Evaluation and Management of Language and Speech Disorders in Preschool Children

Abstract

After completing this article, readers should be able to: Language is the expression of human communication through which ideas, information, emotions, and beliefs can be shared. Typically developing children master the fundamentals of language and speech in the toddler-preschool era. Language and speech skills serve a pivotal role in learning and social relationships. Delays in the early development of language and speech skills, which are prevalent in the population, may affect several domains of function. Management and treatment can improve language and speech skills substantially and reduce the functional impact of persistent disorders. Therefore, identifying children who have language and speech delays in the toddler-preschool period should be a priority for the pediatric clinician. This article reviews the normal process of language development up to school age, discusses the use of screening measures and parent report inventories to verify parental reports of delays, provides a differential diagnosis of language and speech delay, and suggests an approach to the child who has language or speech problems in the absence of history or physical findings suggestive of a specific medical condition associated with language and speech disorders. In addition, the review discusses general management of language and speech disorders and provides updates about management of some of the underlying causes of speech and language delay.Language is the use of systematic, arbitrary, and socially agreed upon signals (words and sentences) to convey meaning within a group or community. Receptive language refers to the ability to understand and expressive language to produce this symbolic communication. Speech is a manifestation of language that uses decodable vocal sounds as the medium of exchange. Speech is created by a series of complex and coordinated movements of the respiratory, laryngeal, velopharyngeal, and oral systems. Natural sign languages are an alternative method to convey meaning. Sign languages have underlying organization comparable with that of spoken language, but use a distinctive vocabulary and grammar based on movements of the hands, body, and face. Children learn sign language at comparable ages as they learn spoken language. There is no definitive evidence about whether teaching sign language to hearing children confers any advantages or disadvantages to the children.Developmental language disorders are persistent and significant limitations on the ability to learn the language of the community.Characteristics of language disorders include limited understanding or production of vocabulary, misuse of words and their meanings, difficulty expressing or following ideas, immature grammatical patterns, difficulty following directions, or altered patterns of conversation. Speech disorders are persistent delays and deficits in the development of speech skills and voice quality. Speech disorders include problems in the production of speech sounds; disruptions in the flow or rhythm of speech; problems with voice pitch, volume, or quality; and poor intelligibility. Phonologic disorders (previously called articulation disorders) are common speech-sound disorders in childhood, in which the child is significantly less skilled than peers in articulating, sequencing, or organizing the sounds of the language. The errors compromise the ability of strangers to interpret the child’s speech, but are relatively consistent. Another speech-sound disorder is verbal apraxia or developmental verbal dyspraxia. This disorder is associated with difficulty in planning, programming, and producing speech sounds. Children who have this disorder usually make highly inconsistent errors that severely compromise intelligibility. Differentiation among speech disorders requires the expertise of a speech-language pathologist.Children often present initially in the toddler-preschool period with a developmental delay in language or speech. When delays persist and affect communicative function, they become classified as disorders. The pediatric clinician frequently is called on to verify delays in the development of language and speech and to decide which affected children warrant further evaluation and management.Language and speech disorders are features of many genetic and chromosomal disorders. For example, children who have Down syndrome typically show verbal skills below those expected on the basis of cognitive functioning. Children who have fragile X and Klinefelter syndromes may present with delayed language skills with or without characteristic physical features. Toddlers and preschoolers who have William syndrome are delayed at early stages of language development, although they ultimately exhibit communication and social skills in advance of other aspects of their cognitive functioning.Language and speech disorders also are features of neurologic diseases. Children who have severe cerebral palsy may have problems with language or the production and coordination of speech sounds. Seizure disorders involving the left hemisphere, such as Landau-Kleffner syndrome, may interfere with the development and use of language. Boys who have Duchenne muscular dystrophy may show early language and speech delay prior to or along with early signs of weakness.In school-age children who have no obvious genetic or neurologic condition, the prevalence of language disorders is approximately 2% to 3%; the prevalence of speech disorders is between 3% and 6%. Some children have both disorders. Speech and language disorders are more common in boys than girls and more common among children who have a family history of language, speech, or reading disorders in a first-degree relative than among children who have a negative family history. The prevalence of language and speech delays in the preschool period is considerably higher, at about 15%, again with considerable overlap. Children of low socioeconomic standing are more likely to show delays in language and, in some studies, speech development than are children of upper and middle socioeconomic standing.Table 1 summarizes language milestones from birth to school age. From the neonatal period, children show interest in human voices and faces in preference to other stimuli, preferences that forge the building blocks of communicative development. By about 2 to 3 months of age, an infant begins to use his or her voice to make melodic vowel sounds called cooing. Shortly thereafter, they begin to enter into reciprocal vocal exchanges with their caregivers. By about 6 months of age, the child adds consonants to vowels, creating syllables known as babble. Also at about 6 months of age, children show emerging abilities to understand elements of the sound stream, responding appropriately to their name and to the word “no.” By 8 to 10 months of age, children can use verbal cues for practiced routines, such as “wave bye-bye.” Expressive communication at that age includes ma-ma or da-da, first used nonspecifically and then for the parent. Children begin to communicate nonverbally by pointing.At around the first birthday, babble becomes increasingly complex jargon, sounding like adult language in terms of the variety of speech sounds and the intonation patterns. Simultaneously, children begin to understand and use real words. Throughout the second year, they are capable of understanding far more than they can produce. They initially learn vocabulary slowly, at a rate of approximately two to three words per week. The early words are simple in structure, often repetitions of a consonant and a vowel, such as wa-wa for water. The early words may be used too broadly, such as applying the label dog to all animals, or too narrowly, such as applying the word dog only to the family pet.Sometime usually between 18 and 24 months of age, when the child’s vocabulary reaches 30 to 60 words, the pace of language learning quickens dramatically. Children learn, on average, three to four words per day and begin combining words into two-word phrases. As sentence length increases, the child masters language-specific grammatical elements, including pronouns, question words, articles, and verb tense markings. At age 3 years, comprehension is extremely good; sentences are three or more words in length; children begin asking questions, first “what” and then “why”; and they engage in short conversations. By 4 to 5 years of age, the child is able to construct complex sentences, participate in meaningful conversation, and tell short stories. After that point, progress in language development is less obvious to the untrained listener. By school age, individual differences in language abilities are revealed in formal testing or laboratory studies.Speech development progresses in tandem with language (Table 1). The first eight consonant sounds that develop are: m, b, y, n, w, d, p, and h. At age 2 years, a child who is developing typically can create speech that is intelligible to an unfamiliar adult at least 50% of the time and at age 3 years, at least 75% of the time. Children may continue to have difficulty with pronouncing some sounds until about 7 years of age. The last eight consonants typically acquired are sh, th as in the word “think,” s, z, th as in the word “the,” l, r, and the zh sound usually spelled as s, as in the word “treasure.” Consonant blends such as sp, tr, and bl also may not emerge until early school age. Nonetheless, 100% of speech should be intelligible by about age 4 years.Fluency—the flow of output—also undergoes developmental change. At around age 3 to 4 years, many children experience a period in which the fluency of their output is poor. Developmental dysfluency is characterized by repetition of whole words and syllables rather than individual sounds, seems to arise from poor coordination of thoughts and words, and typically resolves by age 4 years. Stuttering is a long-term speech problem characterized by disruptions in fluency that create difficulties with communication. Stuttering consists of repetitions of parts of words, prolongations of sounds, and complete blocks. Children who stutter may show evidence of tension and struggle as they attempt to form words.Toddlers rarely cooperate with a health care professional to allow direct assessment of early language and speech in a short office visit. The Early Language Milestone, second edition, and the Clinical Adaptive Test/Clinical Linguistic and Auditory Milestone Scale are brief screening measures that are appropriate for use in the pediatric office. General developmental screening tests provide a pass-fail score and do not offer information specifically about language and speech.Many pediatric practices assess development with history rather than with screening. Therefore, it is imperative that clinicians recognize early signs of disorder and delay. Table 2 describes abnormal findings on history (or developmental observation) at various ages that should prompt further evaluation of a child’s language or speech. In addition, a delay of 25% or greater by 16 to 24 months of age is considered significant. For example, a 24-month-old child who functions as a typical 18-month-old can be considered to have a clinically significant language delay.Parental concerns about language or speech can be corroborated through the use of parent report inventories, such as the Language Development Survey or the MacArthur Communicative Development Inventories-Short Form. These measures, obtained when children are 18 months to 2 years old, have good concurrent validity and predictive validity. Clinicians should not wait until children are 3 years of age or older to evaluate delayed language or speech.Significant language delay (>25%) should not be disregarded because the child is a boy, second- or third-born in a family, or a member of a bilingual household. Studies show that boys function on average only 1 to 2 months behind girls in vocabulary and grammar development. Birth order effects in language development are not consistent across studies. Toddlers from bilingual households may show minor delays at the initial phases of language production and early mixing of the two language systems within a phrase or exchange. Their progress at differentiating languages occurs more quickly when the languages are associated with clear environmental contexts (language #1 at home, language #2 at school) than when they are mixed within the context (the parent uses language #1 70% of the time and language #2 30% of the time). Children may develop uneven skills in the two languages as a function of the amount and quality of exposure to each language.Significant delays in language development can result from either biologic or environmental causes. The differential diagnosis of language delays in children who have no specific findings on history, physical examination, or neurologic examination includes hearing loss, global developmental delay, autism, specific language impairment, and psychosocial deprivation. Hearing loss may be suspected based on the pattern of the child’s understanding and production. Speech sounds at the greatest risk for poor reception and production in the context of moderate sensorineural hearing loss are s, th, and f, which are high-frequency sounds that have low energy (Fig. 1). Global developmental delay may be suspected on the basis of other delays in cognitive or motor skills. If such developmental findings persist into school age, the child may meet diagnostic criteria for mental retardation.Autistic disorder should be suspected when language not only is delayed but also is deviant, that is, different in terms of vocabulary, grammar, or communicative pattern from the language of younger children. In autism, qualitative impairments in communication are accompanied by qualitative impairments in social interaction, such as a lack of eye-to-eye gaze and reciprocity, and by restrictive, repetitive, and stereotyped patterns of behaviors, or Some children who have develop language and speech skills, but children show characteristic impairments in the ability to or conversation, a on stereotyped or language rather than and or intonation patterns. of children who have features and do not meet diagnostic criteria for at that age often that they meet diagnostic criteria at school age, although some children improve language may be suspected when language skills are than other cognitive language may affect only expressive language or both and expressive language. of the language include delays or errors in the use of elements of the grammar that are or in speech, such as understanding or production of the or In some social aspects of communication are of language impairments from Language delays also can result from a poor Children who have child or severe typically have delayed language and speech. less the of vocabulary and the of their skills are associated with the quality and of parental The language development of children from low socioeconomic has to the relatively of children in that reading to and may improve language skills in children by the amount and of language in their Children with language delay should a the assessment that are appropriate for the child’s age. hearing screening children who have or sensorineural hearing loss in the period because of the of the the tests children who have or acquired hearing Therefore, children who have language or speech delay should be for hearing who have normal hearing and of impairments of cognitive or social skills should a developmental Early for children from birth to 3 years of age can provide an assessment of the child’s of in each developmental of to early for diagnostic are that the are at no to the family, and can begin delays are These typically provide a of of in developmental domains but do not offer an or such as cerebral palsy or and medical such as or provide the diagnostic but may in the developmental in all to early and medical is The quality of the can be in several as appropriate to the and of the may poor or a low of in the tests for the are and often to be by a direct If clinicians have concerns about the quality of the include a to child a mental health assessment of or a professional who to be may be to a speech-language for of the and of language or speech delay as as for the and of The treatment of to the speech-language as of developmental dysfluency and in Children who have language or speech delays in to other developmental delays or specific genetic or neurologic also may from the speech-language Early typically include a speech-language on the evaluation and language disorders should be as health care for the of a management concerns are in the context of a long-term between a care and an for communication among and family information and and and The child and family to within both the medical and the of the child’s functional is an of care for a developmental disorder and should be used to treatment and In this the has created the of and This diagnostic provides a about the among functional social and environmental The of functional and social provide a for the assessment of domains that be affected by the developmental Table 3 and that may to children who have speech and language such as the ability to learn and The management should the functional in and domains as they management of hearing loss on both the of loss and the preferences of Auditory is the of management for hearing to an is to and hearing for the family of a child who has hearing loss is the of communication the child This be considered on an individual the child in the language of the but some children who are hearing are at learning and speech. 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