meningkat kira-kira 1,2 morfem per  tahun. Penguasaan morfem mulai terjadi saat anak mulai merangkai kata sekitar usia 2 tahun. Beberapa sumber yang membahas tentang morfem dalam kaitannya dengan morfologi semuanya merupakan bahasa Inggris yang sangat berbeda dengan bahasa Indonesia. ^4,34

Perkembangan Fonologi

Perkembangan fonologi melalui proses yang panjang dari dekode bahasa. Sebagian besar konstruksi morfologi anak akan tergantung pada kemampuannya menerima dan memproduksi unit fonologi. Selama usia pra sekolah, anak tidak hanya menerima inventaris fonetik dan sistem fonologi tapi juga mengembangkan kemampuan menentukan bunyi mana yang dipakai untuk membedakan makna. ⁴

Pemerolehan fonologi berkaitan dengan proses konstruksi suku kata yang terdiri dari gabungan vokal dan konsonan. Bahkan dalam babbling, anak menggunakan konsonan-vokal (KV) atau konsonan-vokal-konsonan (KVK). Proses lainnya berkaitan dengan asimilasi dan substitusi sampai pada persepsi dan produksi suara.⁴

Perkembangan bahasa ekspresif dan reseptif

Myklebust membagi tahap perkembangan bahasa berdasarkan komponen ekspresif dan reseptif sebagai berikut ³²:

1. Lahir – 9 bulan: anak mulai mendengar dan mengerti, kemudian berkembanglah pengertian konseptual yang sebagian besar nonverbal.
2. Sampai 12 bulan: anak berbahasa reseptif auditorik, belajar mengerti apa yang dikatakan, pada umur 9 bulan belajar meniru kata-kata spesifik misalnya dada, muh, kemudian menjadi mama, papa.
3. Sampai 7 tahun: anak berbahasa ekspresif auditorik termasuk persepsi auditorik kata-kata dan menirukan suara. Pada masa ini terjadi perkembangan bicara dan penguasaan pasif kosa kata sekitar 3000 buah.
4. Umur 6 tahun dan seterusnya: anak berbahasa reseptif visual (membaca). Pada saat masuk sekolah ia belajar membandingkan bentuk tulisan dan bunyi perkataan.
5. Umur 6 tahun dan seterusnya: anak berbahasa ekspresif visual (mengeja dan menulis).

II.1.6.  Faktor resiko gangguan perkembangan bicara dan bahasa

Penyebab gangguan perkembangan bahasa sangat banyak dan luas, semua gangguan mulai dari proses pendengaran, penerusan impuls ke otak, otak, otot atau organ pembuat suara. Adapun beberapa penyebab gangguan atau keterlambatan bicara adalah gangguan pendengaran, kelainan organ bicara, retardasi mental, kelainan genetik atau kromosom, autis, mutism selektif, keterlambatan fungsional, afasia reseptif dan deprivasi lingkungan. Deprivasi lingkungan terdiri dari lingkungan sepi, status ekonomi sosial, tehnik pengajaran salah, sikap orangtua. Gangguan bicara pada anak dapat disebabkan karena kelainan organik yang mengganggu beberapa sistem tubuh seperti otak, pendengaran dan fungsi motorik lainnya.^{1, 2, 18, 22, 23}

Beberapa penelitian menunjukkan penyebab ganguan bicara adalah adanya gangguan hemisfer dominan. Penyimpangan ini biasanya merujuk ke otak kiri. Beberapa anak juga ditemukan penyimpangan belahan otak kanan, korpus kalosum dan lintasan pendengaran yang saling berhubungan. Hal lain  dapat juga di sebabkan karena diluar organ tubuh seperti lingkungan yang kurang mendapatkan stimulasi yang cukup atau pemakaian dua bahasa. Bila penyebabnya karena lingkungan biasanya keterlambatan yang terjadi tidak terlalu berat.^{22, 23}

Terdapat tiga penyebab keterlambatan bicara terbanyak diantaranya adalah retardasi mental, gangguan pendengaran dan keterlambatan maturasi. Keterlambatan maturasi ini sering juga disebut keterlambatan bicara fungsional.²²

Keterlambatan bicara fungsional merupakan penyebab yang cukup sering  dialami oleh sebagian anak. Keterlambatan bicara fungsional sering juga diistilahkan keterlambatan maturasi atau keterlambatan perkembangan bahasa. Keterlambatan bicara golongan ini disebabkan karena keterlambatan maturitas (kematangan) dari proses saraf pusat yang dibutuhkan untuk memproduksi kemampuan bicara pada anak. Gangguan seperti ini sering dialami oleh laki-laki dan sering terdapat riwayat keterlambatan bicara pada keluarga. Biasanya hal ini merupakan keterlambatan bicara yang ringan dan prognosisnya baik. Pada umumnya kemampuan bicara akan tampak membaik setelah memasuki usia 2 tahun. Terdapat penelitian yang melaporkan penderita dengan keterlambatan ini, kemampuan bicara saat masuk usia sekolah akan normal seperti anak lainnya.²³

Dalam keadaan ini biasanya fungsi reseptif sangat baik dan kemampuan pemecahan masalah visuo-motor anak dalam keadaan normal. Anak hanya mengalami gangguan perkembangan ringan dalam fungsi ekspresif. Ciri khas lain adalah anak tidak menunjukkan kelainan neurologis, gangguan pendengaran, gangguan kecerdasan dan gangguan psikologis lainnya.^{18, 22, 23}

Tabel 2. Penyebab Gangguan Bicara dan Bahasa menurut Blager BF³⁵

Penyebab                                           Efek pada Perkembangan Bicara

1. Lingkungan

a. Sosial ekonomi kurang                                        a. Terlambat

b. Tekanan keluarga                                                b. Gagap

c. Keluarga bisu                                                      c. Terlambat pemerolehan bahasa

d. Dirumah menggunakan bahasa                           d. Terlambat pemerolehan struktur bahasa

                    bilingual

2. Emosi

a. Ibu yang tertekan                                                 a. Terlambat pemerolehan bahasa

b. Gangguan serius pada orang tua                         b. Terlambat atau gangguan perkembangan 

                                                                                                    bahasa

c. Gangguan serius pada anak                                 c. Terlambat atau gangguan perkembangan bahasa 

3. Masalah pendengaran

a. Kongenital                                                           a. Terlambat atau gangguan bicara 

                                                                                                    permanen                            

b. Didapat                                                                b. Terlambat atau gangguan bicara 

                                                                                                    permanen

4. Perkembangan terlambat                               

a. Perkembangan lambat                                          a. Terlambat bicara

b. Perkembangan lambat, tetapi                               b. Terlambat bicara 

                masih dalam batas rata­rata

c. Retardasi mental                                                  c. Pasti terlambat bicara

5. Cacat bawaan

a. Palatoschizis                                                        a. Terlambat dan terganggu kemampuan bicara

b. Sindrom Down                                                   b. Kemampuan bicaranya lebih rendah

6. Kerusakan otak 

a. Kelainan neuromuscular                                      a. Mempengaruhi kemampuan menghisap, 

                                    menelan, mengunyah dan akhirnya timbul 

                                    gangguan bicara dan artikulasi seperti 

                    disartria

b. Kelainan sensorimotor                                        b.Mempengaruhi kemampuan menghisap, 

                                                                                                   menelan, akhirnya menimbulkan 

                   gangguan artikulasi, seperti dispraksia

c. Palsi serebral                                                       c.Berpengaruh pada pernapasan, makan 

                                                                                                   dan timbul juga masalah artikulasi yang 

                   dapat mengakibatkan disartria dan 

                                                                                                   dispraksia

d. Kelainan persepsi                                                d.Kesulitan membedakan suara, mengerti 

                                   bahasa, simbolisaasi, mengenal konsep, 

                                   akhirnya menimbulkan kesulitan belajar 

   di sekolah

Faktor Internal

Berbagai faktor internal atau faktor biologis tubuh seperti faktor persepsi, kognisi dan prematuritas dianggap sebagai faktor penyebab keterlambatan bicara pada anak.^31,35

Persepsi

Kemampuan membedakan informasi yang masuk disebut persepsi. Persepsi berkembang dalam 4 aspek: pertumbuhan, termasuk perkembangan sel saraf dan keseluruhan sistem; stimulasi, berupa masukan dari lingkungan meliputi seluruh aspek sensori, kebiasaan, yang merupakan hasil dari skema yang sering terbentuk. Kebiasaan, habituasi, menjadikan bayi mendapat stimulasi baru yang kemudian akan tersimpan dan selanjutnya dikeluarkan dalam proses belajar bahasa anak. Secara bertahap anak akan mempelajari stimulasi-stimulasi baru mulai dari raba, rasa, penciuman kemudian penglihatan dan pendengaran. ⁴

Pada usia balita, kemampuan persepsi auditori mulai terbentuk pada usia 6 atau 12 bulan, dapat memprediksi ukuran kosa kata dan kerumitan pembentukan pada usia 23 bulan.^4,36   Telinga sebagai organ sensori auditori berperan penting dalam perkembangan bahasa. Beberapa studi menemukan gangguan pendengaran karena otitis media pada anak akan mengganggu perkembangan bahasa.³⁷     

Sel saraf bayi baru lahir relatif belum terorganisir dan belum spesifik. Dalam perkembangannya, anak mulai membangun peta auditori dari fonem, pemetaan terbentuk saat fonem terdengar. Pengaruh bahasa ucapan berhubungan langsung terhadap jumlah kata-kata yang didengar anak selama masa awal perkembangan sampai akhir umur pra sekolah.⁴

Kognisi

Anak pada usia ini sangat aktif mengatur pengalamannya ke dalam kelompok umum maupun konsep yang lebih besar. Anak belajar mewakilkan, melambangkan ide dan konsep. Kemampuan ini merupakan kemampuan kognisi dasar untuk pemberolehan bahasa anak.⁴

Beberapa teori yang menjelaskan hubungan antara kognisi dan bahasa: ⁴

1. Bahasa berdasarkan dan ditentukan oleh pikiran (cognitive determinism)
2. 2.      Kualitas pikiran ditentukan oleh bahasa (linguistic determinism)
3. Pada awalnya pikiran memproses bahasa tapi selanjutnya pikiran dipengaruhi oleh bahasa.
4. Bahasa dan pikiran adalah faktor bebas tapi kemampuan yang berkaitan.

Sesuai dengan teori-teori tersebut maka kognisi bertanggung jawab pada pemerolehan bahasa dan pengetahuan kognisi merupakan dasar pemahaman kata.

Genetik

Berbagai penelitian menunjukkan, bahwa gangguan bahasa merupakan kecendrungan dalam suatu keluarga yang dapat terjadi sekitar 40% hingga 70%. Separuh keluarga yang memiliki anak dengan gangguan bahasa, minimal satu dari anggota keluarganya memiliki masalah bahasa. Orang tua dapat berpengaruh karena faktor keturunan sehingga mungkin bertanggung jawab terhadap faktor genetik. Mungkin sulit mengetahui berapa banyak transmisi intergenerasi gangguan bahasa tersebut, disebabkan oleh kurangnya dukungan lingkungan terhadap bahasa.^46-48

Menurut Bishop Edmundson, Tallal, Whitehurst dan Lewis 1992 dalam berbagai laporan kasus sering memperlihatkan riwayat keluarga positif pada gangguan komunikasi. Sekitar 28% hingga 60% dari anak-anak dengan gangguan bicara dan bahasa mempunyai saudara kandung dan/atau orang tua yang juga mengalami kesulitan bicara dan bahasa.^{47, 48}

Sedangkan menurut Tallal, Lewis dan Freebairn, anggota keluarga laki-laki lebih berpengaruh dari pada wanita. Bagaimanapun, data terbanyak memperlihatkan anak-anak dengan hanya gangguan bahasa saja dan tidak pada anak dengan gangguan bicara terpisah (isolated speech disorders).⁴⁸

Lewis dan Freebairn berhipotesa bahwa anak-anak dengan riwayat keluarga positif terhadap gangguan bicara akan membentuk grup spesifik ke dalam populasi gangguan bicara. Penemuan mereka tidak mendukung hipotesa karena tidak ada perbedaan bermakna yang ditemukan pada pengukuran artikulasi, fonologi, bahasa, kemampuan-kemampuan oral-motor atau kemampuan membaca dan menulis diantara anak-anak yang memiliki riwayat keluarga dengan gangguan bicara dibanding yang bukan.⁴⁷ Lewis dan Freebair menyimpulkan bahwa riwayat keluarga dengan gangguan bahasa bisa dipertimbangkan sebagai faktor risiko yang dapat digunakan untuk identifikasi awal. Identifikasi awal tersebut memungkinkan dilakukan intervensi dini bagi anak-anak yang keluarganya memperlihatkan gangguan ini.⁴⁷

Demikian pula anak yang berasal dari keluarga yang memiliki riwayat keterlambatan atau gangguan bahasa maka beresiko mengalami keterlambatan bahasa pula.^46-48 Riwayat keluarga yang dimaksud antara lain anggota keluarga yang mengalami keterlambatan berbicara, memiliki gangguan bahasa, gangguan bicara atau masalah belajar. ⁴⁸

Prematuritas

Penyebab khusus berkaitan antara permasalahan periode pre atau perinatal dengan gangguan bicara dan bahasa juga telah dibuktikan. Infeksi selama kehamilan, imaturitas dan berat badan lahir rendah dilaporkan mempunyai efek negatif pada perkembangan bicara dan bahasa.^{49, 50}

Bax Stevenson dan Menyuk menemukan perbedaan yang tidak bermakna sejumlah kejadian antara imaturitas dan berat badan lahir rendah anak.  Sebaliknya Byers-Brown dan kawan-kawan melaporkan secara bermakna tentang keterlambatan proses pengeluaran suara dalam bicara pada bayi prematur.⁴⁹

Weindrich menemukan adanya faktor-faktor yang berhubungan dengan prematuritas yang mempengaruhi perkembangan bahasa anak, seperti berat badan lahir, Apgar score, lama perawatan di rumah sakit, bayi yang iritatif, dan kondisi saat keluar rumah sakit.⁵⁰

Faktor Eksternal (Faktor Lingkungan)

Faktor lingkungan termasuk yang paling menentukan.  Faktor lingkungan di mana seorang anak dibesarkan telah lama dikenal sebagai faktor penting yang menentukan perkembangan anak. Banyak anak yang berasal dari daerah yang sosial ekonominya buruk disertai berbagai layanan kesehatan yang tidak memadai, asupan nutrisi yang buruk merupakan keadaan tekanan dan gangguan lingkungan yang mengganggu berbagai pertumbuhan dan perkembangan anak, diantaranya gangguan bahasa.^56-66

Pola asuh

Law dkk juga menemukan bahwa anak yang menerima contoh berbahasa yang tidak adekuat dari keluarga, yang tidak memiliki pasangan komunikasi yang cukup dan juga yang kurang memiliki kesempatan untuk berinteraksi akan memiliki kemampuan bahasa yang rendah. ⁵⁶

Lingkungan verbal

Lingkungan verbal mempengaruhi proses belajar bahasa anak. Anak di lingkungan keluarga profesional akan belajar kata-kata tiga kali lebih banyak dalam seminggu dibandingkan anak yang dibesarkan dalam keluarga dengan kemampuan verbal lebih rendah.⁵⁷

Studi lain juga melaporkan ibu dengan tingkat pendidikan rendah merupakan faktor risiko keterlambatan bahasa pada anaknya. ^{58, 59}

Chouhury dan beberapa peneliti lainnya mengungkapkan bahwa jumlah anak dalam keluarga mempengaruhi perkembangan bahasa seorang anak, berhubugan dengan intensitas komunikasi antara orang tua dan anak.^{57, 59}

Menurut Gore Eckenrode, McLoyd, McLoyd Wilson, masalah kemiskinan dapat menjadi penyebab meningkatnya risiko berbagai masalah dalam rumah tangga. Kemiskinan secara signifikan mempertinggi risiko terpaparnya masalah kesehatan seperti asma, malnutrisi, gangguan kesehatan mental kurang perhatian dan ketidak-teraturan perawatan dari orang tua, defisit dalam perkembangan kognisi dan pencapaian keberhasilan.^{60, 63}

Beberapa penelitian yang dilaporkan Attar Guerra, Brooks-Gunn, Liaw  Brooks-Gunn dan McLoyd menjelaskan bahwa keluarga yang bermasalah, terpapar lebih besar faktor-faktor risiko daripada keluarga yang tidak berada dibawah tingkat kemiskinan, dan konsekuensi dari faktor-faktor risiko ini dapat lebih berat pada anak dalam keluarga ini.^64,66

Anak yang terpapar berbagai faktor risiko, memiliki risiko mengalami gangguan perkembangan yang semakin meningkat. Salah satu yang termasuk gangguan perkembangan anak tersebut adalah specific language impairment (SLI). Hal ini telah dilaporkan oleh Spitz dan Tallal Flax, mereka menjelaskan secara umum tentang pencapaian yang buruk dalam berbahasa pada anak meskipun anak tersebut memiliki pendengaran dan intelegensi nonverbal yang normal.^{63, 66}

Penelitian Fazio, Naremore dan Connell, lebih mengkhususkan hal ini bahwa dapat diartikan suatu kondisi yang menyebabkan seorang anak memiliki penilaian spesifik dibawah rata-rata standar tes bahasa, tetapi berada pada level rata-rata untuk tes intelegensi nonverbal. Dengan demikian, pencegahan SLI dapat dengan mengidentifikasi faktor resiko anak sebelum diagnosis formal dibuat.⁶⁶

 Beberapa penelitian mengungkapkan faktor-faktor risiko biologi untuk SLI dan penempatan-penempatan faktor lain dengan melihat “outcome” anak-anak sekolah yang ditempatkan di neonatal intensive care units (NICUs) setelah lahir dengan segera. Anak-anak dari populasi ini diketahui memiliki risiko untuk keterlambatan kognisi dan kesulitan akademik karena mereka biasanya lahir prematur, berat badan lahir rendah (kurang dari 2500 g) atau mengalami respiratori distres.^49,50

Menurut Resnick, Rice, Spitz O’Brien dan  Siegel Tomblin, sebagian besar literatur menyatakan bahwa meskipun anak-anak dari NICU lebih berisiko mengalami kesulitan kognisi seperti retardasi mental dan gangguan belajar, mereka tidak memiliki risiko yang meningkat untuk masalah spesifik bahasa, khususnya saat angka penilaian disesuaikan karena prematuritasnya.⁵⁰

Beberapa penelitian yang dilakukan Beitchman, Hood Inglis, Spitz, Tallal Ross, Tomblin telah memperlihatkan bahwa gangguan bahasa umumnya memiliki kecenderungan dalam suatu keluarga berkisar antara 40% hingga 70%. Hampir separuh dari keluarga yang anak-anaknya mengalami gangguan bahasa, minimal satu dari anggota keluarganya memiliki problem bahasa. Dengan demikian orang tua yang berpengaruh pada keturunan ini mungkin bertanggung jawab terhadap faktor-faktor genetik. Mungkin tidak diketahui berapa banyak transmisi intergenerasi gangguan-gangguan bahasa tersebut disebabkan oleh kurangnya dukungan lingkungan terhadap bahasa.^46-48

Kondisi lingkungan merupakan hal yang penting menyangkut hasil perkembangan seorang anak. Beberapa anak yang datang dari keluarga yang tidak stabil dan kurangnya perhatian, perawatan, dan kurang memadainya kebutuhan nutrisi dan perawatan kesehatan, dapat membentuk level stress lingkungan yang merugikan bagi perkembangan anak termasuk bahasa. Risiko dari problem-problem bahasa juga dikaitkan dengan faktor sosioekonomi dan rendahnya status ekonomi.^{55, 59}

Peneliti-peneliti lain mendiskusikan beberapa variabel-variabel lingkungan yang tampak lebih dapat diprediksi. Seperti yang dilaporkan Hoff-Ginsberg, Neils Aram, Pine,  Tallal, Tomblin, Tomblin dan Hardy faktor permintaan cara persalinan ternyata termasuk faktor risiko gangguan perkembangan bicara pada anak. Sedangkan menurut Paul, Rice, Tomblin dan Tomblin menunjukkan pendidikan ibu yang rendah termasuk salah satu faktor risiko gangguan bahasa yang terjadi pada anak.  Orang tua tunggal menurut Andrews, Goldberg, Wellen, Goldberg McLaughlin dan Miller Moore juga merupakan faktor risiko yang harus diperhitungkan.^{59, 61, 62}

Menurut Sameroff dan Barocas, tersusunnya model risiko perkembangan dapat digunakan untuk memprediksi dengan lebih akurat, dengan mengkombinasi satu atau lebih faktor-faktor risiko tersebut adalah efek komulatif dari risiko yang multipel.⁶⁴

Dalam suatu model penelitian dari Sameroff menunjukkan beberapa faktor risiko sosial dan keluarga diantaranya adalah: masalah-masalah kesehatan mental ibu, kecemasan ibu, sikap otoriter ibu dalam mengasuh anak, hubungan ibu-anak yang buruk, pendidikan ibu yang kurang dari menengah atas, orang tua yang kurang atau tidak memiliki ketrampilan dalam pekerjaan, status etnik minoritas, tidak ada bapak, beberapa tekanan kehidupan tahun terdahulu, dan ukuran keluarga yang besar.^{63, 64}

Dilaporkan bahwa semua faktor tersebut adalah rangkaian individu yang berkaitan dengan nilai IQ anak-anak pada usia 4 tahun dan sebagian besar mayoritas masih berhubungan dengan IQ pada usia 13 tahun. Selain itu, jumlah faktor risiko sebagaimana didefinisikan oleh risiko kumulatif dalam, adalah prediktor kuat IQ pada usia 4 tahun dengan 58% dan pada umur 13 dengan varians 61%.⁶⁴

Sebuah penelitian yang dilakukan oleh Hooper, Burchinal, Roberts, Zeisel dan Neebe juga menyajikan fakta-fakta yang menggunakan model risiko komulatif untuk memprediksi kemampuan kognitif dan bahasa pada bayi yang lebih dipengaruhi oleh status sosioekonomi yang rendah pada populasi Afrika Amerika. Hooper  mengidentifikasi satu perangkat dari 10 faktor-faktor risiko sosial dan keluarga berdasarkan pada model risiko dari Sameroff berupa status kemiskinan, pendidikan ibu kurang dari sekolah menengah atas, ukuran keluarga yang besar, ibu yang tidak menikah, hidup yang penuh tekanan, dampak dari ibu yang depresi, interaksi ibu-anak yang buruk, IQ ibu, kualitas lingkungan rumah, dan kualitas perawatan sehari-hari.^{59, 60, 64}

Seluruh faktor risiko sosial dan keluarga dimasukkan ke dalam studi, saat bayi berusia 6 sampai 12 bulan. Peneliti-peneliti menemukan bahwa 9 dari 10 faktor-faktor risiko (tekanan hidup merupakan pengecualian) terkait dengan keberhasilan kognisi dan bahasa dari infan-infan. Komulatif indeks risiko dihubungkan dengan pengukuran bahasa dengan varians sekitar 12% sampai 17% tetapi bukan pengukuran kognisi.^{61, 63}

Evans dan English menyajikan fakta-fakta bahwa anak-anak dengan orang tua berpenghasilan rendah terpapar faktor-faktor risiko lingkungan dalam jumlah yang lebih besar daripada yang berpenghasilan menengah. Mereka memperkenalkan tiga penyebab stress psikososial (kekerasan, pertengkaran keluarga, perpisahan anak dengan keluarga) dan tiga penyebab stress fisik (kekacauan, kegaduhan, kualitas rumah yang rendah) merupakan faktor risiko yang memberikan pengaruh negatif.^{61, 62}

Dalam penelitiannya tentang lingkungan yang miskin, mereka menemukan hanya 20% anak-anak yang hidup dalam keluarga dengan penghasilan yang rendah tidak terpapar satupun faktor risiko. Sebaliknya, 61% keluarga dengan penghasilan menengah tidak terpapar faktor risiko. Temuan ini menyatakan bahwa mayoritas anak-anak dari keluarga berpenghasilan rendah terpapar lebih banyak masalah kemelaratan daripada kelompok berpenghasilan menengah dan disfungsi kognitif, prilaku, atau sosial akan meningkat.^{58, 60}

Sampai saat ini penelitian-penelitian terus mempelajari tentang perbedaan perkembangan bahasa anak yang diambil dari budaya dan latar-belakang sosioekonomi yang berbeda dan pengaruh dari perbedaan-perbedaan ini terhadap pencapaian akademik selanjutnya.⁶³

Robertson membandingkan kemampuan fonologi anak TK dari keluarga dengan kemampuan bahasa tinggi dan rendah dan menemukan bahwa anak-anak dari kemampuan bahasa rendah secara signifikan lebih buruk pada rangkaian pengukuran kognisi, linguistik, pra-baca. Dua tahun pemantauan terlihat bahwa anak-anak ini tidak mengejar anak-anak dari keluarga kemampuan bahasa baik.⁶⁴

Burt, Holm, and Dodd juga menemukan hubungan antara prestasi yang buruk dengan kemampuan bahasa yang rendah dengan menilai prestasi anak-anak pada beberapa tugas-tugas fonologi. Suatu usaha untuk menjelaskan keterkaitan antara kelemahan dan kegagalan sekolah.⁶⁴

Hart and Risley mempelajari perbedaan antara kualitas bahasa ditujukan pada anak-anak dengan latar belakang kemampuan bahasa yang berbeda pada 2¹/2 tahun pertama kehidupan mereka. Mereka melaporkan bahwa anak-anak dari latar belakang kemampuan bahasa yang rendah berada dalam kelemahan karena orang tua mereka atau pengasuh sangat jarang mengajak berbicara; akibatnya mereka miskin perbendaharaan kata dan kemampuan komunikasi dibanding kelompok dengan kemampuan bahasa yang lebih tinggi.⁶⁴

Otitis media

Menurut Grievink didapatkan sekitar 80% dari seluruh anak prasekolah mengalami satu atau lebih episode otitis media Akut atau otitis media effusion Selama episode ini, anak-anak mengalami fluktuasi kehilangan pendengaran, biasanya antara 20 dB dan 50 dB. Dari penilitian Gravel dan Nozza gangguan tersebut mempengaruhi jumlah dan kualitas bicara dan bahasa yang didengar. ⁶⁵

Roberts, Pagel Paden, Roberts Clarke-Klein, dan Schwartz telah melaporkan kemungkinan ada hubungan antara otitis media dengan atau tanpa efusi dan keterlambatan perkembangan bicara dan bahasa. Artikel-artikel tersebut menyimpulkan bahwa banyak anak yang mengalami episode infeksi telinga tengah mempunyai gangguan bicara dan bahasa. Tetapi tidak semua anak yang mempunyai gangguan bicara dan bahasa mengalami infeksi telinga tengah.⁶

Diagnosis gangguan bicara pada anak

Seperti pada gangguan perkembangan lainnya, kesulitan utama dalam diagnosis adalah membedakannya dari variasi perkembangan yang normal. Anak normal mempunyai variasi besar pada usia saat mereka belajar berbicara dan terampil berbahasa. Keterlambatan berbahasa sering diikuti kesulitan dalam membaca dan mengeja, kelainan dalam hubungan interpersonal, serta gangguan emosional dan perilaku. Untuk menegakkan diagnosa harus dilakukan pengujian terhadap intelektual nonverbal anak. Pengamatan pola bahasa verbal dan isyarat anak dalam berbagai situasi dan selama interaksi dengan anak-anak lain membantu memastikan keparahan bidang spesifik anak yang terganggu juga membantu dalam deteksi dini komplikasi perilaku dan emosional.^{1, 40, 41}

Anamnesis

Anamnesis pada gangguan bahasa dan bicara mencakup perkembangan bahasa anak. Beberapa pertanyaan yang dapat ditanyakan antara lain: ⁴²

• Pada usia berapa bayi mulai mengetahui adanya suara, misalnya dengan respon berkedip, terkejut atau mengerakkan bagian tubuh
• Pada usia berapa bayi mulai tersenyum (senyum komunikatif), misalnya diajak berbicara.
•  Kapan bayi mulai mengeluarkan suara “aaaggh”.
• Orientasi terhadap suara, misalnya bila ada suara apakah bayi memalingkan atau mencari arah suara.
• Kapan bayi memberi isyarat daag dan bermain cikkebum.
• Mengikuti perintah satu langkah, seperti “beri ayah sepatu” atau “ambil koran”.
• Berapa banyak bagian tubuh yang dapat ditunjukan oleh anak, seperti mata, hidung, kuping dan sebagainya.

American Psychiatric association’s Diagnostic and Statistical Manual of Mental Disorder (DSM IV) membagi gangguan bahasa dalam 4 tipe.⁴³

1. Gangguan bahasa ekspresif

2. Gangguan bahasa reseptif­ekspresif

3. Gangguan phonological

4. Gagap

Pada gangguan bahasa ekspresif, secara klinis kita bisa menemukan gejala seperti perbendaharaan kata yang jelas terbatas, membuat kesalahan dalam kosakata, mengalami kesulitan dalam mengingat kata-kata atau membentuk kalimat yang panjang dan memiliki kesulitan dalam pencapaian akademik dan komunikasi sosial, namun pemahaman bahasa anak tetap relatif utuh. Gangguan menjadi jelas kira-kira pada usia 18 bulan, saat anak tidak dapat mengucapkan kata dengan spontan atau meniru kata dan menggunakan gerakan badannya untuk menyatakan keinginannya. Jika anak akhirnya bisa berbicara, defisit bahasa menjadi jelas, terjadi kesalahan artikulasi seperti bunyi th, r, s, z, y. Riwayat keluarga yang memiliki gangguan bahasa ekspresif juga ikut mendukung diagnosis.^{1, 10} Pada gangguan bahasa campuran reseptif-ekspresif, selain ditemukan gejala-gejala gangguan bahasa ekspresif, juga disertai kesulitan dalam mengerti kata dan kalimat. Ciri klinis penting dari gangguan tersebut adalah gangguan yang bermakna pada pemahaman bahasa. Gangguan ini biasanya tampak sebelum usia 4 tahun. Bentuk yang parah terlihat pada usia 2 tahun, bentuk ringan tidak terlihat sampai usia 7 tahun atau lebih tua. Anak dengan gangguan bahasa reseptif-ekspresif campuran memiliki gangguan auditorik sensorik atau tidak mampu memproses simbol visual seperti arti suatu gambar. Mereka memiliki defisit dalam menintegrasikan simbol auditorik maupun visual, contohnya mengenali atribut dasar yang umum untuk mainan truk atau mainan mobil penumpang. Anak dengan gangguan bahasa campuran reseptif-ekspresif biasanya tampak tuli.^{1, 10} Anak-anak dengan kesulitan berbicara memiliki masalah dalam pengucapan, yaitu berhubungan dengan gangguan motorik, diantaranya kemapuan untuk memproduksi suara.¹⁹ Anak yang gagap dapat diketahui dari cara dia baerbicara, dimana terjadi pengulangan atau perpanjangan suara, kata, atau suku kata. Biasanya sering terjadi pada anak laki-laki, sangat sering disertai mengedipkan mata dan menggoyangkan kepala. ²⁰

Pemeriksaan Fisik

Pemeriksaan fisik digunakan untuk mengungkapkan penyebab lain dari gangguan bahasa dan bicara. Perlu diperhatikan ada tidaknya mikrosefali, anomali telinga luar, otitis media yang berulang, sindrom William (fasies Elfin, perawakan pendek, kelainan jantung, langkah yang tidak mantap), celah palatum dan lain-lain. Gangguan oromotor dapat diperiksa dengan menyuruh anak menirukan gerakan mengunyah, menjulurkan lidah, dan mengulang suku kata pa, ta, pata, pataka. ³⁶

Pemeriksaan Penunjang

• BERA (Brainstem Evoked Response Audiometry) merupakan cara pengukuran evoked potensial (aktivitas listrik yang dihasilkan saraf VIII, pusat-pusat neural dan traktus di dalam batang otak) sebagai respon terhadap stimulus auditorik.
• Pemeriksaan audiometrik

Pemeriksaan audiometrik diindikasikan untuk anak-anak yang sangat kecil dan untuk anak-anak yang ketajaman pendengarannya tampak terganggu. Ada 4 kategori pengukuran dengan audiometrik: ^{19, 20}

a)      Audiometrik tingkah laku, merupakan pemeriksaan pada anak yang dilakukan dengan melihat respon dari anak jika diberi stimulus bunyi. Respon yang diberikan dapat berupa menoleh ke arah sumber bunyi atau mencari sumber bunyi. Pemeriksaan dilakukan di ruangan yang tenang atu kedap suara dan menggunakan mainan yang berfrekuensi tinggi. Penilaian dilakukan terhadap respon yang diperlihatkan anak. ¹⁹

b)      Audiometrik bermain, merupakna pemeriksaan pada anak yang dilakukan sambil bermain, misalnya anak diajarkan untuk meletakkan suatu objek pada tempat tertentu bila dia mendengar bunyi. Dapat dimulai pada usia 3-4 tahun bila anak cukup kooperatif. ^{19, 44}

c)       Audiometrik bicara. Pada tes ini dipakai kata-kata yang sudah disusun dalam silabus pada daftar yang disebut: phonetically balance word LBT (PB List). Anak diminta untuk mengulangi kata-kata yang didengar melalui kaset tape recorder. Pada tes ini dilihat apakah anak dapat membedakan bunyi s, r, n, c, h, ch. Guna pemeriksaan ini adalah untuk menilai kemampuan anak dalam berbicara sehari-hari dan untuk menilai pemberian alat bantu dengar (hearing aid). ^{19, 44}

d)     Audiometri objektif, biasanya memerlukan teknologi khusus.⁹

• CT scan kepala untuk mengetahui struktur jaringan otak, sehingga didapatkan gambaran area otak yanga abnormal.
• Timpanometri digunakan untuk mengukur kelenturan membrane timpani dan system osikuler. ¹⁹

Selain tes audiometrik, bisa juga digunakan tes intelegensi. Paling dikenal yaitu skala Wechsler, yang menyajikan 3 skor intelegen, yaitu IQ verbal, IQ performance, IQ gabungan: ⁴³

1. Skala intelegensi Wechsler untuk anak III: penyelesaian susunan gambar. Tes ini terdiri dari satu set gambar-gambar objek yang umum, seperti gambar pemandangan. Salah satu bagian yang penting dihilangkan dan anak diminta untuk mengidentifikasinya. Respon dinilai sebagai salah atau benar.
2. Skala intelegensi Wechsler utuk anak III: mendesain balok, anak diberikan pola bangunan dua dimensi dan kemudian diminta untuk membuat replikanya menggunakan kubus dua warna. Respon dinilai sebagai salah atau benar.

Tabel 3. Diagnosis banding beberapa penyebab gangguan perkembangan bahasa dan bicara

Penalaksanaan

Diagnosis yang tepat terhadap gangguan bicara dan bahasa pada anak, sangat berpengaruh terhadap perbaikan dan perkembangan kemampuan bicara dan bahasa. Terapi sebaiknya dimulai saat diagnosis ditegakkan, namun hal ini menjadi sebuah dilema, diagnosis sering terlambat karena adanya variasi perkembangan normal atau orang tua baru mengeluhkan gangguan ini kepada dokter saat mencurigai adanya kelainan pada anaknya, sehingga para dokter lebih sering dihadapkan pada aspek kuratif dan rehabilitatif dibandingkan preventif. Tata laksana dini terhadap gangguan ini akan membantu anak-anak dan orang tua untuk menghindari atau memperkecil kelainan di masa sekolah^{1, 6, 25}

Gangguan bicara dan bahasa pada anak cenderung membaik seiring pertambahan usia, dan pada dasarnya perkembangan bahasa dilatarbelakangi perawatan primer orang tua dan keluarga terhadap anak. Usaha preventif pada masa neonatus, bayi dan balita dapat dilakukan dengan memberi pujian dan respon terhadap segala usaha anak untuk mengeluarkan suara, serta member tanda terhadap semua benda dan kata yang menggambarkan kehidupan sehari-hari. Pola intonasi suara dapat diperbaiki sejalan dengan respon anak yang semakin mendekati pola orang dewasa.

            Secara umum, anak akan berusaha untuk lebih baik saat orang dewasa merespon apa yang diucapkannya tanpa menekan anak untuk mengucapkan suara atau kata tertentu. Sebagai motivasi ketika seorang anak berbicara satu kata secara jelas, pendengan sebaiknya merespon tanpa paksaan dengan memperluas hingga dua kata. ^{1, 2, 6, 15, 25}

            Tindakan kuratif penatalaksanaan gangguan bicara dan bahasa pada anak disesuaikan dengan penyebab kelainan tersebut. Penatalaksanaan dapat melibatkan multi disiplin ilmu dan terapi ini dilakukan oleh suatu tim khusus yang terdiri dari fisioterapis, dokter, guru dan orang tua pasien. Beberapa jenis gangguan bicara dapat diterapi dengan terapi wicara, tetapi hal ini membutuhkan perhatian medis seorang dokter. Anak-anak usia sekolah yang memiliki gangguan bicara dapat diberikan pendidikan program khusus. Beberapa sekolah tertentu menyediakan terapi wicara kepada para murid selama jam sekolah, meskipun menambah hari belajar. ^{1, 6}

Konsultasi dengan psikoterapis anak diperlukan jika gangguan bicara dan bahasa diikuti oleh gangguan tingkah laku, sedangkan gangguan bicaranya dievaluasi oleh ahli terapi wicara. ¹⁵

Skala Receptive Expressive Emergent Language

Skala Receptive Expressive Emergent Language (REEL) adalah salah satu jenis instrumen yang berbentuk kuesioner yang diisi oleh orang tua.  REEL pertama kali dipakai tahun 1971, yang kemudian mengalami revisi pertama kali tahun 1991, dan yang terakhir, REEL-3, tahun 2003.^{45, 46} Skala REEL menggunakan model penilaian tridimensi, yaitu menilai perkembangan bahasa menurut isi, bentuk dan pemakaian bahasa, menurut 4 tahap perkembangannya seperti yang diuraikan oleh Bzoch, dan juga menurut proses berbahasanya baik reseptif maupun ekspresif. Kuesioner penilaiannya dibagi dalam 2 subskala yaitu komponen bahasa reseptif dan bahasa ekspresif. Masing-masing subskala terdiri dari 66 pertanyaan. (lihat lampiran 5) Empat tahap usia perkembangan bahasa dalam skala REEL adalah tingkat pertama ( 0- 3 bulan), kedua (3-9 bulan), ketiga (9-18 bulan)  dan tingkat keempat (18-36 bulan).²⁴ Kelompok usia yang terakhir dipakai dalam penelitian ini. Pengisian kuesioner dapat melalui wawancara langsung dengan orang tua atau caregiver atau pemberi laporan dapat mengisi sendiri formulir kuesioner. Pengisian kuesioner ini membutuhkan waktu kira-kira 15-20 menit, dapat dilakukan di klinik atau di rumah.⁴⁶

Tiap subskala REEL akan dihitung skor masing masing. Skor yang didapat dari tiap subskala ini merupakan nilai mentah yang akan dikonversikan lagi menjadi skor kemampuan bahasa reseptif dan ekspresif. Hasil penjumlahan nilai mentah reseptif dan ekspresif juga akan dikonversikan menjadi skor kemampuan bahasa (language ability score = LAS) (lihat lampiran 5).⁴⁶

 Berdasarkan nilai kemampuan bahasa anak, ditentukan tingkat perkembangan bahasa, selanjutnya akan terlihat apakah ada keterlambatan dalam perkembangan bahasanya.

 Daftar Pustaka

Daftar Pustaka

1. Soetjiningsih. Perkembangan anak dan permasalahannya. Dalam:Narendra MB,Sularyo TS, Soetjiningsih, Suyitno H, 
2. Ranuh IG, penyunting. Buku Ajar Tumbuh Kembang Anak dan Remaja; Edisi I. Jakarta : Ikatan Dokter Anak Indonesia. Jakarta, Sagung Seto, 2002; 91
3. Busari JO, Weggelaar NM. How to investigate and manage the child who is slow to speak. BMJ 2004; 328:272­ 276
4. Parker S, Zuckerman B, Augustyn M. Developmental and behavioral Pediatrics (2nd ed): Language Delays. Philadelphia : Lippincott Williams & Wilkins, 2005
5. Owens RE. Language Development an Introduction, 5th edition. New York:Allyn and Bacon; 2001.
6. Smith C, Hill J, Language Development and Disorders of Communication and Oral Motor Function. In : Molnar GE, Alexander MA,editors. Pediatric Rehabilitation. Philadelphia: Hanley and Belfus;1999.p. 57-79.
7. Rydz D, Srour M, Oskoui M, Marget N, Shiller M, Majnemer A, et.al. Screening for developmental delay in the setting of a community pediatr clinic: A Prospective assessment of parent-Report questionnaires. Pediatrics 2006;118;e1178-e1186.
8. Silva PA, Williams SM, McGee R. A longitudinal study of children with developmental language delay at age three; later intelligence , reading and behavior problems. Dev Med Child Neurol 1987;29;630-640.
9. Chris V, Suzanne H, Erik JA, Scherder, Ben M, Esther H. Motor Profile of Children With Development Speech and Language Disoreders. Pediatris, v0l 120 no 1 July, pp.e158-e163.
10. K. Alcock. Oral movements and language. Down Syndrome Research and Practice 11(1), 1-8. © 2006 The Down Syndrome Educational Trust. All Rights Reserved. ISSN: 0968-7912. Diunduh dari http://information. downsed. Org/ dsrp/11/01
11. Moore CA, Ruark JL. (1996). Does speech emerge from earlier appearing oral motor behaviors? Journal of Speech and Hearing Research 1996;39(5), 1034-1047.
12. Dworkin JP, Culatta RA . Oral structural and neuromuscular characteristics in children with normal and disordered articulation. Journal of Speech and HearingmDisorders 1985;50(2), 150-156.
13. Chaer A, Psiokolinguistik Kajian Teoritik. Jakarta: Rineka Abdi.. 2003
14. Owens RE. Language Development an Introduction, 5th edition. New York:Allyn and Bacon; 2001.
15. Salim P, Salim Y, Kamus Bahasa Indonesia Kontemporer, Edisi kedua.Jakarta: Modern English Press;1995.
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17. Oxford Learner’s Dictionary, New Ediition. Oxford University Press. 2003
18. Coplan, James. Normal speech and language development : Pediatric In Review1995; 91­99
19. Markum, AH. Gangguan perkembangan berbahasa. Dalam : Markum, Ismael S, Alatas H, Akib A, Firmansyah A, Sastroasmoro S, editor. Buku ajar ilmu kesehatan anak. Jilid I. Jakarta : Balai Penerbit FKUI, 1991; 56­69
20. Virginia W, Meredith G, Dalam : Adam, boeis highler. Gangguan bicara dan bahasa. Buku ajar penyakit telinga, hidung, tenggorok. Edisi 6. Jakarta : EGC, 1997 ; 397­410.
21. Kaplan,   Harold   I.   Gangguan   komunikasi.   Dalam   :   I   Made   Wiguna,   editor. Sinopsis  psikiatri  :  Bina  Rupa  Aksara, 1997 ; 766­82
22. British medical journal. Language disorders: a 10 year  research  update  review.  Bmj ; 2000.
23. Council on Children with Disabilities, Section on Developmental Behavioral Pediatrics, Bright Futures Steering committee and Medical Home Initiatives for Children with special needs Project Advisory Committee.  Identifying infants and young children with  developmental disorders in the Medical Home: An algorithm for developmental surveillance and screening. Pediatrics 2006;118;405-420.
24. Law J, Bowle J, Harris F, Harkness A, Nye C., Screening for speech and language delay; a systematic review of literature, In: Health Technology Assessment 1998 Vol2(9).
25. Sidiarto L. Berbagai gangguan berbahasa pada anak. Proceedings of Pertemuan Linguistik Lembaga Bahasa Atma Jaya Keempat. Jakarta: Penerbit Kanisius; 1991.
26. Departemen Rehabilitasi Medik. Buku laporan pasien rawat jalan. Jakarta. 2006
27. Wahjuni S. Pemeriksaan Penyaring Keterlambatan Perkembangan Bahasa pada Anak Batita dengan Early Language Milestone Scale di Kelurahan Paseban Jakarta Pusat. Jakarta. FKUI. 1998
28. Victor M, Ropper AH. Priciples of Neurology Adams and Victor’s, seventh edition. McGraw-Hill.2001.
29. Lundsteen SW, Tarrow NB. Guiding young children’s learning. New York; Mc Graw Hill; 1981.
30. Rahyono FX. Dalam : Pesona Bahasa Langkah Awal Memahami Linguistik. Editor : Kurhayanti.Penerbit PT Gramedia Pustaka Utama Jakarta, 2007,hal 32-37.
31. Myklebust M. Prelinguistic Communication. In: Yule W, Rutter M,eds.  Language development and disorders; Clinics in developmental medicine. 1968.
32. Guyton AC, Hall JE. Dalam : Irawati Setyawan, penyunting. Buku ajar fisiologi kedokteran. Edisi 9. Jakarta : EGC, 1997 ; 909­19
33. Myklebust M. Prelinguistic Communication. In: Yule W, Rutter M,eds.  Language development and disorders; Clinics in developmental medicine. 1968.
34. Heidi M. Feildman Evaluation and management of speech and language disorder in preschool children. Pediatrics in Review 2005 ; 26 (4) 131­142. 
35. Maturana HR, Biology of Language: The Epistemology of Reality. IN: Psychology and Biology of Language and Thought. New York :Academic Press; 1978.p.27-63.
36. Soetjiningsih. Gangguan bicara dan bahasa pada anak. Tumbuh kembang anak. Jakarta EGC, 1995 ; 237­40
37. Blum NJ, Baron MA. Speech and language disorders. In: Schwartz MW, ed. Pediatric primary care: a problem oriented approach. St. Louis: Mosby, 1997:845-9.
38. Departemen kesehatan RI. Pedoman penggolongan dan diagnosis gangguan jiwa III. Edisi I. Jakarta : Direktorat Jenderal Pelayanan Medik Depkes RI, 1995 ; 
39. Soedjatmiko. Deteksi dini gangguan tumbuh kembang balita. Sari Pediatri 1995; 3. 
40. Simkin Z, Conti G. Evidence of reading difficulty in subgroups children with specific language impairment. Child language teaching and therapy 2006 ; 22 (3) ; 315­3
41. Roberts, Susan. Speech and language disorders. Dalam : Harvey D, Miles M, Smyth D, editor. Community Child Health and Pediatrics. London : Butterworth Heinemann, 1997 ; 505­12
42. Bzoch K, League R. Receptive Expressive Emergent Language Test (REEL), 3^nd ed. Pro-Ed. Austin. 2003.
43. Anitta Florence ST, Modifikasi Skala Reseptive Expresive Emergent Language sebagai instrument penyaring keterlambatan bahasa anak usia 18 sampai 36 bulan, Jakarta oktober 2008
44. Bzoch K, League R. Receptive Expressive Emergent Language Test (REEL), 3^nd ed. Pro-Ed. Austin. 2003.
45. Anitta Florence ST, Modifikasi Skala Reseptive Expresive Emergent Language sebagai instrument penyaring keterlambatan bahasa anak usia 18 sampai 36 bulan, Jakarta oktober 2008
46. Fisher S, Vargha-Khadem F, Watkins KE, Monaco AP, Pembry, ME. Localisation of a gene implicated in a severe speech and language disorder. Nature Genetics 1998, 18, 168.
47. 47.  Vargha-Khadem F, Watkins K, Alcock KJ, Fletcher P, Passingham R. Praxic and nonverbal cognitive deficits in a large family with a genetically transmitted speech and language disorder. Proceedings of the National Academy of Sciences of the United States of America 1995, 92(3), 930-933.
48. 48.  Gopnik, M. & Crago, M. B.. Familial aggregation of a developmental language disorder. Cognition 1991, 39, 1-50.
49. Liaw, F., & Brooks-Gunn, J. (1994). Cumulative familial risks and low birthweight children’s cognitive and behavioral development. Journal of Clinical Child Psychology, 23, 360–372.
50. Halsey, C. L., Collin, M. F., & Anderson, C. L. (1993). Extremely low birth weight children and their peers: A comparison of preschool performance. Pediatrics, 91, 807–811.
51. Johnston J.  Factors that Influence Language Development. In : Tremblay RE, Barr RG, Peters R, eds. Encyclopedia of Language and Literacy Development (pp1-6). London. Canadian language and Literacy Research network. 2006.
52. Fox A, Dodd B, Howard D. Risk factors for speech disorders in children. Int J Lang Common Disord 2002;37(2):117-131.
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55. 55.  Fox A. V.¹; Dodd B.¹; Howard D.¹Risk factors for speech disorders in children. International Journal of Language & Communication Disorders, Volume 37, Number 2, 1 April 2002 , pp. 117-131(15)
56. 56.  O’Callaghan, Michael, Williams, Gail M.Andersen, Margaret J.
    Bor, William Najman, Jake M. Social and Biological Risk Factors for Mild and Borderline Impairment of Language Comprehension in a Cohort of Five-Year-Old Children. Developmental Medicine and Child Neurology. 1995-01-01;37,12,1051-1061
57. 57.  Tina L. Stanton-Chapman, Derek A. Chapman, Ann P. Kaiser, Terry B. Hancock .Cumulative Risk and Low-Income Children’s Language Development. Topics in Early Childhood Special Education, Vol. 24, No. 4, 227-237, 2004
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Supported  by

CHILDREN SPEECH CLINIC

Yudhasmara Foundation

Office ; JL Taman Bendungan Asahan 5 Jakarta Indonesia 10210

phone : 62(021) 70081995 – 5703646

email : judarwanto@gmail.com,

http://speechclinic.wordpress.com/

Clinic and Editor in Chief :

Dr WIDODO JUDARWANTO

email : judarwanto@gmail.com

curriculum vitae

Copyright © 2009, Children Speech Clinic  Information Education Network. All rights reserved

Santi, gadis mungil cantik berusia 5 tahun sedang gelisah di rumah. Dengan sangat berharap menunggu dengan antusias. Kaki kecilnya bolak-balik melangkah dari ruang tamu ke pintu depan. Diliriknya jalan raya depan rumah. Belum ada. Santi masuk lagi. Keluar lagi. Belum ada. Masuk lagi. Keluar lagi. Begitu terus selama hampir satu jam. Suara si Mbok yang menyuruhnya berulang kali untuk makan duluan tidak digubrisnya.

Saat kumandang adzan magrib tiba. Terdengar suara bel mobil di hjalaman rumah Tinnn……….. Tiiiinnnnn………….. !! Santi kecil melompat girang! Mama pulang! Papa pulang! Dilihatnya dua orang yang sangat dicintainya itu masuk ke halaman rumah.

Sang papa langsung menuju ke kamar mandi. Si mama menghempaskan diri di sofa sambil mengurut-urut kepala. Wajah-wajah yang letih sehabis bekerja seharian, apalagi tadi pagi sempat mendapat omelan bos di kantor. Bagi si kecil Santi juga yang tentunya belum mengerti banyak. Di otaknya yang kecil, Santi cuma tahu, ia kangen Mama dan Papa, dan ia girang Mama dan Papa pulang. “Mama, mama…. Mama, mama….” Santi menggerak-gerakkan tangan Mama. Mama diam saja. Dengan cemas Santi bertanya, “Mama sakit ya? Mananya yang sakit? Mam, mana yang sakit?” Mama tidak menjawab. Hanya mengernyitkan alis sambil memejamkan mata. Santi makin gencar bertanya, “Mama,  mama… mana yang sakit? Santi ambilin obat ya? Ya? Ya?”

Tiba-tiba… “Santi!! Kepala mama lagi pusing! Kamu jangan berisik!” Mama membentak dengan suara tinggi. Kaget, Santi mundur perlahan. Matanya menyipit. Kaki kecilnya gemetar. Bingung. Santi salah apa? Santi sayang Mama… Santi salah apa? Takut-takut, Santi menyingkir ke sudut ruangan. Mengamati Mama dari jauh, yang kembali mengurut-ngurut kepalanya. Otak kecil Santi terus bertanya-tanya: Mama, Santi salah apa? Mama tidak suka dekat-dekat Santi? Santi mengganggu Mama? Santi tidak boleh sayang Mama? Berbagai peristiwa sejenis terjadi. Dan otak kecil Santi merekam semuanya.

Maka tahun-tahun berlalu. Santi tidak lagi kecil. Santi bertambah tinggi. Santi remaja. Santi mulai beranjak menuju dewasa. TIN TIIIN ! Mama pulang. Papa pulang. Santi menurunkan kaki dari meja. Mematikan TV. Buru-buru naik ke atas, ke kamarnya, dan mengunci pintu. Menghilang dari pandangan. “Santi mana?”. “Sudah makan duluan, Tuan, Nyonya.”

Malam itu mereka kembali hanya makan berdua. Dalam kesunyian berpikir dengan hati terluka: Mengapa anakku sendiri, yang kubesarkan dengan susah payah, dengan kerja keras, nampaknya tidak suka menghabiskan waktu bersama-sama denganku? Apa salahku? Apa dosaku? Ah, anak jaman sekarang memang tidak tahu hormat sama orangtua! Tidak seperti jaman dulu.

Di atas, Santi mengamati dua orang yang paling dicintainya dalam diam. Dari jauh. Dari tempat dimana ia tidak akan terluka. Mama, Papa, katakan padaku, bagaimana caranya memeluk seekor landak?

Di tengah kesibukan kehidupan modern, seringkali terjebak rutinitas dan padatnya aktifitas pekerjaan. Seringkali tidak disadari waktu yang sangat terbatas untuk komunikasi dengan keluarga atau anak disia-siakan begitu saja. Bahkan tidak jarang waktu yang sangat sempit untuk berkomunikasi dengan anak dan keluarga ditumpahkan dengan omelan dan kemarahan akibat beban berat kerja dalam pekerjaan.

Apapun letih yang mendera tubuhmu, sepanas apapun  kulit kepalamu sepulang kesibukan padat yang menyita waktumu. Jangan sekalipun disia-siakan waktu dengan keluarga dan anak.  Kuantitas komunikasi dan kasih sayang orangtua adalah hak anak yang harus dipenuhi setiap orangtua setiap saat apapun keadaan yang terjadi. Perhatian dengan penuh kasih sayang adalah kebutuhan utama anak,  melebihi harta apapun yang  sudah  diberikan orangtua  untuk anak.

Supported  by

CHILDREN SPEECH CLINIC

Yudhasmara Foundation

Office ; JL Taman Bendungan Asahan 5 Jakarta Indonesia 10210

phone : 62(021) 70081995 – 5703646

email : judarwanto@gmail.com,

http://speechclinic.wordpress.com/

Clinic and Editor in Chief :

Dr WIDODO JUDARWANTO

email : judarwanto@gmail.com

curriculum vitae

Copyright © 2009, Children Speech Clinic  Information Education Network. All rights reserved

dr Widodo judarwanto, pediatrician

Children learn language by interacting with other people. There is a wide variation in the rate at which children develop speech, language and communication skills. Some some children develop quickly while others may take a little more time. In many cases, children who are slow to develop these skills initially can catch up with other children. But for some children, developing communication can be a very difficult process and they may need extra help to develop their skills. If you are concerned about your child’s communication

COMMUNICATION KINDERGARTEN

Listening

• Listen to and understand age-appropriate stories read aloud
• Follow a simple conversation
• Follow 1-2 simple directions in a sequence

Speaking

• Answer open-ended questions (e.g., “What did you have for lunch today?”)
• Retell a story or talk about an event
• Participate appropriately in conversations
• Show interest in and start conversations
• Be understood by most people
• Answer simple “yes/no” questions

Reading

• Compare and match words based on their sounds
• Understand that letters represent speech sounds and match sounds to letters
• Identify upper- and lowercase letters
• Recognize some words by sight
• “Read” a few picture books from memory
• Imitate reading by talking about pictures in a book
• Know how a book works (e.g., read from left to right and top to bottom in English)
• Understand that spoken words are made up of sounds
• Identify words that rhyme (e.g., cat and hat)

Writing

• Draw a picture that tells a story and label and write about the picture
• Write upper- and lowercase letters (may not be clearly written)
• Print own first and last name

COMMUNICATION FIRST GRADE

Listening

• Respond to instructions
• Follow 2-3 step directions in a sequence
• Remember information

Speaking

• Use most parts of speech (grammar) correctly
• Ask and respond to “wh” questions (who, what, where, when, why)
• Stay on topic and take turns in conversation
• Give directions
• Start conversations
• Be easily understood
• Answer more complex “yes/no” questions
• Tell and retell stories and events in a logical order
• Express ideas with a variety of complete sentences

Reading

• Match spoken words with print
• Know how a book works (e.g., read from left to right and top to bottom in English)
• Identify letters, words, and sentences
• Sound out words when reading
• Have a sight vocabulary of 100 common words
• Read grade-level material fluently
• Understand what is read
• Create rhyming words
• Identify all sounds in short words
• Blend separate sounds to form words

Writing

• Spell frequently used words correctly
• Begin each sentence with capital letters and use ending punctuation
• Write a variety of stories, journal entries, or letters/notes
• Express ideas through writing
• Print clearly

COMMUNICATION SECOND GRADE

Listening

• Understand direction words (e.g., location, space, and time words)
• Correctly answer questions about a grade-level story
• Follow 3-4 oral directions in a sequence

Speaking

• Clarify and explain words and ideas
• Give directions with 3-4 steps
• Use oral language to inform, to persuade, and to entertain
• Stay on topic, take turns, and use appropriate eye contact during conversation
• Open and close conversation appropriately
• Be easily understood
• Answer more complex “yes/no” questions
• Ask and answer “wh” questions (e.g., who, what, where, when, why)
• Use increasingly complex sentence structures

Reading

• Explain key elements of a story (e.g., main idea, main characters, plot)
• Use own experience to predict and justify what will happen in grade-level stories
• Read, paraphrase/retell a story in a sequence
• Read grade-level stories, poetry, or dramatic text silently and aloud with fluency
• Read spontaneously
• Identify and use spelling patterns in words when reading
• Have fully mastered phonics/sound awareness
• Associate speech sounds, syllables, words, and phrases with their written forms
• Recognize many words by sight
• Use meaning clues when reading (e.g., pictures, titles/headings, information in the story)
• Reread and self-correct when necessary
• Locate information to answer questions

Writing

• Organize writing to include beginning, middle, and end
• Spell frequently used words correctly
• Progress from inventive spelling (e.g., spelling by sound) to more accurate spelling
• Write legibly
• Use a variety of sentence types in writing essays, poetry, or short stories (fiction and nonfiction)
• Use basic punctuation and capitalization appropriately

COMMUNICATION THIRD GRADE

Listening

• Understand grade-level material
• Listen attentively in group situations

Speaking

• Use subject-related vocabulary
• Stay on topic, use appropriate eye contact, and take turns in conversation
• Summarize a story accurately
• Explain what has been learned
• Speak clearly with an appropriate voice
• Ask and respond to questions
• Participate in conversations and group discussions

Reading

• Predict and justify what will happen next in stories and compare and contrast stories
• Ask and answer questions regarding reading material
• Use acquired information to learn about new topics
• Read grade-level books fluently (fiction and nonfiction)
• Reread and correct errors when necessary
• Demonstrate full mastery of basic phonics
• Use word analysis skills when reading
• Use clues from language content and structure to help understand what is read

Writing

• Write stories, letters, simple explanations, and brief reports
• Spell simple words correctly, correct most spelling independently, and use a dictionary to correct spelling
• Write clearly in cursive
• Plan, organize, revise, and edit
• Include details in writing

COMMUNICATION FOURTH GRADE

By the end of fourth grade children should be able to do the following:

Listening

• Form opinions based on evidence
• Listen for specific purposes
• Listen to and understand information presented by others

Speaking

• Understand some figurative language (e.g., “the forest stretched across…”)
• Participate in group discussions
• Give accurate directions to others
• Summarize and restate ideas
• Organize information for clarity
• Use subject area information and vocabulary (e.g., social studies) for learning
• Make effective oral presentations
• Use words appropriately in conversation
• Use language effectively for a variety of purposes

Reading

• Read for specific purposes
• Use reference materials (e.g., dictionary)
• Explain the author’s purpose and writing style
• Read and understand a variety of types of literature, including fiction, nonfiction, historical fiction, and poetry
• Compare and contrast in content areas
• Make inferences from texts
• Paraphrase content, including the main idea and details
• Read grade-level books fluently
• Use previously learned information to understand new material
• Follow written directions
• Take brief notes
• Link information learned to different subjects
• Learn meanings of new words through knowledge of word origins, synonyms, and multiple meanings

Writing

• Write effective stories and explanations, including several paragraphs about the same topic
• Develop a plan for writing, including a beginning, middle, and end
• Organize writing to convey a central idea
• Edit final copies for grammar, punctuation, and spelling

COMMUNICATION FIFTH GRADE

By the end of fifth grade children should be able to do the following:

Listening

• Listen and draw conclusions in subject area learning activities

Speaking

• Maintain eye contact and use gestures, facial expressions, and appropriate voice during group presentations
• Participate in class discussions across subject areas
• Summarize main points
• Report about information gathered in group activities
• Make planned oral presentations appropriate to the audience

Reading

• Read grade-level books fluently
• Read a variety of literary forms
• Describe development of character and plot
• Describe characteristics of poetry
• Analyze author’s language and style
• Use reference materials to support opinions
• Learn meanings of unfamiliar words through knowledge of root words, prefixes, and suffixes
• Prioritize information according to the purpose of reading

Writing

• Write for a variety of purposes
• Vary sentence structure
• Revise writing for clarity
• Edit final copies
• Use vocabulary effectively

Supported  by

CHILDREN SPEECH CLINIC

Yudhasmara Foundation

Office ; JL Taman Bendungan Asahan 5 Jakarta Indonesia 10210

phone : 62(021) 70081995 – 5703646

email : judarwanto@gmail.com,

http://speechclinic.wordpress.com/

Clinic and Editor in Chief :

Dr WIDODO JUDARWANTO

email : judarwanto@gmail.com

curriculum vitae

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