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Pediatric Grand Rounds 21 October 2011 University of Texas Health Science Center at San Antonio

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Texas Pediatric Society 2016 Annual Meeting

My Child Isn’t Talking: Speech‐Language Disorders in Children

Nhung T. Tran, MD, FAAP Developmental‐Behavioral Pediatrics Associate Professor BaylorScott&White Health McLane Children’s Hospital Texas A&M University Health Science Center

Disclosures

 Policies and standards of the Texas Medical Association, the

Accreditation Council for Continuing Medical Education, and the American Medical Association require that speakers and planners for continuing medical education activities disclose any relevant financial relationships they may have with any entity producing, marketing, re‐ selling, or distributing health care goods or services consumed by, or used on, patients whose products, devices or services may be discussed in the content of the CME activity.

Disclosures

The planners and speakers have no relevant

relationships to disclose.

I do not intend to discuss an

unapproved/investigative use of a commercial product/device in my presentation.

Pediatric Grand Rounds 21 October 2011 University of Texas Health Science Center at San Antonio

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Objectives

Describe the difference between speech and

language

Describe the screening, evaluation and

management of speech‐language disorders in children

Know how to interpret results of speech‐language

evaluations

Overview

Speech‐language delays are prevalent

 ~10‐15% of preschoolers  Difficult to assess in a well‐child visit

Definitions:

 Communication  Language: receptive versus expressive  Speech

Requirements for speaking

Social Interactions Verbal Input Hearing Brain Function Oral mechanisms Supportive Adequate Intact Healthy Functioning

Pediatric Grand Rounds 21 October 2011 University of Texas Health Science Center at San Antonio

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Pre-speech Period (0-10 months)

Cooing (3 months) Localizing sounds is the

earliest step in receptive language

Cooing is one of the

earliest steps in expressive language

Pre-speech Period (0-10 months)

Reduplicate babbling Adults assist

development of language by giving sounds meaning

Pre‐speech Period (0‐10 months)

Age Receptive Expressive 1 month Startles to loud noise Makes sound other than crying (e.g., throaty noises) 3 months Regards speaker Coos (vowels), chuckles, vocalizes when talked to 6 months Responds to name, stops momentarily to “no”, gestures “up” Reduplicate babble (consonants + vowels), listens then vocalizes, smiles and vocalizes to mirror 9 months Enjoys gesture games,

• rients to name well

Says “mama” & “dada” nonspecifically, non‐reduplicate babble

Pediatric Grand Rounds 21 October 2011 University of Texas Health Science Center at San Antonio

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Naming Period (10-18 months)

1st words (12 months)

Naming Period (10‐18 months)

Age Receptive Expressive 10 months Waves “bye‐bye” back Waves bye‐bye, says “dada” specifically 12 months Follows 1‐step command with gesture 1st word (not mama or dada), proto‐ imperative pointing, uses several gestures with vocalizing 13 months Looks when asked ”Where’s the ball?” Immature jargoning 15 months Point to 1 body part, gets

• bject from another room

3‐5 words, proto‐declarative pointing, names 1 object

Word Combo Period (18‐24 months)

Age Receptive Expressive 18 months Points to 2 out of 3 objects, 3 body parts, self, familiar people 10‐25 words, giants words (“all gone”), environmental sounds, names 1 picture 20 months Point to 3 pictures Holophrases (“Mommy?”), 2‐word combinations (adjective + noun), answers requests with “no” 24 months Follows 2‐step commands, understands “me” and “you”, points to 5‐10 pictures 2‐word sentences (noun + verb), 50+ words, 50% intelligibility, refers to self by name, names 3 pictures

Pediatric Grand Rounds 21 October 2011 University of Texas Health Science Center at San Antonio

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Preschool aged

Age Receptive Expressive 36 months Points to parts of pictures, understands action words 200+ words, 3‐word sentences, pronouns, asks questions, 75% intelligible 48 months Follows 3‐step commands, understands objects by function Tells stories, uses feeling words, 100% intelligible 60 months Understands adjectives Defines simple words, retells stories

School aged

Reading is a language‐based skill  Requires mapping sounds

(phonemes) to letters (graphemes)

 Relies on verbal and visual memory  Is highly associated with phonemic

awareness (rhyming, word games, etc.)

Role of the provider

Is there a speech- language delay? Typical vs. atypical Screening tool Do I suspect a speech- language disorder? Refer to SLP for evaluation Do I suspect a more significant developmental disorder? Refer for additional evaluations Can I determine the etiology? Refer for medical evaluations /studies What is next, when a speech- language disorder is identified? Treatment Anticipatory guidance

Pediatric Grand Rounds 21 October 2011 University of Texas Health Science Center at San Antonio

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Screening

Is there a speech- language delay? Typical vs. atypical Screening tool Do I suspect a speech- language disorder? Refer to SLP for evaluation Do I suspect a more significant developmental disorder? Refer for additional evaluations Can I determine the etiology? Refer for medical evaluations /studies What is next, when a speech- language disorder is identified? Treatment Anticipatory guidance

Screening Tools

 Ages & Stages Questionnaire (ASQ)  Batelle Developmental Inventory Screening Tool (BDI-ST)  Bayley Infant Neurodevelopmental Screen (BINS)  Brigance Screens-II  Child Development Inventory (CDI)  Denver-II Developmental Screening Test  Parents’ Evaluation of Developmental Screen (PEDS) *See AAP 2006 for detailed description.

Identification

Is there a speech- language delay? Typical vs. atypical Screening tool Do I suspect a speech- language disorder? Refer to SLP for evaluation Do I suspect a more significant developmental disorder? Refer for additional evaluations Can I determine the etiology? Refer for medical evaluations /studies What is next, when a speech- language disorder is identified? Treatment Anticipatory guidance

Pediatric Grand Rounds 21 October 2011 University of Texas Health Science Center at San Antonio

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Do I suspect speech‐language d/o?

Refer to speech‐language pathologist for formal

evaluation

 Early Child Intervention (0‐3 years) – will evaluate all

developmental domains

 School (3‐5 years) – may help identify learning issues  Rehabilitative therapy agency (any age)

Do I suspect other developmental d/o?

“can’t speak”

Articulation d/o Dysarthria Dyspraxia Stuttering Voice, resonance d/o Expressive language d/o

“doesn’t understand”

Mixed receptive‐expressive language d/o Pragmatic (social) communication d/o Intellectual disability Autism spectrum disorders

Speech & Language

Speech Sounds Voice & Resonance Fluency Phonology Morpho‐syntax Semantics Pragmatics

Pediatric Grand Rounds 21 October 2011 University of Texas Health Science Center at San Antonio

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Language

Phonology: sounds, rules Morpho‐syntax: grammar Semantics: meanings Pragmatics: social functions

Language disorder

Receptive, expressive

and/or pragmatic disorder

Degree of impairment  Mild (‐1.5 to ‐2.0 SD)  Moderate (‐2 to ‐2.5 SD)  Severe (‐2.5 to ‐3SD)

SS: 55 70 85 100 115 130 145

Language disorder

Treatment: language

therapy + language stimulation

Prognosis: depends on

severity

SS: 55 70 85 100 115 130 145

Pediatric Grand Rounds 21 October 2011 University of Texas Health Science Center at San Antonio

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Speech & Language

Speech Sounds Voice & Resonance Fluency

Speech sounds

Requires (in addition to hearing):

 Motor planning (towards execution)  Coordination of mouth/tongue and breathing  Articulation (production)

Speech sound disorders:

 Dyspraxia  Dysarthria  Articulation Disorder

Articulation (Sander, 1972)

Age 2 3 4 5 6 7 8 p, m, h, n, w b k, g, d t, ng f, y r, l s ch, sh z v j th (thin) th (then) zh

Pediatric Grand Rounds 21 October 2011 University of Texas Health Science Center at San Antonio

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Articulation disorder

Difficulty with producing speech sounds, often

consonants

 Features: errors consistent, better with imitation  Treatment: speech therapy  Prognosis: good

Dysarthria

Difficulty with neuromotor function involving oral &

speech subsystems (e.g., respiration, phonation)

 Uncommon except in neurological disorders  Features: consistent with overall movement patterns

(spastic, hypotonic, ataxic)

 Treatment: speech therapy

 May have additional goals for swallowing/feeding (e.g. dysphagia)

 Prognosis: depends on underlying disorder

Dyspraxia (a.k.a., Childhood Apraxia of Speech)

Difficulty with motor planning  Often suspected if low response to therapy  Features: errors inconsistent and/or unusual pattern of

consonant errors and vowel distortion; worse with imitation; often observable physical struggle

 Treatment: intensive ST, often needing Augmentative &

Alternative Communication

 Prognosis: depends on severity

Pediatric Grand Rounds 21 October 2011 University of Texas Health Science Center at San Antonio

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Voice & Resonance

Speech Sounds Voice & Resonance Fluency

Voice & Resonance Disorders

Voice disorders

 Rare in children  Ex: vocal abuse (i.e., yelling), vocal cord dysfunction (e.g., intubation)  Treatment: voice therapy/hygiene

Resonance Disorders

 Related to oral structure, function  Ex: hypernasality in submucosal cleft palate  Treatment: depends on condition, may involve surgery + ST

Fluency

Speech Sounds Voice & Resonance Fluency

Pediatric Grand Rounds 21 October 2011 University of Texas Health Science Center at San Antonio

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Fluency

Flow of speech output Developmental dysfluency

 Usually resolves by 4 years old  Involves whole word repetitions, primarily at beginning of

sentences

Stuttering Disorder

Abnormal dysfluency

 Usually emerges between 3 and 6 years old  Single sound or part word repetitions, prolongation and/or blocking  Involves grimacing, other movements

Treatment: intensive ST

 Decrease stuttering events  Prevent secondary characteristics & negative affective response

Prognosis: good if early, intensive ST

Let’s look at some evaluations (see handout)

Pediatric Grand Rounds 21 October 2011 University of Texas Health Science Center at San Antonio

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Etiology

Is there a speech- language delay? Typical vs. atypical Screening tool Do I suspect a speech- language disorder? Refer to SLP for evaluation Do I suspect a more significant developmental disorder? Refer for additional evaluations Can I determine the etiology? Refer for medical evaluations /studies What is next, when a speech- language disorder is identified? Treatment Anticipatory guidance

Etiology

Social Interactions Verbal Input Hearing Brain Function Oral mechanisms Unsupportive Inadequate Impaired Impaired Impaired Child abuse or neglect Low language stimulation Hearing loss Genetic disorders, CNS disorders Cleft palate, VPI, CP

*But most common is constitutional delay

Hearing impairment

Universal NBHS detects many (not all) cases Hearing test needed even if passed NBHS to detect

 Mild‐moderate loss  Syndromes with progressive or acquired hearing loss  Unilateral hearing loss

Management: May involve amplification, cochlear

implantation

Pediatric Grand Rounds 21 October 2011 University of Texas Health Science Center at San Antonio

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Brain impairment

Features Example. Fetal Alcohol Syndrome Phenotype Developmental Language Disorder, Intellectual Disability Behavioral ADHD, ODD, sensory processing, poor social cognition Medical Growth deficiency, vision problems, microcephaly, seizures Motor Visual‐motor deficits, dysgraphia

Myths

Myth Fact

Boys are very delayed (>6 months) Boys are slightly delayed (1‐2 months) 2nd and 3rd born children let their

• lder sibling speak for them

Children have strong motivation to speak when they can Children from bilingual households are significantly delayed Children from bilingual households may show minor delays and early mixing OME causes significant delay OME may cause mild‐moderate delay Delays will resolve without intervention Response to interventions depends on the reason and severity of delays

Role of the provider

Is there a speech- language delay? Typical vs. atypical Screening tool Do I suspect a speech- language disorder? Refer to SLP for evaluation Do I suspect a more significant developmental disorder? Refer for additional evaluations Can I determine the etiology? Refer for medical evaluations /studies What is next, when a speech- language disorder is identified? Treatment Anticipatory guidance

Pediatric Grand Rounds 21 October 2011 University of Texas Health Science Center at San Antonio

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Management

 Treatment  Prognosis  Anticipatory guidance

 Language stimulation  Sign language, gestures do not delay speech  Secondary problems: behaviors, disciplining, socializing,

learning

Early Childhood Intervention (ECI)

 0‐3 years old  State funded, appropriate for all income levels  Referred by anyone:  DARS referral information: www.dars.state.tx.us/ecis/referral  TPS referral form: www.txpeds.org  Family‐centered: focus is on skills training, natural setting  Other services: behavioral counseling, nutrition services,

vision & hearing services, school transition services, etc.

Special Education

≥3 years old IDEA disability category of “Speech Impairment” Requested by ECI, parent or teacher May qualify for:

 ST only: 1‐2 30‐minute sessions/week, small groups  Preschool Program for Children with Disabilities (PPCD): if

• ther developmental deficits or severe language disorder

Pediatric Grand Rounds 21 October 2011 University of Texas Health Science Center at San Antonio

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Rehabilitative agency

 Client is the focus

 Beneficial for medically involved, complex

Format of therapy

 Individual versus group  Home health versus clinic based

 Frequency depends on condition, authorization,

child’s participation, schedule, availability, etc.

Treatment

For children <3 years old

 ECI is ideal because of service coordination and parental

involvement

For children ≥3 years old

 School and/or private agency depending on severity,

underlying condition

Bilingual language development

Monolingualism is the exception, not the rule Simultaneous versus sequential bilingualism When screening, use same language milestones

 1st word by 12 months  50 words by 2 years – add up the number of words  2‐word phrases by 2 years – blending is expected (e.g., “I want agua”)

Pediatric Grand Rounds 21 October 2011 University of Texas Health Science Center at San Antonio

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Language stimulation

Have handouts ready! Easy tip…

Taking turns Imitating Pointing out Setting the stage

Language stimulation

Consider play dates, Kids Day

Out, or preschool program

Turn off the technology! Talk! Read!

Bilingual language stimulation

Consider parents’ proficiency when giving advice Reassure will not cause delay Stress needs to hear and speak daily

 Conversation  Books  Audiotapes and CDs  Videos and DVDs (better for learning concepts > language)  Language camps & educational programs

Pediatric Grand Rounds 21 October 2011 University of Texas Health Science Center at San Antonio

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Final comments…

You’ve learned

 How prevalent is speech‐language delay  What are speech and language disorders  Some tips on interpreting evaluations  Your role as the primary care provider in identifying,

referring, managing children with delays; promoting early intervention Questions? VienNhung.Tran@BSWHealth.org