All of the following are suggestions for effectively practicing your speech except_______.

Medscape J Med. 2008; 10(6): 136.

Published online 2008 Jun 11.

Abstract and Introduction

Abstract

Speech-language problems are the most common disability of childhood yet they are the least well detected, particularly in primary care settings. The goal of this article is to: (1) define the nature of speech-language problems, their causes, and consequences; (2) facilitate early recognition by healthcare providers via accurate screening and surveillance measures suitable for busy clinics; and (3) describe the referral and intervention process.

Introduction

Speech-language deficits are the most common of childhood disabilities and affect about 1 in 12 children or 5% to 8% of preschool children.[1] The consequences of untreated speech-language problems are significant and lead to behavioral challenges, mental health problems, reading difficulties,[2] and academic failure including in-grade retention and high school dropout.[3] Yet, such problems are ones that are least well detected in primary care,[4] even though intervention is available and plentiful.

Speech-language impairments embrace a wide range of conditions that have, at their core, challenges in effective communication. As the term implies, they include speech disorders which refer to impairment in the articulation of speech sounds, fluency, and voice as well as language disorders which refer to impairments in the use of the spoken (or signed or written) system and may involve the form of language (grammar and phonology), the content of language (semantics), and the function of language (pragmatics).[5] These may also be described more generally as communication disorders which are typically classified by their impact on a child's receptive skills (ie, the ability to understand what is said or to decode, integrate, and organize what is heard) and expressive skills (ie, the ability to articulate sounds, use appropriate rate and rhythm during speech, exhibit appropriate vocal tone and resonance, and use sounds, words, and sentences in meaningful contexts). There are common conditions in infants, toddlers, and preschoolers that are associated with receptive and expressive communication challenges as presented in Table 1.[6–17]

Table 1

Disorders in Young Children Commonly Associated With Receptive and Expressive Communication Problems

It is important to distinguish speech and language impairment from language delay and language difference. Language delay is characterized by the emergence of language that is relatively late albeit typical in its pattern of development. In contrast to an impairment or a delay, a language difference is associated with systematic variation in vocabulary, grammar, or sound structures. Such variation is “used by a group of individuals [and] reflects and is determined by shared regional, social, or cultural and ethnic factors” and is not considered a disorder.[18]

Unfortunately, non-native speakers of English, speakers of various dialects (whose language also varies within dialect), and bilingual or multilingual speakers are frequently classified as language delayed or disordered when, in fact, they are language different[18,19]–although problems of underidentification also occur. This is particularly important in an increasingly pluralistic society such as ours in which 1 of 4 people identify as other than white non-Hispanic, approximately 17% of the population is bilingual (mostly speaking Spanish and English), and where minorities represent more than 50% of the population in several cities and counties.[20]

The overidentification of culturally and linguistically diverse populations commonly occurs when a mismatch is observed and incorrectly interpreted between a language used in a particular community and that of the majority culture. This may be seen most clearly in the improper use of formal tests of speech and language to assess the competencies of speakers who are dissimilar to the sample upon which the test was normed and developed.[21] Similar errors also occur during informal evaluations of language and literacy as when the sound structure of the language influences the spelling or grammatical conventions used in written discourse.[22] With regard to bilingualism, it is commonly assumed that children's acquisition of 1 or both languages is delayed; however, the effects of bilingualism are more complex and differ with the age of the child, the nature of the linguistic input, and the manner and timing of language acquisition. What is clear is that equivalent proficiency in each language should not be expected or assumed as this has the potential to lead to misidentification of a speech and language impairment. (For more information on the effects of bilingualism on language learning, see http://asha.org/public/speech/development/BilingualChildren.htm and http://asha.org/public/speech/development/second.htm) In the case of culturally and linguistically diverse individuals, decisions to intervene and bring language use in line with that of the majority culture or promote proficiency in the dominant language are not inappropriate; however, such decisions must be seen as separate from the language difference vs disorder question.

• In your experience, which of the following is the most important barrier to the effective assessment of speech and language impairment in young children? (Select only 1 answer.)

  • ○

    Variability in the development of speech and language in young children

  • ○

    Lack of effective screening tools that discriminate children with and without speech and language impairment

  • ○

    Lack of accurate parent interview tools that identify clear concerns in speech and language development

  • ○

    Insufficient time with young children in the clinical setting to observe speech and language skills

  • ○

    Inadequate understanding of milestones for speech and language development

• How confident are you that you are up-to-date in the diagnosis and management of speech and language impairment in young children? (Select only 1 answer.)

  • ○

    Not at all confident

  • ○

    Somewhat confident

  • ○

    Confident

  • ○

    Very confident

All of the following statements about young children with speech and language impairment are true except:

• ○

  Young children tend to produce words with sounds that are consistent with the words they already know

• ○

  Young children are able to communicate intent before speaking their first words

• ○

  Disfluency is a common occurrence in a young child's early speech

• ○

  Children usually begin to put 2 words together at 30 months

Answer: Children usually begin to put 2 words together at 30 months. Children usually begin to put 2 words together at 18 months.

Etiology, Neurobiology, and Prevalence of Speech-Language Impairments

The etiology of most cases of speech-language impairments is unknown but diverse causes are suspected. The range of causes or origins includes anatomical abnormalities, cognitive deficits, faulty learning, genetic differences, hearing impairments, neurologic impairments, or physiologic abnormalities.[6] As noted above, language differences as revealed in the communication output associated with diverse cultural, ethnic, regional or social dialects are not considered disorders.[5] Speech and language impairments may be acquired (ie, result from illness, injury or environmental factors) or congenital (ie, present at birth).

Children with speech and language impairment are an under-representation of the broader occurrence of communication disorders,[23] especially considering the co-occurrence of communication disorders with other disabilities (eg, learning disabilities). Approximately 8% to 12% of preschool populations exhibit language impairments.[6] Among children enrolled in early intervention programs, 46% have communication impairments while 26% have developmental delays in multiple areas, usually including language skills.[24] These findings indicate that the most common presentation of disability in preschoolers involves problems with language.

In a family with a child with a speech and language impairment, which of the following would be clinically appropriate?

• ○

  Reassure the parents that the child is just a late talker and will catch up

• ○

  Urge the parents to have their child undergo genetic testing

• ○

  Discourage the child's parents and sibling(s) from talking for the child as this may be a primary cause of a speech and language impairment

• ○

  Advise the parent to have the child's hearing tested

Answer: Advise the parent to have the child's hearing tested. This is appropriate because hearing would be the first condition to rule out as a potential cause of a speech and language delay.

Course and Prognosis

Speech-language impairment sometimes emerges during infancy with challenges in response to sound, atypical birth cries, or limited response to others and progresses through the toddler and preschool age with limited comprehension of spoken language and difficult interactions with peers and others as well as delays in producing first words and word combinations. Speech and language difficulties often persist in school age with difficulties following directions, attending and comprehending oral and written language, and problems producing narratives and using language appropriately in social contexts. Parents are often the first to notice difficulties as they encounter other children with more advanced speech-language skills and thus often wonder if their child is behind.[25] Although many parents raise concerns to primary care providers, many do not. In turn, primary care providers who do not use quality screening tools often dismiss parental concerns with panaceas such as, “He's a boy. Boys talk later.” Or, “Let's give this some time and see if it continues.” Yet, parental concerns about speech and language are associated with developmental disabilities[26] and, thus, careful screening with accurate tools is the requisite response.[27]

The use of a “wait and see” approach underscores the difficulty in distinguishing children who are language delayed from those who have a speech and language impairment. Although most children who have aspeech and language impairment have a history of language delay, only one quarter to one half of late-talkers are eventually diagnosed with a language disorder.[19] In advocating for a more aggressive response for late-talking children, some have argued for careful scrutiny of other risk factors that may guide decisions to refer and intervene.[19] Predictors of a true speech and language impairment that should be considered include poor receptive language skills,[28] limited expressive language skills (eg, small vocabulary, few verbs), and limited development in the sound structure of a language (eg, limited number of consonants, limited variety in babbling structure, vowel errors).[26] Additional predictors include nonspeech (eg, behavioral problems, few gestures, little imitation or symbolic play), environmental (eg, low socioeconomic status, parental use of a directive rather than sensitive and responsive interactional style), and hereditary factors (eg, family history).[26] As a general recommendation, professionals are urged to consider a larger number of risk factors with greater concern.[26]

Often speech-language impairments can be difficult to distinguish from what is considered typical variations in speech and language. For example, disfluencies in speech may be either normal or abnormal. In the nonstuttering child, the most common disfluencies include 1-unit word repetitions (eg, “I… I want that”), interjections (eg, “I saw a… um… picture”), and revisions (eg, “I don't know where… Mommy, help me find my doll”) and, when combined, comprise no more than 10% of words spoken.[29] In the stuttering child, the fluency disorder typically emerges between the ages of 2 and 5 years, is more common among males than females, and is characterized by more than 10% disfluencies in speech, multi-unit syllable (eg, “s-s-s-s-s-September”) and word (eg, “That's my-my-my ball”) repetitions, and may be accompanied by secondary behaviors such as eye-blinking, head-bobbing, or grimacing, as well as feelings of frustration or embarrassment surrounding the stuttering event.[29]

Identification of speech and language impairments is further complicated by the fact that they often masquerade as other diagnostic conditions. For example, children with a diagnosis of attention-deficit/hyperactivity disorder (ADHD) may in fact have an underlying language disorder. Differential diagnosis is challenged by the diagnostic criteria shared between the 2 conditions. Specifically, the diagnostic criteria for ADHD share several characteristics with language disorders including difficulty listening when spoken to, following instructions, talking excessively, blurting out answers, interrupting, and waiting for turns in conversation.[30] Similarly, 50% of preschoolers presenting for psychiatric services were found in several studies to have undiagnosed language impairment.[31,32]

The diagnostic criteria for speech-language impairments are defined both by the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV)[33,34] and by the Individuals with Disabilities Education Act (IDEA) through the US Department of Education. Table 2 specifies the criteria for communication disorders as described in the DSM-IV. As an example of eligibility criteria for speech-language impairment in response to IDEA guidelines, Vermont indicates that children must demonstrate significant deficits greater than 2 standard deviations below the mean in listening comprehension (eg, measures of auditory (language) processing or comprehension of connected speech including semantics, syntax, phonology, recalling information, following directions and pragmatics) and/or oral expression (eg, measures of oral discourse-syntax, semantics, phonology and pragmatics; voice; fluency; articulation) to qualify as speech or language impaired.[35]

Table 2

Characteristics of Communication Disorders as Described in the DSM-IV[33,34]

Distinguishing children with speech-language deficits from those with other disabilities is often a challenging task as several disabilities share characteristics and have similar diagnostic criteria. For example, an intellectual disability is one in which a child's performance falls at or below 1.5 standard deviations from the mean on a test of intellectual ability with concurrent deficits in adaptive behavior. Children with intellectual disabilities, however, often have significant challenges in receptive and expressive communication as is typical of children with speech and language impairments. Children with learning disabilities have deficits in 1 or more basic skill areas including oral expression and listening comprehension, challenges characteristic of children with speech-language impairments. Children with pervasive developmental disorders/autism exhibit marked impairments in communication and social interaction and restricted and repetitive stereotyped patterns of behavior. Although social impairment is a defining feature of autism, communication impairments are similar to those with a speech-language impairment.

Which of the following is not true of speech-language impairment?

• ○

  Early intervention is critical as speech-language impairments place children at risk for later academic difficulties

• ○

  Most children with speech-language impairments have intellectual deficits

• ○

  Communication disorders may manifest themselves at different stages of life

• ○

  Children with learning disabilities are likely to have speech and language impairments

Answer: Most children with speech-language impairments have intellectual deficits. Although many children who have mental retardation have speech-language impairments, most children with specific speech-language impairments have nonverbal intelligence within normal limits.

Screening and Early Assessment of Speech-Language Disorders

The American Academy of Pediatrics recommends ongoing surveillance and periodic use of broad-band screening measures at all well-visits. Table 3 provides information on a number of tools that have high levels of accuracy in detecting speech-language problems and other disabilities. All included measures were standardized on national samples, proven to be reliable, and validated against a range of measures. When used, referral rates to early intervention programs rise to meet prevalence.[36] In the absence of accurate measures, most providers rely on informal milestone checklists. These lack criteria and are probably the leading reason why only about 1 in 4 children with disabilities of any kind are referred for needed assistance.

Table 3

Accurate Developmental, Mental Health/Behavioral, and Academic Screens Suitable for Primary Care*

The first column in Table 3 provides publication information and the cost of purchasing a specimen set. The “Description” column provides information on alternative ways, if available, to administer measures (eg, waiting rooms). The “Accuracy” column shows the percentage of patients with and without problems identified correctly. The “Time Frame/Costs” column shows the costs of materials per visit along with the costs of professional time (using an average salary of $50 per hour) needed to administer and interpret each measure. Time/cost estimates do not include expenses associated with referring. For parent report tools, administration time reflects not only scoring of test results, but also the relationship between each test's reading level and the percentage of parents with less than a high school education (who may or may not be able to complete measures in waiting rooms due to literacy problems and will need interview administrations).

Even when screens are deployed, it is nevertheless helpful to complement these brief measures with clinical observation. The brevity of screens useful for primary care means that some skills may not be captured. For example, at any given age range, a brief screen may not present articulation items, measure ability to repeat a story, describe daily events, ask questions, or engage in conversation, etc. The value in routinely administering validated, accurate screening tools, however, is essential to improving currently problematic and extremely low rates of early detection on the part of primary healthcare providers.

Table 4 describes some major language developmental milestones in the prelinguistic (birth to 1 year) and linguistic period (1 year and beyond).[37,38] It is important to note that there are wide variations in the speed (and style) with which typically developing children acquire language skills.

Table 4

Average Age and Range of Ages for Achievement for Important Language Developmental Milestones*[37,38]

Providers are reminded that these indicators are an aid to early detection but do not substitute for quality measurement. See Table 3 for a list of screening measures with proven accuracy.

Screening for Other Potential Contributors to Speech-Language Deficits

Another critical avenue for exploration into possible contributors to speech-language deficits is psychosocial risk. Parents who are depressed and/or have housing or food instability have children more likely to have language problems, perhaps because parents lack the energy and freedom from preoccupations to engage in the kinds of language-mediated social interactions known to support optimal child language development. Some parents are not aware of positive parenting practices that promote development, especially language skills (eg, talking with and reading to their child, creating opportunities for sustained dialogue, responding contingently to a child's initiations). Detecting and intervening when psychosocial risk factors, including abuse and neglect, are present has the potential to prevent language problems from developing. Screens for psychosocial risk factors including depression and parent-child interactions are widely available and include the Family Psychosocial Screen and the Brigance Parent-Child Interactions Scale. Both are included in PEDS: Developmental Milestones[39] as supplementary measures helpful for surveillance and offer evidence-based compliance with recommendations in early detection from the American Academy of Pediatrics.[40], Many other screens, such as the Ages and Stages Questionnaire, include a background information questionnaire that captures common psychosocial risk factors.[41]

Screening Older Children

With school-age children, obtaining and reviewing group achievement test scores can help reveal undiagnosed language deficits. Such children typically have weaknesses in general information (eg, science, social studies knowledge), problems with reading comprehension, and sometimes also problems with math concepts. Table 3 also includes screens suitable for primary care professionals working with children aged 8 years and older.

For both preschoolers and school-age children, broad-band screens (or review of group achievement test results) should be deployed first and serve as a guide to the selection of narrow-band instruments. For example, attentional deficits can be due to a range of conditions such as language impairment, learning disabilities, and mental health problems such as depression. The optimal approach is to administer a broad developmental or academic screen along with a measure such as the Pediatric Symptom Checklist (which discriminates mental health from attentional difficulties). Only afterward and as suggested by the results of broad-band measures should a narrowly focused tool such as the Vanderbilt ADHD Diagnostic Rating Scale be administered. Making sure that other conditions are treated first or at least concomitantly with ADHD is essential.

Billing and Coding for Screening

Primary care providers can use the – 25 modifier to their preventive service code (to indicate that stand-alone services were offered and then use 96110 times the number of screens administered, eg, 96110 X 2. For insurers not accepting units, the distinct procedural service of each screen is best represented with the – 59 modifier appended to each additional unit of 96110.

In 2005, the Centers for Medicare and Medicaid Services published a total relative value unit (RVU) of 0.36 for 96110, which amounts to a Medicare payment of $13.64. None of this can guarantee that a valid claim will be accepted, so the American Academy of Pediatrics is willing to help with denied claims via their Coding Hotline: 800-433-9016, x4022, or at .gro.paa@eniltohgnidocpaa RVUs do not cover physician time, so making use of office staff and parent-report tools is essential.

Referrals and Other Interventions

Once suspicion exists that a child may have a speech-language impairment, referral to early intervention or to the public schools (depending on age) is the first step. These programs offer intervention by speech-language pathologists. If sufficient quantity is not available, referrals can also be made to private therapy services, which may be covered by the patients' insurance. If there appear to be underlying medical conditions, assessment by other disciplines, such as developmental-behavioral or neurodevelopmental pediatrics, is important.

For families with psychosocial risk factors, developmental promotion is essential as is careful monitoring of progress. If brief advice and information handouts are not effective and particularly if children have delays not sufficiently great as to qualify for services, then parent training, quality day care, Head Start, after-school tutoring, and private speech-language therapy should be recommended. Table 5 shows a list of professional development and referral resources. Table 6 provides a list of resources and information for parents.

Table 5

Professional Development and Referral Resources

Table 6

Resources and Information for Parents

Components of a Diagnostic Evaluation of Speech-Language Impairment and the Nature of Interventions

Although screening tools for speech-language often identify those children who have speech-language impairments, a screening is not a diagnostic evaluation and only suggests a child requires a more comprehensive assessment. There are several goals in a diagnostic assessment, including verifying that a speech-language impairment exists, describing the strengths and challenges of the child's speech and language, evaluating the severity of the problem, ascertaining the etiology, determining recommendations for a treatment plan, and providing a prognosis.[6] Assessment requires obtaining a sample of communication skills across settings through a number of procedures. It is critical to collect information not only from standardized, formal tools but also to gather more authentic, real-life information to facilitate meaningful and accurate decisions. Typically, case history information, parent interviews, checklists from other providers, systematic observation, hearing screening, and examination of the speech mechanism is included.[6] Formal norm-referenced tests are used to assess articulation, phonology, grammatical understanding and production, and pragmatic language use. The collection of data from the authentic assessment tools and the formal measures provide a comprehensive picture of the speech-language needs of a young child with a communication impairment.

All of the following are true in the assessment of a young child with speech-language impairments except:

• ○

  Obtaining information from multiple sources across settings is necessary to specify communication strengths and challenges

• ○

  Speech-language pathologists (SLPs) make diagnoses of specific speech-language impairment, identify probable causes, determine severity, describe the likely prognosis, and provide recommendations

• ○

  Clinical judgment is most appropriate for determining the severity of a child's speech-language impairment

• ○

  During assessment, speech, language, hearing, and processing abilities should be probed

Answer: Clinical judgment is most appropriate for determining the severity of a child's speech-language impairment. Objective criteria are important to ensure consistency in the assessment of severity.

To determine the prognosis for a young child with a speech-language impairment, which of the following is true?

• ○

  A clinician should avoid providing prognostic information, as questions like “Will my son outgrow his speech-language impairment?” cannot be answered

• ○

  Trial therapy during an assessment period is an appropriate strategy to inform prognosis

• ○

  Families and clinicians have little difficulty making decisions about whether or not a young child with early expressive language delay will benefit from therapy

• ○

  Single evaluation measures can be used to determine the severity of a young child's speech-language impairment and the prognosis for successful outcomes

Answer: Trial therapy during an assessment period is an appropriate strategy to inform prognosis. Clinicians often probe a child's response to intervention strategies to determine responsiveness to treatment and to inform the development of the treatment plan.

Intervention Approaches and Outcomes

The complexity of impairments in speech and language requires a variety of intervention approaches that can address deficits in language form (syntax, phonology, morphology), language content (semantics), and language use (pragmatics) as well as speech and voice production. Further, intervention for young children may involve not just the speech-language pathologist but also care providers and peers.

The ultimate goal of intervention is to increase a child's success in using language to communicate his or her intent, respond to the intent of others, and participate in reciprocal interactions. The speech and language targets vary for each child depending on the context and aspects of communication affected. Targets may or may not follow a strict developmental approach. Sometimes a more functional approach is appropriate, supporting communication at the point of frustration and breakdown.[6] Intervention targets should consider the family's desired outcomes for their child's communication. Targets should be developmentally appropriate and meaningful to the child.

Several teaching methods are used to support the speech and language of children. Modeling is a typical intervention strategy that provides focused stimulation on the speech or language targets selected for an individual child. Cueing is another frequently used technique that includes direct and indirect verbal cues (eg, asking a child to imitate a sound, word, or utterance) or nonverbal cues (eg, giving a child a jar with a desired item that can't be opened without help). In addition, responding to a child's communication efforts through reinforcement or corrective feedback (eg, “Remember to say the ending sound /t/ so we know you mean the word ‘boat’”) is frequently used to facilitate effective communication.[6]

Case Studies

Case 1

Bobby [pseudonym] is a 7-year-old boy whom you have seen in your office for a number of years. He comes to you today for his annual check-up. Bobby is enrolled in the second grade. His mother is concerned because Bobby's teachers have noted difficulties in his ability to learn to read. Specifically, Bobby's teachers say that he has difficulties with word recognition and reading comprehension. Bobby's mother indicates that this is consistent with her own observations that he seems to have trouble with understanding what is being said (eg, directions, questions) and storytelling. Moreover, she suspects that Bobby's vocabulary is less well developed compared with his peers. She also describes frequent errors in how he formulates sentences such as omitting possessives (eg, “Sam dog” instead of “Sam's dog”) and verbs (eg, “He cooking” instead of “He is cooking”) that she fears are atypical. Bobby's nonverbal IQ is in the typical range.

The difficulties described above are most consistent with a possible diagnosis of:

• ○

  Autism spectrum disorder

• ○

  Intellectual disability

• ○

  Specific language impairment

• ○

  Language delay

Answer: Specific language impairment.

Case Studies

Case 2

Darius [pseudonym] is a 5-year-old African American boy whom you are meeting today for the first time. He and his mother have recently moved to your area and she has brought him to you because he seems to be developing a nasty cough. When talking with Darius, you notice that he is extremely difficult to understand. Darius is a speaker of African American English; however, even with young speakers of this dialect, you have never had such difficulty understanding and communicating effectively. You learn that he and his parents have just moved from an impoverished community in South Carolina where he attended an age-appropriate class in a school in which approximately 85% of his classmates were black, to a school district in your area that almost entirely comprises white administrators, staff, and students. His mother further reports that Darius's new teachers have expressed concerns about his language. They say he is hard to understand, has a limited vocabulary, cannot master letter-sound correspondences, and has trouble listening to and understanding others.

Which of the following additional patient characteristics obtained from the mother would increase your suspicion of a diagnosis of speech and language impairment? (Select all that apply.)

• ▪

  Darius's mother reports that he has always talked differently compared with his parents, siblings, and peers

• ▪

  Darius's scores on a test of articulation of standard English are in the 10th percentile

• ▪

  Darius becomes frustrated when you ask him to repeat himself

• ▪

  Even though they are consistent with the sound structure of African American English, errors in Darius's spelling are quite common (eg, he writes "nes" instead of “nest”)

Answer: Darius's mother reports that he has always talked differently compared with his parents, siblings, and peers.

Which of the following additional patient or parent characteristics would increase your suspicion that Darius is exhibiting a language difference as opposed to a speech and language impairment? (Select all that apply.)

• ▪

  Not only do you find Darius difficult to understand, but his mother is equally difficult to understand; both seem to be using a variation of African American English dialect that, although not commonly heard in your area, is characteristic of their native community

• ▪

  Darius's scores on a test of vocabulary standardized on a cross-section of North American native English speakers are in the 35th percentile

• ▪

  Darius's mother has no trouble understanding him

• ▪

  Darius's mother does not share these concerns and considers him competent in all aspects of his language development

Answer: Not only do you find Darius difficult to understand, but his mother is equally difficult to understand; both seem to be using a variation of African American English dialect that, although not commonly heard in your area, is characteristic of their native community. Darius's mother does not share these concerns and considers him competent in all aspects of his language development.

Case Studies

Case 3

You have been Sam's [pseudonym] primary care physician since he was born. He is now 18 months old and comes to you for his annual flu shot. During this visit, his mother expresses concerns about his speech and language development. More specifically, she reports he is “not talking like other kids his age” and uses repeated vocalizations (eg, “eh eh eh eh” while pointing) to communicate. Very recently, Sam has begun to use some words which are often paired with a gesture (eg, “Daddy” while pointing or “up” while raising hands to be picked up). You notice during your visit that Sam is a social and attentive child. He looks at other people and follows their eye gaze to distal objects. He also seems to understand the speech that his mother directs to him and he can easily carry out 2-step commands (eg, “Pick up the cup and sit next to me, please”). Sam's mother is aware of no immediate or extended family members who have ever had a speech or language impairment. Sam has no history of ear infection, and a recent hearing screen indicated hearing in the normal range.

Which of the following additional patient characteristics obtained from the mother would increase your suspicion of a diagnosis of speech and language impairment? (Select all that apply.)

• ▪

  Limited imitation

• ▪

  Limited pretend play

• ▪

  Limited facial expressiveness

• ▪

  Excessive use of nonverbal communicative gestures (eg, reaching, pointing, looking)

Answer: Limited imitation. Limited pretend play.

What should the mother expect with time if her child does not have a speech and language impairment but is rather a late-talker? (Select all that apply.)

• ▪

  The child will begin to engage in unusual repetitive behaviors

• ▪

  The child will steadily albeit slowly add new words and begin to combine them into 2-word utterances

• ▪

  Any new words that the child utters are likely to be distorted and difficult to understand

• ▪

  The child may develop aggressive behaviors to cope with his inability to communicate effectively

Answer: The child will steadily albeit slowly add new words and begin to combine them into 2-word utterances.

Case Studies

Case 4

Theresa [pseudonym] is a 3-year-old female whom you have seen in your office regularly since her birth. She comes to you today for her annual check-up. During her visit, you observe that Theresa is precocious in her language development. Indeed, her mother reports that she has always been a “great talker” and that she began to speak in well-formed utterances at age 18 months. During this visit, you notice a number of disfluencies in Theresa's speech. At one point, she repeats a word 3 times before getting the rest of the sentence out (ie, “I see… see… see a book with a clown”). Theresa's mother states that these kinds of disfluencies began about 1 month ago and, although she characterizes them as relatively infrequent, she has questions about whether this kind of speech is normal.

Which of the following additional patient characteristics obtained from your observation of Theresa would increase your suspicion of a diagnosis of a fluency disorder? (Select all that apply.)

• ▪

  Theresa seems aware of and perturbed by her disfluencies

• ▪

  Theresa sometimes jerks her head when hesitating to utter her next word

• ▪

  Approximately 20% of Theresa's words appear to constitute disfluencies

• ▪

  Theresa produces multi-unit syllable repetitions (eg, “t-t-t-time”)

• ▪

  All of the above

Answer: All of the above.

Footnotes

Contributor Information

Patricia A. Prelock, Department of Communication Sciences, University of Vermont, Burlington, Vermont.

Tiffany Hutchins, Department of Communication Sciences, University of Vermont, Burlington, Vermont.

Frances P. Glascoe, Department of Pediatrics, Vanderbilt University, Nashville, Tennessee.

References

2. Boudreau DM, Hedberg NL. A comparison of early literacy skills in children with specific language impairment and their typically developing peers. Am J Speech-Lang Pathol. 1999;8:249–260. [Google Scholar]

3. Shonkoff JP, Phillips DA. From Neurons to Neighborhoods: The Science of Early Childhood Development. Washington, DC: National Academies Press; 2000. [Google Scholar]

4. Sices L, Feudtner C, McLaughlin J, Drotar D, Williams M. How do primary care physicians identify young children with developmental delays? A national survey. J Dev Behav Pediatr. 2003;24:409–417. [PubMed] [Google Scholar]

5. American Speech-Language Hearing Association. Definitions of communication disorders and variations. ASHA. 1993;35(Suppl 10):40–41. [PubMed] [Google Scholar]

6. Owens RE, Metz DE, Haas A. Introduction to Communication Disorders: A Life Span Perspective. 2nd ed. Boston, Mass: Allyn & Bacon; 2003. [Google Scholar]

7. Lord C. Enhancing communication in adolescents with autism. Topics Lang Dis. 1988;9:72–81. [Google Scholar]

8. Chapman SB, Watkins R, Gustafson C, Moore S, Levin H, Kufera JA. Narrative discourse in children with closed head injury, children with language impairment, and typically developing children. Am J Speech Lang Pathol. 1997;6:66–76. [Google Scholar]

9. Mentis M, Lundgren K. Effects of prenatal exposure to cocaine and associated risk factors on language development. J Speech Hear Res. 1995;38:1303–1318. [PubMed] [Google Scholar]

10. Miller JF, Chapman R, MacKenzie H. Individual differences in the language acquisition of mentally retarded children. Proceedings of the 2nd Wisconsin Symposium Research Child Language; Madison, Wis: University of Wisconsin; 1981. [Google Scholar]

11. Boudreau DM, Chapman R. The relationship between event representation and linguistic skills in narrative of children and adolescents with Down syndrome. J Speech Lang Hear Res. 2000;43:1146–1159. [PubMed] [Google Scholar]

12. Kamhi A. Trying to make sense of developmental language disabilities. Lang Speech Hear Serv Sch. 1998;29:35–44. [PubMed] [Google Scholar]

13. Weismer SE, Hesketh LJ. Lexical learning by children with specific language impairment: Effects of linguistic input presented at varying speaking rates. J Speech Lang Hear Res. 1996;39:177–190. [PubMed] [Google Scholar]

14. Miller CA, Kail R, Leonard LB, Tomblin JB. Speed of processing in children with specific language impairment. J Speech Lang Hear Res. 2001;44:416–433. [PubMed] [Google Scholar]

15. Weismer SE, Evans J, Hesketh LJ. An examination of verbal working memory capacity in children with specific language impairment. J Speech Lang Hear Res. 1999;23:1234–1248. [PubMed] [Google Scholar]

16. Oetting JB, Morohov JE. Past-tense marking by children with and without specific language impairment. J Speech Lang Hear Res. 1997;40:62–74. [PubMed] [Google Scholar]

17. Brinton B, Fujiki M, Powell JM. The ability of children with language impairment to manipulate topic in a structured task. Lang Speech Hear Serv Sch. 1997;28:3–11. [Google Scholar]

18. Bland-Stewart LM. Difference or deficit in speakers of African-American English? What every clinician should know… and do. The ASHA Leader. 2005;6–7:30–31. [Google Scholar]

19. McCauley R. Assessment of Language Disorders in Children. Mahwah, NJ: Lawrence Erlbaum; 2001. [Google Scholar]

20. Owens RE. Language Development: An Introduction. Needham Heights, Mass: Allyn & Bacon; 2001. [Google Scholar]

21. Seymour H, Roeper T, de Villiers J. The Diagnostic Evaluation of Language Variation. San Antonio, Tex: Harcourt; 2004. [Google Scholar]

22. Silliman ER, Jimerson TL, Wilkinson LC. A dynamic systems approach to writing assessment in students with language learning problems. Topics Lang Dis. 2000;20:45–64. [Google Scholar]

23. Lubker BB. Language learning disorders in children with chronic health conditions: epidemiologic perspectives. Perspectives in Language Learning and Education. 1997;4:2–5. [Google Scholar]

24. Markowitz J, Carlson E, Frey W, et al. Preschoolers' Characteristics, Services, and Results: Wave 1 Overview Report from the Pre- Elementary Education Longitudinal Study (PEELS) Rockville, Md: Westat; 2006. [Google Scholar]

25. Glascoe FP. Can clinical judgment detect children with speech language problems? Pediatrics. 1991;87:317–322. [PubMed] [Google Scholar]

26. Olswang L, Rodriquez B, Timler G. Recommending intervention for toddlers with specific language learning difficulties: We may not have all the answers, but we know a lot. Am J Speech-Lang Pathol. 1998;7:29. [Google Scholar]

27. Glascoe FP. The value of parents' concerns to detect and address developmental and behavioral problems. J Paediatr Child Health. 1999;35:1–8. [PubMed] [Google Scholar]

28. Bates E. Commentary: Comprehension and production in early language development. Monogr Soc Res Child Dev. 1993;58:222–242. [PubMed] [Google Scholar]

29. Guitar B. Stuttering: An Integrated Approach to Its Nature and Treatment. New York, NY: Lippincott Williams & Wilkins; 2006. [Google Scholar]

30. Westby C, Watson S. Perspectives on ADHD: Executive functions, working memory, and language disabilities. Semin Speech Lang. 2004;25:241–254. [PubMed] [Google Scholar]

31. Beitchman JH, Wilson B, Johnson CJ, et al. Fourteen-year follow-up of speech-language-impaired and control children: psychiatric outcome. J Am Acad Child Adolesc Psychiatry. 2001;40:75. [PubMed] [Google Scholar]

32. Helland WA, Heimann M. Assessment of pragmatic language impairment in children referred to psychiatric services: a pilot study of the Children's Communication Checklist in a Norwegian sample. Logoped Phoniatr Vocol. 2007;32:23–30. [PubMed] [Google Scholar]

33. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: APA; 1994. [Google Scholar]

34. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed – text revision. Washington, DC: APA; 2000. [Google Scholar]

35. Vermont Department of Education. Special education regulations. Available at: http://education.vermont.gov Accessed May 9, 2008.

36. Earls MF, Hay SS. Setting the stage for success: implementation of developmental and behavioral screening and surveillance in primary care practice–the North Carolina Assuring Better Child Health and Development (ABCD) Project. Pediatrics. 2006;118:183–188. [PubMed] [Google Scholar]

37. Bee H, Boyd D. The Developing Child. 11th ed. New York, NY: Harper Collins; 2006. [Google Scholar]

38. Berko-Gleason J. The Development of Language. 6th ed. New York, NY: Allyn & Bacon; 2005. [Google Scholar]

39. Glascoe FP, Robertshaw NSP. EDS: Developmental Milestones. Nashville Tenn: Ellsworth & Vandermeer Press; 2007. [Google Scholar]

40. American Academy of Pediatrics Council on Children With Disabilities; Section on Developmental Behavioral Pediatrics; Bright Futures Steering Committee; Medical Home Initiatives for Children With Special Needs Project Advisory Committee. Identifying infants and young children with developmental disorders in the medical home: an algorithm for developmental surveillance and screening. Pediatrics. 2006;118:405–420. [PubMed] [Google Scholar]

41. Bricker D, Squires J. Ages and Stages Questionnaires: A Parent-Completed Child-Monitoring System. 2nd ed. Baltimore, Md: Paul Brookes; 1999. [Google Scholar]

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