Communication disorders in young children

What is communication ?

Exchange of information with others

produce understandmessages

Forms of communication

• Nonlinguistic (gestures, bodyposture, facial expression, eye contact, head and body movement)

• Verbal = words (speaking, writing, sign language)

• Paralinguistic (tone of voice, emphasis of words)

Communication development

• Signals: joint attention, gestural communication, turn-taking

• Language comprehension• Language production

The ability to understand develops before the ability to speak

!! !!!!

Communication

• Communication varies with the child’s age and developmental status

Speech milestones

• 1 to 6 months

• 6 to 9 months• 10 to 11 months• 12 months

• 13 to 15 months

• 16 to 18 months

• 19 to 21 months• 22 to 24 months

• Coos in response to voice

• Babbling • says "mama/dada”, no meaning • Says "mama/dada" with meaning

• Four to seven words & jargon

• 10 words, some echolalia, jargon

• Vocabulary of 20 words• Two-word phrases, vocabulary>50

Speech milestones

• 2 to 2 1/2 years

• 2 1/2 to 3 years

• 3 to 4 years

• 4 to 5 years

• 400 words, two- to three-word phrases, use of pronouns

• Plurals and past tense, knows age and sex, 3-5 words per sentence

• 3-6 words per sentence, asks questions, tells stories

• 6-8 words per sentence, names four colors, counts 10 pennies correctly

Signs of concern

• Not babbling by 12 to 15 months• Not comprehending simple commands

by the age of 18 months• Not talking by 2 years • Not making sentences by 3 years• Difficulty telling a simple story by

4-5 years

Speech delay

• Speech delay is defined as the failure to acquire words by 18-24 months of age or phrases by 3 years of age

Delayed acquisition of speech is not always due to late maturation in children !

The impact of communication disorder

• The communication has a long-term impact on:

– learning (reading) – social interaction

Communication

• Language - rule-based system of symbolic communication involving a set of small units

• Speech - oral production & articulation of words

• Form: phonology morphology syntax

• Content: semantics• Function: pragmatic

• Articulation• Fluency • Voice

Language Speech

• Improper use of words and their meanings

• Inability to express ideas

• Inappropriate grammatical patterns

• Reduced vocabulary• Inability to follow

directions

• Dysfluency• Articulation or

phonological disorders

• Difficulties with the pitch, volume or quality of the voice

Language disorders Speech disorders

Major types of communication disorders

• Language disorders (60%)– general language delay (MR, autism, DD)– specific language impairment

(expressive, receptive + expressive)

• Speech disorders (40%)• Hearing disorders

Epidemiology of communication disorders

• The most common developmental problem in young children (25-50%)

• The disorder is 3-4 times more common in boys than in girls

Early identification and early intervention are important

Language variations

Familiar setting during examination !

• Cultural background• Bilingualism• Maturation delay - Late talkers

Bilingualism • A temporary delay in the onset of

both languages • Comprehension of the two languages

is normal • The child usually becomes proficient

in both languages before 5 years

Children cannot have a communication disorder in one language alone

Causes of language disorders• Hearing loss• Mental retardation• Autism /PDD• Acquired brain damage

(left hemisphere)

• Expressive language disorder• Receptive aphasia

Specific language impairment

• Seizures• CP• Elective mutism• Psychosocial deprivation

Hearing Loss• The most frequently overlooked

disorder affecting speech development

• Common causes: recurring middle ear infections, congenital malformations, meningitis, trauma, genetic disorders

• Diagnosis - behavioral or physiologic audiometry

Hearing Loss

• Suspect hearing loss when a child does not seem to understand; is inattentive; looks intently at others who are speaking; or better recognizes sounds with more lip movement, such as the letter W.

Developmental Delay

• Speech delay caused by late maturation can be mild, moderate, severe, or very severe, depending on the level of impairment of word sounds, spoken language, and language comprehension.

Mental Retardation

• Over half of all mentally retarded children are speech delayed

• Speech development is relatively more delayed in MR children than are other fields of development

Generalized delay suggestsmental retardation as the cause

of a child's speech delay

Mental retardation

• Don't overlook common coexisting contributors such as: deafness, dysarthria, or sensory deprivation

• Global language delay, delayed auditory comprehension and delayed use of gestures

Pervasive Developmental DisordersDSM-IV

• Autistic disorder• PDD-NOS (Pervasive developmental

disorder-not otherwise specified)• Asperger’s disorder• Rett’s syndrome• Childhood disintegrative disorder

(Heller’s syndrome)

Autism

• Onset before 36 months (18-30 mo.)• Prevalence 1-2:1000 • Autism is more common in boys (3-4:1) • Recurrence risk in families 3-8%• Biologic cause in 10-30%: genetic

syndromes, congenital infections, HIE, neurocutaneus, metabolic, epileptic

Autism• Onset occurs before 36 months• Autistic children fail to make eye

contact, smile socially, respond to being hugged or use gestures to communicate

• Ritualistic and compulsive behaviors, including stereotyped repetitive motor activity

• Autism is three to four times more common in boys than in girls

Autism-clinical

• Impairment in social interaction• Impairment in language &

communication• Restricted, repetitive & stereotyped

pattern of behavior, interest & activities

Autism & language

• About half of autistic children don't develop useful speech by age 5 and have a poor prognosis

• Speech abnormalities: echolalia, perseveration, pronoun confusion, abnormalities of prosody, semantic pragmatic disorder

Cerebral Palsy• Delay in speech is common in CP• Speech delay occurs most often in

athetoid type of CP• Factors that may account for the

speech delay: hearing loss, spasticity or incoordination of the muscles of the tongue, coexisting MR or a defect in the cerebral cortex

Left Cerebral Lesion• If acquired before 6 years, left-brain

lesions shift the language center to the right hemisphere

• May cause speech delay and "pathologic" left-handedness (too early or without a family history of left-handedness)

• Aphasia, the loss of previously acquired speech, is almost always traced to a left cerebral lesion

Seizures• When these begin in the

first decade, they can cause delayed speech or aphasia and can result in verbal auditory agnosia (word deafness)

Elective mutism• These children are negativistic, shy,

timid and withdrawn • Symptoms of poor adjustment, such as

poor peer relationships or overdependence on their parents

• Anxiety, attention seeking, or embarrassment about a speech deficit

• Usually family psychopathology• Can persist for months or years

Psychosocial Factors

• Speech development can be slower in:– twins– younger siblings– children in lower socioeconomic classes– children of deaf-mute parents– children exposed to more than one

language.

Language regression

• Autistic regression• Landau Kleffner - Aquired epileptic

aphasia• ESES - Electrical status epilepticus in

sleep • Disintegrative disorder

Specific language impairment = Developmental language disorders (DLD)

• 5-10% of preschooler• Difficulties in language acquisition

(without hearing impairment, low intelligence and neurological damage)

• Diagnosis by exclusion• Risk for reading/academic difficulty

& social failure

Developmental language disorders (DLD) - major types

• Phonology-syntactic:– Mixed receptive-expressive (verbal

auditory agnosia)– Expressive only (verbal dyspraxia)

• Higher order processing (semantic-pragmatic):– Autistic spectrum

Receptive Aphasia-word deafness

• A deficit in comprehension of spoken language with normal responses to nonverbal auditory stimuli

• The speech is delayed, sparse, agrammatic and indistinct in articulation

• Most children with gradually acquire a language of their own, understood only by those who are familiar with them

Prognosis

• Expressive delay alone resolve spontaneously in the pre-school period

• A poorer prognosis for children with expressive/receptive delays

• It is not possible to predict at the time of identification, which of the children with expressive delay are likely to have persistent problems

Diagnostic evaluation

• Audiometry with special earphones • Tympanometry• An auditory brain-stem response• Imaging modalities are not indicated• Prolonged sleep EEG is indicated in

language regression (subclinical epileptiform EEG)

All children with speech delay should be referred for audiometry

Diagnostic evaluation• Additional tests should be ordered only when

they are indicated • A karyotype for chromosomal abnormalities

and a DNA test in children who have the phenotypic appearance of fragile X synd.

• An EEG should be considered in children with seizures or with significant receptive language disabilities or language regression (subclinical seizure activities)

Developmental language disorders -etiology

• Genetic !• Twin studies (96% concordance in

MZ, 69% in DZ)• Linkage to chromosome 7q31• FOXP2 gene (Nature 413:4 oct,2001)