anna catalina aniag-dimalanta, md. to present a case of 31 month old male patient with speech delay...
TRANSCRIPT
CASE PRESENTATION
Anna Catalina Aniag-Dimalanta, MD
OBJECTIVES
To present a case of 31 month old male patient with speech delayTo discuss the approach to diagnosis of a patient with speech delay
GENERAL DATA
RC.31 month oldMale
CHIEF COMPLAINT
“He speaks mostly in jargons and cannot speak
well.”
HISTORY OF PRESENT ILLNESS
Mother noted delay in language development Started babbling at 8 mos. Old First real word at 1 year old At 2 years old, slow vocabulary acquisition
Speaks mostly in jargonCan say a few words with articulation difficultiesTurns when name is calledPoints to needs; points to picturesFollows 2-step commants
HISTORY OF PRESENT ILLNESS
At 2 years and 7 months old, Still speaks in jargonVocabulary was limited to less than
50 words Speaks fast but words cannot be
understoodSpeech is only 25% intelligible(+) pointing and hand leadingPlays with other children
REVIEW OF SYSTEMS
No fever, no weight loss, no trauma No cough, colds No cyanosis, tachypnea, difficulty of
breathing No vomiting, diarrhea, abdominal
distention No dysuria, no hematuria No bipedal edema, weakness of
extremities No seizures, no alteration in sensorium
BIRTH HISTORY
Full termDelivered via CS to a 40 y/o mother and
a 56 y/o fatherG2P2 (2002) at SLMC. BW 6 lbsUnremarkable perinatal and maternal
historyNewborn Screening normalHearing screening passed both ears
Feeding History
Breastfed for 6 months Semisolids started at 6 months Now has 3 meals and 2 snacks in a
day Bottle feeds (7 oz bottles x 4/day) Dislikes vegetables Can feed independently using a
spoon Eats at the dining table Typical meal duration: 20 mins
PAST MEDICAL HISTORY
(+) Bronchial asthma- admitted when he was 1 ½ yrs old, and then at 2 yrs old
FAMILY HISTORY
(+) hypertension- maternal grandfather
No neurologic/ developmental problems
Family History
MOTHER Shy as a child Average student Finished 2nd yr
college then went into modeling
Now a stay-at-home mom
Has a 19 yr old son from a previous relationship
FATHER French; based in
France Slow to warm up to
others Average student Engineer Has 2 children from
previous marriage
Personal and Social History Primary caretaker: Mother Lives with mother and 19 year old half-
brother Parental involvement: Speaks with the
father through the computer. Patient and mother were based in France but came home because of older brother.
Usual activities: Stays home and plays. Exposed to TV 4-6 hrs/day. Rarely reads books.
Developmental History
Gross motor: Roll over at 3 months Sits without support at 8 months Walks with one hand held at 12 months Walks alone at 14 months Runs at 18 months
Developmental History
Fine motor: Reaches for objects at 6months Holds bottle at 8 months Drinks from cup at 18 months
Personal-Social Social smile at 2-3 months Waves bye bye at 9 months Plays with other children at 18 months
Developmental History
Language: Babbles at 8 months First word: mama at 1 yr old Obeys simple commands at 12 months Says “mama” and “dada” discriminately at 14
months
DEVELOPMENTAL MILESTONES
GROSS MOTOR: can walk, run, and jump without difficulty
FINE MOTOR: can write using his fist and consistently writes with right hand. Can write in scribbles.
PERSONAL-SOCIAL: can initiate play with other kids. Can imitate adult activities and can do pretend play
LANGUAGE: speech is 25% intelligible; cannot combine 2 words in a sentence; speaks in jargons; can say few words, with articulation difficultiesFollows 2 step commands; turns when name is called; (+)protoimperative and proteodeclarative pointing
SELF HELP: can communicate toileting needs; eats with a spoon; can remove some shoes and shorts, needs help with shirt; can wear shorts
Physical Examination
Awake, Not in DistressAfebrile; HR 94 RR 20 WT 14 kg (zscore: 0-2) Ht 92 cm (zscore: 0-2) Pink palpebral conjunctiva, Anicteric scleraeMoist lips and buccal mucosa; No tonsillopharyngeal congestion, No cervical lymphadenopathyNo retractions, good air entry, Clear breath soundsAdynamic precordium, AB 4th LICS MCL, No murmursNondistended abdomen, normoactive bowel sounds, non-tender, no organomegalyFull and equal pulses
Neurologic Exam
GCS 15, alert, awakeCranial nerves intactMotor:5/5 in all extremitiesSensory: withdraws to touch and painReflexes: normoreflexive (-) Babinski, (-) ClonusNo signs of meningeal irritation
PEDS
M-CHAT
PEDS – Path B (1 predictive concern: Expressive Language and articulation
MCHAT – PASS Brigance – FAIL ( Total Score: 68/100;
Delay Cutoff Score: <72 Advance Cutoff score: >83)
Brigance Self-help- below Average Brigance Social Emotional - Average
IMPRESSION
t/c Language Delay
Language Delay
No universally accepted definition of “language delay” in developmental conditions.
“Delay”- Catch up will occur Approximately 60% will catch up by 4
years of age
American Academy of Pediatrics, Developmental and Behavioral Pediatrics
R.G. Voigt, M.D. 2011
Language Disorder
Specific Language Impairment (SLI): impairment in the ability to understand and/or use words in context, both verbally and nonverbally
American Academy of Pediatrics, Developmental and Behavioral Pediatrics
R.G. Voigt, M.D. 2011
Language Disorder
Receptive Disorders Expressive Disorders Mixed Receptive and Expressive
American Academy of Pediatrics, Developmental and Behavioral Pediatrics
R.G. Voigt, M.D. 2011
Red Flags for Delayed Language DevelopmentAGE MILESTONE
6 months No cooing responsively
10 months No babbling
12 months No basic gesturing like waving bye-bye
18 months No words other than mama, dadaNo pointing to what he wants
24 months <50 wordsNo 2-word phrases
36 months No 3-word sentences<75 % intelligibilityAmerican Academy of Pediatrics, Developmental and Behavioral
PediatricsR.G. Voigt, M.D. 2011
Causes of Language Delay
Auditory(Hearing loss) Mental Retardation Autism Spectrum Disorder Learning Disorder
Hearing Loss Can have a devastating impact on language,
social, and learning abilities if not detected Delayed development of speech is a universal
symptom of hearing impairment Hearing testing- Auditory Brainstem Response
Testing
American Academy of Pediatrics, Developmental and Behavioral Pediatrics
R.G. Voigt, M.D. 2011
Mental Retardation Intellectual disability A disability characterized by significant
limitations in both intellectual functioning and in adaptive behavior as expressed in conceptual, social, and practical adaptive skills
American Academy of Pediatrics, Developmental and Behavioral Pediatrics
R.G. Voigt, M.D. 2011
Autism Spectrum Disorder ASDs are a heterogenous group of
neurodevelopmental disorders without an identified unifying pathological or neurobiological etiology.
Can cause severe and pervasive impairment in thinking, feeling, language, and ability to relate to others
American Academy of Pediatrics, Developmental and Behavioral Pediatrics
R.G. Voigt, M.D. 2011
Identification and Evaluation of Children With Autism Spectrum Disorders
C.P.Johnson, et.al. PEDIATRICS Volume 120, Number 5, November 2007
Autism Spectrum Disorder severe social skills deficits and
restricted, repetitive, and stereotyped patterns of behavior, interests, and activities are core features of all ASDs
significant language delays are characteristic of only AD and PDD-NOS.
Learning Disorders DSM-IV-TR states that learning disorders
are diagnosed “when the individual’s achievement on individually administered, standardized tests in reading, mathematics, or written expression is substantially below that expected for age, schooling, and level of intelligence”.
American Academy of Pediatrics, Developmental and Behavioral Pediatrics
R.G. Voigt, M.D. 2011
Plans
Referral to a Developmental Pediatrician
For hearing testing Language enhancement exercises at
home Observe closely his learning,
development, and behavior
THANK YOU!