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Communication disorders
in young children
What is communication ?
Exchange of information
with others
understand
produce
messages
Forms of communication
• Nonlinguistic (gestures, body
posture, 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
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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
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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
Language
Speech
• Form: phonology
morphology
syntax
• Articulation
• Content: semantics
• Function: pragmatic
• Fluency
• Voice
Language disorders
• Improper use of
words and their
meanings
• Inability to
express ideas
• Inappropriate
grammatical
patterns
• Reduced vocabulary
• Inability to follow
directions
Speech disorders
• Dysfluency
• Articulation or
phonological
disorders
• Difficulties with
the pitch, volume
or quality of the
voice
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
•
•
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Hearing loss
Mental retardation
Autism /PDD
Acquired brain damage
(left hemisphere)
• Seizures
• CP
• Elective mutism
• Psychosocial
deprivation
Specific language impairment
• Expressive language disorder
• Receptive aphasia
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
Generalized delay suggests
mental retardation as the cause
of a child's speech delay
• 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
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 Disorders
DSM-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 (semanticpragmatic):
– 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
All children with speech delay
should be referred for audiometry
• 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)
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)