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Development a nd
Disorder s in Children
Helen M. Sharp, PhD*, Kathryn Hillenbrand, MA
KEYWORDS
Child language Developmental disabilities
Articulation Apraxia Cleft palate Autism
Speech-languate evaluation Speech therapy
Department of Speech Pathology and Audiology, Western Michigan University, 1903 West
Michigan Ave., MS 5355, Kalamazoo, MI 49008, USA
* Corresponding author.
E-mail address: helen.sharp@wmich.edu (H.M. Sharp).
Infants recognize parents voices and respond to adult speech from birth. Infants
produce 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 inflections
of 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-word
phrases such as Mommy up. The typical milestones for the development of
language comprehension and expression are summarized in Table 1.
Many congenital, genetic, and environmental conditions are known risk factors for
speech and language delays and disorders. Some conditions, such as cleft palate,
Speech and Language Development and Disorders 1161
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.
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).
1163
1164 Sharp & Hillenbrand
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
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 of
and 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
1166 Sharp & Hillenbrand
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.
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.
1168 Sharp & Hillenbrand
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 expressive
language 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.
Speech and Language Development and Disorders 1169
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 and
frequency 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.
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
Speech and Language Development and Disorders 1171
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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