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Developmental Speech and Language Disorders: Hopethrough Research.National Inst. of Neurological and CommunicativeDisorders and Stroke (NIH), Bethesea, Md.NIH-88-2757Mar 8839p.

National institutes of Health, Bethesda, MD 20892.Guides - Non-Classroom Use (055)

MF01/PCO2 Plus Postage.Brain Hemisphere Functions; Clinical Diagnosis;*Communication Disorders; Communication Research;Early Intervention; *Etiology; Expressive Language;*Handicap Identification; Hearing (Physiology);Incidence; *Intervention; Language Acquisition;*Language Handicaps; Parents as Teachers; PhysicalDeveloament; Physiology; Prenatal Influences;Eeceptive Language; *Speech Handicaps; SpeechPathology; Speecn TherapyNational Institutes of Health

This pamphlet pres,:nts an overview of speech andlanguage disorders including a description of symptoms, possiblecauses, identification, intervention, and current research.Description of the disorders includes examples of symptoms; the fourcomponents and the physical tools of speech; and the role of thebrain, including its hemispheres, problems during maturation, and itslanguage centers. Examples are given of speech disorders(phonological impairment, verhal dyspraxia, and dysarthria); languagedisorders (form errors, cente.c errors, and use errors) andexpressive and receptive languag,i disorders. The concept of delayversus disorder is discussed. The process o: handicap identificationis described, noting conditions which must be ruled out and stressirothe importance of early identification and intervention. Currentmethods of therapy are described, and research is cited indicatingthat speech disorders may be outgrown by adolescence but thatdifficulties involving language use may persist into adulthood.Ongoing research involves investigation of differences in brainorganization, investigation of the genetic connection, and the use ofcomputers to train children with language impairments to processspeech and language more rapidly. Seven erganiz-,tiens are listed towrite or call for additional information. A chart of languaaemilestones for ages one through six is also provided. (BRM)

*************************************.t*********************************Reproauztions supplied by EDRS are the best that can be made

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DevelopmentalSpeech and

LanguageDisorders

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aZr./ Hope Through Research

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Public Health ServiceNational Institutes of Health

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CoverBy watching and irritating his 3peech therapist, ihts youngster tsimproving the qualii'y of his speech.

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Developmental Speechand Language DisordersHope Throueh Research

E liza, age 21/2, toddles around her nurset y schoolclassroom, the straps of her purple overalls slipping

off her shoulders. She watches and smiles, and generallyshe follows directions, but Eliza is silent. 1,1e only wordsshe utters are cl).2 to describe a wooden plaything andwhen it's time to go homebus.

Ben is older, nearly 5, and as sweet-faced as littleEliza. But his only "words"used sparingly in two-word phrasesare all but unintelligible to a stranger.Ben wants to join in the activities of his class, but hecannot understand his teacher's instructons aboutputting a beanbag on his head, on h:s shoe, on hisshoulder. He simply holds on to the beanbag and smiles,waiting to imitate the other children's responses.

Eliza and Ben are in a special program for pre-schoolers with speech and language disorders. Eliza islanguage disordered and has a brain dysfunction: sheis delayed primarily in her ability to translate thoughtsinto language, even though she un&rstands almosteverything that a child her age is expected to. Ben isdisordered in both speech and language. His problemsinvolve the neurological motor skills that producespeech, as we!! as the brain function of understandinglanguage. The treatment he requires is mcre complex.And if Ben has normal intelligencewhich can be deter-mined by specialized testingthen this intelligence ismasked by his halting, stumbling phrases.

What causes speech and language disorders inchildren like these? How zan the problems be treated?Will children who are slow to speak and understandwhat is said to them also be slovi, to read, to write, tothink logically! Evidence suggests that the answer tothe latter question may be yes for some children, butscientists continue to search for causes and effectivetreatments that will give parents and professionals abasis for hope. Encouraged by the National 'stituteof Neurological and Communicatise Disorders andStroke (NINCDS), the primary source t, f Federal sup-port for research on the brain and disorders of speech

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These children mat be helped in later years because their speech andlanguage problems were recognized and treated early in life.

and language, investigators around the country aredevelopiry new techniques for studying normal anddisordered speech and language acquisition as well astreatments for speech and language impairments.

Eliza and Ben have a chance of being helped becausetheir problems have been discovered and are beingtreated early in life. But many questions will remainunanswed for years. The children will be watchedclosely when hey enter schoolBen probably in aspecial classroom, Eliza perhaps mainstreamed into aregular schoolto see whether their speech and ln-guage delays sho,A, up later in other guises, particularlyas reading disabilities. And as they reach adulthood,another question loom,: Will they pass their speech andlanguage difficulties oi to their ow n children?

The scope of the problemA child with a language disorder has difficulty

understanding language or putting wolds together tomake sense, indicating a problem with brain function.A child with a speech disorder has troulle producing the

Help depends on earlydetection.

sounds of language, often resulting from a combinationof brain-coordination and neurological motor dysfunc-tion. Either child will lag significantly behind the levelof speech and language development expected of aplaymate of the same age, environment, and intellectualability.

Language impairment may show itself in several ways:

Children may have trouble giving names to objectsand using those names to formulate ideas about howthe world is organized. For example, they cannot learnthat a toy they play with is called car, or that a toy car ofanother color, or a real car, can also be called car.

They may have trouble learning the rules ofgrammar. Such children might not learn, for example,how to use prepositions and other small words like inor the.

They may not use language appropriately for thecontext; for example, they might respond to a teacher'squestion by reciting an irrelevant jingle heard on televi-sion.

Speech problems seem to be more prevalent thanlanguage problems. Both disorders appear to decline aschildren get older. Speech disorders affect an estimated10 to 15 percent of preschoolers, and about 6 percentof children in grades 1 through 12. Language disordersaffect about 2 to 3 percent of the preschool populationand about 1 percent of the school-age population. Inall, nearly 6 million children under the age of 18 arespeech or language disordered. Two-thirds of them areboys.

It is difficult to be more precise about just howprevalent the problem is, because the definition itselfis so unwijdy. How delayed must a child be to qualifyas "disordered"? How does one recognize the delay inthe first place?

When is there a problem?Experts use nhrases such as developmental language

diSorder, delayed speech, impaired language, motor

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A true d' :ay differs from slowlearning.

disorder, and idiopathic (no known cause) speech andlanguage disorders to describe a variety of speech andlanguage difficulties in children. In this pamphlet,delayed speech or delayed language means a problemthat appears in the course of the child's developmentand for which there is no apparent cause. Eliminatedfrom this discussion are speech or language problemsthat can be traced to deafness, mental retardation,cerebral palsy, or autism.

Speech-language pathologists generally definechildren as disordered if they lag significantly behindtheir age peers in reaching certain speech and languagemilestones. The significance of this lag is deterninedby a thorough professional examination. British studiesshow that the range of normal for early languageacquisit:on is enormous. Normal children speak theirfirst word at anywhere from 6 to 18 months, and com-bine words into phrases for the first time at anywherefrom 10 to 24 months. It takes a skilled pnictitioner todistinguish between a slow child who will c.ventuallycatch up and a child with a true delay.

Speech and language professionals have devised ageneral outline of what speech sounds should have beenacquired by a certain age. A child who is not quite onschedule, of course, is not necessarily delayed or dis-ordered; it may just be that the child's individual time-table is different from most children's.

An understanding of what constitutes normal lan-guage development is helpful when parents try toevaluate whether their child is abnormally slow. Themost widely accepted speech and language milestonesfor children age 1 to 7 years are outlined in the chartsat the end of this pamphlet.

Language problems are most obvious among 2- to3-year-olds, %those language skills are usually developingvery rapidly. Many of these problems subsequentlyresolve themselves; ethers require the aid of therapy.

Among oHer chil(ren, speech and language disordersmight emerge in a different guise. A 5- or 6-year-oldmight have caught up in language nd social skills

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sufficiently to communicate with others, but not suffi-ciently for good reading or thinking. Such a child couldbe considered reading- or learning-disabled.

The physical tools of speechSpeech has fo....r components: articulation, ph-nation,

resonance, and rhythm:

".rtealation is the ability to make specific sounds:the g in gum, the b in bear, the s in snake. Articulationis the component most often affected In children withspeech disorders of unknown cause.

Phonation is the utterance of vocal soundsthevoiceproduced in the larynx or "voice box."

Resonance is the modification of the voice after itleaves the larynx. The voice is modified by the cavitiesinside the mouth, nose, and pharynx (the throat).

Rhythm, or what scientists call prosody, involvesthe rate and timing of speech.

For speech to begin, the urain and the vocal andauditory systems must be in good working order. Thehuman vocal system components are perfectly adaptedfor speech. Our teah, for example, are usually ei.enlyspaced and equal in size (unless there are dental prob-lems), and our top and bottom teeth can get cluseenough to pronounce such sounds as s, f, sh, and th.Our lips have more developed muscles than the lips ofother primates, and our relatively small mouths canopen and shut rapidly to form sounds such as p andb. The size of our mouth opening c:an be varied topronounce a range of vowel sounds.

The location of the larynx is perhaps the most im-portant fetture of the human voca' system. In the adulthuman, the larynx, where the vocal cords are locatcdand voice sounds originate, is located farther down inthe throat than is the larynx of any other primate. Thisextra room allows humans to modulate sr zech and topronounce such sounds as the consonant., in gut andcut.

p 5

Hard palate

Right and left bronchi

The structures of the vocal system.

Defects in the strur* ire of the lips, palate, or teethcan interfere v.ith a child's ability to make speech soundscorrectly. A hole in the palate the "cleft palate" seenin some newbornsis the most common such problem.A cleft palate can usually be corrected surgically, buteven after surgery affected children may have too muchnasal resonance and difficulty producing certain speechsounds. Other children with growths in the larynx orvocal cords may have voices with a harsh, husky sound.

The auditory system comprises the three parts of theearthe outer ear, the middle ear, and the inner earand the connections between the inner ear and theauditory center of the brain. The middle ear is proneto infcction during childhood because of the angle ofthe eustachian tube, which connects the middle ear to

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the 'hroat. When a child has a cold, the short eustachiantube cannot drain excess mucus properly, and the fluidthat builds up becomes a breeding ground for bacteria.The resulting condition is called otitis media.

If the auditory system is not in good order and ahearing loss exists as a result of continual ear infectionsand fluid buildup, the child may mishear adult spee-hand produce it incorrectly. To avoid tnis problem, anotolaryngologist, a physician who specializes in ear,nose, and throat disorders, should be com ulted at thefirst sign of a hearing loss. The otolarynpologist mayrefel the child for testing to an audiologist, an experton the hearing process.

The role of the brainIf scientists were asked to identify the most important

feature of the brain that enables humans to speak, theywould point to the brain's functional division into leftand right hemispheres. This characteristic appears to berelated in most people to the brain's asymmetry. EvenEt birth one can see evidence of this asymmetry: tt,eleft hemisphere tends to be larger than the right in mostnewborns.

Although most complex functions involve both sidesof the brain to some extent, certain functions can betraced to one hemisphere or the other. In approximately90 percent of us, the right hemisphere controls hov wesee spatial relationships (such as the recognition of faces)anu recognize patterns (such as a musical melody). Inthat same 90 pement of us, the left hemisphere controlsnow we process sequences of information invok inglanguage.

Neuroscientists once thought that a person's handed-ness showed which side of the brain was dominant forlanguage: rigat-handed people were thought to derivelanguage skills from the left hemisphere, left-handedpeople were thought to draw these skills from the righthemisphere. But we now know that the tendency is formost individuals, no matter which hand they prefer, torely on the left hemisphere for language abilities

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In certain situations, however, the right hemisp'serecan take over language function. In young childrel, forexample, the loss of left-hemisphere language functionafter certain kinds of brain surgery can be well com-pensated for by the right hemisphere. But in ado.escentsand young adults the right hemisphere is les, able totake over language or speech production.

The maturing nervous system. The development ofthe brain's asymmetry is part of the overall maturationof the nervous system which oc rs before birth. Scien-tists believe that sometime in the micla le of gestation,nerve cells, or neurons, migrate from germinal zones

The axon of a neuron iscoveted by a myelin sheath. afatty casing that facilitates thetransmission of brainmessages.

AxonMyelin sheath

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Faulty migration of brain cellsmay cause lanpage delay.

areas where cells reproduceto the regions of the brainin wnich they will reside. This brain cell migrationusually begins at about the 16th week and ends by the24th week.

If the migration of cells to the brain is incomplaeor interruptee by something in the fetus' environment(perhaps an antibody developed by thc body in responseto a foreign substance), tile fetus could die befor: orshortly after birth. If migration occurs, but with errors,the result could be language delay.

After mid-gestation, and probabi:, through the firstdecade of life, the neurons of a child's brain begin tomature. As neurons develop, the) grow axons: long con-necting arms linking one brain cell to another. Asneuronal development continues, these axons arecovered by a my:lin sheath, a fatty casing that protectsthe axons and helps them transmit messages moreefficiently. This myelinization of mesJage pathways inthe brain occurs at a rapid rate until about age 2 andcontinues at a slower pace until puber:y. The processis crucial to the child's growing capacity forunderstanding and expressing language.

The brain's language centers. Two areas in the brainare known to be involved in speech and language.Broca's area, named after the French surgeon Pierre-Paul Broca, is in the left frontal lobe, close to the partof the brain that controls movcments of the tongue,larynx, and other structures involved in speech. Broca'sarea is responsible for translating thoughts into speech

Wernicke'. area, named after the German neurologistKarl Wernickz, is located behind Broca's area, justaround the temples. It contributes to the understandingof the spoken and written word, and in most individualsis larger in the left hemisphere than in the right.Wernicke's area is quite dose to the auditory cortex, thebrain region that controls the input and analysis ofsound.

The difference in 1 unction of the two language regionsis apparent when either area is Jamaged. Aphasia is the

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Motor cortex

Auditory area

Wernicke's area

Broca's area

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iThe areas of the brain involved in speech and language.

loss of language after a brain injury. An adult aphasicwith damage to Broca's area ha4 reduced speech thatsounds like a message in a teiegram: asked about theweatha, he might respond "rainy" or, if pressed, "rainyday. " An adult with damage to Wernicke's area mayarticulate well and form grammatically correct sen-tences, but provides very little coherent information inhis speech. Such a patient might answer a questionabort the weather by saying, "I think it's not good. Idon't like a when it's like that. " Many aphasic patientsmay have other language problems as well.

Thanslating sounds into meaning. Some children mayhave language difficulty because ofa problem with thebrain's ability to analyze speech. Research scientists havestudied dozens of language-delayed children and found

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that they are unable to process rapid speechlike signalsproduced by a computer. But they can be trained todifferentiate among sounds if the time between soundsis prolonged.

Scientists now kn,:w that soon after birth, babies areaNe to detect differences between speech sounds. In-

- vestigators have found that infants as young as I monthcan detect the minute differences between closely relatedspeech sounds such as pat and bat.

Most children develop a phonological system, an in-ternal sense of how different categories of speech soundsare used, by about age 3. This system differs accordingto the child's native language. An English-speakingchild, for instance, does not have within his phonologi-cal system the same s sound a- - Sranish-soeaking child,a sound that is somewhere bet ...cen the English s and th,or the gutteral kh sound of a German-speaking child_

Children must first perceive the unique characteristicsof a sound in order to be able to repeat it. But manysounds in the English language differ only minutelyand sometimes the differences are a matter of timing.The difference between the initial sounds for the wordsbin and pin, for example, is a function of somethingcalled voice onset time. To utter the b sound, the vocalcords begin to vibrate almost as soon as the speakerreleases air by opening the lips. For the p sound, thereis a delay of about 20 extra milliseconds between thetime the lips first open and the time the vocal cords startvibrating.

Even though these differences are very small, mostpersons can discriminate between b and 2, or d and t,or g and kconsonants distinguishable by short dif-ferences in voice onset time. Speech-language patholo-

sts believe that whrn children consistently fail to makethese distinctions, they may have incorrectly establishedthe sounds in their phonological systems.

Think of what happens to an adult trying to learna foreign language. The adult can generally imitate thesounds of that language after hearing a word about 50

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to 100 times, but still does not know the phonologythe range of possible sounds of the language and therules for their order. Similarly, a child can imitate thesounds his rtieech pathologist urges him to make, butto him they're like a foreign tongue. A little boy whospeaks like Elmer Fudd, the cartoon character who callsBugs Bunny a "scwewy wabbit," may be capable ofmaking an r sound the way he's told to, but to him ther sound isn't supposed to sound like an r. He thinksit should sound like a w.

Other influencing factorsThe normal development of speech and language

depends largely on the health of the brain and the vocaland auditory systems. But children who are abnormallyslow in speech or language acquisition may show nosigns of physical problems that could mplain the delay.In such cases, certain other factors may be slowingthings down.

Ear infections. Controversy exists about the relation-ship between chronic otitis media and the rapidity withwhich a child learns to speak. Most studies investigating

'411,

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Early recognition and treatment of mfectrons helps avoid thepossibility of language-threatening hearing loss.

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Environment may alsocontribute to langua2eproblems.

karnina

the question have fcund no clear association betweenotitis media and language disorder, unless a hearing lossis present. The prudent course is to treat ear infectionspromptly and to re alert to signs of poor hearinginattentiveness, failure to respond, requests to havewords repeated or to have the television volume raisedin a child with frapent otitis media. Treatment mayinclude antibiotic therapy and the insertion of a tubeinto the middle ear to drain the fluid. Recent NINCDS-supported -.udies found that decongestant and anti-histamine compounds are ineffective for otitis medza butthat the antibiotic amoxicillin is effective.

Poor models in the home. The role of the environ-ment in language acquisition has never been fullyexplained. For ,:xample, a normal child whose parentsuffers from a language problem may reach full lan-guage competence despite an environment in whichlanguage models are scant. Psycho linguists, who studythe psychological and biological roots of language,believe most children have an innate drive to learn thelanguage of the community no matter what theenv conment.

Eut children whose brain structures are ab ormal,even in quite subtle ways, may be born with a tendencytoward language problems, and if their environmentsare language-deficient they just don't have the intierresources to compensate. in addition, a vicious cy le ofsilence is all too easy to establish in the home of alanguage-impaired child. Parents react to the cues theirbabies give them. If a baby does not respond withsounds and words, the parent is unlikely to know t atthe baby is indeed ready for conversation. Accordi gto one scientist, the communication difficulties oflanguage-impaired children have a direct impact on theparent's efforts to talk to them.

A collection of disordersSpeech and language disorders wear many faces.

7ommon spe...:11 disorders include:

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Speech and language disorderstake many nises.

Phonological impairment, also called misarticula-Lion. Here the child says the sounds wrong, or omitsor duplicates certain sounds within a word. The problemmay reflect poor neurologicai motor skills, a learningerror, or difficulty in identifying certain speech sounds.Examples of common errors are wabbit for rabbit,thnake for snak..-, dood for good, and 222 for spoon.

Another phonological 'mpairment is unstressed sylla-ble deletion, in which a child simply skips over a syllablein a long word, as in nana for banana oi te-phone fortelephone. Many of these misproductions are a part ofnormal development and are expected in the speech ofvery young childien, but when they persist past theexpected age they are considored abnormal and usuallyindicate brain dysfunction.

Verbal dyspraxia. This term i5. usat b omescientists and clinicians to describe the inability toproduce the se4nential, rapid, and precise movementsrequired for speech. Nothing is wrong with the child'svocal apparatus, but the child's brain cannot give correctinstructions for the motor movements involved inspeech. This disorder is charao,-rized by many soundomissions. Some verbally i ,praxic children, forinstance, speak only in vowels, making their speechnearly unintelligible. One little boy trying to say "Myname is Billy" can only manage "eye a eh ee-ee. " mhesechildren also have very slow, halting speech with manyfalse starts before the right sounds are produ:ed. Theirspeech errors may be similar to those of childon withphonological impairment.

Dysarthna. Here muscle control problems affect thespeech-making apparatus. Dysaahria most commonlyoccurs in combination with other rervons system dis-orders such as cerebral palsy. A dysarthric child cannotcontrol the muscles involved in speaking and eating, sothe mouth may be open all the time or the tongue mayprotrude.

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A child with a language problem has difficulty com-prehending or using language, and several different typesof errors may resliit. Three of ne more common are:

Form errors. These are presc it when the child can-not understand or use the rules of grammar. A childwith this problem might say "We go pool" instead of"We went to the pool. "

Language-disordered children seem to have particulardifficulty with complex sentence constructions such asquestions and negative forms (Table 1).

Table 1. Examples of Form Errors

Correct sentenceThey won't play with me.I can't sing.He doesn't have money.When will he come?What is that?

Mordered sentenceThey no p:ay ith me.I no can sing.He no have mcney.When he will come?What that?

Coniont errors. This language disorder is involvedwhen the semantizs, or what the child understands ortalks about, is limited or inaccurate. The child may havea limited vocabulary or may fail to understand that thesame wordmatch, for examplecan have multiplemeanings.

Use errors. This term concerns what linguists callpragmatics, the ability of the child to follow the rulesof communication: when to talk, how to request infor-mation, how to take turns. A child with a use errormight be unable to ask an adult for help, even thoughhe knows that help is needed and the adult can provideit. Autistic children who have difficulty communicatingwith people may have use errors.

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Categorizing patientsIf children with a speech or language problem are to

benefit from different treatment approaches now avail-able, they must be accurately subgrouped according totype of impairment. In categorizing speech- and lan-guage-impaired children, experts tend to ask two ques-tions. First, is the disorder expressive, receptive, or amixture of both? Second, is the child simply delayedin speech or language development, or is the child notonly delayed but abnormal in speech and language whenthese skills begin to develop?

Expressive or receptive? Some language-impaired chil-dren have primarily expressive (speaking) disorders;others have mainly receptive (understanding) disorders.Most have a combination of both.

Clinicians often encounter children who may beunable to communicak effectively, but nonetheless showsigns of understanding others quite well. ConsiderBecky, a 6-year-old girl seen at a speech clinic. Herconversation with a clinician goes like this:

Clinician: What is your favorite game?Becky: Doctor.Clinician: How many can play that game?Becky: Two four.Clinician: Two or four?Becky: Or three.Clinician: How do you play doctor?Becky: One has to be doctor.Clinician: Anything else?Becky: One operation man.Clinician: Anything else?Becky: No.Clinician: What do you want to be?Becky: A nurse.Clinician: Oh, you need a nurse?Becky: No, you don't.

NriMM16 1 C.1N ty

A child with a receptive language disorder might pointto the wagon's bed when asked to point to Ole wagon's

r wheels

Becky has an expressive language disorder. Herresronses are limited to incomplete sentences that maybe inappropriate to the question, and they reveal Becky'sinability to use verbs, conjunctions, or any of the sub-tleties of language. Like some children with expressivelanguage problems, Becky has a good vocabulary, butshe has difficulty connecting words. Een though sheis 6, she talks like a 2-year-old.

Children with expressive language problems may ormay not have articulation problems. But even if theirspeech is perfectly articulated, communication is im-paired becw.Ase language remains ungrammatical,reduced, hubyish.

Paul, who is 7 years old, is Becky's opposite, a childwith a receptie language disorder who has difficultyunderstanding language. Receptive language problemsrately occur alone; usually they are accompanied by atleast some degree of expressive language disorder. The

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Diagnosis often begins with thepediatrician.

cond.tion often is misdiagnosed as attention problems,behavilral problems, or hearing problems. Standardizedlanguage tests may reveal, though, that a child with areceptive language disorder is trying to cooperate butsimply cannot understand the instructions.

Paul, for instance, cannot point to a picture that bestreveals his understanding of single vocabulary words orof grammatical associations between words. When askedto point to a picture of "the ball under the table," Paulmight just as readily point to a picture of a ball on thetable. When asked to point to the picture of "the boyrunning after the girl, " he might instead choose the oneof a girl running after a boy.

Delay or disorder? Scientists have not agreed onwhether language- ,npaired children acquire languagenormallybut more slowlythan other children orwhether they develop language in an abnormal waywhen they begin to talk and understand. If anyconsensus has been reached in the past decade, it is thatboth sides may be right. There may be two quite separateconditions, one in which speech or language is delayed,and another in which speech or language is not onlydelayed but also incorrect.

In the '970's, several groups of scientists tackled theproblem. Generally, children had been categorized ac-cording to certain measures of language developmentsuch as the average length of spontaneous sentences.One study found that language-impaired children usedsimpler grammatical sentences and fewer questions thanothcr children. Another study found that language-im-paired children undemood the meanings and relation-ships of words in much the same way that other childrendid. Language-impaired chAdren seemed to develop theirability to express themselves in the same progression asnormal children, but only after they had reached ahigl- .-than-normal level of language comprehension.

The general consensus from research of recent yearsis: many langu.._ impaired children seem to be merely

IMO

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This wother and her child's physician discuss test results to determineif the boy has a speech or language dist:Prier.

A chi'd is likely to be tested to rule out the followingconditions:

Hearing problems. Language acquisition b a con-tinual process of hearing, imitating or spontaneouslytrying a word or phrase, hearing one's own productions,and refining them. Scientists have observed that infantswho have impaired hearing from birth tend to be delayedin their instinctive babbling and produce fewer differentsounds.

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delayed, but a sizable number also develop language inan abnormal way. The disaction is important, bnauseit can help clinicians recognize that some children shouldbe treated aggressively and others left alone.

A visit to the doctorA child whose parents suspect a speech or language

disorder will probably enter the health care systemthrough the pediatrician's office. Before referral to aspeech-language pathologist for assessment, the physi-cian will try to determine if there are underlying condi-tions that might be the indirect cause of the speech orlanguage delay.

:' ,4,-.

A physician faced with a child over 2 years old whodoes not speak often will refer that child for completeaudiological testing. Such tests involve the use of tonesdelivered through headphones: as soon is the tone isheard, the child responds by raising a finger or pedorm-ing some other behavior or gesture. Occasionally, chil-dren with hearing problems may unintentionally hidetheir conditions from their parents because they becomeso adept at using environmental cuesfacial expres-sions, vibrations, and what little hearing they havetoget by. These cues fall short of helping the children learnthe complex sown:3 of language.

This child is undergoingaudiological testing todiagnose her speech andlanguage problems. When shehears a tone in one ear, thegirl signals the technician byholding a wood block up tothat ear

Mental retardation. The developmental languagedisorders described in this pamphlet occur in childrenof normal or above-normal intelligence. Howevel,language problems are also common among the men-tally retarded. Experts estimate that nearly half of allmildly retarded children, 90 percent of severely retardedchildren, and 100 percent of profoundly retardedchildren have language disorders of come sort.

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Children may mask poorhearing by respondin,: to facialand other cue.

A pediatrician may suspcct mcntal rctardation if thcdelay in achieving speech and language milestoncs isaccompanied by a delay in othcr mcntal and physicalmilcstoncs. Gross ncurological motor developmentsitting, standing, crawling, and walkingand fine motordevelopmentreaching, grasping, building towers ofblocksarc often intcrpretcd as clucs to whcthcr achild's mcntal capacitics arc normal. If mcntal retarda-tion is a sourcc of conccrn, tests arc available to scc justwhere a child ranks with his or hcr agc pccrs in mcntaland physical arcas of development. Thcsc tcsts involvcsuch tasks as baying thc child imitate an cxamincr'sarrangcmcnt of blocks or copy eeometric shapcs.

Autism. One of thc hallmarks of the disordcr callcdautism is thc inability of thc child to communicatc.Autism begins bcfore agc 2' 2 years; it includes particularspccch and languagc problcms: total lack of languagc,a perNasive lack of rcsponsivcncss to pcoplc, and pecu-liar specch pattcrns. The lattcr includc immcdiatc ordelaycd echoing of anothcr's comments, spcaking inmetaphoi:., or reversing pronouns. In addition to havingcommunication problems, autistic childrcn may bcresistant to changc, may ly_. overly attached to objccts,and may havc bizarre and unexpected rcsponses to theirem ironments. A child ncurologist will ask about thechild's bchavior to rulc )ut autism.

Cerebral palsy. The muscic control problcmscharactcristic of ccrcbral palsy can sometimcs intcrfcrcwith speaking. Whcn this happens, childrcn may undcrstand 'anguage bettcr than they can spcak. i'hey mayhave trouble expressing themselves becausc of difficultymoving their lips or tongue.

Acquired aphasia. Childrcn arc considcrcd aphasicwhen thc brain injury that causcs loss of languagcoccurs after speech and language have begun to develop.Aphasia can occur after severe head trauma or a brainir,fection. Sor.e acquired aphasia is an unfortunate con-sequence of surgery, as in those rafe cases whcn children

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A team of expertsOnce a child has been identified as having a speech

or language disorder, most successful diagnosis andtreatment involves a team of aperts. The audiologist,an expert in the process of hearing, evaluates and assiststhose with hearing disorders. The audiologist may wrkin consultation with an oullaryngologist, a physivanwho specializes in ear, nose, and throat disorders. Thesetwo health professionak determine which hearingconditions can be treatedand perhaps correctedmedically or surgically, and which require rehabilitativetechniques such as hearing aids or lip reading.

The speech-language pathologist, also called a speechtherapist, studies the normal and abnormal processesof speech and language and measures and diagnosesspeech and language problems. The pathologist can alsoenhance early karning of language, teach the correctproduction of speech and language, and help a childlearn to understand words and sentences.

The neurologist is a physician with expertise in theworkings of the brain and nervoub system. The neurol-ogist may modern brain imaging techniques to "see"through the skull and letect brain abnormalities in achild with speech or language delay. A range of pencil-and-paper and physical tests ha \ e also been devised tohelp diagcame any undei lying disorder that miginaccount for the language problem.

The psychologist studies the science of human devel-odment and personality, and can ...minister tests toevaluate the child's cognitive capabilities. Such tests canhelp determine how the child's language age comparesto his or her mental ard elronologic. ages.

The new therapyIn the 1970's, language-delayed children were taught

to repeat sentences in a robotlike fa ihion. As oneNINCDS scientist puts it, "These children could say,'We went swimming today' perfectly, but they couldn'tchange it to say the same thinb with different words. "Today the emphasis in therapy is less on imitation than

23

on grasping the context of language. Children play %ithtoys and are taught to translate the;r activities into%ordsa mode of learning that is more meaningful forthem and that gives them the tools to construct theirown sentences.

For the child whose speech is impaired or delayed,treatment may focus on one sound group at a time,starting with the sounds that babies naturally learn first.Young clients are encouraged to use the sounds in avariety of contexts, to watch the clinician make thesoundeven putting their hands on the clinician's throator mouth while the sound is spokenand to watchthemselves make the sound, putting their hands on theirown mouths and watching themselves in a mirror.

The most important and continuous help comes fromparents. Guided by speech and language pathologists,parents can do a great deal to improve the languageenvironment in their hoa..e.

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Reading to a child and expanding on the child's comments can helpin language development.

24

Parents' verbal responses canhelp expand lang.uatte skills

Parents can learn better ways to respond to theirchildren's utterances so that language skills improve.When a child says, "more milk, " a parent may respondseveral ways. The least helpful are silently to refill themilk glass, or to say, "here milky in cuppy, " or someother form of nongrammatical babytalk. But adultsare tempted to give such answers with youngsters whonever seem to benefit from more sophisticated re-plies such as, "Do you want more milk?" A betterresponse would be the simple statement, "More milkfor Sam. "

If the parent peppers responses with what linguistscall expansionsnew words, new sentence constructions,new rules of grammarthe child can eventually learnnew bits of language (Table 2). Expansions intrrducenew information or help the parent e_ clop the child'swords into a grammatically correct .,entence.

Table 2.Ways Adults Can Help a Child Learn Language

1. Expand the statement, preserving the child'sintent.a. Expand the statement using the same noun.

Child: kitty jumpAdult: The kitty is on the chair.

b. Replace the noun with a pronoun.Chikl: kitty jumpAdult: She is jumping.

c. Expand the statement adding newin formrion.Chikk kitty jumpAdult: The dog is jumping, too.

2. Respo id by indicating the truth value of thechild's utterance, rather than its linguisticaccuracy (or inacct. acy).

Child: kitty jumpAdult: Yes, the kitty is jumping.

25

The long-term outlookHow do speech- and language-impaired children fare

in adolescence and adulthood9 Most followup studiesindicate that speech disorders tend to be outgrown byadolescence, but that difficulties involving language use,production, or understanding can persist into adult-hood.

One study from the University of Iowa examined 36adults, 18 of whom had been diagnosed as speech-disordered and 18 as language-disordered when theywere children. Nine of the language-disordered childrenstill had communication and learning difficulties inadulthood, compa,ed to only one in the speech-dis-ordered group.

A Cleveland-based study of 63 preschoolers withspeech and language disorders found that 5 years afterinitial diagnosis, 40 percent of the children still hadspeech and language problems, and 40 percent had otherlearning problems such as below normal achievementin reading and in math. NINCDS-supported scientists

1 at the University of California at San Diego are nowconducting a study of 100 language-impaired 4-year-olds

1 to see how they fare up to 5 years after identificationof their language problems. Preliminary results suggestthat children with only expressive language lasses havea lower risk of long-term problems than do children withboth expressive and receptive impairments.

The promise of researchScientists are pursuing research leads that promise

improved therapy for children with speech and languagedisorders. Studies of these disorders are supported byNINCDS, other Federal agencies including the NationalInstitute of Mental Health and the National Instituteof Child Health and Human Development, and privatcand medical institutions.

The brain's organization. Studies of cell structure inthe brains of dyslexic individualsotherwise normalpeople who have extraordinary difficulty learning AI:o

26

readshow that speech and language disorders may becaused by abnormal development of the brain's lan-guage centers sometime before or soon after birth.

"From the middle of gestation until about the firstor second year, the actual floor plan of the brain is beinglaid down, " says one of the NINCDS grantees whoconducted these studies at Boston's Beth Israel Hospital.

Using a technique called cytoarchitectonics, in whichthe actual structure and arrangement of cells is revealed,the investigators examined the brains of seven adultswho had been diagnosed as dyslexic. They found a seriesof abnormalities in the cerebral cortex. These includedectopias, neurons found in the language centers of thebrain that seem to have arisen elsewhere and migratedto the wrong area; dysplasias, or misshapen neurons;and so-called brain warts, neurons that are nodular inappearance. The brains also failed to show the normaldegree of asymmetry.

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:3 27

......I ein imaging techniques mayreveal the site of soundprocessing.

.....

Other methods are being used to study how the brainmay be abnormal in children with speech or languagedisorders. Some scientists are using brain imaging tech-niques to try to locate the site of auditory processingin the brains of children with expressive and receptivelanguage impairments. These investigators hope to pin-poim regions where speech sounds are processed andto see how those regions differ between language-impaired and normal children.

The genetic connection. Speech and language prob-lems seem to run in families. T1 is could be accountedfor by environmental influences: a home in which lan-guage is misused is a home where children develop poorlanguage skills. But most scientists think there may bea large genetic component. Investigators are now study-ing families with speech and language problems to findout how these disorders are inherited.

i

Scientists studying speech and language problems have developed acomputer program that translates speech into a visual pattern so a childcan see the difference between certain sounds

28 3 ;

This child is being asked to 'member and repeat the hard to-pronounce, nonsense name of the stuffed monks Her responses

help si emus characterize different patterns of iconi asindancein langi,Goe-delaved and normal childlen

Speeding things up. Some lan&uage disorders mayoriginate in the abnormally sloss rate at sshich thx.brain is able to process information. To test this theory,scientists are experimenting ith ssays to train language-impaired cluldren to process speech and language morerapidly. NINCDS grantees at the Uniei.aty of Califor-nia at Sa Diego are using computers to teach childrento hear the most subtle sound shiftssuch as those thatdifferentiate ba from daby exaggerating those differemes. The computer produce and gradually speedsup speech sounds until the children can hear the ba 'dadistinction at the raft. at %khich u ocLurs in ordinaryconversation.

I29

Some language-delayed children avoid words that arehard to pronounce. In an NINCDS-supported study ofword avoidance, scientists at Purdue University are ask-ing both normal and language-delayed children to saythe hard-to-pronounce nonsense names assigned tounusual objects and toys. By characterizing the patternsof word avoidance in the two groups, the scientists hopeto devise improved treatment methods for the language-delayed children.

As scientists learn more about how the normal braincontrols language and initiates speech they will alsodiscover just what goes wrong in brains when problemsarise. After the underlying mechanisms are detected,investigators hope to develop new treatment techniquesto help the millions of children whose thoughts andfeelings are poorly expressed.

Where to get helpA number of private organizations have been set up

to help people with speech and language disorders.These organizations distribute educational materialsand, in some cases, provide lists of treatment experts.For more information, call or write to the followingorganizations:

American Speech-Language-Hearing Association10801 Rockville PikeRockville, MD 20852(301) 897-5700

The Council for Exceptional ChildrenDivision of Children with Communicati in Disorders1920 Association DriveReston, VA 22091(703) 620-3660

National Association for Hearing and Speech ActionSuite 10006110 Executive BoulevardRockville, MD 20R52(301) 897-8682

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National Easter Seal Society, Inc.2023 West Ogden AvenueChicago, IL 60612(312) 243-8400

The Orton Dyslexia Society, Inc.724 York RoadTowson, MD 21204(301) 296-0232

Tourette Syndrome Association42-40 Bell BoulevardBayside, NY 11361(718) 224-2999(800) 237-0717 (toll frec)

NINCDS informationFor more information about the research programs

of the NINCDS, contact:

Office of Scientific and Health ReportsNational Institute of Neurological andCommunicative Disorders and StrokeBuilding 31, Room 8A-16National Institutes of HealthBethesda, MD 20892(301) 496-5751

3 4 31

Language Milestones*

Child's age Speech behavior the child should havemastered

1 year Says 2 to 3 words (may not be clearlypronounced)

Repeats same syllable 2 to 3 times("ma, ma, ma")

Carries out simple direction whenaccompanied by gestures

Answers simple questions withnonverbal response

Imitates /oice patterns of others

Uses single word meaningfully to labelobjec: or person

2 years Says 8 to 10 words by age 1, 10 to15 words by age 2

Puts two words together ("morecookie, " "where kitty?")

Points to 12 familiar objects whennamed

NameF 3 body parts on a doll, self, oranother person

Names 5 family members includingpets and self

Produces animal sound uses soundfor animal's name (cow is"moo-moo")

Asks for some common food items byname when shown ("milk, ""cookie, " "cracker")

*(Adarcd from the Portagc Guide to Early Education, f..1976,Coorerative Educational Service Agency.)

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3 years

4 years

Produces two-word phrases combiningtwo nouns ("ball chair"), noun andadjective ("my ball"), or noun andverb ("daddy go")

Uses no or not in speechAnswers where, who, and whatquestions

Carries out a series of two relatedcommands

Consistently uses verb form("running"), regular plural form("book/books"), and some irregularpast tense forms ("went, " "did, ""was")

Uses is and a in statements ("This is aball.

Uses possessive form of nouns("daddy's")

Uses some class names ("toy, ""animals, " "food")

Uses a vocabulary of 200 to 300 words

Uses is at beginning of questions whenappropriate

Carries out series of two unrelatedcommands

Expresses future occurrences withgoia_to, have to, want to

Changes word order appropriately toask questions ("Can I?" "Does he?")

Uses some common irregular plurals("men, " "feet")Tells two events in order of occurrence

[6 33

Carries out series of three directions

Demonstrates understanding of passivesentences ("Girl was hit by boy. ")

Uses compound and complex sentences

Uses contractions can't, don't, won't

Points out absurdities in picture

Tells final word in opposite analogies

Names picture that does not belong inparticular class ("one tha"s not ananimal")

Tells whethff two words rhyme

6 years Points to some, many, several

Tells address and telephone number

Tells simple jokes

Tells daily experiences

Answers wl_y question with anexplanation

Defines words

Photograph Credits:Bill Branson, NIH, cover I. pages 2, 17, 19, 20, 24, 28.

Howard Harmer, N1H, pages 6, 8, 10.

Boys Town Institute for Communication Disorders in Children.Omaha, Nebraska, page 12.

James Robinson. Tots. Inc., The Bronx, New York, page 22

Dr. Albert M. Galaburda, Dyslexia Research Lab., Beth IsradHospital, Boston, Massachusetts, page 27.

David Umberger. Purdue University, West Lafayette, Indiana,page 29.

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