CHAPTER 38

SPEECH AND LANGUAGE DEVELOPMENT AND DISORDERS

MICHELLE M. MACIAS, MD LYNN M. WEGNER, MD

Speech and language disorders are the most common developmentally disabling condition of childhood. Physicians and other health care providers are the rst line of defense concerning identication of these problems. Early recognition and intervention are necessary to provide children with the best possible outcome.

All humans communicate. The most effective and efcient communicators use a symbolic system for information delivery: language. Language represents objects or actions in symbolic form. Language communicates ideas, intentions, and emotionsall forms of expression. The listener must extract both explicit and implied meaning from what is said; this constitutes receptive understanding. Speech and language disorders are the most prevalent developmentally disabling disorders affecting children. Early identication and management of these disorders is paramount to minimize or eliminate the social and educational problems that arise. Most children naturally acquire normal language understanding and expression, although concerns about speech and language skills are voiced by 30% of all parents when questioned by their childs physician during routine well-child check-ups. Current prevalence estimates of speech and language delay in preschool children range from 7 to 10%, with a signicantly higher proportion of boys being affected. Pure disorders of receptive and expressive language alone are found in 3 to 6% of children in this age group. The term speech/language delay implies that the child will catch up in their language abilities, and for some children, classied as late talkers, the delay is not permanent. However, one long-term study revealed that 42.5% of young children whose early language delays showed improvement were later found to have reading or cognitive
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decits. Preschoolers with language disorders are at higher risk for language-based learning disorders, social, and behavioral problems.

Neurobiologic Basis of Speech and Language

The general location of basic language centers was determined in the nineteenth century by Paul Broca and Carl Wernicke, which then led to the theory of cerebral dominance. For virtually all right-handed people and two-thirds of left-handed people, speech and language are processed in the left cerebral hemisphere. Lesions bordering the sylvian ssure of the dominant hemisphere usually cause disturbances in speech and language. A functional anatomic loop connects the eyes and ears to the visual and auditory system, an intrahemispheral section through white matter connects the temporal with the frontal lobes, and the frontal lobes connect to the mouth and hand. Meaning is provided to sounds and shapes through intrahemispheral and transcallosal pathways to the rest of the brain from the sylvian region. Recent advances in functional neuroimaging studies have suggested specic cortical areas associated with individual language skills. Positron emission tomography scans have shown increased metabolic activity across the left and right temporal and frontal cortex areas of the brain during

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speech and nonspeech acoustic processing. Functional magnetic resonance imaging studies show differences between the sexes, with activation in the left inferior frontal gyrus for males and activation in both right and left inferior frontal areas for females during phonologic tasks. Word analysis and articulation has been mapped to Brocas area of the inferior frontal gyrus, whereas skilled word form discrimination involves the occipitotemporal region. A substantial heritable component exists in speech and language disorders, but the underlying genetic basis is complex and involves different risk factors. Close examination of families with persistent signs of disordered language skills have suggested a genetic basis; however, exclusive of recognized genetic disorders with strong, specic language differences (eg, velocardiofacial syndrome, Williams syndrome, or fragile X syndrome), no genetic markers for developmental language disorder have been clearly identied. Recent genome scanning techniques have identied chromosomes 2, 13, 16, and 19 as having potential candidate genes involved with more common forms of language impairment. Molecular genetic techniques are being initiated to investigate speech and language disorders.

tences. Prosody is the vocal intonation that can modify the literal meaning of what is said. Discourse is the linking of sentences so that a narrative is constituted. Pragmatics refers to the meanings of language in various contexts and can be thought of as the social use of language or the ability to read emotional expression. A language disorder may include inability in any of these areas, but will usually only be suspected if the individual demonstrates impaired daily functioning. For example, a child can be said to have a language disorder if he or she has a poor vocabulary, has difculty generating meaningful messages, or has poor understanding of the use of language in different social contexts. Typical language milestones are listed in Table 38-1. 0 to 12 Months: Precursors to Speech and Language In the rst year of life, the infants inherent biologic disposition interfaces with variable environmental conditions. Children show varying levels of desire for contact with the environment and the individuals in the immediate environment respond at different degrees of intensity. Very early in life, infants are capable of distinguishing between different classes of speech sounds. Although the child may seem more dependent on environmental reinforcement early on, the second 6 months of life shows clear self-driven imitation of others speech sounds by the infants imitative effects, with a rich interplay between the infant and the older individuals in his or her life. Vocal development occurs in at least four stages: (1) phonation stage (0 to 2 months; quasivowels, glottals), (2) primitive articulation stage (2 to 4 months; cooing), (3) expansion stage (4 to 6 months; full vowels, raspberries, marginal babbling), and (4) canonical stage (6 to 10 months; well-formed syllables, reduplicated sequences). The phonetic characteristics of canonical babbling include well-formed syllables with rapid transitions between consonant and vowel elements and is an immediate precursor of meaningful speech. Vegetative sounds (coughing, sneezing, burping) and fixed vocal signals (crying, laughing, moaning, etc) are different from the protophones, or crucial sounds that are specic precursors to speech. Protophones and speech are unique to humans, while vegetative sounds and xed vocal signals are present in many species. 12 to 24 Months: Early Language Language development after 1 year of age is often perceived as a general wellness indicator of a young childs developmental attainment. Typically, the period between 12 and 18 months of life show the child using language expressively to communicate increasing awareness of concepts and the association with linguistic labels. The toddler conveys desires, More!; specic objects, Cookie!; and emotions, No! Increasing awareness and mastering of phonology, syntax, semantics, and pragmatics are

Overview of Speech and Language Development

Speech produces complex acoustic signals that communicate meaning and is the result of interactions between the respiratory, laryngeal, and oral structures. This acoustic signal varies with regard to vocal pitch, intonation, and voice quality. The symbols need to conform to the language code so that they can be decoded as meaningful communication. A speech disorder reects problems with creating the appropriate sounds representing the language symbols (the words), and, therefore, communication is impaired. These problems include speech uency disorders (stuttering), voice disorders, and articulation disorders. Speech disorders may or may not also include weaknesses in expressive language. Language involves both expressive and receptive components. Expressive language involves the communication of ideas, intentions, and emotions. Receptive language involves understanding what is said by someone else. Receptive language includes auditory comprehension (listening), literate decoding (reading), and mastery of visual signing. Language involves a number of dimensions. Phonology involves phonemes and morphemes. Phonemes are individual sound units that are put together in a particular order to produce morphemes. Morphemes are the smallest meaningful units of a word that are combined to create a word. Syntax, or grammar, is the order or combination of words in phrases and sentences. The lexicon, or vocabulary, is the collection of all meaningful words in a language. Semantics are the meanings that correspond to lexical items and senCurrent Management in Child Neurology, Third Edition 2005 Bernard L. Maria, All Rights Reserved BC Decker Inc

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Speech and Language Development and Disorders / 227 TABLE 38-1. Speech and Language Milestones
0 to 12 months Receptive language Listens selectively to words, understands no; recognizes own name 12 to 24 months Understands up to 50+ words; follows 1-step commands with (12 to14 months) and without (16+ months) a gesture 24 to 42 months Knows primary colors, aware of past and future; follows 2-step commands 312 to 7 years 7 to 12 years Follows 3 -step comUnderstands all declaramands; understands tive and interrogative same versus differsentences; understands ent; understands abstract language if, when, why (idioms, proverbs) questions and common daily living words Uses complete sentences, Uses mature discourse tells a story sequentsentence length, can ially, uses past tense, make innite number denes in terms of of phrase/sentence use, asks denitions, combinations from uses mature sentence a nite set of rules structure and form; by 4 years 100% intelligible

Expressive language

0 to 4 months: smiles Points to body parts, reciprocally, coos points to pictures, 4 to 9 months, babbling moves from single by 6 to 8 months, words to 2-word gestures by 9 months; sentences, 25% rst words by 12 months intelligibility

Uses 3-word sentences, uses adjectives and adverbs, begins to ask questions, uses pronouns and plurals, uses negative, tells full name, age, sex; 50 to 75% intelligible

demonstrated. There is a signicant disparity between the receptive word knowledge and expressive use; 50 words may be understood before 10 words are said. Children understand much more than they say and the words understood are not necessarily used. 24 to 42 Months: Word Explosion As the childs lexicon (vocabulary) increases, reliance on the prosody and facial expression of speakers diminishes. By 2 years of age, most children rely on their understanding of word meanings to develop a full appreciation of the discourse. This is the beginning of literal language interpretation, which continues through the late elementary school years for most girls and boys irrespective of cognitive ability. Between 2 and 3 years of age, most children show a dramatic increase in vocabulary (few dozen to 300 to 1,000 words) and expressive complexity. The child increasingly is able to understand and use more complex language forms, such as conditionals (ifthen), connectors (but,however) and prepositions (on, under,beside). The ability to infer develops and is frequently demonstrated as the child supplies missing information when the speaker delivers an incomplete message. Pragmatically, the childs increasing ability to infer intent and meaning allows him or her to participate in settings away from home. 312 to 7 Years: Mastering Fluency In the preschool through the early elementary years, the receptive vocabulary multiplies to 1,000 to 8,000+ words. There is progressive understanding of more complex locational, relational, and temporal word associations. This increasing mastery of connected discourse allows the child to more accurately maintain a conversational topic, completely carry out instructions, and convey new information to an audience. The child improves his pragmatic exibility as he
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adjusts speech and language to varying audiences, whereas a younger child often rambles with little plot or causal relationships. By 7 years of age, the childs narrative abilities include discourse with a beginning, a middle, and an end. 7 to 12 Years: Communicative Competence The school years initiate the time of conveying information and mastering information. The school years also are the period where the child learns two skills highly dependent on language: reading and writing. Phonemic awareness must be intact, for uent reading and written expression is highly dependent on semantic (word knowledge) range and syntactic (grammar) mastery. Although children enter school with varying levels of receptive and expressive abilities, it is expected that by middle school most students will attain adult linguistic levels. Although early adolescents do not fully resemble adults, pragmatically they are expected to demonstrate those skills necessary for larger group settings: taking turns, adapting to novel discourse rules, and cognitive exibility in conveying ideas (ie, code switching).

Disorders of Speech Development

Articulation Disorders An articulation disorder (dysarticulated sounds) is a disorder of the quality of speech characterized by the substitution, omission, distortion, and addition of phonemes. Articulation errors may occasionally occur in typically developing children; however, by age 7 years a child should be able to produce all sounds and sound combinations. Speech Apraxia/Dyspraxia Dyspraxia is difculty with complex movement and motor planning that is not secondary to paralysis, weakness,

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incoordination, sensory loss, or comprehension impairments. The deficits are presumed to be in the cortical motor association areas and cause disturbances in articulation, phonation, respiration, and resonance, resulting in dysuent and unintelligible speech. Voluntary oral control during speech is impaired but other oral skills (chewing, swallowing, spitting) are preserved. Verbal dyspraxia is often comorbid with neurologic soft signs, and associated expressive language delays are often observed. Voice Disorders and Disorders of Nasal Resonance Although differences in pitch, loudness, resonance, and quality may occur in isolation, they are often combined with receptive or expressive delays. Abnormalities in resonance lead to voice quality that may sound hypo- or hypernasal. Hypernasal speech is often secondary to velopharyngeal incompetence and may be related to a submucous cleft, palatal incompetence, overt cleft palate, or neurologic dysfunction. Alternatively, hyponasal speech quality may often reflect air impeded by the adenoids. Finally, poor pitch regulation (modulation of tone or volume) may be seen in children with sensory regulation differences (autism, pervasive developmental disorder, Aspergers syndrome), nonverbal learning disorders, and some genetic syndromes (eg, fragile X syndrome). Fluency Disorders Dysuent speech (pauses, hesitations, interjections, prolongations, and interruptions) typically begins in very early childhood (212 to 4 years), when the childs mastery of larger expressive units is expected, and is known as normal dysuency of childhood. Continued or progressive dysfluency is more likely stuttering, which arises in the preschool years in 85% of affected children. Boys are affected more often than girls in a 4:1 ratio. Dysarthria Dysarthria is a motor speech disorder that involves problems of articulation, respiration, phonation, or prosody as a result of paralysis, muscle weakness, or poor coordination. Motor function may be excessively slow or rapid, with poor timing and decreased range or strength. Dysarthric speech is characterized by weakness in specific speech sound production and is frequently associated with cerebral palsy. Dysarthric speech also may encompass problems in coordinated breath control and head posture.

receptive/expressive language disorder. Disordered development may be seen in all language areas: semantics, syntax, morphology, reading, written expression, and pragmatics. The most commonly used labels are developmental language disorder or specific language impairment. These designations imply a clinically significant discrepancy between the clinical cognitive level and formally assessed language skills. Some language specialists also use these two terms for children with formal language score 2 standard deviations below the mean value for age (ie, standard score 70), even if the overall cognitive level is not more than 20 points greater than the language score. Receptive Language Disorder Accurate understanding of what is heard is dependent on abilities separate from innate language knowledge. Precise hearing is essential. The child must have an adequate attention span to register what is said, and memory functions (immediate recall, working memory, short- and long-term memory) must be intact for full meaning to develop. As linguistic competence ensues, the young child relies more on linguistic knowledge and less on nonlinguistic strategies for comprehension (interpreting communicative gestures and nonword vocalizations, using supportive situational cues, etc). Previously discussed milestones of typical receptive language development allow comparison with the following abnormalities often seen in varying combinations: failure to grasp double word meaning, misapplication of emphasis with resulting misinterpretation, weak understanding of complex grammatical structures (eg, double negatives), rare use of clarification questions (What do you mean?), overuse of clarification questions (Tell me again), or inappropriate responses. A caveat is that mild receptive disorders may not be discovered in the presence of more severe expressive delays. Adults may assume receptive skills are intact because the child has overcompensated by relying on contextual cues and routines and the adults have modified tasks by giving a series of one-step comments rather than multistep instructions. Auditory Processing Disorders The term auditory processing disorder (APD) has been recommended to replace the term central auditory processing disorder to emphasize the interactions of disorders at both peripheral and central sites. APD is a decit in the processing of information despite normal auditory thresholds and can be characterized as a receptive language disorder. Characteristically, difculties are found with comprehension of incoming verbal messages in competing speech or noise backgrounds. APD is not a single disease entity, but rather

Disorders of Language Development

Disordered language development may include understanding (receptive disorder), expressing ones thoughts (expressive disorder), or more commonly a mixed
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Speech and Language Development and Disorders / 229

is a description of functional decits. It is auditory specic, but is associated with a range of attention, language, and learning decits, and is best diagnosed with a comprehensive assessment involving audiologists, speech/language pathologists, psychologists, and physicians. Expressive Language Disorders Expressive disorders reect a broad range of delays, from developmentally inappropriate short expressive units (small mean length of utterances), word-nding weakness with phonologic substitutions (mat for map), semantic switches (hat for scarf ), and inability to master grammatical morphemes (eg, plural -s, past tense -ed). Over time, a child is expected to increase the accuracy and complexity of his or her expressive output. Signs of expressive delays may include the following: using many words to explain a word in lieu of the specic term (circumlocutions), use of nonspecific words (like or stuff ), excessive use of starters (you know), and place holders (um or uh), difculty generating a correctly ordered narrative, or using gestures excessively rather than words to convey meaning, more than is developmentally appropriate (eg, the A-OK sign with hands). Mixed ReceptiveExpressive Language Disorders Unless formal language testing using standardized instruments supports the presence solely of an isolated articulation disorder or specic receptive or expressive weakness, a child with a past history of language delays should be presumed to have had some combination of language understanding and expression weaknesses. A variety of receptiveexpressive subgroups have been labeled including: verbal auditory agnosia, an impairment in interpreting the phonology of aural information and resultant limited comprehension of spoken language; phonologicsyntactic decit, extreme difculty producing language with variable levels of comprehension; semanticpragmatic deficit, expressively fluent with sophisticated use of words but poor comprehension and shallow use of conversational speech; and lexicalsyntactic decit, word-nding weakness and higher order expressive skills weakness.

taining, and terminating a conversation; modifying a topic for the audience; and including others in a conversation. Pragmatic weakness may occur in isolation from other disorders of language development but as with other areas may occur independently of cognitive level. Specic developmental disorders often accompany pragmatic weakness, including autism spectrum disorders (autism, Aspergers syndrome) and some nonverbal learning disorders.

Language-Based Reading Disorders

The term most commonly used to describe a reading disorder is dyslexia, yet dyslexia is a very specic form of reading disorder: the words are visually perceived but not understood. It is neurobiologic in origin and is characterized by difculties with accurate and uent word recognition and by poor spelling and decoding abilities. All weaknesses affecting normal language development can also affect reading or decoding, including poor phonologic awareness, semantic deciency, syntactic problems, and weak metalinguistics. Poor phonologic awareness impairs ability to associate the individual sounds with visual symbols (letters, words). Difficulties in this area can lead to weakness in decoding written words as well as encoding words during spelling. Weak semantic abilities result in the child having a restricted range of word meanings. This deficit affects reading comprehension in later school years, when the vocabulary exponentially increases with additional technical and specialized terms. Children with syntactic weakness may have difficulty with reading as the complexity of sentence structure increases. Inverted clauses, ambiguous references, and other literary modifications lead to labored reading rate and poor comprehension. Poor metalinguistics (ie, understanding how language works) often accompanies higher order language weakness and leads to poor comprehension as reading material transitions from more literal passages to more abstract, conceptual topics.

Written Expression Disorders

Efcient and effective written expression is a predominant and essential skill for academic attainment. Written expression comprises four basic skills: (1) ne motor (to hold and manipulate the writing instrument), (2) attention (focused attention to the task allowing effective task completion), (3) memory (visual memory to identify correct spelling, letter formation, alignment of the prose on the page), and (4) language (all the elements described in reading development). Writing is a very sophisticated skill with respect to language and children with specic language disorders are at risk for written expression weakness.

Pragmatic Disorders
Children with weak pragmatic skills show variable ability to apply the rules governing appropriate use of language for social communication. Generally speaking, the individual has difculty saying the right thing at the right time with appropriate voice modulation and reciprocal body language and is unable to appropriately regulate social interactions using language. Specic behavior examples might include improper distance from the conversation partner; excessive voice pitch; problems initiating, mainCurrent Management in Child Neurology, Third Edition 2005 Bernard L. Maria, All Rights Reserved BC Decker Inc

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Assessment and Diagnosis

Differential Diagnosis When screening a child for speech and language impairments, etiologic factors as well as differential diagnosis must be considered. First, the hearing status of the child must be evaluated by formal audiometric evaluation. Even if a child passed a hearing screening at birth, formal behavioral audiometrics should be completed on the child with a speech or language delay. This will evaluate for high-frequency or more severe hearing impairments resulting in a speech or language disorder. Cognitive status should be determined. A common reason for not meeting language milestones is mental retardation or global delay, and the first indicator of global impairment is a language delay. Landau-Kleffner syndrome must also be considered in the presence of normal socialization and nonverbal communication, seizures or abnormal electroencephalogram, and an acquired aphasia. Finally, a high index of suspicion for autism spectrum disorders must exist in a child with delayed onset of language and poor interactions. The earliest signs of an autism spectrum disorder are verbal and nonverbal language delay (lack of response to name, absence of joint attention, pointing or gesturing to regulate social interactions) with impaired socialization and delayed or absent parallel or interactive play skills. Screening Various screening tools exist to screen for language disorders in the pediatric setting, and the use of these will depend on the health care providers level of interest and competency in screening techniques. It is extremely important to ascertain the reliability and validity of the screening tool before using that particular method. Screening tools include directly administered screens (eg, Early Language Milestones Scale, Clinical Linguistic Auditory Milestones Scale) and parent-completed questionnaires (eg, ReceptiveExpressive Emergent Language Scale, language subscale of the Child Development Inventory). Informal techniques include observation of all oral language attempts (babbling, jargoning, true words) and nonverbal communication attempts (eg, facial expression, gesturing or pointing to indicate wants and to share enjoyment, presence of joint attention, body postures, and eye gaze). If a language disorder is suspected or a child fails a language screen, a full evaluation should be completed by a certied speech and language therapist. Children with language regression should have an immediate neurologic evaluation as well as a formal speech/language evaluation, and the prospect of autism, Rett syndrome, and LandauKleffner syndrome considered.
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Treatment The goal of speech or language therapy is always to establish the skills necessary to effectively communicate with others, be that by verbal or nonverbal means. Speech or language therapy can help to prevent further delays as well as remediate problems of intelligibility, uency, and language impairment. Most language specialists recognize that early language delays may herald later language irregularities. If a child had early language delays and subsequently has problems in reading, written expression, learning a foreign language, or age-appropriate social interactions, another formal language assessment should be considered. Therapy and treatment goals will depend on the specic type of speech or language disorder that exists. For children aged 0 to 3 years, services can be obtained through the Individuals with Disabilities Education Act (IDEA), Part C. School-age children can receive services through the public schools. It is essential to recognize that most children do not outgrow speech or language disorders. Although no accurate statistics exist regarding persistence of specic language disorders through adulthood, they should be considered developmental disorders and thus may persist with differing presentations throughout the lifespan. Early identication and intervention are imperative in order to prevent further deterioration and allow improvement in communication abilities.

Suggested Readings
Blackwell PB, Baker BM. Estimating communication competence of infants and toddlers. J Pediatr Health Care 2002;16:2935. Coplan J. The early language milestone scale (revised). Austin (TX): Pro-ed; 1987. Damasio AR, Damasio H. Brain and language. Sci Am 1992; 8995. Oller DK, Eilers RE. Precursors to speech in infancy: the prediction of speech and language disorders. J Commun Disord 1999;32:22345. Practice parameters for the assessment and treatment of children and adolescents with language and learning disorders. J Am Acad Child Adolesc Psychiatry 1998;37:46S62S. Rapin I. Practitioner review: developmental language disorders: a clinical update. J Child Psychol Psychiatry 1996;37:643755. Shaywitz S. Overcoming dyslexia. New York (NY): Alfred A. Knopf; 2003. Tallal P, Merzenich MM, Miller S, Jenkins W. Language learning impairments: integrating basic science, technology, and remediation. Exp Brain Res 1998;123:2109.

Practitioner and Patient Resources

American Speech/Language and Hearing Association http://www.asha.org

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Speech and Language Development and Disorders / 231 The ASHA Web site contains information for professionals and consumers regarding general information on speech/language disorders and state and local resources. Apraxia/Dyspraxia http://www.apraxia-kids.org This Web site contains information on apraxia/dyspraxia for consumers. KidSource Online http://www.kidsource.com/NICHCY/speech.html From the National Information Center for Children and Youth with Disabilities.

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