Basics
Description
- Communication is the exchange of ideas between two or more individuals.
- Language is a systematic means of communication that relies on a socially agreed upon set of symbols and rules for combining those symbols. Language includes comprehension, expression, and social-pragmatic rules (e.g., eye contact and turn-taking).
- Speech is produced through vocal and articulatory movements using neuromotor control of respiration, phonation (vocalization), and articulation to shape airflow and vocal sounds into strings of speech sounds (phonemes) to form words and word combinations.
- Articulation refers to the use of oral and pharyngeal structures (lips, tongue, palate, teeth) to shape vocal sounds and airflow into recognizable speech.
- Hearing is the process of transferring sound from the environment to the brain via the outer, middle, and inner ear systems.
- Speech disorders have three general points of origin: (1) neurologic, (2) structural, or (3) functional. Functional disorders are those that are unrelated to neurologic or structural disorders. More than one of these causes may be present in the same child.
- Speech disorders can be classified and are described as follows:
- Articulation or phonologic disorders
- Disrupt the way a child says one or more speech sounds
- Simplifications of complex adult speech are often normal very early in speech development but should be evaluated if these changes linger or are atypical.
- Fluency disorders
- Disrupt the easy flow of speech production and include the conditions of stuttering and cluttering.
- Examples of stuttering include repetitions of sounds, syllables, words, or phrases, pauses, blocks, or hesitations.
- Easy repetitions are common in children ages 2 " “4 years and typically resolve quickly. Persistence, visible struggle, or avoidance of talking warrant referral.
- Motor speech disorders
- Disrupt timing, coordination, or the execution of the motor plan for speech
- Divided into two major categories: (1) dysarthrias, which are most often related to neuromotor weakness or paralysis, and (2) apraxia, a motor planning disorder in the absence of neuromotor weakness or paralysis
- Voice disorders
- Heard as atypical laryngeal quality such as hoarseness (dysphonia) or completely absent voice (aphonia)
- Resonance disorders
- Describe speech quality usually described as nasality
- Hypernasality (excessively nasal quality) is associated with velopharyngeal dysfunction and is atypical.
- Hyponasality (inadequate nasality) is common in young children in association with acute upper respiratory infection or adenoid hypertrophy.
- Language disorders may occur in receptive, expressive, pragmatic, or some combination of these domains. Language disorders may occur in conjunction with other developmental, sensory, neurologic, or structural concerns but may also be isolated as an area of delay (see "Language Delay " ¯ and "Autism " ¯ chapters).
Epidemiology
- The American Speech-Language Hearing Association states that communication disorders occur in 1 of every 8 people in the population.
- Newborn screening identifies hearing loss or deafness in 1 " “6 per 1,000 newborns, with higher rates in neonatal intensive care.
- Speech sound disorders including articulation, phonologic, and developmental apraxia of speech are considered the most prevalent communication problem diagnosed in 10 " “15% of preschoolers and 6% of school-aged children.
- Fluency disorders affect 11% of children by age 4 years. Boys are nearly three times more likely to persist in stuttering beyond age 4 years.
- Cerebral palsy affects 1 in 500 children born each year and may include mild to severe motor speech disorders and risk of other communication disorders.
- Voice disorders such as chronic hoarseness are reported in 6 " “23% of children.
Diagnosis
History
- Prenatal history
- Prenatal exposures to alcohol, prescription or nonprescription medications, or infections are known to relate to developmental delay and/or hearing loss.
- Medical history
- Prematurity, trauma, seizure disorders, major surgeries, and systemic infections are all risk factors for communication disorders.
- Multiple anomalies may relate to an underlying syndrome.
- Feeding history
- Neuromotor and structural disorders may be noted in early feeding history
- Ask about failure to thrive, frequent pneumonia, prolonged feeding time, or chronic nasal regurgitation.
- Family history
- Heredity may be a factor associated with stuttering, specific language impairment, autism spectrum disorders, cleft palate, developmental apraxia of speech, hearing loss, deafness, and other speech-language disorders.
- Social history
- Evaluate for history of abuse, trauma, or neglect.
- Smoking in the home is a known risk for middle ear infections.
- Frequent verbal interaction and reading promote speech and language skills.
- Speech and language history
- Routine screening for speech and language milestones aid early identification.
- Duration of symptoms for voice and resonance disorders will separate acute infection from true disorders.
- Regression of speech or language skills may be associated with autism spectrum disorders or trauma.
- Key milestones
- By 1 year of age
- Points to (or gazes toward) known person or object name (Where 's mama?)
- Produces at least one true word; may not be recognized by all but is consistent
- By 2 years of age
- Identifies body parts, follows one-element commands (Get your book.)
- Uses about 50 expressive words and starts to combine 2 words together (up dada)
- By 3 years of age
- Follows 2 " “3 element commands, combines 3-word phrases, and uses short questions (e.g., Why?)
- Speech is understood by familiar listeners the majority of the time.
- By 4 years of age
- Uses longer sentences and tells short stories/sequences of events
- Answers who, what, where, and when questions
- Speech is understood by an unfamiliar listener nearly all the time.
- Physical and social development
- Missed physical or social milestones are indicative of overall delay. Delayed or absent social milestones may aid in early identification of autism spectrum disorders.
Physical Exam
- Face. Evaluate for facial symmetry at rest (structural) and during movement (neurologic). Drooling is typical during early infancy and teething but should resolve by 18 " “24 months.
- Eye color. Iris heterotropia together with white forelock frequently associate with hearing loss in Waardenburg syndrome.
- Skin. Cafe au lait spots are associated with neurofibromatosis and hearing loss.
- Head shape and size. Microcephaly, macrocephaly, or plagiocephaly or other skull asymmetries may be associated with developmental delay, hypotonia, or craniosynostosis conditions.
- Symmetry, structure, and height of ears. Ear tags, atresia, and low-set ears have high association with hearing loss and should prompt audiologic and otolaryngology evaluation.
- Intraoral exam. Dental health, palatal shape, and jaw relationships should be noted. Soft palate (velar) elevation should be symmetric on "ah. " ¯ Bifid uvula, bluish color of velum, or V-shaped notch at the border of the hard and soft palate are indicative of a submucous cleft palate. Absent gag response is not a contraindication to feeding but should be noted.
- Phonation. Listen to vocal quality on sustained "ah. " ¯ Wet voice may indicate swallowing disorder. Rough, hoarse, or strained vocal quality is atypical and requires evaluation.
Diagnostic Tests & Interpretation
Screening Procedures
- Speech-language screening
- Brief check on domains of communication designed to determine whether to refer child for full speech-language evaluation
- Results often reported as "Pass/Refer " ¯ with minimal or no interpretation.
- May be conducted by speech-language pathologist, audiologist, teacher, or other professional
- Hearing screening
- Brief assessment that may be conducted for newborns or older children to detect presence or absence of response to sound at a set hearing level across frequencies
- Results often reported as "Pass/Refer " ¯ with minimal or no interpretation.
- Screening may be conducted by an audiologist, speech-language pathologist, nurse, or trained paraprofessional.
Diagnostic Procedures/Other
- Speech-language evaluation
- Measurement of receptive, expressive, and/or pragmatic language skills; articulatory/phonologic development; and oral structural and physiologic examination with interpretation of findings and recommendations
- Conducted by speech-language pathologist
- Hearing evaluation
- Testing to obtain auditory thresholds (in decibels, dB) across sound frequencies (in Hertz, Hz) in both ears
- If hearing loss is identified, further testing to determine if the source is middle ear (conductive) or inner ear (sensorineural) or mixed (both conductive and sensorineural)
- Very young children may be tested using auditory brainstem response (ABR) or otoacoustic emissions (OAE).
- Conducted by an audiologist
- Cognitive evaluation
- Testing to assess overall cognitive development across verbal and nonverbal domains with results interpreted together with recommendations for interventions and/or school placement
- Typically conducted by a psychologist
- Genetics evaluation and testing
- Comprehensive family history, physical exam, metabolic, and/or cytogenetic testing often to identify or rule out specific diagnoses (e.g., fragile X, 22q deletion syndrome, neurofibromatosis, or genes associated with hereditary hearing impairment)
- Interpretation of findings includes explanation to family of carrier status and recurrence risk.
- Typically conducted by clinical geneticist or interdisciplinary genetics clinic
- Radiologic or other imaging studies: rarely used to assess underlying cause of speech or language disorders but may be used to rule out or identify related conditions such as intraventricular hemorrhage or swallowing and resonance disorders
Differential Diagnosis
Communication disorders may be associated with other underlying conditions. A diagnosis of speech or language delay should include a process of evaluating the child for underlying causes, which alter the treatment approach: ‚
- Hearing loss. Evaluate for familial or congenital loss; chronic middle ear infection; or acquired loss (e.g., ototoxic medications, systemic infection, underlying syndrome, or noise exposure).
- Developmental delay or autism spectrum disorders. Failure to develop verbal language in the absence of hearing loss should yield examination of physical and social " “behavioral milestones to rule out overall delay and/or autism spectrum disorders.
- Neuromotor disorders. Neuromotor disorders may yield low facial/oral tone, weakness, or paralysis that may reduce speech intelligibility. Developmental apraxia of speech requires assessment and may coincide with limb apraxia.
- Vocal overuse or trauma. Evaluate for overuse patterns from habitual screaming, poor singing technique, and cheerleading.
- Structural and dental changes. Dental malocclusion or oral structural anomalies may reduce speech intelligibility for particular speech sounds.
- Sleep apnea. Poor sleep may be the cause of behavioral and learning concerns.
- Selective mutism. Specific situations in which the child will not speak in the absence of evident speech or language disorder. May coincide with social withdrawal, shyness, social anxiety
- Social isolation, neglect, or malnutrition should be ruled out, as these may associate with delays or losses of communication skills.
- Seizure disorders such as Landau-Kleffner syndrome can be associated with loss of language skills.
Treatment
- Direct service
- In-home services
- Evaluation and treatment for high-risk infants and toddlers in family-centered, natural environment, with minimal or no expense to family
- Clinic-based services. Evaluation and individual or group treatment through a hospital, private, or university speech " “language " “hearing clinic
- May be needed for specialized services
- School-based services
- Evaluation, individual or group treatment usually through special education services that yield an Individualized Education Plan (IEP)
- Service delivery is often limited to conditions that impact the child 's educational performance.
- Related services
- Interdisciplinary team care
- Children with complex medical needs should be served by an interdisciplinary team such as a cleft palate/craniofacial, spina bifida, autism, feeding, or multiple disability clinic.
- Provides comprehensive physical, functional, and psychosocial care of the child and family in collaboration with primary care providers
- Otolaryngology. Detailed examination of laryngeal structures, airway, palatal structures, enlarged tonsils, and/or management of otologic concerns
Ongoing Care
- Early identification of hearing, speech, or language problems is critical and leads to better outcomes.
- Children who have untreated hearing, speech sound, and language disorders are at risk for academic difficulties.
- Many speech problems can be resolved with short-term treatment. Some conditions may require longer term management extending through adolescence.
- Adenoid removal is usually contraindicated for children with cleft palate, including submucous cleft palate. Airway and apnea management may be an exception that requires interdisciplinary decision making.
Additional Reading
- American Speech-Language-Hearing Association (ASHA). http://www.asha.org.
- Graham ‚ SA, Fisher ‚ SE. Decoding the genetics of speech and language. Curr Opinion Neurobiol. 2013;23(1):43 " “51. ‚ [View Abstract]
- Possamai ‚ V, Hartley ‚ B. Voice disorders in children. Pediatr Clin North Am. 2013;60(4):879 " “892. ‚ [View Abstract]
- Sharp ‚ HM, Hillenbrand ‚ K. Speech and language development and disorders in children. Pediatr Clin North Am. 2008;55(5):1159 " “1173. ‚ [View Abstract]
Codes
ICD09
- 784.59 Other speech disturbance
- 315.35 Childhood onset fluency disorder
- 784.69 Other symbolic dysfunction
- 784.52 Fluency disorder in conditions classified elsewhere
ICD10
- R47.9 Unspecified speech disturbances
- F80.81 Childhood onset fluency disorder
- R48.2 Apraxia
- R47.82 Fluency disorder in conditions classified elsewhere
SNOMED
- 29164008 Disturbance in speech (finding)
- 288271000119103 childhood onset fluency disorder (disorder)
- 361276003 Verbal apraxia (disorder)
- 229621000 disorder of fluency (disorder)
FAQ
- Q: Does ankyloglossia negatively affect speech production?
- A: The tongue tip is used for speech sounds /t, d, n, l, s, z/. If the child can make one or more of these sounds, then ankyloglossia can go untreated.
- Q: Does "baby sign " ¯ help or delay the acquisition of speech and language?
- A: Evidence suggests teaching gestural communication is associated with slightly advanced auditory " “verbal language skills before 24 months of age and may decrease toddler " “parent frustration. By 30 " “36 months of age, no significant differences are observed between children who used baby sign and those who did not.
- Q: Does chronic otitis media slow the acquisition of speech or language?
- A: Early speech and language may be delayed in the presence of otitis media. If treated, differences in language skills typically resolve by school age.