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Speech Delay, Pediatric

Basics

Description

- Mixed receptive and expressive disorders - Verbal auditory agnosia: impaired ability to decode speech, resulting in a severe expressive impairment. Can often learn language visually - Phonologic/syntactic deficit disorder: most common type of DLD. Comprehension exceeds spoken ability. Speech is dysfluent, grammatically incorrect with short utterances. - Most frequent causes of speech delay: - Hearing loss - SLI - Autism spectrum disorder - Intellectual disability (formerly mental retardation)

- Nutritional - Malnutrition - Iron deficiency

- Infectious - HIV encephalopathy - Other in utero viral infection - Congenital toxoplasmosis - Congenital syphilis

- The American Academy of Pediatrics recommends a specific development screening tool be administered at the 9, 18, and 24 or 30-month well-child care visits and an autism-specific tool be administered at the 18- and 24-month visits. - Office development screening tools - Denver Developmental Assessment II

- Selected speech/language milestones - 2 months: cooing, response to voice - 6 months: babbling - 4 " “9 months: turns to sound, responds to name - 9 months: dada/mama nonspecific, begins to understand "no " ¯ - 9 " “12 months: jargon - 12 months: dada, mama specific, 1 additional word, jargon is complex, points to gesture, follows 1-step command - 18 months: 10 words, knows body parts - 2 years: 50 words, 2-word phrases, 50% intelligible by strangers, pronouns, can point to specific objects in a picture, may know 1 color, follows 2-step commands - 3 years: 300 " “500 words, tells stories, 75% intelligible by strangers - 4 years: grammatically correct sentences, 100% intelligible by strangers

  • Speech delay is delay in the acquisition of spoken language.
  • Language is a system of symbols through which humans communicate thoughts, feelings, and ideas. It has 3 components " ”receptive, expressive, and visual language.Receptive language is the ability to process and understand language.Expressive language is the ability to communicate through speech, written, or formal sign language.Visual elements include eye contact, pointing, and gestures.
  • Speech delay can be primary as in specific language impairment (SLI) or developmental language disorder (DLD), or secondary to another condition such as a syndrome or neurologic disorder. SLI is impaired speech/language in an otherwise normally developing child who lacks signs or stigmata of other conditions.
  • Constitutional language delay, a retrospective diagnosis, is language delay associated with eventual achievement of normal speech and language milestones by school age. There are no subsequent difficulties with learning to read or write.
  • Expressive language disorders include the following:Verbal dyspraxia: little speech produced with great effort, very dysfluent, single words most commonlySpeech programming deficit disorder: poorly organized, difficult-to-understand speech
  • Mixed receptive and expressive disordersVerbal auditory agnosia: impaired ability to decode speech, resulting in a severe expressive impairment. Can often learn language visuallyPhonologic/syntactic deficit disorder: most common type of DLD. Comprehension exceeds spoken ability. Speech is dysfluent, grammatically incorrect with short utterances.Most frequent causes of speech delay:Hearing lossSLIAutism spectrum disorderIntellectual disability (formerly mental retardation)

Epidemiology

  • Up to 15% of 2-year-old have speech and language delays.
  • 5% of school-aged children have speech and language delays.
  • 3:1 male-to-female ratio in DLD

Risk Factors

  • Family history of speech/language delay or disorder
  • Male gender
  • Low maternal education
  • Maternal depression
  • Prematurity
  • Birth weight <1,000 g

Diagnosis

Differential Diagnosis

  • Hearing lossIsolated genetic hearing lossHearing loss secondary to in utero cytomegalovirus (CMV) infection: full syndrome at birth or asymptomatic infection with delayed onset of progressive hearing lossAcquired hearing loss: following head trauma, tumor-associated, complication of bacterial meningitis, end result of frequent acute otitis media or chronic otitis media with effusion
  • Intellectual disability
  • Autism spectrum disorder
  • SLI
  • Constitutional language delay
  • Selective mutism
  • EnvironmentalLack of stimulation and/or poor linguistic environmentChild abuse or neglectLead poisoning
  • CongenitalCerebral palsyHydrocephalusDown syndromeFragile X syndrome22q11 microdeletion syndromeFetal alcohol syndromeTurner syndromeKlinefelter syndromePrader-Willi syndromeAngelman syndromeMuscular dystrophyTuberous sclerosisNeurofibromatosisWilliams syndromeBranchio-oto-renal (BOR) syndromeCraniofacial anomalies such as Treacher Collins and Goldenhar syndromes
  • NutritionalMalnutritionIron deficiency
  • InfectiousHIV encephalopathyOther in utero viral infectionCongenital toxoplasmosisCongenital syphilis

Alert

  • Avoid late referral of congenital hearing loss: Amplification and therapy by 6 months of age can result in near-normal rate of speech/language acquisition.
  • Constitutional language delay is a retrospective diagnosis. Do not miss a language disorder if assuming a delayed toddler is a "late bloomer. " ¯
  • Avoid overlooking fine or gross motor delays.
  • Avoid missing a genetic or neurologic diagnosis.

History

Does the family note a concern about speech delay or hearing impairment? ‚

  • Question: Perinatal history?
  • Significance: prenatal care, maternal illness, NICU admission, hyperbilirubinemia requiring exchange transfusion, treatment with ototoxic drugs such as gentamicin, newborn hearing screen results
  • Question: Full developmental history?
  • Significance: to determine if global delay or isolated speech and language delay
  • Question: Parental concern about delayed expressive language?
  • Significance: often the presentation of autism
  • Question: History of feeding, swallowing difficulties, or poor acceptance of textured foods?
  • Significance: signs of oromotor dysfunction which may indicate a neurologic problem
  • Question: Family history of speech delay, hearing loss, neurologic disorder, or syndrome?
  • Significance: may direct further evaluation
  • Question: Any regression or loss of language milestones?
  • Significance: should prompt a neurologic and metabolic workup
  • Question: What is the social interaction of the child?
  • Significance: Lack of interest in playing is a red flag for autism.
  • Question: Any concern regarding child abuse or neglect or psychosocial deprivation?
  • Significance: may have occurred as the result of a parental, genetic, or developmental disorder; drug or alcohol abuse; poverty; child malnutrition; or environmental toxins such as lead
  • Question: History of frequent acute otitis media or otitis media with effusion and conductive hearing loss?
  • Significance: may precede speech delay
  • Question: Visual impairments?
  • Significance: may impact speech development because interpretation of facial expressions and gestures is a component of infant receptive language development
  • Question: History of traumatic brain injury?
  • Significance: Speech delay may occur with a seizure disorder.

Physical Exam

Complete examination looking for signs that may be associated with speech delay. ‚

  • Finding: Microcephaly?
  • Significance: associated with intellectual disability, in utero CMV infection, or dysmorphic features
  • Finding: Macrocephaly?
  • Significance: associated with hydrocephalus, various syndromes
  • Finding: Dysmorphic features?
  • Significance: suggestive of a syndrome
  • Finding: Excess drooling and open-mouth posture?
  • Significance: signs of poor oral motor control of muscles used for speech production
  • Finding: Craniofacial abnormalities?
  • Significance: Articulation difficulty may be due to velopalatal insufficiency (VPI) seen with unrepaired cleft lip or palate.
  • Finding: Scarred tympanic membranes or middle ear fluid?
  • Significance: may be clue to acquired intermittent or chronic conductive hearing loss
  • Finding: Macroorchidism?
  • Significance: fragile X syndrome
  • Finding: Neurologic exam " ”hypertonia or hypotonia, abnormal reflexes, other focal findings?
  • Significance: suggestive of neurologic impairment
  • Finding: Cafe au lait spots, hypopigmented macules, shagreen patch, axillary or inguinal freckling?
  • Significance: skin findings suggestive of a neurocutaneous syndrome

Diagnostic Tests & Interpretation

  • The American Academy of Pediatrics recommends a specific development screening tool be administered at the 9, 18, and 24 or 30-month well-child care visits and an autism-specific tool be administered at the 18- and 24-month visits.
  • Office development screening toolsDenver Developmental Assessment II
  • Early Language Milestone Scale (ELMS)
  • Clinical Linguistic and Auditory Milestone Scale (CLAMS)
  • Hearing evaluationMost states have mandated Universal Newborn Hearing Screening Programs.Screening tests: automated auditory brainstem response (AABR) and transient evoked otoacoustic emissions (OAEs)Hearing should be tested in all speech-delayed children, even if the newborn hearing screen was normal.<6 months of age: The definitive test is brainstem auditory evoked response (BAER).>6 months of age in a neurologically normal child: The definitive test is behavioral audiometry, such as visual reinforcement audiometry (VRA), performed by a trained audiologist.
  • Selected speech/language milestones2 months: cooing, response to voice6 months: babbling4 " “9 months: turns to sound, responds to name9 months: dada/mama nonspecific, begins to understand "no " ¯9 " “12 months: jargon12 months: dada, mama specific, 1 additional word, jargon is complex, points to gesture, follows 1-step command18 months: 10 words, knows body parts2 years: 50 words, 2-word phrases, 50% intelligible by strangers, pronouns, can point to specific objects in a picture, may know 1 color, follows 2-step commands3 years: 300 " “500 words, tells stories, 75% intelligible by strangers4 years: grammatically correct sentences, 100% intelligible by strangers
  • Routine cranial imaging or screening tests for metabolic diseases are not recommended.
  • Test: Full speech and language evaluation
  • Significance: To delineate the disorder and determine therapy
  • Test: Individuals with Disabilities Education Act (IDEA) mandates early intervention services from birth to 3 years.
  • Significance: Children can get a full developmental evaluation and appropriate therapy if sufficient delays are demonstrated.
  • Test: EEG
  • Significance: Indicated if there is concern for seizures
  • Test: Genetics evaluation
  • Significance: Should be obtained for congenital hearing loss or if there is concern for a syndrome or genetic diagnosis
  • Test: Prolonged sleep EEG
  • Significance: Indicated with loss of language milestones (consider the diagnosis of Landau " “Kleffner syndrome)

Treatment

General Measures

  • Congenital hearing loss is managed by a team consisting of an otolaryngologist, audiologist, and speech/language therapist who individualize management. Options are amplification, cochlear implant for the severely impaired, or use of sign language.
  • Speech and language therapy can be provided through physician referral or parent-generated referral to early intervention programs.
  • Sign language can be used as a bridge to promote communication while the child learns verbal skills. It will not preclude or delay the development of speech.
  • Augmentative communication devices such as picture boards or programmed computers with voice synthesizers can be used by children with physical impairments such as cerebral palsy.
  • Children with DLD usually speak adequately by school age. Some percentage will go on to have difficulty reading and writing.
  • Children with constitutional language delay will achieve normal milestones by school entrance without reading disability or other learning problem.

Additional Reading

  • Agin ‚ M. The "late talker " ¯ " ”when silence isn 't golden. Contemp Pediatr. 2004;21:22 " “32.
  • Campbell ‚ T, Dollaghan ‚ C, Rockette ‚ H, et al. Risk factors for speech delay of unknown origin in 3-year old children. Child Dev. 2003;74(2):346 " “357. ‚ [View Abstract]
  • Coplan ‚ J. Normal speech and language development: an overview. Pediatr Rev. 1995;16(3):91 " “100. ‚ [View Abstract]
  • Feldman ‚ H. Evaluation and management of language and speech disorders in preschool children. Pediatr Rev. 2005;26(4):131 " “140. ‚ [View Abstract]
  • Rapin ‚ I. Practitioner review: developmental language disorders: a clinical update. J Child Psychol Psychiatry. 1996;37(6):643 " “655. ‚ [View Abstract]
  • Sokol ‚ J, Hyde ‚ M. Hearing screening. Pediatr Rev. 2002;23(5):155 " “162. ‚ [View Abstract]

Codes

ICD09

  • 315.39 Other developmental speech disorder
  • 315.34 Speech and language developmental delay due to hearing loss
  • 315.31 Expressive language disorder
  • 315.32 Mixed receptive-expressive language disorder
  • 315.35 Childhood onset fluency disorder
  • 784.59 Other speech disturbance

ICD10

  • F80.9 Developmental disorder of speech and language, unspecified
  • F80.4 Speech and language development delay due to hearing loss
  • F80.1 Expressive language disorder
  • F80.2 Mixed receptive-expressive language disorder
  • F80.0 Phonological disorder
  • R47.9 Unspecified speech disturbances
  • F80.81 Childhood onset fluency disorder
  • F80.89 Other developmental disorders of speech and language

SNOMED

  • 229721007 speech delay (disorder)
  • 441719005 Speech and language developmental delay due to hearing loss (disorder)
  • 229734008 Expressive language delay (disorder)
  • 702528003 Developmental delay in receptive-expressive language (disorder)
  • 62221000119105 Severe expressive language delay (disorder)
  • 62231000119108 Mild expressive language delay (disorder)
  • 62415009 Delayed articulatory and language development (finding)
  • 62211000119103 Moderate expressive language delay (disorder)

FAQ

  • Q: Do 2nd- and 3rd-born children speak later than 1st-born children?
  • A: No. The norms for expected speech/language development are the same regardless of birth order. 2nd- and 3rd-born children should have the same degree of motivation to speak as their 1st-born sibling.
  • Q: When should I refer a child for speech/language evaluation?
  • A: If the parents or physician have any concern for speech delay, then referral for evaluation is wise. Some speech-delayed children will eventually normalize and meet all milestones. It is difficult to distinguish who is constitutionally delayed from those who have another disorder. There are several indications for a prompt referral: no pointing or babbling by 1 year, no single words by 16 months, no 2-word spontaneous phrases by 2 years, no sentences by 3 years, poor intelligibility for age, child has behavioral "melt downs " ¯ or tantrums with efforts to communicate, or any regression in language skills.
  • Q: Do children raised in bilingual households have expressive language delay?
  • A: No. Living in a bilingual household is not a cause of expressive language delay. However, toddlers who are learning 2 languages may interchange words in both languages. Total vocabulary and phrase length are typically normal in these children by 2 " “3 years of age.