1. Language and Speech Development

2. CONTINUITY CLINIC Objectives Describe key stages in the development of language and speech Describe key stages in the development of language and speech Know when to refer for further evaluation of speech and language delays Know when to refer for further evaluation of speech and language delays Generate a differential for language and speech delay Generate a differential for language and speech delay

3. CONTINUITY CLINIC Definitions Language – use of systematic, socially agreed upon signals to convey meaning Language – use of systematic, socially agreed upon signals to convey meaning Receptive language – ability to understand Receptive language – ability to understand Expressive language – ability to produce symbolic communication Expressive language – ability to produce symbolic communication Speech – series of vocal sounds used as form of language Speech – series of vocal sounds used as form of language

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5. Correcting Misconceptions about Speech and Language Delay Which of the following are true and which are false? Which of the following are true and which are false? Boys tend to be delayed > 6 months compared to girls Boys tend to be delayed > 6 months compared to girls Children from bilingual households are significantly delayed Children from bilingual households are significantly delayed Otitis Media causes language delay Otitis Media causes language delay Second- and third-borns let their older siblings speak for them Second- and third-borns let their older siblings speak for them

6. CONTINUITY CLINIC Correcting Misconceptions about Speech and Language Delay ALL ARE FALSE!!!!!!!!! ALL ARE FALSE!!!!!!!!! Boys tend to be delayed > 6 months compared to girls Boys tend to be delayed > 6 months compared to girls Boys tend to be only slightly delayed (1-2 months) Children from bilingual households are significantly delayed Children from bilingual households are significantly delayed Children MAY show mild delay and early mixing only! Otitis media causes language delay Otitis media causes language delay Otitis media is associated with language delay Second- and third-borns let their older siblings speak for them Second- and third-borns let their older siblings speak for them Children have strong motivation to speak when able

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8. Background Speech and language delays are the leading developmental concerns in parents of children less than 5 years old Speech and language delays are the leading developmental concerns in parents of children less than 5 years old Of children eligible for Early Intervention, 80% have problems in the communication domain Of children eligible for Early Intervention, 80% have problems in the communication domain 15-20% of young children have a communication disorder 15-20% of young children have a communication disorder

9. Normal Milestones in the Development of Language and Speech

10. Age Receptive Skills Expressive Skills Birth Turns to source of sound Shows preference for voices & interest in faces Cries 2-4 months Coos Takes turns cooing 6 months Responds to name Babbles 9 months Understands verbal routines (wave bye-bye) Points Says ma-ma, da-da 12 months Follows a verbal command Uses jargon Says first words 15 months Points to body parts by name Learns words slowly 18-24 months Understands sentences Learns words quickly Uses 2 word phrases 24-36 months Answers questions Follows 2 step commands Phrases 50% intelligible 3 or more word sentences Asks “what” questions 36-48 months Understands much of what is said Asks “why” questions Phrases 75% intelligble Masters m, b, y, n, w, d, p, h 48-60 months 100% intelligble and tells stories

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12. Risk Factors for Delays Family history - There's a higher risk of continued delay if one of a toddler's parents or siblings had long- term language and learning difficulties. Family history - There's a higher risk of continued delay if one of a toddler's parents or siblings had long- term language and learning difficulties. Otitis media with effusion - causing a fluctuating hearing loss during the period of speech development. Otitis media with effusion - causing a fluctuating hearing loss during the period of speech development. Low socioeconomic status and educational level - These families are more likely to have a child with a poor outcome. Low socioeconomic status and educational level - These families are more likely to have a child with a poor outcome.

13. CONTINUITY CLINIC Warning Signs for Delay little sound play or babbling as an infant, with limited number of consonant sounds and, possibly, vowel distortions as a toddler little sound play or babbling as an infant, with limited number of consonant sounds and, possibly, vowel distortions as a toddler poor verbal imitation skills; reliance on direct model and prompting poor verbal imitation skills; reliance on direct model and prompting immature play skills; little pretend play immature play skills; little pretend play interactions with adults more than peers interactions with adults more than peers few communicative gestures (the late bloomer who caught up with his peers within a year used significantly more gestures than the child who had persistent delay) few communicative gestures (the late bloomer who caught up with his peers within a year used significantly more gestures than the child who had persistent delay) impaired social skills or behavior problems impaired social skills or behavior problems small vocabulary for age; less diverse verb repertoires small vocabulary for age; less diverse verb repertoires comprehension delay of six months or greater relative to chronologic age comprehension delay of six months or greater relative to chronologic age

14. CONTINUITY CLINIC Absolute Indications for Referral no babbling, pointing, or gesturing by 12 months no babbling, pointing, or gesturing by 12 months no single words by 16 months no single words by 16 months no two-word spontaneous phrases by 24 months no two-word spontaneous phrases by 24 months any regression in language or social skills at any age any regression in language or social skills at any age

15. CONTINUITY CLINIC Language Impairment A child with a receptive or expressive language disorder, or both, and no other developmental disability has specific language impairment (SLI) A child with a receptive or expressive language disorder, or both, and no other developmental disability has specific language impairment (SLI) AKA language-learning impairment, developmental language disorder, developmental dysphasia, or developmental aphasia. AKA language-learning impairment, developmental language disorder, developmental dysphasia, or developmental aphasia. Incidence of SLI in 5 year olds - 7.6% (NIH) Incidence of SLI in 5 year olds - 7.6% (NIH) Children with SLI are usually late talkers and most—67% to 84%—are boys. Children with SLI are usually late talkers and most—67% to 84%—are boys. At 3 or 4 years old, most children with SLI have a limited vocabulary and speak in short phrases rather than sentences At 3 or 4 years old, most children with SLI have a limited vocabulary and speak in short phrases rather than sentences The cause of SLI is unknown, but it appears to run in families. If a child has SLI, there is a 25% chance that another family member will be affected. The cause of SLI is unknown, but it appears to run in families. If a child has SLI, there is a 25% chance that another family member will be affected.

16. CONTINUITY CLINIC Speech Disorders Include disorders of articulation and phonology (dysarthria, apraxia, and phonologic disorder). Include disorders of articulation and phonology (dysarthria, apraxia, and phonologic disorder). Articulation - individual speech sounds and how they are pronounced Articulation - individual speech sounds and how they are pronounced All children, not just those with a speech disorder, misarticulate sounds in the course of normal speech development. All children, not just those with a speech disorder, misarticulate sounds in the course of normal speech development. They may use sound substitutions such as "wady" for "lady"; omit sounds, saying "baw" instead of "ball"; or distort sounds, so that "snake" comes out "snek," or "silly" comes out "shhilly." They may use sound substitutions such as "wady" for "lady"; omit sounds, saying "baw" instead of "ball"; or distort sounds, so that "snake" comes out "snek," or "silly" comes out "shhilly." Concern arises when these errors continue beyond the time a child normally outgrows them. Concern arises when these errors continue beyond the time a child normally outgrows them.

17. CONTINUITY CLINIC Speech Disorders Phonologic development - the gradual process of acquiring adult speech Phonologic development - the gradual process of acquiring adult speech The majority of children pick up most phonologic rules by age 5. For example, most children stop deleting the final consonant in words (as when a child says "cuh" instead of "cup") between ages 2 and 3. And children usually outgrow velar fronting by 3 years. An example of velar fronting is, "Mommy, tan you div me one?" (for "Mommy, can you give me one?"). In such cases, the child is replacing consonants made with the tongue moving toward the back of the mouth, such as "k" and "g," with consonants produced at the front of the mouth: "t" and "d." The majority of children pick up most phonologic rules by age 5. For example, most children stop deleting the final consonant in words (as when a child says "cuh" instead of "cup") between ages 2 and 3. And children usually outgrow velar fronting by 3 years. An example of velar fronting is, "Mommy, tan you div me one?" (for "Mommy, can you give me one?"). In such cases, the child is replacing consonants made with the tongue moving toward the back of the mouth, such as "k" and "g," with consonants produced at the front of the mouth: "t" and "d." Children with a phonologic disorder make sound substitutions consistently but, when given auditory and visual cues, are able to imitate correct sounds or words. Usually, they have normal oral muscle tone. Children with a phonologic disorder make sound substitutions consistently but, when given auditory and visual cues, are able to imitate correct sounds or words. Usually, they have normal oral muscle tone.

18. CONTINUITY CLINIC Speech Disorders Dysarthria - motor speech disorders that result from nervous system injury Dysarthria - motor speech disorders that result from nervous system injury There is a lack of strength and control of the muscles used for both speech and non-speech functions, such as smiling and chewing. There is a lack of strength and control of the muscles used for both speech and non-speech functions, such as smiling and chewing. Many children with cerebral palsy have a dysarthric speech pattern, slurring words, distorting vowels, and often producing slow, labored, nasal speech. Many children with cerebral palsy have a dysarthric speech pattern, slurring words, distorting vowels, and often producing slow, labored, nasal speech. Children with dysarthria have difficulty in the actual production of speech sounds. Children with dysarthria have difficulty in the actual production of speech sounds. In particular, they are more likely to distort consonant sounds. This differs from apraxia, in which consonants are omitted. In particular, they are more likely to distort consonant sounds. This differs from apraxia, in which consonants are omitted.

19. CONTINUITY CLINIC Speech Disorders Verbal apraxia - neurologic motor speech impairment that affects the planning, executing, and sequencing of speech movements Verbal apraxia - neurologic motor speech impairment that affects the planning, executing, and sequencing of speech movements Causes a breakdown in the neural transmission of messages to the muscles of the jaw, cheeks, lips, tongue, and palate (no muscle weakness) Causes a breakdown in the neural transmission of messages to the muscles of the jaw, cheeks, lips, tongue, and palate (no muscle weakness) These children may point, grunt, and become increasingly angry at their inability to communicate These children may point, grunt, and become increasingly angry at their inability to communicate Sometimes the same word can come out four different ways. The more these children try to talk, the more stymied they become and the harder they are to understand. Sometimes the same word can come out four different ways. The more these children try to talk, the more stymied they become and the harder they are to understand. They may drop the final consonant in single syllable words: "Cat come home" becomes "Ca co hoe." They may transpose sounds within a word. Instead of saying "elephant," they may say "efelant." They may drop the final consonant in single syllable words: "Cat come home" becomes "Ca co hoe." They may transpose sounds within a word. Instead of saying "elephant," they may say "efelant." Often a history of limited babbling and vocal play Often a history of limited babbling and vocal play

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21. Use of Screening Tools AAP policy statement recommends that pediatricians conduct standardized developmental screening tests on all infants and children at their 9-, 18- and 24- or 30-month well-child visits AAP policy statement recommends that pediatricians conduct standardized developmental screening tests on all infants and children at their 9-, 18- and 24- or 30-month well-child visits Examples: Ages and Stages Questionnaire (ASQ), Parents' Evaluations of Developmental Status (PEDS), Denver II Examples: Ages and Stages Questionnaire (ASQ), Parents' Evaluations of Developmental Status (PEDS), Denver II

23. Evaluation and Management Lead testing for those with dev. delay Lead testing for those with dev. delay Some of these children spend a prolonged time in the oral-motor stage of play Some of these children spend a prolonged time in the oral-motor stage of play An elevated lead level can cause behaviors that resemble developmental delay, autism, and emotional disturbance An elevated lead level can cause behaviors that resemble developmental delay, autism, and emotional disturbance Referral to Early Intervention or Developmental Pediatrician to help prevent later language-based learning disabilities, including reading disabilities (dyslexia) Referral to Early Intervention or Developmental Pediatrician to help prevent later language-based learning disabilities, including reading disabilities (dyslexia)