Evaluation and Management of the Child with Speech Delay
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.
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.
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
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 (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.
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.
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 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.
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.
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