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Spe e ch a nd L a ng uage

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

Communication is the exchange of information using a socially accepted system of


symbols and behaviors. Although humans communicate with gestures, posture, and
facial expression, most human communication relies heavily on converting ideas
into language that is written or spoken. Spoken communication is received by the
listener through hearing. Language is a socially agreed on, rule-governed system of
symbols that is used to represent ideas about the world. Language includes shared
understanding of what words mean (semantics); the capacity to change words in
systematic ways, such as adding s to the end of a noun to make it plural (morphol-
ogy); and rules that govern word order in a sentence (syntax).1 The use of language as
a social tool (pragmatics) involves a complex set of rules about using eye contact,
interpreting nonverbal messages together with words that may have a different literal
meaning, structuring requests that are polite, and sustaining conversation topics.
Language disorders are identified when a person has difficulty with expressive
language (sharing his or her thoughts and ideas), receptive language (understanding
what others say), or pragmatic language (the social use of language).1
Speech is the oral means of communicating language. Speech is produced through
the complex coordination of respiration and laryngeal, velopharyngeal, and articula-
tory movements. Respiration provides the air pressure to initiate sound production
through vocal fold vibration at the larynx. Sound from the larynx together with airflow
are then directed nasally or orally by the velopharynx and shaped by the other articu-
lators (eg, tongue, lips, teeth, and jaw) to create speech sounds. When these sounds
are sequenced together, listeners are able to recognize words and sentences. Speech
production can be categorized into three main areas: voice, fluency, and speech intel-
ligibility, which includes articulation and speech resonance.1 Voice quality reflects the
sound produced by the vocal folds, a function that is influenced by respiratory
support. Fluency refers to the rhythm and rate of speech, whereas articulation refers

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).

Pediatr Clin N Am 55 (2008) 11591173


doi:10.1016/j.pcl.2008.07.007 pediatric.theclinics.com
0031-3955/08/$ see front matter 2008 Elsevier Inc. All rights reserved.
1160 Sharp & Hillenbrand

to the coordinated movement of the articulators to produce the consonants and


vowels we recognize as speech. For example, children must learn how to combine
laryngeal and articulatory control to differentiate sounds such as b from m, which
use lip closure, but m is produced nasally, whereas b involves stopping and
releasing airflow through the oral cavity. Speech disorders are identified when
a persons voice, fluency, or articulation call attention to the speaker because his or
her speech is sufficiently different from the norm.1
Hearing is the conduction of sound from the environment through the outer, middle,
and inner ear to the brain where the signal is interpreted. Hearing is an essential ele-
ment in the development of oral speech and language. Those who have hearing loss
can be expected to have difficulty developing and maintaining speech and language
skills for oral communication (see the article by XX found elsewhere in this issue).

TYPICAL DEVELOPMENT OF SPEECH AND LANGUAGE

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.

DELAYS AND DISORDERS OF SPEECH AND LANGUAGE

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.

DISORDERS OF SPEECH PRODUCTION

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).

Cleft Lip and Palate


Clefts of the lip and palate are among the most common congenital anomalies, occur-
ring in approximately 1 in every 600 live births.10 Intact palatal structures are critical
for the development of normal speech because the hard palate and soft palate (velum)
act to separate the oral cavities from the nasal cavities. The velopharynx closes to
direct airflow orally for most speech sounds and opens to permit nasal resonance
on nasal speech sounds (in English: m, n, and ng). When dynamic function of
the velopharynx is disrupted, speech is hypernasal in quality. Samples of hypernasal
speech are available through the American Cleft PalateCraniofacial Associations
Web site.10
One of the most commonly identified syndromes in individuals who have cleft
of the secondary palate is velocardiofacial syndrome (also called 22q;22q1113,
1162
Sharp & Hillenbrand
Table 1
Summary of prespeech, speech, and language milestones in the first 5 years of life

Age Language Comprehension Skills Expressive Speech and Language Skills


Birth3 mo Startles to loud sounds Coos to indicate pleasure
Quiets or smiles to familiar voice Uses different cries for different needs
Increases or decreases sucking behavior in response Smiles when sees familiar people
to sound
48 mo Localizes to sound Begins to produce clear vowel sounds
Reacts to changes in tone of voice Imitates adult mouth movements, vowel sounds, and nonspeech
Is aware that toys that make sounds movements (eg, raspberries)
Attends to music Babbles alternating consonants and vowels (eg, bababa), often with
b, p, and m
Uses voice to communicate excitement and displeasure
Gurgles when alone and when playing with an adult
714 mo Listens to speech and localizes to sound Babbles with short sequences
Discriminates between speech sounds in native language Adds sounds k, g, t, and d
Recognizes words for common items such as daddy Uses speech or noncrying sounds to get and keep attention
or juice Uses one or two true words such as bye-bye or mama
Responds to some requests such as Want more?
Enjoys social turn-taking games such as peek-a-boo
12 y Identifies at least a few body parts Uses at least 10 words by 18 mo
Follows simple commands in context such as Throw the ball. Uses many different consonant sounds at the beginning of words
Understands simple questions in context such as Wheres Simplifies adult speech by dropping a syllable, consonant blend,
your sock? or word ending
Listens to stories, songs, and rhymes Steadily increases vocabulary, particularly from 18 to 24 mo
Points to familiar pictures in a book Begins to combine words into two-word phrases and questions
Girls tend to be slightly more advanced at this stage
23 y Follows two-part commands such as Get your shoe Speech is understood by caregivers most of the time
and give it to me. Has a word for almost everything
Consistently identifies body parts Uses two- to three-word phrases to ask questions or to describe events
Uses speech to get attention or to make a request
May repeat starting phrases or words (eg, I, I, I, I want) but should
not get stuck or frustrated
34 y Understands easy wh questions and gives appropriate Unfamiliar listeners can understand most of the childs speech
response to who, what, where, and why forms Can describe events that take place away from home or parent
Learns vocabulary and sentence structure from adult Uses longer sentences of four or more words
conversation and being read to Usually talks fluently without repeating syllables or words
45 y Attends to and understands short stories Voice sounds clear
Can answer questions about a story Uses sentences that give a lot of details (eg, I like to read my books)
Understands most of what is said in home, preschool, Tells stories that stick to a topic
and school environments Communicates easily and clearly with other children and adults

Speech and Language Development and Disorders


Says most sounds correctly (exceptions are th, ch, r, l, s,
and z, which may not yet be accurate)
Uses regional or familys rules of grammar
13,21,51
Data from Refs.

1163
1164 Sharp & Hillenbrand

Shprintzens syndrome, or DiGeorge syndrome).11 This syndrome is characterized by


a triad of symptoms: velopharyngeal dysfunction (with or without a frank palatal cleft),
cardiac anomaly, and learning difficulties including language delay. Any child who has
a cleft and any history of cardiac involvement, from a mild murmur to cardiac surgery,
should be evaluated for this syndrome.12 Other genetic and craniofacial disorders are
addressed in this issue (see the article by XX found elsewhere in this issue).
Although most clefts are recognized at birth, some microforms of cleft palate may
go unnoticed or unreported, particularly if they are not symptomatic during feeding.
Any infant who has persistent nasal leakage associated with feeding and any child
who has persistent hypernasal speech should be evaluated for submucous cleft
palate.13 Careful evaluation of palatal structure is also advisable before a child
undergoes adenoidectomy because velopharyngeal closure for speech often occurs
at the level of the adenoid. Any child who has persistent hypernasality 4 to 6 months
after adenoidectomy should be referred to a speech-language pathologist affiliated
with a cleft palate team to determine whether the child is physically able to achieve
velopharyngeal closure. When physical closure is evident on some speech sounds,
the child is a candidate for behavioral intervention, but if the child can never achieve
closure, then other physical management strategies must be explored.

Speech Disfluency or Stuttering


Stuttering is a disruption in the expected rate or fluency of speech that can include
prolongations of sounds in words, use of filler words such as um, difficulty with start-
ing to speak (blocks), and repetitions. Repetitions may vary from repeating one speech
sound (often in word initial position, such as s-s-sunny), syllables, words, or phrases
(I want, I want, I want an ice cream). Stuttering occurs more often in boys than in girls
and appears to have an underlying genetic component.14
Some disruptions in the fluency of speech are expected in all speakers because
speech is an immensely complex coordinated motor activity. Effortless repetitions
of syllables, words and phrases are observed to increase in young children during
the time at which they begin to produce complex utterances and may persist for
a period of a few months. In a typically developing child, this period of developmental
disfluency occurs between 2 and 3 years of age.15 Referral for a speech evaluation
should be made when a child has a positive familial history or demonstrates any of
the following characteristics: prolonged disfluency (>6 months), self-awareness of
talking difficulty, avoiding talking, tense pauses in speech, blocks, or extraneous facial
or body movements while talking or when trying to initiate speech.16

Childhood Apraxia of Speech


Childhood apraxia of speech (CAS) is characterized by impaired volitional motor
programming for speech production in the absence of paralysis or weakness of the
oral musculature.17 It may be associated with known neurologic impairment or may
be idiopathic. A cardinal sign of CAS is inconsistency in speech production: a child
may be able to produce a speech sound or a sequence of sounds one moment and
then be unable to do so the next. The childs connected speech is likely to be limited
to vowel sounds and speech that appears to be effortful. Children who have CAS are
often described as groping for accurate placement of the articulators when they try
to produce consonant speech sounds. The difficulty executing oral movements for
speech often corresponds with a significant delay in speech development in a child
who has intact auditory comprehension skills.
Children who have CAS may develop methods of communication that do not rely on
speech to express themselves, for example, pointing, grunting, and idiosyncratic
Speech and Language Development and Disorders 1165

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

Speech Delay or Disorder


It is typical for a child who is learning to speak to simplify adult productions of words
and speech sounds. For example, a child might say efun instead of elephant.
Many of these simplifications should begin to reduce by 24 months of age and be
eliminated by 36 months of age among children who do not have musculoskeletal
anomalies.18 Most children should be attempting most speech sounds by age
36 months, but many sounds such as s, th, ch, sh, f, v, l, and r
continue to be perfected in conversational speech beyond age 4 years.19,20
Children should be 50% intelligible by age 36 months and about 75% intelligible by
age 48 months.21 Persistent speech production problems may reflect difficulty with
learning or coordinating articulatory placement for individual sounds (eg, th for s),
which is called an articulation disorder. Alternatively, children may have mislearned
the rules that guide the sound system (phonology) in their native language. Children
who have a phonologic disorder tend to demonstrate recognizable patterns of speech
errors such as omitting syllables in multisyllabic words (banana becomes nana), us-
ing front sounds (t and d) to substitute for speech sounds usually produced at the
back of the mouth (k and g), or deleting all final consonant sounds in words.22
Formal assessment and detailed analysis of speech sounds are often necessary to
differentiate articulation problems from phonologic disorders of speech production or
from CAS. Children who have persistent difficulty with speech intelligibility beyond age
36 months should be referred for a comprehensive evaluation of speech and
language.

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

communication, and problems interpreting metaphoric language. Children who have


autism may also demonstrate problems with reading and writing.24
The American Academy of Pediatrics published several clinical reports related to the
pediatricians role in the early identification, evaluation, and management of
autism.25,26 As part of its Autism Listen Act Refer Monitor screening program,23 the
American Academy of Pediatrics recommended screening starting at the 9-month
visit, with autism-specific screening at the 18-month visit using the following red
flags to initiate comprehensive evaluation:
Lack of babbling, pointing, or other gestural communication by age 12 months
Lack of the use of single words by age 16 months
Lack of two-word novel phrases by age 24 months
Loss of language or social skills at any age
Greenspan and colleagues27 recommended a broader functional framework for
identifying children at risk for ASD that focuses on a childs ability to initiate and sus-
tain engagement, demonstrate social reciprocity with caregivers, and solve social
problems with caregivers through use of gestures to communicate and negotiate
getting desired items. The goal of early identification is to initiate early intervention,
which has been shown to improve outcomes for children who have ASD.28

Specific Language Impairment


Specific language impairment (SLI) is a delay in the acquisition of expressive language
in a child who has no known hearing, neurologic, or physical problems and occurs in
the presence of normal nonverbal intelligence.29 Children who have SLI exhibit smaller
vocabularies, use shorter utterances, omit grammatical endings and function words,
and demonstrate more grammatical errors than their same-aged peers. An epidemio-
logic study identified a prevalence of 7.4% (8% boys; 6% girls) among children in kin-
dergarten.29 Of those who had SLI, parental awareness of a speech or language
problem was 29%.30 SLI appears to have a genetic component, because children
who have SLI are more likely than typically developing children to have a relative
who has a language disorder.30,31 SLI is also linked to parent education and income.29
Early identification of SLI in young children is important because the language deficits
are associated with academic problems, particularly the acquisition of literacy skills.32

Central Nervous System Injuries


Focal brain injuries such as intracranial hemorrhage can occur in infants, toddlers, and
throughout childhood. Diffuse injuries may occur through blunt head trauma, penetrat-
ing injuries, or abuse. Any damage to the developing brain can negatively affect cog-
nition, memory, attention, learning, language comprehension, language production,
and pragmatic language and can disrupt motor control and motor programming for
speech and swallowing.3336 Although it has been suggested that young children
have greater neural plasticity for mapping new learning, the evidence suggests that
earlier age of injury is associated with poorer long-term outcomes.33
Communication problems associated with brain injury can range from a minimal
reduction in speech intelligibility to profound impairments of language and cognition
that limit communication in activities of daily living. The long-term outcome of very
early injury to the cortex is often classified generally as cerebral palsy. Depending
on the timing, site, and extent of cerebral damage, speech intelligibility is likely to
be affected because of imprecision and discoordination of the respiratory, laryngeal,
and articulatory movements for speech. As a result, speech may be limited to a few
Speech and Language Development and Disorders 1167

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.

Social Environmental Risks for Language and Cognitive Development


Children need a stimulating home environment from early in life, and the language
learning environment has the potential to affect a childs capacity to acquire language.
Children who experience traumatic events are known to be at risk for disrupted devel-
opment.38 Children who have postnatal traumatic stress combined with prenatal alco-
hol exposure have lower intelligence scores and more significant neurodevelopmental
deficits, greater oppositional defiant behavior, and greater problems with attention
and social interaction than traumatized children who do not have alcohol exposure.38
Children who are known to have been neglected or abused are candidates for
a comprehensive evaluation of cognition, development, language, and social develop-
ment, ideally through an interdisciplinary pediatric team that specializes in working
with children who have this history.

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

Therapy for Speech Disorders


Treatment for articulation impairments targets the correct production of specific
consonant or vowel sounds, whereas treatment for systematic mislearning of the pho-
nologic system in the language addresses the patterns of error, rather than teaching
each sound individually.43 After production of target sounds is achieved in structured
contexts, treatment addresses generalization of sounds into more natural speaking
tasks. Treatment for CAS differs from the approaches used for articulation or phono-
logic problems and often requires intensive treatment over a longer course of therapy
than treatment for children who have other speech sound disorders.44
Isometric oral-motor exercises have often been recommended to strengthen and
increase range of movement in the oral mechanism. Because few speech production
disorders relate to muscular weakness or reduced range of motion, the finding of
limited efficacy of oral exercises is not surprising.45

Therapy for Language Disorders


Children can exhibit language problems in a number of areas including expressive lan-
guage, receptive language, written language, and social (pragmatic) language. The
goals of language therapy and the approaches used are based on the results of a com-
prehensive language evaluation. Children up to age 3 years are likely to benefit from
a focus on language using play-based therapy in which the child and a parent
participates as the speech-language pathologist creates an environment rich in
opportunities to communicate.46 As the child is reinforced for using new behaviors
to communicate in this semistructured play setting, the child begins to learn the social
power that these new behaviors bring. This setting also is valuable in demonstrating to
the parent language stimulation activities to use at home.
Older preschoolers and school-aged children can benefit from individual or group
therapy that focuses on their specific language needs (ie, vocabulary, longer word
combinations, or the use of more grammatically complex utterances). It is critical
that structured language intervention be extended into functional contexts for chil-
dren, including the school curriculum, to promote generalization of skills into natural
communication settings. When the goal of therapy is to increase social language skills,
children are often enrolled in group therapy, which provides natural opportunities for
supported interaction with peers when working on language and written
communication.47

Therapy for the Child who is Nonverbal


When a child is not able to use speech to communicate, the primary goal of speech-
language therapy is to establish a reliable means of communication using the childs
capacity for communication skills, which may include the use of gestures, idiosyn-
cratic signs, more formal baby signs, or an established manual sign language. It
is important that treatment provide the child opportunities for communicative success,
irrespective of the communication modality used. As the child develops a reliable way
to communicate basic needs, nonspeech techniques are expanded to allow for max-
imal expressive language development. Speech models are given simultaneously as
the child works on nonspeech communication to continue to provide opportunities
for developing speech production skills; most children demonstrate increased speech
production as their communication skills increase.48
Some children do not develop functionally adequate speech communication due to
neuromotor, structural, or cognitive impairments. Children who have severe impair-
ments in speech production may benefit from the use of communication
1170 Sharp & Hillenbrand

technology, ranging from the use of a picture communication board to a speech-


generating device to a computer-based system that features access to word process-
ing and voice output.49 A speech-language pathologist can provide evaluation and
intervention for the use of alternative communication systems to determine the level
and type of technology that best fits the childs daily communication needs.

THERAPY APPROACHES AND SETTINGS

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.

ENSURING AN EVIDENCE BASE

In addition to broad efforts to conduct outcomes research in the field of speech-


language pathology, many clinical sites participate in the American Speech-
Language-Hearing Association National Outcomes Measurement System, which is
a centralized system designed to track changes in functional communication skills be-
tween admission to and discharge from speech and language services. Scales to
measure patient performance across speech and language domains are available to
clinicians in a variety of clinical settings. For example, the preschool scales include
specific measures across the domains of articulation/intelligibility, cognitive orienta-
tion, pragmatics, spoken language comprehension, spoken language production,
and swallowing.50 Aggregate outcomes data are used to examine the value of
speech-language services for policy makers, third-party payers, and consumers
and to provide members information about best practices.

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

diagnosis is critical to designing appropriate intervention. Intervention for voice,


speech, and language problems should be tailored to the parents goals along with
the childs clinical and educational needs. Early identification and intervention assist
in educational planning and are often associated with better long-term outcomes.
Any speech-language therapy plan should be designed with measurable goals and
consistent monitoring of progress toward those goals.

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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