speech and language development and disorders in children

8/2/2019 Speech and Language Development and Disorders in Children.

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Speec h and LanguageDevelopment and

Disorders in Children

Helen M. Sharp, PhD*, Kathryn Hillenbrand, MA

Communication is the exchange of information using a socially accepted system of

symbols and behaviors. Although humans communicate with gestures, posture, and

facial expression, most human communication relies heavily on converting ideas

into language that is written or spoken. Spoken communication is received by the

listener through hearing. Language is a socially agreed on, rule-governed system of

symbols that is used to represent ideas about the world. Language includes shared

understanding of what words mean (semantics); the capacity to change words in

systematic ways, such as adding s to the end of a noun to make it plural (morphol-ogy); and rules that govern word order in a sentence (syntax).1 The use of language as

a social tool (pragmatics) involves a complex set of rules about using eye contact,

interpreting nonverbal messages together with words that may have a different literal

meaning, structuring requests that are polite, and sustaining conversation topics.

Language disorders are identified when a person has difficulty with expressive

language (sharing his or her thoughts and ideas), receptive language (understanding

what others say), or pragmatic language (the social use of language).1

Speech is the oral means of communicating language. Speech is produced through

the complex coordination of respiration and laryngeal, velopharyngeal, and articula-

tory movements. Respiration provides the air pressure to initiate sound productionthrough vocal fold vibration at the larynx. Sound from the larynx together with airflow

are then directed nasally or orally by the velopharynx and shaped by the other articu-

lators (eg, tongue, lips, teeth, and jaw) to create speech sounds. When these sounds

are sequenced together, listeners are able to recognize words and sentences. Speech

production can be categorized into three main areas: voice, fluency, and speech intel-

ligibility, which includes articulation and speech resonance.1 Voice quality reflects the

sound produced by the vocal folds, a function that is influenced by respiratory

support. Fluency refers to the rhythm and rate of speech, whereas articulation refers

Department of Speech Pathology and Audiology, Western Michigan University, 1903 WestMichigan Ave., MS 5355, Kalamazoo, MI 49008, USA* Corresponding author.E-mail address: [email protected] (H.M. Sharp).

KEYWORDS

Child language Developmental disabilities Articulation Apraxia Cleft palate Autism Speech-languate evaluation Speech therapy

Pediatr Clin N Am 55 (2008) 11591173doi:10.1016/j.pcl.2008.07.007 pediatric.theclinics.com0031-3955/08/$ see front matter 2008 Elsevier Inc. All rights reserved.
mailto:[email protected]://pediatric.theclinics.com/http://pediatric.theclinics.com/mailto:[email protected]


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to the coordinated movement of the articulators to produce the consonants and

vowels we recognize as speech. For example, children must learn how to combine

laryngeal and articulatory control to differentiate sounds such as b from m, which

use lip closure, but m is produced nasally, whereas b involves stopping and

releasing airflow through the oral cavity. Speech disorders are identified when

a persons voice, fluency, or articulation call attention to the speaker because his or

her speech is sufficiently different from the norm.1

Hearing is the conduction of sound from the environment through the outer, middle,

and inner ear to the brain where the signal is interpreted. Hearing is an essential ele-

ment in the development of oral speech and language. Those who have hearing loss

can be expected to have difficulty developing and maintaining speech and language

skills for oral communication (see the article by XX found elsewhere in this issue).

TYPICAL DEVELOPMENT OF SPEECH AND LANGUAGE

Infants recognize parents voices and respond to adult speech from birth. Infantsproduce voice when they cry, and gradually begin to gain voluntary control over respi-

ratory and laryngeal function to produce prespeech sounds. As oral, laryngeal, and re-

spiratory control develop, babies begin to produce vowel-like sounds (cooing)

between 1 and 4 months of age, and this progresses to production of definitive vowel

sounds along with other oral productions such as raspberries typically between 3 and

8 months of age. Babbling or the sequential production of a consonant and vowel

(eg, babababa) occurs between 5 and 10 months of age.2 The speech sounds m,

b, and p are often produced early because they are produced anteriorly in the

mouth and are therefore easy to imitate. Before true words emerge, infants string

together longer sequences of consonants and vowels and begin to add the inflectionsof their native language. This pattern of output is called jargon.3

While the infant is learning to exert control over the respiratory, vocal, and articulatory

mechanisms, she is also listening to and perceiving the language spoken around her.

Infants who have normal hearing thresholds respond to the human voice and reinforce

caregivers by attending to their speech and smiling. Adults adopt a higher pitched voice

with greater inflection and prolongation of vowel sounds when speaking to infants, and

this style of speech is referred to as motherese4 and, in some contemporary literature,

as parentese. Infants are also reinforced by hearing their own prespeech cooing,

babbling, and jargon. When infants are severely hearing impaired, early vocal behaviors

are often present but may stop developing or extinguish.5

Language comprehension nearly always precedes language expression.3 For

example, an 8-month-old infant may turn his head and look at his father when asked,

Where is Daddy? but will not yet be able to say Daddy. A true word is produced

when an infant uses the same sound sequence consistently to refer to the same thing,

but this word may be recognizable only to the parent; for example, baba is bottle

and ba is ball. Most infants produce at least one true word between 10 and

15 months of age. After the infant begins to say true words, her expressive vocabulary

should expand steadily. By age 2 years, toddlers should have an expressive vocabu-

lary of at least 50 words and should start to combine words together in two-wordphrases such as Mommy up. The typical milestones for the development of

language comprehension and expression are summarized in Table 1.

DELAYS AND DISORDERS OF SPEECH AND LANGUAGE

Many congenital, genetic, and environmental conditions are known risk factors for

speech and language delays and disorders. Some conditions, such as cleft palate,

Sharp & Hillenbrand1160


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are identified at birth and yield clear opportunities to initiate early intervention. For

many disorders of speech (eg, stuttering) and language (eg, autism), however, there

are some familial and environmental links but, at this time, no definitive risk factors

or clearly understood underlying etiologies. Therefore, most speech and language

delays and disorders are not evident until the child reaches a developmental point

at which typical milestones are noted to be absent. Thus, many speech and language

disorders are identified during the toddler years by parents and pediatricians.

For purposes of simplicity, the authors divided the discussion of specific disorders

into disorders of speech production and disorders of language, but it is important to

note that for many children, this distinction is blurred. For example, cleft palate is a dis-

order of a structure that is integral to speech production. Although production of

speech is the primary concern for most children who have cleft palate, these children

have an increased likelihood of impaired language performance and reading prob-

lems.68 Similarly, children who have Down syndrome often have a principal delay in

language acquisition that is accompanied by delayed learning of speech sounds.9

Children who have Down syndrome may also demonstrate distorted speech sound

productions related to oral structural differences. When there is overlap between

disorders of language and speech, the authors discuss the issues in the context of

the primary domain (ie, speech or language) and discuss overall communication

function, as well as feeding and swallowing disorders.

DISORDERS OF SPEECH PRODUCTION

Any change to the structures or physiologic function of the speech mechanism can

result in disorders of speech. Most speech disorders in children relate to functional

mislearning or are caused by organic anomalies that affect oral, pharyngeal, or laryn-

geal structures or neuromuscular functions. Oropharyngeal anomalies include macro-

glossia, asymmetries related to hemifacial microsomia, or cleft palate. Laryngeal

changes include alterations to the vocal folds, such as laryngeal papilloma or intuba-

tion trauma. Vocal pathology is relatively rare in children, so laryngeal changes are not

discussed here. Any child who has an unusual voice quality should be referred to

otolaryngology to rule out structural disorders of the larynx. Speech disorders occur

when there is disruption in the neuromotor coordination of respiration, laryngeal,

and articulatory functions, seen, for example, in muscular dystrophies and in many

forms of cerebral palsy. Because speech is a representation of a language system,some disorders or disruptions of speech may actually be symptoms of an underlying

language learning problem, particularly when the disorder relates to learning the rules

that guide the sound system of the childs primary spoken language (phonology).

Cleft Lip and Palate

Clefts of the lip and palate are among the most common congenital anomalies, occur-

ring in approximately 1 in every 600 live births.10 Intact palatal structures are critical

for the development of normal speech because the hard palate and soft palate (velum)

act to separate the oral cavities from the nasal cavities. The velopharynx closes to

direct airflow orally for most speech sounds and opens to permit nasal resonanceon nasal speech sounds (in English: m, n, and ng). When dynamic function of

the velopharynx is disrupted, speech is hypernasal in quality. Samples of hypernasal

speech are available through the American Cleft PalateCraniofacial Associations

Web site.10

One of the most commonly identified syndromes in individuals who have cleft

of the secondary palate is velocardiofacial syndrome (also called 22q;22q1113,

Speech and Language Development and Disorders 1161


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Table1

Summary of prespeech, speech, and language milestones in the first 5 years of life

Age Language Comprehension Skills Expressive Speech and Lan

Birth3 mo Startles to loud soundsQuiets or smiles to familiar voiceIncreases or decreases sucking behavior in response

to sound

Coos to indicate pleasurUses different cries for dSmiles when sees familia

48 mo Localizes to sound

Reacts to changes in tone of voiceIs aware that toys that make soundsAttends to music

Begins to produce clear

Imitates adult mouth momovements (eg, raspbBabbles alternating cons

b, p, and mUses voice to communicaGurgles when alone and

714 mo Listens to speech and localizes to soundDiscriminates between speech sounds in native languageRecognizes words for common items such as daddy

or juiceResponds to some requests such as Want more?Enjoys social turn-taking games such as peek-a-boo

Babbles with short sequAdds sounds k, g, t,Uses speech or noncryinUses one or two true wo

12 y Identifies at least a few body partsFollows simple commands in context such as Throw the ball.Understands simple questions in context such as Wheres

your sock?Listens to stories, songs, and rhymesPoints to familiar pictures in a book

Uses at least 10 words bUses many different conSimplifies adult speech b

or word endingSteadily increases vocabBegins to combine wordGirls tend to be slightly


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23 y Follows two-part commands such as Get your shoeand give it to me.

Consistently identifies body parts

Speech is understood byHas a word for almost evUses two- to three-wordUses speech to get attenMay repeat starting phra

not get stuck or frustr

34 y Understands easy wh questions and gives appropriateresponse to who, what, where, and why formsLearns vocabulary and sentence structure from adult

conversation and being read to

Unfamiliar listeners can Can describe events thatUses longer sentences ofUsually talks fluently wit

45 y Attends to and understands short storiesCan answer questions about a storyUnderstands most of what is said in home, preschool,

and school environments

Voice sounds clearUses sentences that give Tells stories that stick toCommunicates easily anSays most sounds correctl

and z, which may noUses regional or familys

Data from Refs. 13,21,51


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Shprintzens syndrome, or DiGeorge syndrome).11 This syndrome is characterized by

a triad of symptoms: velopharyngeal dysfunction (with or without a frank palatal cleft),

cardiac anomaly, and learning difficulties including language delay. Any child who has

a cleft and any history of cardiac involvement, from a mild murmur to cardiac surgery,

should be evaluated for this syndrome.12 Other genetic and craniofacial disorders are

addressed in this issue (see the article by XX found elsewhere in this issue).

Although most clefts are recognized at birth, some microforms of cleft palate may

go unnoticed or unreported, particularly if they are not symptomatic during feeding.

Any infant who has persistent nasal leakage associated with feeding and any child

who has persistent hypernasal speech should be evaluated for submucous cleft

palate.13 Careful evaluation of palatal structure is also advisable before a child

undergoes adenoidectomy because velopharyngeal closure for speech often occurs

at the level of the adenoid. Any child who has persistent hypernasality 4 to 6 months

after adenoidectomy should be referred to a speech-language pathologist affiliated

with a cleft palate team to determine whether the child is physically able to achieve

velopharyngeal closure. When physical closure is evident on some speech sounds,

the child is a candidate for behavioral intervention, but if the child can never achieve

closure, then other physical management strategies must be explored.

Speech Disfluency or Stuttering

Stuttering is a disruption in the expected rate or fluency of speech that can include

prolongations of sounds in words, use of filler words such as um, difficulty with start-

ing to speak (blocks), and repetitions. Repetitions may vary from repeating one speech

sound (often in word initial position, such as s-s-sunny), syllables, words, or phrases

(I want, I want, I want an ice cream). Stuttering occurs more often in boys than in girlsand appears to have an underlying genetic component.14

Some disruptions in the fluency of speech are expected in all speakers because

speech is an immensely complex coordinated motor activity. Effortless repetitions

of syllables, words and phrases are observed to increase in young children during

the time at which they begin to produce complex utterances and may persist for

a period of a few months. In a typically developing child, this period of developmental

disfluency occurs between 2 and 3 years of age.15 Referral for a speech evaluation

should be made when a child has a positive familial history or demonstrates any of

the following characteristics: prolonged disfluency (>6 months), self-awareness of

talking difficulty, avoiding talking, tense pauses in speech, blocks, or extraneous facialor body movements while talking or when trying to initiate speech.16

Childhood Apraxia of Speech

Childhood apraxia of speech (CAS) is characterized by impaired volitional motor

programming for speech production in the absence of paralysis or weakness of the

oral musculature.17 It may be associated with known neurologic impairment or may

be idiopathic. A cardinal sign of CAS is inconsistency in speech production: a child

may be able to produce a speech sound or a sequence of sounds one moment and

then be unable to do so the next. The childs connected speech is likely to be limited

to vowel sounds and speech that appears to be effortful. Children who have CAS areoften described as groping for accurate placement of the articulators when they try

to produce consonant speech sounds. The difficulty executing oral movements for

speech often corresponds with a significant delay in speech development in a child

who has intact auditory comprehension skills.

Children who have CAS may develop methods of communication that do not rely on

speech to express themselves, for example, pointing, grunting, and idiosyncratic



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gestures or manual sign language.17 Parents of children who have CAS often describe

the frustration that the child experiences related to the inability to express his or her

needs. Caregivers also become frustrated as they work to decipher what the child

is trying to communicate. As a result, communication may not be a positive experience

for children who have CAS, and some children may resort to using negative behaviors

(eg, hitting) to communicate. When a child demonstrates inconsistent production of

consonants and vowels on repeated productions of syllables or words, lack of smooth

transitions between sounds and syllables, or inappropriate inflection patterns

(prosody), he should be referred for a full speech and language evaluation.17

Speech Delay or Disorder

It is typical for a child who is learning to speak to simplify adult productions of words

and speech sounds. For example, a child might say efun instead of elephant.

Many of these simplifications should begin to reduce by 24 months of age and be

eliminated by 36 months of age among children who do not have musculoskeletal

anomalies.18 Most children should be attempting most speech sounds by age

36 months, but many sounds such as s, th, ch, sh, f, v, l, and r

continue to be perfected in conversational speech beyond age 4 years.19,20

Children should be 50% intelligible by age 36 months and about 75% intelligible by

age 48 months.21 Persistent speech production problems may reflect difficulty with

learning or coordinating articulatory placement for individual sounds (eg, th for s),

which is called an articulation disorder. Alternatively, children may have mislearned

the rules that guide the sound system (phonology) in their native language. Children

who have a phonologic disorder tend to demonstrate recognizable patterns of speecherrors such as omitting syllables in multisyllabic words (banana becomes nana), us-

ing front sounds (t and d) to substitute for speech sounds usually produced at the

back of the mouth (k and g), or deleting all final consonant sounds in words.22

Formal assessment and detailed analysis of speech sounds are often necessary to

differentiate articulation problems from phonologic disorders of speech production or

from CAS. Children who have persistent difficulty with speech intelligibility beyond age

36 months should be referred for a comprehensive evaluation of speech and

language.

DISORDERS OF LANGUAGE

Autism

Autism is one of the most frequently diagnosed communication disorders, with

estimates that 1 in every 150 children is affected.23 The wide range and severity of

symptoms within the autism spectrum disorders (ASD) include classic autism,

Aspergers syndrome, Rett syndrome, childhood disintegrative disorder, and perva-

sive developmental disorders.

Autism is a complex condition characterized by a wide range of symptoms that can

include communication problems such as lack of expressive eye contact with care-

givers, reduced interest in vocal exchange with caregivers, lack of recognition ofand response to caregivers voices, onset of babbling after age 9 months, decreased

or absent prespeech behaviors such as social waving, alterations in speech rate and

rhythm, and failure to develop speech.24,25 The most common characteristic across

individuals who have autism is difficulty in the social use of communication and lan-

guage (pragmatics). Pragmatic problems may include impairment in understanding

and using nonverbal communication, reduced understanding of spoken or symbolic



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communication, and problems interpreting metaphoric language. Children who have

autism may also demonstrate problems with reading and writing.24

The American Academy of Pediatrics published several clinical reports related to the

pediatricians role in the early identification, evaluation, and management of

autism.25,26 As part of its Autism Listen Act Refer Monitor screening program,23 the

American Academy of Pediatrics recommended screening starting at the 9-month

visit, with autism-specific screening at the 18-month visit using the following red

flags to initiate comprehensive evaluation:

Lack of babbling, pointing, or other gestural communication by age 12 months

Lack of the use of single words by age 16 months

Lack of two-word novel phrases by age 24 months

Loss of language or social skills at any age

Greenspan and colleagues27 recommended a broader functional framework for

identifying children at risk for ASD that focuses on a childs ability to initiate and sus-tain engagement, demonstrate social reciprocity with caregivers, and solve social

problems with caregivers through use of gestures to communicate and negotiate

getting desired items. The goal of early identification is to initiate early intervention,

which has been shown to improve outcomes for children who have ASD.28

Specific Language Impairment

Specific language impairment (SLI) is a delay in the acquisition of expressive language

in a child who has no known hearing, neurologic, or physical problems and occurs in

the presence of normal nonverbal intelligence.29 Children who have SLI exhibit smaller

vocabularies, use shorter utterances, omit grammatical endings and function words,

and demonstrate more grammatical errors than their same-aged peers. An epidemio-

logic study identified a prevalence of 7.4% (8% boys; 6% girls) among children in kin-

dergarten.29 Of those who had SLI, parental awareness of a speech or language

problem was 29%.30 SLI appears to have a genetic component, because children

who have SLI are more likely than typically developing children to have a relative

who has a language disorder.30,31 SLI is also linked to parent education and income.29

Early identification of SLI in young children is important because the language deficits

are associated with academic problems, particularly the acquisition of literacy skills.32

Central Nervous System Injuries

Focal brain injuries such as intracranial hemorrhage can occur in infants, toddlers, and

throughout childhood. Diffuse injuries may occur through blunt head trauma, penetrat-

ing injuries, or abuse. Any damage to the developing brain can negatively affect cog-

nition, memory, attention, learning, language comprehension, language production,

and pragmatic language and can disrupt motor control and motor programming for

speech and swallowing.3336 Although it has been suggested that young children

have greater neural plasticity for mapping new learning, the evidence suggests that

earlier age of injury is associated with poorer long-term outcomes.33

Communication problems associated with brain injury can range from a minimalreduction in speech intelligibility to profound impairments of language and cognition

that limit communication in activities of daily living. The long-term outcome of very

early injury to the cortex is often classified generally as cerebral palsy. Depending

on the timing, site, and extent of cerebral damage, speech intelligibility is likely to

be affected because of imprecision and discoordination of the respiratory, laryngeal,

and articulatory movements for speech. As a result, speech may be limited to a few



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syllables per breath, with inconsistent loudness and inflection, and vocal quality may

sound strained or breathy. Speech resonance may sound hypernasal, which is related

to poor coordination of the velopharyngeal mechanism. Children who have difficulty

producing speech due to central nervous system damage will likely also have prob-

lems manipulating food for chewing and bolus control and may have difficulty coordi-

nating laryngeal closure for airway protection during swallowing.37 In addition to oral

motor difficulties that affect speech and swallowing, some children who have cerebral

palsy have hearing loss and others have cognitive impairments that impact auditory

comprehension and language development. Children who have sustained focal or

diffuse injury to the brain in infancy or early childhood should be monitored by an

interdisciplinary team that can evaluate the child across a spectrum of skills related

to cognitive, speech, language, and motor skill development.

Social Environmental Risks for Language and Cognitive Development

Children need a stimulating home environment from early in life, and the languagelearning environment has the potential to affect a childs capacity to acquire language.

Children who experience traumatic events are known to be at risk for disrupted devel-

opment.38 Children who have postnatal traumatic stress combined with prenatal alco-

hol exposure have lower intelligence scores and more significant neurodevelopmental

deficits, greater oppositional defiant behavior, and greater problems with attention

and social interaction than traumatized children who do not have alcohol exposure.38

Children who are known to have been neglected or abused are candidates for

a comprehensive evaluation of cognition, development, language, and social develop-

ment, ideally through an interdisciplinary pediatric team that specializes in working

with children who have this history.

International Adoption

When children are adopted internationally, they most often experience an abrupt

change in language exposure from their native language to the language of the adoptive

family. This sudden change has been termed arrested language development.39

Language acquisition theories suggest that the older a child is at the time of adoption,

the more likely it is she will have difficulty acquiring the new language. Age at adoption

may also be mediated by the length of time a child was cared for in an institution.40

Glennen41 reported that older children catch up with their peers more slowly than a co-hort of children adopted at younger ages, whereas other researchers have found that

age at adoption is less predictive than time since adoption.42

Parents who adopt children internationally often have questions about what to

expect with respect to language acquisition. A speech-language pathologist can con-

sult with the family to review these expectations, particularly when the child has

a known medical condition such as cerebral palsy or cleft palate. When a child is at

significant risk for ongoing speech and language difficulties, therapy may be initiated

shortly after adoption; however, when a child appears to be following a typical devel-

opmental trajectory, an evaluation of speech and language skills conducted within the

first 3 to 6 months after adoption is likely to be inconclusive. Parent-report and com-pleted inventories such as the MacArthur-Bates Communicative Development Inven-

tory are strongly correlated with other clinical assessment techniques, at least during

the first year post adoption.42 Sequential administration of this parent-report of recep-

tive and expressive language skills can provide a child-specific baseline and measure

of acquisition of language skills over time and offer the advantage of monitoring

speech and language skills without repeated appointments at the speech clinic.



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SPEECH-LANGUAGE EVALUATION

Speech-language evaluations vary in scope depending on the reason for referral but

should provide a comprehensive assessment of speech production and receptive

and expressive language skills. A comprehensive audiologic evaluation is ideal, but

a hearing screening meets the minimal requirement to rule out hearing loss as a con-tributing factor to speech sound disorders or language impairments. Examination of

oral structures and functions also serves to rule out structural contributions to speech

sound distortions and weakness or paralysis of the tongue or soft palate that would

contribute to speech disorders and swallowing difficulty.

Speech and language skills in children must be assessed within a developmental

framework; thus, information from the parents and pediatrician about the childs over-

all development is critical. The childs medical, developmental, and psychosocial his-

tories are obtained before the evaluation by chart review, parent interview, or both.

Interdisciplinary team contexts often allow a richer understanding of the childs devel-

opment, the family system, and any medical or dental issues.The goal of the evaluation is to assess the childs speech and language function

relative to age and developmental expectations. Each evaluation is tailored to the fam-

ilys concern and the childs needs, although a child who has a speech problem may

exhibit decreased speech intelligibility as a sign of an underlying language impairment,

so all domains should be evaluated using observation or structured assessment tasks.

The evaluation begins in the waiting room as the speech-language pathologist notes

the childs eye contact, use of social greetings, shyness, or willingness to engage in

play. Assessments may include observing the parent-child interaction, involving the

child in play activities to elicit a spontaneous speech and language sample, and

administering a standardized test of articulation, comprehension, and expressivelanguage use. Requests made in play or structured activities, such as Put the balls

under the bucket, allow assessment of the childs understanding of nouns (ball

and bucket), plurals (more than one ball), and prepositions (under). Similarly, struc-

tured tasks allow assessment of the childs use of language concepts. For example,

pointing to a picture and asking, Whose shoes are those? should elicit a response

such as The boys that demonstrates use of the possessive form.

Articulation tests allow the speech-language pathologist to elicit all the speech

sounds in the language in each word position, within a few minutes. This process

yields an inventory of speech sounds that the child uses and those on which she

makes errors. These data can then be evaluated to identify common features across

the speech sounds and allow comparison with normative data.

The speech-language pathologist evaluates all the data obtained and should review

the findings with the parents at the time of the evaluation or at follow-up. Recommen-

dations may include no further assessment or treatment, waiting and re-evaluating,

giving parents some tips for facilitating communication at home, or direct service

intervention.

TREATMENT

When therapy is recommended, the primary goal is to give the child a reliable way to

exchange ideas and information in his daily social and educational environment. Treat-

ment is tailored to the specific communication needs of each child, which vary with

disorder type and severity, the childs age, and the etiology of the problem. Any

speech or language intervention requires that the childs family and educators be

involved to provide ongoing support for the child outside of the clinical setting.



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Therapy for Speech Disorders

Treatment for articulation impairments targets the correct production of specific

consonant or vowel sounds, whereas treatment for systematic mislearning of the pho-

nologic system in the language addresses the patterns of error, rather than teaching

each sound individually.43

After production of target sounds is achieved in structuredcontexts, treatment addresses generalization of sounds into more natural speaking

tasks. Treatment for CAS differs from the approaches used for articulation or phono-

logic problems and often requires intensive treatment over a longer course of therapy

than treatment for children who have other speech sound disorders.44

Isometric oral-motor exercises have often been recommended to strengthen and

increase range of movement in the oral mechanism. Because few speech production

disorders relate to muscular weakness or reduced range of motion, the finding of

limited efficacy of oral exercises is not surprising.45

Therapy for Language DisordersChildren can exhibit language problems in a number of areas including expressive lan-

guage, receptive language, written language, and social (pragmatic) language. The

goals of language therapy and the approaches used are based on the results of a com-

prehensive language evaluation. Children up to age 3 years are likely to benefit from

a focus on language using play-based therapy in which the child and a parent

participates as the speech-language pathologist creates an environment rich in

opportunities to communicate.46 As the child is reinforced for using new behaviors

to communicate in this semistructured play setting, the child begins to learn the social

power that these new behaviors bring. This setting also is valuable in demonstrating to

the parent language stimulation activities to use at home.

Older preschoolers and school-aged children can benefit from individual or group

therapy that focuses on their specific language needs (ie, vocabulary, longer word

combinations, or the use of more grammatically complex utterances). It is critical

that structured language intervention be extended into functional contexts for chil-

dren, including the school curriculum, to promote generalization of skills into natural

communication settings. When the goal of therapy is to increase social language skills,

children are often enrolled in group therapy, which provides natural opportunities for

supported interaction with peers when working on language and written

communication.

47

Therapy for the Child who is Nonverbal

When a child is not able to use speech to communicate, the primary goal of speech-

language therapy is to establish a reliable means of communication using the childs

capacity for communication skills, which may include the use of gestures, idiosyn-

cratic signs, more formal baby signs, or an established manual sign language. It

is important that treatment provide the child opportunities for communicative success,

irrespective of the communication modality used. As the child develops a reliable way

to communicate basic needs, nonspeech techniques are expanded to allow for max-

imal expressive language development. Speech models are given simultaneously asthe child works on nonspeech communication to continue to provide opportunities

for developing speech production skills; most children demonstrate increased speech

production as their communication skills increase.48

Some children do not develop functionally adequate speech communication due to

neuromotor, structural, or cognitive impairments. Children who have severe impair-

ments in speech production may benefit from the use of communication



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technology, ranging from the use of a picture communication board to a speech-

generating device to a computer-based system that features access to word process-

ing and voice output.49 A speech-language pathologist can provide evaluation and

intervention for the use of alternative communication systems to determine the level

and type of technology that best fits the childs daily communication needs.

THERAPYAPPROACHES AND SETTINGS

Early intervention services are available to at-risk children from birth to age 3 years.

Many programs in county-based school systems provide interdisciplinary evaluation

and treatment teams through center-based or in-home services. Children in preschool

through high school are most often served by speech-language pathologists in the

community or through the school system. School services may be defined for those

children identified as having a speech or language deficit (or both) that would interfere

with their education. Based on the evaluation findings and recommendations, an

Individualized Education Program (IEP) is written, which specifies the goals andfrequency of therapy to be implemented through school services.46 In the school set-

ting, children receive services individually or in small groups, based on the IEP. Chil-

dren aged 0 to 26 years who have severe communication or cognitive impairments

may receive services through a center-based program operated by a regional school

district. These centers provide comprehensive educational day programs that

integrate therapy services in an interdisciplinary team model.

Many communities have independent speech-language and hearing centers

through hospitals, rehabilitation centers, outpatient clinics, and private practices.

In addition, universities with speech-language and hearing training programs may

have a clinic on campus that serves as a training site for students in their prepro-

fessional education and can serve as a resource for patients who have limited in-

surance coverage or other resources for services not covered through other

agencies.

ENSURING AN EVIDENCE BASE

In addition to broad efforts to conduct outcomes research in the field of speech-

language pathology, many clinical sites participate in the American Speech-

Language-Hearing Association National Outcomes Measurement System, which is

a centralized system designed to track changes in functional communication skills be-tween admission to and discharge from speech and language services. Scales to

measure patient performance across speech and language domains are available to

clinicians in a variety of clinical settings. For example, the preschool scales include

specific measures across the domains of articulation/intelligibility, cognitive orienta-

tion, pragmatics, spoken language comprehension, spoken language production,

and swallowing.50 Aggregate outcomes data are used to examine the value of

speech-language services for policy makers, third-party payers, and consumers

and to provide members information about best practices.

SUMMARY

Speech and language development should be consistent with the childs overall

development and can be tracked using typical milestone markers for comprehension

of language and for expressive speech and language skills. Differential diagnosis

allows for the distinction between overall language delay, language impairments

limited to the expressive domain, and speech production difficulties. Differential



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diagnosis is critical to designing appropriate intervention. Intervention for voice,

speech, and language problems should be tailored to the parents goals along with

the childs clinical and educational needs. Early identification and intervention assist

in educational planning and are often associated with better long-term outcomes.

Any speech-language therapy plan should be designed with measurable goals and

consistent monitoring of progress toward those goals.

ACKNOWLEDGMENTS

Erin McGraw, MA, contributed research and writing of the section on international

adoption. Amy Esh, BA, contributed to the introductory paragraphs and the table of

language development milestones.

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