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Complete Evaluation of the Child Referred for Speech Delay Instructional Course 4713-1
Otolaryngologist: Dr. Kenneth Grundfast ///// Neurodevelopmental Disability Specialist: Dr. Elliott Gersh American Academy of Otolaryngology Head and Neck Surgery I. September 12, 2012

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Speech Delay Evaluation 1,2 a. Criteria for speech delay evaluation Concern by the parent, teacher, professional, or other caregiver about the child's speech or language Slowed or stagnant speech and language development Excessive drooling Difficulty sucking, chewing, or swallowing Difficulty coordinating movements of lips, tongue, and jaw No babbling by nine months No first words by 15 months No consistent words by 18 months No word combinations by 24 months Speech is difficult for parents to understand at 24 months Speech is difficult for strangers to understand at 36 months Dysfluencies (stutters) consist of more than tension-free whole-word repetitions Child is frustrated by communication difficulty Child is teased by peers for "talking funny" Child avoids talking situations Child acquires vocabulary and sentence structure but does not use language appropriately for communicative purposes Language is unusual or confused, or ideas are not expressed clearly Child cannot follow instructions without supplemental visual cues Loss of milestones Poor memory skills at five to six years b. Screening tools for developmental delay: http://www.commonwealthfund.org/Resources/2007/Dec/Part-II--Guides-to-Facilitate-YourChoice-and-Use-of-Screening-Instruments.aspx 2,3 Voice, Speech and Language a. Voice: sound produced by pushing air past vocal folds, causing vibrations b. Speech: expression of language, requiring intact neural language centers and properly coordinated muscle action of the tongue, lips, jaw, and vocal tract c. Language: set of shared rules guiding effective communication through speech, the written word, or gestures 4 Development of Speech and Language a. Requires consistent exposure to speech during the critical period of the first 3 years of life, when cognitive language centers are most rapidly developing

Complete evaluation of the child referred for speech delay

Instructional course # 4713-1

Age 1 to 6 months 6 to 9 months 10 to 11 months 12 months 13 to 15 months 16 to 18 months 19 to 21 months 22 to 24 months 2 to 2 years 2 to 3 years 3 to 4 years 4 to 5 years

Achievement Coos in response to voice Babbling Imitation of sounds; says mama/dada without meaning Says mama/dada with meaning; often imitates two - and three-syllable words Vocabulary of four to seven words in addition to jargon; < 20% of speech understood by strangers Vocabulary of 10 words; some echolalia and extensive jargon; 20% to 25% of speech understood by strangers Vocabulary of 20 words; 50% of speech understood by strangers Vocabulary > 50 words; two-word phrases; dropping out of jargon; 60% to 70% of speech understood by strangers Vocabulary of 400 words, including names; two- to three-word phrases; use of pronouns; diminishing echolalia; 75% of speech understood by strangers Use of plurals and past tense; knows age and sex; counts three objects correctly; three to five words per sentence; 80% to 90% of speech understood by strangers Three to six words per sentence; asks questions, converses, relates experiences, tells stories; almost all speech understood by strangers Six to eight words per sentence; names four colors; counts 10 pennies correctly

Information from Schwartz ER. Speech and language disorders. In: Schwartz MW, ed. Pediatric primary care: a problem oriented approach. St. Louis: Mosby, 1990:696 700. IV. Causes of Speech Delay a. Hearing abnormalities i. Congenital hearing loss or early hearing loss without intervention greatly impairs 5 development of speech production ii. Currently in the US universal newborn hearing screen is mandated 1. Auditory Brainstem Response (ABR) or Ootoacoustic Emissions (OAE) methods 6 iii. Auditory Neuropathy Spectrum Disorder (ANSD) 1. Normal/near-normal OAE + absence of normal middle ear reflexes + abnormal/absent ABR 2. Functional inner ear that cannot relay signals to brain properly 3. Evaluation and management a. Highly variable deficits in hearing and speech recognition abilities b. Presence of hearing difficulties could signify underlying cognitive disability c. ANSD babies should be followed closely, many isolated cases resolve spontaneously 7,8 iv. Otitis Media 1. Controversy exists over resulting speech delay due to recurring middle ear effusions (MEE) and whether tympanostomy improves future development 9,10 b. Structural abnormalities i. Ankyloglossia

Complete evaluation of the child referred for speech delay

Instructional course # 4713-1

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Can present early with breast feeding difficulties, most commonly poor latching and maternal nipple pain 2. Controversy exists over tongue tie and speech delay 3. A child with tongue tie and speech delay should be evaluated by speech pathologist before operating 4. Management a. First seek speech therapy b. Surgical therapy indicated if speech therapy fails i. Frenuloplasty ii. Fren-Z-Plasty 11 Language abnormalities i. Abnormalities in comprehension (receptive) and word production (expressive) ii. Pervasive Developmental Disorders (PDDs) [NOTE: Autism, Asperger Syndrome and PDD-NOS fall under the term Autism Spectrum Disorder] 1. Autism Disorder a. Defect in social and communication capacities b. Delayed language comprehension/production, delayed echolalia, formulaic speech (repetitive word choice), odd word-choice, gaze avoidance, avoidance of meaningful verbal communication c. Some children illustrate normal progression followed by regression of skills 2. Asperger Syndrome a. Milder form of autism, often with less affected language/cognitive deficits 3. Rett Disorder a. Exclusively in females, characterized by normal development followed by global deterioration of skills 4. Childhood Disintegrative Disorder (CDD) a. Similarly to Rett disorder, a child who exhibits progression in language, social and motor function experiences dramatic regression in skills 5. PDD-Not Otherwise Specified (PDD-NOS) a. A child who presents impaired social and language development with stereotyped behaviors of ASD but does not meet the criteria for any of the above diagnoses iii. Neurogenetic Syndromes 11, 12 1. Angelman Syndrome a. Global developmental defects, profound speech delay, seizures, stereotypically happy demeanor b. Global reduction in white matter tract development/function 2. Fragile X Syndrome a. In males, most common etiology of Autism Disorder and mental retardation thus often presents with speech and language delay b. Morphology: long face, large ears, flat feet, hyperextensible joints, large testes 6 Neurological defects i. Apraxia: Impairment in transmission of motor control to speech producing musculature; 1. Often caused by hemispheric lesion 1.

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Complete evaluation of the child referred for speech delay

Instructional course # 4713-1

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ii. Dysarthria: focal damage (Stroke/Tumor/Palsy) can impair language centers or associated ascending/descending fibers 1. Commonly associated with dysphagia, other focal difficulties 13 Constitutional speech delay (late-talkers) i. Often follows parental pattern of speech development ii. Signs 1. Parents note they were late bloomers 2. Receptive language intact appears to understand 3. Gesturing often used for communication 4. Child presents positive progression of language use, despite slow rate iii. Evaluation 1. History taking, family history of speech development 2. Eval of other developmental markers often late-talkers are of normal intelligence

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Resources and references


1. Up-To-Date. Evaluation and treatment of speech and language disorders in children. (Updated May 3, 2012). http://www.uptodate.com/contents/evaluation-and-treatment-of-speech-and-language-disorders-inchildren?source=search_result&search=speech+delay&selectedTitle=2~45#. [Aug 12, 2012]. McLaughlin MR. Speech and Language Delay in Children. Am Fam Physician. 2011 May 15;83(10):1183-1188. http://www.aafp.org/afp/2011/0515/p1183.html National Institute of Deafness and Communication. (Updated May 13, 2011). http://www.nidcd.nih.gov/health/voice/Pages/Default.aspx. [Aug 26, 2012]. Schwartz MW, ed. Pediatric primary care: a problem oriented approach. St. Louis: Mosby, 1990:696700. Leung AK. Evaluation and Management of the Child with Speech Delay. Am Fam Physician. 1999 Jun 1;59(11):31213128., http://www.aafp.org/afp/1999/0601/p3121.html Roush, Patricia. Auditory neuropathy spectrum disorder: Evaluation and management. Hearing Journal, Nov 2008, Vol61;11, pp 36,38-41. http://journals.lww.com/thehearingjournal/Fulltext/2008/11000/Auditory_neuropathy_spectrum_disorder__Evaluati on.8.aspx?WT.mc_id=HPxADx20100319xMP Paradise JL, Dollaghan CA, Campbell TF, Feldman HM, Bernard BS, Colborn DK, Rockette HE, Janosky JE, Pitcairn DL, Kurs-Lasky M, Sabo DL, Smith CG. Otitis media and tympanostomy tube insertion during the first three years of life: developmental outcomes at the age of four years. Pediatrics. 2003 Aug;112(2):265-77 Feldman HM, Dollagen HM, Campbell TF Paradise JL. Parent-reported language skills in relation to otitis media during the first 3 years of life. J Speech Lang Hearing Res. 2003 Apr;46(2):273-87 Messner AH, Lalakea ML. The effect of ankyloglossia on speech in children. Otolaryngol Head Neck Surg. 2002 Dec;127(6):539-45.

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10. Suter VG, Bornstein MM. Ankyloglossia: facts and myths in diagnosis and treatment. J. Periodontol 80(8) 2009:120419 11. Johnson CP, Myers SM. American Academy of Pediatrics Council on Children With Disabilities. Identification and evaluation of children with autism spectrum disorders. Pediatrics 2007; 120:1183.

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12. Wilson BJ, Sundaram SK, Hug AH. Abnormal language pathway in children with Angelman syndrome. Pediatr Neurol. 2011 May;44(5):350-6. 13. Late Blooming or Language Problem? http://www.asha.org/public/speech/disorders/LateBlooming.htm ASHA Website

14. Lang Hearing Res. 2003 Apr;46(2):273-87

Note: Dr. Grundfast and Dr. Gersh will bring with them to the instructional course for distribution to all course attendee hard copy handouts of their entire Powerpoint presentations. In addition, course attendees will receive a brochure produced by the American Speech-Language Hearing Association entitled How Does Your Child Hear and Talk.

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Complete evaluation of the child referred for speech delay

Instructional course # 4713-1

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