Bauer Speech Delay

8/13/2019 Bauer Speech Delay

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Speech and Language Delay

Competency: The resident should:

1. Understand the key developmental milestones for speech and language2. Know the indications for further evaluation of speech and language delay3.

Generate a differential diagnosis for speech and language delay4. Be able to explain the components of evaluation and management options forspeech and language delay

5. Provide a medical home for children with speech and language delay and be ableto manage the comorbid issues of attention and learning

Case: A five-year-old boy presents to clinic for the first time, and his mother is concerned abouthis speech development. According to his mother, he is not saying as many words as his brother

did at his age. In addition, his teachers are concerned he is difficult to understand.

Questions:

1.

What are the key developmental milestones for speech and language?2. What are the key aspects of the history for children who present with speechand language delay? What are the key aspects of the physical exam for

children who present with speech and language delay? What are some of the

key developmental observations that you can do during a brief office visit?

3. What is the epidemiology of speech and language delay, and what is itssignificance?

4. What are the etiologies of speech delay?5. What is the diagnostic evaluation of speech delay?6. What are the appropriate interventions for children with speech delay?

References:

American Academy of Pediatrics, Committee on Children with Disabilities. The

pediatricians role in the diagnosis and management of autistic spectrum disorder

in children. Pediatrics.2001;107:1221-26.Carter J, Musher K. Etiology of speech and language impairment in children.

UpToDate. 19 Apr 2005.

Carter J, Musher K. Evaluation and treatment of speech and language impairment inchildren. UpToDate. 27 Apr 2005.

Feldman HM. Evaluation and management of language and speech disorders in

preschool children. Pediatr Rev. 2005;26:131-41.Kripke C. Therapy for speech and language delay. Am Fam Phys. 2004;69:2823-24.

Law J, Boyle J, Harris F, et al. Prevalence and natural history of primary speech and

language delay: findings from a systematic review of the literature. Int J LangComm Dis. 2000;35:165-88.

Leung AKC, Kao CP. Evaluation and management of the child with speech delay. Am

Fam Phys. 1999;59:3121-27.

Rossman MJ, Hyman SL, Rorabaugh ML, et al. The CAT/CLAMS assessment for earlyIntervention services: clinical adaptive test/clinical linguistic and auditory milestone

Scale. Clin Pediatr. 1994;33:404-09


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Competency:

The resident should:

6. Understand the key developmental milestones for speech and language7. Know the indications for further evaluation of speech and language delay8.

Generate a differential diagnosis for speech and language delay9. Be able to explain the components of evaluation and management options forspeech and language delay

10. Provide a medical home for children with speech and language delay and be ableto manage the comorbid issues of attention and learning

Case: A five-year-old boy presents to clinic for the first time, and his mother is concerned abouthis speech development. According to his mother, he is not saying as many words as his brother

did at his age. In addition, his teachers are concerned he is difficult to understand.

Background: Speech development requires a favorable environment including adequate

language exposure and stimulation, reinforcement of communication attempts, and realisticexpectations for speech according to childrens developmental stages. In order to speak and

understand language, individuals must possess hearing sensitivity, perception, interactivecaregivers, nonverbal developmental competencies, structural integrity, oral-motor skill, and

emotional stability. Speech and language delay occurs when a compromise in any of these

components occurs, and it is the most common developmental concern raised by parents betweenthe ages of 1 and 3 years of age.

Questions:

1. What are the key developmental milestones for speech and language?

The normal receptive (R) and expressive (E) milestones are as follows:

Birth:o changes state and fixes on faces (R)o cries (E)

2 months:o alerts to sound, soothes when picked up (R)o smiles (E)

3 months: coos (E) 4 months:

o turns to voice (R)o

laughs aloud (E) 5 months: ah goo, razzes (E) 6 months:

o responds to name (R)o babble (E)

9 months:o waves bye-bye, pauses briefly to no (R)


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o uses gesture language, points and says ma-ma, da-da (E) 12 months:

o follows a verbal command with gesture (R)o uses immature jargon and says first words (E)

15 months:o points to body parts (R)o uses 3 words that are not peoples names (E)

18 months:o understands sentences, points to one picture (R)o uses 7-10 words, uses mature jargon (E)

21 months:o points to 2 pictures (R)o uses 20 words, uses two-word phrases (mommy more, daddy juice) (E)

24 months:o follows two-step commands (give me the spoon and take the cup to the

sink) and answers questions (R)

o 50 words, asks what, two-word sentences (E) 36-48 months:

o names one color and understands much of what is said (R)o counts to 3, 75% intelligible, asks why, masters early speech sounds of m,

b, y, n, w, d, p, h (E)

48-60 months:o speech is understood at cognitive level (R)o sings Happy Birthday, 100% intelligible, tells stories, creates sentences,

prints name (E)

6 years: pronounces most speech sounds correctly, may have difficulty with sh, th s,z, l, r, and s; know how to read cat and dog (E)

7 years: pronounces speech sounds correctly, including sp, tr, and bl (E)

2. What are the key aspects of the history and physical examination for children who

present with speech delay?

The key aspects of the history involve addressing the caregivers concerns, a thoroughdevelopmental history, birth history, and maternal history. In particular, the following

statements should arouse concern: no babbling by 12 months; not comprehending simplecommands by 15 months; no words by 2 years of age; not making sentences and mostly

unintelligible by 3 years of age; and difficulty telling a simple story by 4-5 years of age.Significant maternal history includes history of perinatal trauma, infection, asphyxia, gestational

age at birth, birth weight, ototoxic drugs, psychosocial history, languages spoken by the child,and family history of speech delay or major illness. As our mentors have reiterated to us, two

reasons exist for referring to a developmentalist: caregivers are concerned or clinicians are

concerned.


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Key aspects of the physical examination include height, weight, and head circumference. In

addition, a thorough neurological exam including vision and hearing should be performed. Acomprehensive developmental assessment is crucial, for speech delay is the most common

manifestation of global delay. For infants and young children, the Denver Developmental

Screening Test and the Ages and Stages Questionnaire are appropriate initial evaluations. The

strength of the Denver is its toy kit. The strength of the Ages and Stages Questionnaire is that itis representative of diverse US norms. If the results are abnormal, the child needs more

definitive testing such as the Bayley Scales of Infant Development 2; the Capute Scale

(CAT/CLAMS); and the Wechsler Preschool and Primary Scale of Intelligence 2(WPPSI2) orthe Stanford Binet 5

thEdition.

3. What is the epidemiology of speech delay, and what is its significance?

Speech delay is the most common developmental concern voiced by parents of children between

the ages of 1 and 3 years of age. It occurs in 3 to 10 percent of children, and it is 3-4 times more

common in boys than girls. It is important to note parents of children later diagnosed with

autism initially express concerns about speech delays and unusual behaviors. In school-agechildren with no other neurological or developmental concerns, the prevalence of speech

disorders is 3 to 6 percent.

Children learn language when they are young and later use language to learn. Speech disorders

increase the risk of difficulty with reading as well as written language, and these challengespersist throughout adolescence and adulthood. Thus, early intervention in speech delay is

essential to minimizing the risk of later learning disorders.

4. What are the etiologies of speech delay?

Hearing loss

Pervasive developmental disorders Global developmental delay Specific language impairment Mental retardation Developmental language disorders Epileptic aphasia syndrome Developmental expressive aphasia Psychosocial deprivation Elective mutism Cerebral palsy

5. What is the diagnostic evaluation of speech delay?

The following questions should be answered in a speech evaluation:

Does impairment in communication exist in receptive, expressive, nonverbal, andplay skills?

What is the nature of the impairment? What intervention should be initiated?


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All children presenting with speech delay should have a full audiologic assessment. Auditorybrainstem response (ABR) is a quantitative physiologic means of ruling out peripheral hearing

loss, and it is useful for infants and uncooperative children. A comprehensive developmental

assessment should be performed on all children with speech delay. Furthermore, an assessment

of the home environment tailored to the individual family should evaluate for the quality ofstimulation at home as well as the quality of caregiver-child interaction. If deemed necessary,

additional tests include a karyotype for chromosomal abnormalities and molecular Fragile X. If

concern exists regarding regression, and EEG and neuroimaging (CT/MRI) are indicated. Forexample, some children with language difficulties have subclinical seizure activity in the

temporal lobes and have an EEG pattern that is called Landau-Kleffner syndrome.

6. What are the appropriate interventions for children with speech delay?

Clinicians should conceptualize speech delay as a chronic special health care condition in order

to appropriately provide a medical home for these children. In particular, referral to medical

specialists and intervention services should be made as soon as possible. Two importantperspectives exist. No child is ever too young to be tested by a pediatric audiologist, even

children who are not yet saying words. No child who is talking as a toddler or preschooler is toolow for speech therapy so as to have a communication strategy such as signs, pictures, and

augmentive devices. The primary goal of therapy is to teach children strategies for

comprehending spoken language as well as to produce appropriate communicative behavior. Forchildren with hearing loss, management possibilities include hearing aids, auditory training, and

lip-reading instruction. Children with elective mutism may benefit from considerations of

combined medications and behavioral management. Parents and caregivers should learn toadjust to the speech level of children, to provide a stimulating environment for the acquisition of

speech, including prelinguistic interventions and increasing parent responsivity. One of themajor tools for home activities is the Hanen Early Language Program (www.hanen.org). Both

Early Intervention, Head Start, and preschools can provide group learning activities as well as

input from a speech therapist. It is better to receive quality early childhood educational

experiences than to wait for speech to catch up by receiving two or more weekly outpatienttherapy interventions. Teachers should be aware that children with speech delay may benefit

from small-group instruction, music, and social communication activities. As part of the medical

home, physicians coordinate services and facilitate communications among the specialists caringfor the children, including emotional support. Children with language disorders require long-

term care, for they have an increased risk of language-based learning disorders (reading, spelling,

writing stories or book reports), attentional, and behavioral disorders as well as educationalunderachievement and extracurricular participation restrictions.
http://www.hanen.org/http://www.hanen.org/


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References:

American Academy of Pediatrics, Committee on Children with Disabilities. The

pediatricians role in the diagnosis and management of autistic spectrum disorder

in children. Pediatrics.2001;107:1221-26.Carter J, Musher K. Etiology of speech and language impairment in children.

UpToDate. 19 Apr 2005.

Carter J, Musher K. Evaluation and treatment of speech and language impairment inchildren. UpToDate. 27 Apr 2005.

Feldman HM. Evaluation and management of language and speech disorders in

preschool children. Pediatr Rev. 2005;26:131-41.Kripke C. Therapy for speech and language delay. Am Fam Phys. 2004;69:2823-24.

Law J, Boyle J, Harris F, et al. Prevalence and natural history of primary speech and

language delay: findings from a systematic review of the literature. Int J LangComm Dis. 2000;35:165-88.

Leung AKC, Kao CP. Evaluation and management of the child with speech delay. AmFam Phys. 1999;59:3121-27.

Rossman MJ, Hyman SL, Rorabaugh ML, et al. The CAT/CLAMS assessment for earlyIntervention services: clinical adaptive test/clinical linguistic and auditory milestone

Scale. Clin Pediatr. 1994;33:404-09.

Author: Sarah Bauer M.D.

Reviewer: Michael Msall M.D.

Bauer Speech Delay

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