How to investigate and manage the child who is slow to speak
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《英国医生杂志》
1 Emma Children's Hospital, Academic Medical Centre, Meibergdreef 9, 1105 AZ, Amsterdam, Netherlands
Correspondence to: J O Busari, Department of Paediatrics, Boven IJ Hospital, Statenjachtstraat 1, 1030 BD, Amsterdam Ojay33@hotmail.com
Children who are slow to speak often present clinicians with a dilemma—should they conduct further investigations or just wait and see if the problem resolves (as it does in most children aged under 3 years)? Two paediatricians propose a guideline that can be used to investigate and manage children with speech or language delays
Introduction
We did a database search on Medline (National Library of Medicine) using the following key words: "speech and language disorders", "children (0-18 years)", "screening methods", "diagnostics", and "interventions". We chose relevant review and research articles that had been published on the subject after 1990 because we were interested in the latest developments in the area. We used 10 articles to prepare this report, chosen on the basis of the originality of content and relevance to the topic of this review. We used two paediatric neurology textbooks as additional sources of information. A general practitioner, general paediatrician, paediatric neurologist, and linguist commented on the review.
Summary points
Delay in speech and language development in children can be defined as a "delay in speech and/or language development compared with controls matched for age, sex, cultural background, and intelligence"
To evaluate such children, carefully analyse the child's cognitive strengths and weaknesses
The analysis should take account of the history and context in which the child is developing, the observed performance of the child, and the results of a validated test of cognitive function
In all cases of suspected speech and language delay, audiometry and a good clinical evaluation of the central nervous system and ear, nose, and throat are mandatory
The management of children with speech and language delay should be multidisciplinary, involving the child's parents and school teacher, as well as various health professionals
Definitions
A thorough knowledge of language development in the population of normal children is necessary when investigating a delay in speech or language development. According to Fenson et al, the order of the language learning process is firm but with a great range of variation in timing.4 This makes it difficult for the clinician to discriminate normal (but delayed) language development from a typical disorder of language development. In the normal language learning process, children start babbling at 6-10 months, understand words by 8-10 months, and, on average, speak their first words around their first birthday. By 14-24 months, most children start to produce two-word phrases, and at 3 years a child should be able to make three-word combinations. At the age of 4 years, clear syntax is part of most children's speech.5
Domains of language development
To analyse language and to define language disorders most linguists divide language into four domains: phonology, grammar, semantics, and pragmatics.
Phonology refers to the ability to produce and discriminate the specific sounds of a given language. Phonological receptivity to different languages is optimal at birth but starts to decline at about age 10 months, reaching a rather general inability to acquire native phonology by preadolescence.
Grammar refers to the underlying rules that organise any specific language. Children start to learn grammar when they start to speak about objects, people, and actions.
Semantics, the study of meaning, includes the study of vocabulary and the number of words a child knows. The size of a child's vocabulary is thought to be the best predictor of school success.1
Pragmatics refers to the ability of the child to use his or her language in interactions with others. Understanding and producing language is a complex process in which different systems are involved. Chevrie-Muller and Rigoard described these systems in their neuropsycholinguistic model as the complex interactions of the brain (cerebral cortex), semantics and pragmatics, phonology, grammar, and language production.6 They showed how these systems were interrelated and how a disturbance at any one of the levels could result in language impairment.
A universal classification of language disorders in children is difficult to provide because there are different ways of approaching the problem. We suggest a classification of speech and language development disorders (that is, receptive, expressive, or combined disorders) based on the systems involved in language development6 and whether the disorder is secondary to an underlying organ dysfunction, cognitive disorder, or both (see box A on bmj.com).
Identifying and managing the child who is slow to speak
The evaluation of children with speech or language disorders demands an understanding of basic definitions and processes involved in language development. Clinicians should be aware of the appropriate interventions in order to make efficient referrals and monitor progress effectively. In the evaluation and management of children who are slow to speak, we strongly recommend a good account of the child's medical history, development, and performance, as well as a careful analysis of the child's cognitive strengths and weaknesses with a validated screening test of cognitive function (see figure).
Algorithm for evaluating and managing children who are slow to speak
Additional educational resources
Suggested reading
American Academy of Child and Adolescent Psychiatry. Practice parameters for the assessment and treatment of children with language and learning disorders. J Am Acad Child Adolesc Psychiatry 1998;37(suppl): S46-62
Law J, Boyle J, Harris F, Harkness A, Nye C. Screening for speech and language delay: a systematic review of the literature. Health Technol Assessment 1998;2(9)
Toppelberg CO, Shapiro T. Language disorders: a 10-year research update review. J Am Acad Child Adolesc Psychiatry 2000;39: 143-52
Law J, Boyle J, Harris F, Harkness A, Nye C. The feasibility of universal screening for primary speech and language delay: findings from a systematic review of the literature. Dev Med Child Neurol 2000;42: 190-200
For patients
www.kidsource.com/ASHA/index.html (accessed 19 Jan 2004). This link to the American Speech-Language-Hearing Association provides information on speech and language disorders, as well as referrals to certified speech-language therapists
http://members.tripod.com/Caroline_Bowen/devel1.htm (accessed 19 Jan 2004). This site provides useful and theoretically sound information about some aspects of human communication disorders. It also aims to provide a forum where speech and language pathologists, students, practitioners, and researchers can communicate with each other
http://learninfreedom.org/talking.html (accessed 19 Jan 2004). This site is about taking responsibility for your own learning. This specific page provides an overview of resource materials for speech disorders in children
http://pediatrics.about.com/cs/speechdelays/ (accessed 19 Jan 2004). This page provides a comprehensive index of speech development topics and also provides links to other relevant websites
http://selectcommunities.org/form/Page_3x.html (accessed 19 Jan 2004). This page provides a resource of organisations that deal with speech and language development disorders in children. It also provides important links to relevant websites with more information on the topic
A fuller summary box and three boxes about classifying and evaluating speech and language disorders are on bmj.com
We thank B Poll-The, C de Kruiff, P Jiya, and M Koster for the helpful feedback on the early drafts of this paper. We also thank A Leenders for his help in the literature search.
Contributors: Both authors participated in the design and analysis and in writing the paper. They have both seen and approved the final version. JOB will act as guarantor for the paper.
Funding: No external funding.
Competing interests: None declared.
References
Law J, Boyle J, Harris F, Harkness A, Nye C. Screening for speech and language delay: a systematic review of the literature. Health Technol Assess 1998;2(9).
Toppelberg CO, Shapiro T. Language disorders: a 10-year research update review. J Am Acad Child Adolesc Psychiatry 2000;39: 143-52.
Beitchman JH. Summary of the practice parameters for the assessment and treatment of children and adolescents with language and learning disorders. J Am Acad Child Adolesc Psychiatry 1998;37: 1117-9.
Fenson L, Dale PS, Reznick JS, Bates E, Thal DJ, Pethick S. Variability in early communicative development. Monogr Soc Res Child Dev 1994;59: 1-173.
Crosley CJ. Speech and language disorders. In: Swaiman KF, Ashwai S, eds. Pediatric neurology, principles and practice. Minneapolis: Mosby, 1999: 568-75.
Chevrie-Muller C, Rigoard M-Th. Child speech and language assessment and measurement. Acta Otorhinolaryngol Belg 2000;54: 419-25.
Wetherby AM, Allen L, Cleary J, Kublin K, Goldstein H. Validity and reliability of the communication and symbolic behavior scales developmental profile with very young children. J Speech Lang Hear Res 2002;45: 1202-18.
Coplan J, Gleason JR. Quantifying language development from birth to three years using the early language milestone development scale. Pediatrics 1990;86: 963-71.
Cronin VS. The syntagmatic-paradigmatic shift and reading development. J Child Lang 2002;29: 189-204.
Gillberg C. Clinics in developmental medicine. In: Aicardi J, Bax M, Gillberg C, Ogier H, eds. Diseases of the nervous system in childhood. Cambridge: Mac Keith Press, 1998: 850-1.
Berman S. Language disorders. In: Berman S, ed. Pediatric decision making. St Louis: Mosby, 1996: 40-2.
Cantwel DP, Baker L. Psychiatric and developmental disorders in children with communication disorders. Washington, DC: American Psychiatric Press, 1991.(Jamiu O Busari, paediatri)
Correspondence to: J O Busari, Department of Paediatrics, Boven IJ Hospital, Statenjachtstraat 1, 1030 BD, Amsterdam Ojay33@hotmail.com
Children who are slow to speak often present clinicians with a dilemma—should they conduct further investigations or just wait and see if the problem resolves (as it does in most children aged under 3 years)? Two paediatricians propose a guideline that can be used to investigate and manage children with speech or language delays
Introduction
We did a database search on Medline (National Library of Medicine) using the following key words: "speech and language disorders", "children (0-18 years)", "screening methods", "diagnostics", and "interventions". We chose relevant review and research articles that had been published on the subject after 1990 because we were interested in the latest developments in the area. We used 10 articles to prepare this report, chosen on the basis of the originality of content and relevance to the topic of this review. We used two paediatric neurology textbooks as additional sources of information. A general practitioner, general paediatrician, paediatric neurologist, and linguist commented on the review.
Summary points
Delay in speech and language development in children can be defined as a "delay in speech and/or language development compared with controls matched for age, sex, cultural background, and intelligence"
To evaluate such children, carefully analyse the child's cognitive strengths and weaknesses
The analysis should take account of the history and context in which the child is developing, the observed performance of the child, and the results of a validated test of cognitive function
In all cases of suspected speech and language delay, audiometry and a good clinical evaluation of the central nervous system and ear, nose, and throat are mandatory
The management of children with speech and language delay should be multidisciplinary, involving the child's parents and school teacher, as well as various health professionals
Definitions
A thorough knowledge of language development in the population of normal children is necessary when investigating a delay in speech or language development. According to Fenson et al, the order of the language learning process is firm but with a great range of variation in timing.4 This makes it difficult for the clinician to discriminate normal (but delayed) language development from a typical disorder of language development. In the normal language learning process, children start babbling at 6-10 months, understand words by 8-10 months, and, on average, speak their first words around their first birthday. By 14-24 months, most children start to produce two-word phrases, and at 3 years a child should be able to make three-word combinations. At the age of 4 years, clear syntax is part of most children's speech.5
Domains of language development
To analyse language and to define language disorders most linguists divide language into four domains: phonology, grammar, semantics, and pragmatics.
Phonology refers to the ability to produce and discriminate the specific sounds of a given language. Phonological receptivity to different languages is optimal at birth but starts to decline at about age 10 months, reaching a rather general inability to acquire native phonology by preadolescence.
Grammar refers to the underlying rules that organise any specific language. Children start to learn grammar when they start to speak about objects, people, and actions.
Semantics, the study of meaning, includes the study of vocabulary and the number of words a child knows. The size of a child's vocabulary is thought to be the best predictor of school success.1
Pragmatics refers to the ability of the child to use his or her language in interactions with others. Understanding and producing language is a complex process in which different systems are involved. Chevrie-Muller and Rigoard described these systems in their neuropsycholinguistic model as the complex interactions of the brain (cerebral cortex), semantics and pragmatics, phonology, grammar, and language production.6 They showed how these systems were interrelated and how a disturbance at any one of the levels could result in language impairment.
A universal classification of language disorders in children is difficult to provide because there are different ways of approaching the problem. We suggest a classification of speech and language development disorders (that is, receptive, expressive, or combined disorders) based on the systems involved in language development6 and whether the disorder is secondary to an underlying organ dysfunction, cognitive disorder, or both (see box A on bmj.com).
Identifying and managing the child who is slow to speak
The evaluation of children with speech or language disorders demands an understanding of basic definitions and processes involved in language development. Clinicians should be aware of the appropriate interventions in order to make efficient referrals and monitor progress effectively. In the evaluation and management of children who are slow to speak, we strongly recommend a good account of the child's medical history, development, and performance, as well as a careful analysis of the child's cognitive strengths and weaknesses with a validated screening test of cognitive function (see figure).
Algorithm for evaluating and managing children who are slow to speak
Additional educational resources
Suggested reading
American Academy of Child and Adolescent Psychiatry. Practice parameters for the assessment and treatment of children with language and learning disorders. J Am Acad Child Adolesc Psychiatry 1998;37(suppl): S46-62
Law J, Boyle J, Harris F, Harkness A, Nye C. Screening for speech and language delay: a systematic review of the literature. Health Technol Assessment 1998;2(9)
Toppelberg CO, Shapiro T. Language disorders: a 10-year research update review. J Am Acad Child Adolesc Psychiatry 2000;39: 143-52
Law J, Boyle J, Harris F, Harkness A, Nye C. The feasibility of universal screening for primary speech and language delay: findings from a systematic review of the literature. Dev Med Child Neurol 2000;42: 190-200
For patients
www.kidsource.com/ASHA/index.html (accessed 19 Jan 2004). This link to the American Speech-Language-Hearing Association provides information on speech and language disorders, as well as referrals to certified speech-language therapists
http://members.tripod.com/Caroline_Bowen/devel1.htm (accessed 19 Jan 2004). This site provides useful and theoretically sound information about some aspects of human communication disorders. It also aims to provide a forum where speech and language pathologists, students, practitioners, and researchers can communicate with each other
http://learninfreedom.org/talking.html (accessed 19 Jan 2004). This site is about taking responsibility for your own learning. This specific page provides an overview of resource materials for speech disorders in children
http://pediatrics.about.com/cs/speechdelays/ (accessed 19 Jan 2004). This page provides a comprehensive index of speech development topics and also provides links to other relevant websites
http://selectcommunities.org/form/Page_3x.html (accessed 19 Jan 2004). This page provides a resource of organisations that deal with speech and language development disorders in children. It also provides important links to relevant websites with more information on the topic
A fuller summary box and three boxes about classifying and evaluating speech and language disorders are on bmj.com
We thank B Poll-The, C de Kruiff, P Jiya, and M Koster for the helpful feedback on the early drafts of this paper. We also thank A Leenders for his help in the literature search.
Contributors: Both authors participated in the design and analysis and in writing the paper. They have both seen and approved the final version. JOB will act as guarantor for the paper.
Funding: No external funding.
Competing interests: None declared.
References
Law J, Boyle J, Harris F, Harkness A, Nye C. Screening for speech and language delay: a systematic review of the literature. Health Technol Assess 1998;2(9).
Toppelberg CO, Shapiro T. Language disorders: a 10-year research update review. J Am Acad Child Adolesc Psychiatry 2000;39: 143-52.
Beitchman JH. Summary of the practice parameters for the assessment and treatment of children and adolescents with language and learning disorders. J Am Acad Child Adolesc Psychiatry 1998;37: 1117-9.
Fenson L, Dale PS, Reznick JS, Bates E, Thal DJ, Pethick S. Variability in early communicative development. Monogr Soc Res Child Dev 1994;59: 1-173.
Crosley CJ. Speech and language disorders. In: Swaiman KF, Ashwai S, eds. Pediatric neurology, principles and practice. Minneapolis: Mosby, 1999: 568-75.
Chevrie-Muller C, Rigoard M-Th. Child speech and language assessment and measurement. Acta Otorhinolaryngol Belg 2000;54: 419-25.
Wetherby AM, Allen L, Cleary J, Kublin K, Goldstein H. Validity and reliability of the communication and symbolic behavior scales developmental profile with very young children. J Speech Lang Hear Res 2002;45: 1202-18.
Coplan J, Gleason JR. Quantifying language development from birth to three years using the early language milestone development scale. Pediatrics 1990;86: 963-71.
Cronin VS. The syntagmatic-paradigmatic shift and reading development. J Child Lang 2002;29: 189-204.
Gillberg C. Clinics in developmental medicine. In: Aicardi J, Bax M, Gillberg C, Ogier H, eds. Diseases of the nervous system in childhood. Cambridge: Mac Keith Press, 1998: 850-1.
Berman S. Language disorders. In: Berman S, ed. Pediatric decision making. St Louis: Mosby, 1996: 40-2.
Cantwel DP, Baker L. Psychiatric and developmental disorders in children with communication disorders. Washington, DC: American Psychiatric Press, 1991.(Jamiu O Busari, paediatri)