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In young children who are producing little if any speech, it can be difficult to determine whether a speech disorder, a language disorder, or both are present. As noted in Chapter 3 on treatment, early intervention for such children generally is designed to facilitate both language and speech skills. When children reach an age that allows each area to be assessed separately, it becomes possible to narrow the focus of treatment according to whether deficits are found only in speech, only in language, or in both.
Overview of Speech and Language Development and Disorders The foundations for the development of speech and language begin in utero, with the growth of the anatomical structures and physiological processes that will eventually support sensory, motor, attention, memory, and learning skills.
Before the end of the prenatal period, fetuses are able to hear, albeit imperfectly, speech and other environmental sounds, and within a few minutes after birth they show special attention to human faces and voices.
This early interest in other people appears to set the stage for forming relationships with caregivers, who scaffold the child's growing ability to anticipate, initiate, and participate in social routines e.
Language development and literacy
The social experiences and skills that occur during the infant's first months of life are important precursors to pragmatic language skills: In the first few months of life, infants show improvement in their ability to recognize increasingly detailed patterns of speech, a precursor to linking spoken words with their meanings.
Also in the first months of life, infants begin to use their oral mechanisms to produce nonspeech sounds, such as cooing and squealing, as they develop control of their muscles and movements. Thus, they are able to produce increasingly consistent combinations of speech-like sounds and syllables babblinga precursor to articulating recognizable words e.
Evidence from neurophysiological habituation, neuroimaging, and preferential looking studies shows that children begin to recognize speech patterns that recur in their environments early in the first year of life Friedrich et al, ; Pelucchi et al.
When tested using behavioral measures, most to month-old children show that they can understand at least a few words in the absence of gestural or other cues to their meaning e. They also can produce at least a few intelligible words during this period e.
Their speech skills progress in a systematic fashion over the next few years, as they learn first to say relatively simpler consonants e. Receptive language, expressive language, and speech all develop at a rapid pace through the preschool period as children learn to understand and say thousands of individual words, as well as learn the grammatical or morpho-syntactic rules that enable them to understand and produce increasingly lengthy, sophisticated, intelligible, and socially acceptable combinations of words in phrases and sentences e.
These speech and language skills enable children to achieve communication goals as diverse as understanding a simple story, taking a turn in a game, expressing an emotion, sharing a personal experience, and asking for help e.
By the end of the preschool period, children's ability to understand the language spoken by others and to speak well enough for others to understand them provides the scaffolding for their growing independence.
The end of the preschool period is also when most children show signs that they can think consciously about sounds and words, an ability known as metalinguistic awareness Kim et al. Awareness of the phonological sound characteristics of words, for example, enables children to identify words that rhyme or words that begin or end with the same speech sound.
Such phonological awareness skills have been linked to children's ability to learn that speech sounds can be represented by printed letters—one of the skills necessary for learning to read words Troia, Reading requires more than recognizing individual words, however. Competent readers also must understand how words combine to express meanings in connected text, such as phrases, sentences, and paragraphs.
Strong evidence shows that children's receptive language skills—such as their knowledge of vocabulary and grammar—are important contributors as well to this aspect of reading comprehension Catts and Kamhi, ; Duke et al. In short, by the time children enter elementary school, the speech and language skills they have acquired through listening and speaking provide the foundation for reading and writing. These new literacy skills are critical for learning and social development through the school years and beyond.
At the same time, ongoing growth in spoken language skills contributes to building personal and professional relationships and participating independently in society. It is worth noting that children's speech and language experiences may vary substantially depending on the values and expectations of their culture, community, and family. This point is most obvious for children being raised in multilingual environments, who acquire more than one language.
Although the majority of people in the world speak two languages, bilingualism currently is not the norm in the United States, and bilingualism has sometimes been assumed to increase the risk of speech and language disorders.
However, there is no evidence that speech or language disorders are more prevalent in bilingual than in monolingual children with similar biological and sociodemographic profiles Gillam et al. Similarly, some investigators have reported differences in the amounts and kinds of language experienced by children according to their socioeconomic circumstances, and some of these differences have been associated with scores on later tests that emphasize language skills, including tests of vocabulary and verbal intelligence Hart and Risley, ; Hurtado et al.
The language spoken to children certainly influences their language skills, and some aspects of language have been linked to parents' socioeconomic and educational backgrounds e. However, the range of language variations observed to date has not been found to increase the risk of speech or language disorders independent of other factors associated with low socioeconomic status, including inadequate or poor-quality health care, hunger, reduced educational and social resources, and increased exposure to environmental hazards Harrison and McLeod, ; Parish et al.
Speech Disorders As described above, speech refers to the production of meaningful sounds words and phrases from the complex coordinated movements of the oral mechanism. Speech requires coordinating breathing respiration with movements that produce voice phonation and sounds articulation. Respiration yields a stream of breath, which is set into vibration by laryngeal mechanisms voice box, vocal cords to yield audible phonation or voicing.
Exquisitely timed and coordinated movements by the articulatory mechanisms, including the jaw, lips, tongue, soft palate, teeth, and upper airway pharynxthen modify this voiced stream to yield the speech sounds, or phonemes, of the speaker's native language Caruso and Strand, Speech disorders are deficits that may prevent speech from being produced at all, or result in speech that cannot be understood or is abnormal in some other way. This broad category includes three main subtypes: Speech sound disorders can be further classified into articulation disorders, dysarthria, and childhood apraxia of speech.
The speech variations produced by speakers of different dialects and non-native speakers of English are not defined as speech disorders unless they significantly impede communication or educational achievement.
Speech sound disorders, often termed articulation or phonological disorders, are deficits in the production of individual speech sounds, or sequences of speech sounds, caused by inadequate planning, control, or coordination of the structures of the oral mechanism.
Dysarthria is a speech sound disorder caused by medical conditions that impair the muscles or nerves that activate the oral mechanism Caruso and Strand, Dysarthric speech may be difficult to understand as a result of speech movements that are weak, imprecise, or produced at abnormally slow or rapid rates Morgan and Vogel, ; Pennington et al.
Neuromuscular conditions, including stroke, infections e. Another rare speech sound disorder, childhood apraxia of speech, is caused by difficulty with planning and programming speech movements ASHA, Children with this disorder may be delayed in learning the speech sounds expected for their age, or they may be physically capable of producing speech sounds but fail to produce the same sounds correctly when attempting to use them in words, phrases, or sentences.
Voice disorders also known as dysphonias occur when the laryngeal structures, including the vocal cords, do not function correctly Carding et al. For example, a voice that sounds hoarse or breathy may be due to growths on the vocal cords, allergies, paralysis, infection, or excessive vocal abuse when speaking. A complete inability to produce any sound, called aphonia, may be caused by inflammation, infection, or injury to the vocal cords.
Stuttering also known as fluency disorder or dysfluency is a speech disorder that disrupts the ability to speak as smoothly as desired. Language Disorders As described above, language refers to the code, or system of symbols, for representing ideas in various modalities, including hearing and speaking, reading, and writing. Language may also refer to the ability to interpret and produce manual communication, such as American Sign Language. Language disorders interfere with a child's ability to understand the code, to produce the code, or both American Psychiatric Association, ; WHO, Children with expressive language disorders have difficulty in formulating their ideas and messages using language.
Children with receptive language disorders have difficulty understanding messages encoded in language. Children with expressive-receptive language disorders have difficulty both understanding and producing messages coded in language. Language disorders may also be classified according to whether they affect pragmatics, semantics, or grammar.
Pragmatic language disorders may be seen in children who generally lack social reciprocity, a contributor to the dynamic turn-taking exchanges that typify the earliest communicative interactions e. A child with a receptive pragmatic language disorder may have difficulty understanding messages that involve abstract ideas, such as idioms, metaphors, and irony. A child with an expressive pragmatic disorder may have difficulty producing messages that are socially appropriate for a given listener or context.
A child with a receptive semantic disorder may not understand as many vocabulary words as expected for his or her age, while a child with an expressive semantic disorder may find it difficult to produce the right word to convey the intended meaning accurately. A child with a receptive grammatical deficit may not understand the differences between word endings that indicate concepts such as past walked or present walkingor may not understand complex sentences e. Similarly, a child with an expressive grammatical disorder may produce short, incomplete sentences that lack the grammatical endings or structures necessary to express ideas clearly or completely.
Language disorders can interfere with any of these subsystems, singly or in combination. For example, children with severe pragmatic deficits may appear uninterested in communicating with others. Other children may try to communicate, but suffer from semantic disorders that prevent them from acquiring the words they need to express their messages. Still other children have normal pragmatic skills and vocabularies, but produce grammatical errors when they attempt to combine words into phrases and sentences.
Finally, children with phonological disorders may be delayed in learning which sounds belong in words. As mentioned earlier, language disorders first identified in the preschool period have been linked to learning disabilities when children enter school Sun and Wallach, For this reason, children with a history of language disorders as preschoolers are monitored closely when they enter elementary school, so that services can be provided to those whose language disorders adversely affect literacy, learning, and academic achievement.
Box summarizes the major types of speech and language disorders in children. Types of Speech and Language Disorders in Children. Co-occurring Speech and Language Disorders Speech and language disorders may co-occur in children, and in children with severe disorders it is plausible that less obvious deficits in other aspects of development, such as cognitive and sensorimotor processing, may also be implicated.
In the first few years of life it may be particularly difficult to determine whether a child's failure to speak is the result of a speech disorder, of a language disorder, or of both. For one thing, many speech and language abilities emerge during the early years of development, and disorders cannot be identified until children have reached the ages at which various speech and language abilities are expected.
This difficulty is compounded by the fact that children under the age of approximately 30 months are often difficult to evaluate because they may be reluctant or unable to engage in formal standardized tests of their speech and language skills.
Fortunately, effective treatments for very young nonspeaking children exist that do not depend on differentiating speech from language disorders, and a child's rate of progress in treatment may provide important evidence on the nature and severity of the disorders.
In addition, studies of children with primary speech and language disorders often reveal that they have abnormalities in other areas of development. For example, studies by Brumbach and Goffman suggest that children with primary language impairment show general deficits in gross and fine motor performance, and such children also show deficits in working memory and procedural learning Lum et al.
Conversely, some children who have primary speech sound disorders as preschoolers have deficits in reading and spelling during their elementary school years Lewis et al.
In short, considerable evidence suggests that spoken language skills, including speech sound production, constitute an integrated system and that clear deficits in one area may coexist with deficits in other areas that can compromise future development in language-related domains such as literacy.
Intensive monitoring of speech and language development in such children is important for early detection and intervention to lessen the effects of speech and language disorders. In many children, however, speech and language disorders occur for unknown reasons. In such children, diagnosing speech and language disorders is a complex process that requires assessing not only speech and language skills but also cognitive, perceptual, motor, and socioemotional development; biological, medical, and socioeconomic circumstances; and cultural and linguistic environments.
Best-practice guidelines recommend evaluating across multiple domains and obtaining information from multiple sources, including a combination of formal, standardized, or norm-referenced tests; criterion-referenced observations by speech-language pathologists and other professionals; and judgments of familiar caregivers about the child's speech and language competence relative to community expectations for children of the same age ASHA, ; Nelson et al.
On norm-referenced tests, children's scores are compared with average scores from large, representative samples of children of the same age. Children scoring below a cutoff value are defined as having a deficit, and severity is defined according to how far below average their scores fall.
Deficits can range from mild to severe. In clinical practice, scores that fall more than two but less than three standard deviations below the mean are described as severely or extremely low; only 2. Scores that fall three or more standard deviations below the mean are extraordinarily low; only 0. Figure represents these numbers in graphic terms. It shows that only 1 child in 1, would be expected to score three or more standard deviations below the mean, and only about 22 children in 1, would score more than two but less than three standard deviations below the mean.
FIGURE In a normative sample of 1, children, only 1 child shown in orange is expected to score three or more standard deviations below the mean. Another 22 children shown in light green are expected to score more than two but less than three standard more As noted in Chapter 1these clinical criteria for defining severity are not identical to the legal standards for severity specified in the regulations for the Supplemental Security Income SSI program, which also considers functional limitations that are the result of the interactive and cumulative effects of all impairments to determine the severity.
Chapter 4 includes an in-depth review of how children are evaluated for disability in the SSI eligibility determination process. Norm-referenced testing is not always possible because children may be too young or too disabled to participate in formal standardized testing procedures.
In children younger than 3 years and others incapable of formal testing, behaviors and skills are compared with those of typically developing children using criterion-referenced measures or observational checklists Salvia et al. Some criterion-referenced measures involve detailed observations of specific skills, such as parent checklists of the number of words that children say.
For example, 3-year-old children are expected to say 50 or more different words; those who fail to reach this criterion may be identified as having a significant vocabulary delay. Similarly, by months of age, children are expected to communicate with their caregivers using nonlinguistic signals such as pointing and clapping; a month-old who appears uninterested in others and fails to produce such basic communicative precursors to language may be identified as having a significant delay in the pragmatic domain of language.
Still other criterion-referenced measures involve more global judgments of whether the child's language abilities are generally commensurate with those of peers, such as asking parents whether they are concerned about their child's ability to talk or understand as well as other children of the same age. For example, a month-old with the skills of children half her age i. In many states, delays of more than percent are used to identify children under age 3 years for early intervention under Part C of the IDEA Ringwalt, Validated norm-referenced tests may not be available for children who are members of cultural and linguistic communities that are not represented adequately in normative samples e.
In addition, norm-referenced test scores may be influenced by such extraneous factors as additional or confounding deficits e. Finally, norm-referenced testing may not adequately reflect the functional limitations that speech and language deficits impose on the child's ability to participate in some demanding, real-world contexts.
For example, a child with a speech sound disorder may be able to articulate a single word reasonably clearly on a norm-referenced speech test, but be incapable of coordinating the many events necessary to produce an intelligible sentence in fast-paced, dynamic conversation.
Similarly, a child with an expressive language disorder may be able to produce single words and short phrases successfully elicited by a norm-referenced test, but be incapable of producing grammatical sentences, much less stories that include them. And a child with a receptive language disorder may understand words presented individually and point to a picture on a norm-referenced test, but be unable to comprehend sentences, especially if the sentences are lengthy, complex, spoken at the normal rate of two to four words per second, or spoken in noisy or distracting environments.
For all of these reasons, best diagnostic practices require that evidence from norm- and criterion-referenced testing by professionals be considered in conjunction with judgments made by people who are familiar with the child's usual functioning in his or her daily environment e.
Although prevalence estimates are available for some of the causes described below, and speech and language disorders are frequently mentioned among their sequelae, evidence on the percentage of speech and language disorders attributable solely to the underlying condition is not available. For example, Down syndrome, a chromosomal disorder with a prevalence of 1: Speech and Language Disorders with Known Causes Determining the underlying etiology of a speech or language disorder is essential to providing the child with an appropriate set of interventions and the parents with an understanding of the cause and natural history of their child's disability.
These conditions include primary disorders of hearing, as well as specific genetic diseases, brain malformation syndromes, inborn errors of metabolism, toxic exposures, nutritional deficiencies, injuries, and epilepsy. Children who are deaf or hard of hearing provide an especially clear example of the interrelationships among the many causes and consequences of speech and language disorders in childhood Fitzpatrick, Because adequate hearing is critically important for developing and using receptive language, expressive language, and speech, being deaf or hard of hearing can lead to speech and language disorders, which in turn contribute to socioemotional and academic disabilities.
This is particularly the case when the onset of hearing problems is either congenital or acquired during the first several years of life.
Therefore, it is essential that hearing be assessed in children being evaluated for speech and language disorders. Childhood hearing loss may result from or be associated with a wide variety of causes, which are categorized in Box Hearing may be affected by disorders of either the sensory component of the auditory system i.
Peripheral causes may be either unilateral or bilateral and are subdivided into conductive types, which are due to developmental or acquired abnormalities of the structures of the outer or middle ear, and sensorineural types, which are due to a variety of disorders affecting the sound-sensing organ—the cochlea—and its nerve that goes to the brain—the cochlear nerve.
Conductive-related causes of reduced hearing levels include congenital structural malformations of the outer and inner ear, consequences of acute or recurrent middle-ear infections, eustachian tube dysfunction, tumors, and trauma. Sensorineural types are even more diverse. A variety of genetic disorders have been identified that affect the function of the cochlea or cochlear nerve, and the disorder may be sporadic or inherited in an autosomal dominant, autosomal recessive, or X-linked manner, depending on the specific gene.
Sensorineural types may be secondary to medical illness or even treatments for babies who must be placed in neonatal intensive care units because of either prematurity or a variety of perinatal disorders, such as hypoxia oxygen deficiencydisturbances of blood flow, infections, or hyperbilirubinemia excessive bilirubin levels that lead to jaundice and brain dysfunction known as kernicterus.
Prenatal infections due to maternal cytomegalovirus, toxoplasmosis, or rubella TORCH infections can have a significant congenital impact on the sensorineural hearing mechanism, as can postnatal infectious illnesses such as meningitis inflammation of membranes around the brain and spinal cord.
Ironically, the treatment of meningitis or other bacterial infections with certain antibiotics can result in decreased hearing levels, as some of these life-saving drugs are ototoxic i. The impact of antibiotics on central hearing function is much less common in childhood and generally does not lead to total deafness.
The best-recognized cause affecting central hearing is Landau-Kleffner syndrome, or acquired epileptic aphasia, a rare condition that typically presents in early childhood with either minimal speech and language development or loss of previously acquired speech and language due to cortical deafness secondary to persistent epileptiform activity in the electroencephalogram, even in the absence of clinical seizures.
Lastly, neonatal hyperbilirubinemia kernicterus can impact both sensorineural and central hearing, the latter as a result of dysfunction at the level of the brainstem. Importantly, in addition to the causes described above, many factors that impact hearing are themselves caused by, or co-occur with, underlying conditions that affect other aspects of children's development.
Apart from being deaf or hard of hearing, there are a diverse set of conditions that should be considered as other potential causes of speech and language disorders, as summarized in Box As is the case with hearing, abnormal development of anatomic structures critical to the proper generation of speech may lead to speech sound disorders or voice disorders.
For example, articulation and phonological disorders may result from cleft palate. A wide variety of genetic syndromes are known to be associated with disordered speech and language development. These include well-characterized conditions that are due to an abnormal number of a specific chromosome, such as Down syndrome associated with three rather than two copies of chromosome 21 Tedeschi et al. Well-recognized genetic syndromes due to a mutation in a single gene such as fragile X syndrome, neurofibromatosis type I, Williams syndrome, and tuberous sclerosis are associated with speech or language disorders, and current research has demonstrated that alterations in small groups of genes copy number variations such as 16p In general, when indicated by history and clinical examination, these genetic conditions can be detected with clinically available blood-based laboratory tests.
Primary malformations of the central nervous system—such as hydrocephalus an expansion of the fluid-filled cavities within the brainagenesis of the corpus callosum the absence of the main structure that connects the right and left hemispheres of the brainand both gross and microscopic abnormalities of cortical development cortical dysplasia, an abnormal layering or location of neurons —also may be associated with speech and language disorders.
In general, these primary disruptions in brain anatomy may be diagnosed by magnetic resonance imaging MRI and in some cases discovered via an in utero maternal-fetal ultrasound examination.
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