Speech Problems

Speech Problems: Excerpt from The 5-Minute Pediatric Consult

Judith A. Turow, MD

Speech Problems - BASICS

Speech Problems - description

• Language: A system of symbols with a systematic relationship that is used to communicate new ideas
• Speech: The expression of language in a verbal fashion
• Phonemes are the units of sound in speech.
• Phonology is the order in which speech sounds form words.
• Articulation: The process by which words are expressed through muscular movements controlled by complex neuromuscular changes with the production of vocal and articulate sounds
• Children can have central, structural, or functional reasons for speech disorders. The most common speech problems include:
  • Disorders of articulation: Articulation disorders can be organic or functional and occur when children misarticulate words by:
    • Using substitutions of 1 sound for another, commonly “W” for “R”
    • Omitting sounds commonly at the beginning of a word “kip” for “skip”
    • Distorting or adding sounds as “puhlay” for “play”
    • Apraxia is a motor disorder of speech involving central programming for the production of phonemes and the sequencing of voluntary muscle movements for the production of words. Also called “apraxic dysarthria”
    • Dysarthria is a disorder of speech sound production with demonstrable dysfunction or structural abnormality of the tongue, lips, teeth, or palate
    • Phonologic disorders are functional problems with multiple phoneme errors.
  • Disorders of voice are noted to be disorders of pitch, loudness, quality and resonance.
    • Dysphonia: A disorder of the voice
    • Rhinolalia: Altered speech due to some abnormality of nasal structures
    • Hoarseness is the most common problem, and results from problems with the vocal folds or their nerve supply. The most common condition in childhood is vocal nodules, which can be removed, but need to be followed by a period of voice rest.
    • Hypernasal speech is the result of a short, cleft or paralyzed palate as a result of an incompetent palatopharyngeal sphincter. It may also occur with a profoundly deaf child because nasal sounds provide the maximal feedback.
    • Hyponasal speech is often acutely due to nasal congestion as seen with viral upper respiratory tract infections or in association with adenoidal hypertrophy when chronic.
  • Disorders of fluency include pauses, hesitations, repetitions, interjections, or prolongations.
    • Aphasia is a loss or impairment of ability to produce and/or comprehend language due to brain damage. It is usually due to damage of the language centers of the brain (Broca’s aphasia is due to damage in the frontal lobe, and Wernicke’s aphasia is due to damage of the temporal lobe).
    • Dysrhythmia: A disorder coordination between respiration and articulatory function (see “Stuttering” chapter)
  • Secondary speech disorders are speech disorders not associated with dysfunction or structure but due to other diseases or adverse environmental factors, including mental retardation, hearing defects, psychiatric disorders, and extreme social deprivation, isolation, or institutionalization.
  • Mixed speech disorder: A mixture of 2 or more of the categories above (e.g., a cleft lip with abnormal hearing and mental retardation)
  • Developmental language impairment and specific language impairment (see “Speech Delay” chapter).

Speech Problems - epidemiology

Communication disorders are the most common developmental problems in preschool aged children:

• Nearly 20% of 2-year-olds are thought to have delayed onset of speech.
• By age 5, 19% of children are considered to have speech and language disorders—6.4% from speech impairment, 4.6% from speech and language impairment, and 8% from language impairment.
• 50% of mentally retarded children fail to acquire any symbolic communication skills
• The majority of language disorders, up to 85%, are seen in boys.

Speech Problems - DIAGNOSIS

Speech Problems - signs & symptoms

Speech Problems - history

• Is there a history of prolonged feeding time, tongue thrusts, choking on foods, and/or nasal reflux during feeding? Dysarthria is often preceded by dysphasia.
• Persistent nasal reflux during feeding is always a pathologic sign and may be indicative of velopharyngeal insufficiency due to an anatomical or neurological abnormality.
• Frequent pneumonia, recurrent upper respiratory tract infections, or nasal congestion? Is there evidence for palatal insufficiency?
• Recurrent ear infections, or recent infections implying chronic or acute middle ear fluid?
• Any disorders of the mouth, palate, or tongue? Is there a structural reason for dysarthria?
• Prematurity, intrauterine growth retardation, or meningitis? Are there factors that predispose the child to deafness or mental retardation?
• Family history of speech problems?
• Family history of deafness?
• History of lower motor neuron damage or trauma to the pharynx?
• History of hearing loss?
• Voice overuse?
• Odd/stereotypic behavior, unusual social interactions, or limited play skills? Is there evidence for autistic spectrum disorder, pervasive developmental disorder?
• Discrepancy among the areas of skill sets, or regression of skills? Is there any evidence of autistic regression or Landau–Kleffner syndrome (epileptic aphasia)?

Speech Problems - physical exam

• Finding: Iris heterotropia, white forelock (piebaldism), or dystopia canthorum
• Seen in Waardenburg syndrome and with associated deafness
• Microcephaly: May be associated with brain damage from underlying in utero infection, toxin exposure, or genetic disorder
• Enlarged tonsils: Potential reason for abnormal resonance, such as hyponasal speech
• Any impaired sucking or swallowing, bifid or notched uvula, drooling, abnormal gag reflex, tongue thrusts, evidence of tracheotomy scar, potential reason for functional or structural dysarthria, potential reason for damage to vocal cords?
• Upper motor neuron signs, such as involuntary grimacing, drooling, abnormalities of the gag reflex, impairment of sucking and swallowing: May be seen with cerebral palsy, Mobius syndrome.

Speech Problems - tests

• Formal testing to examine overall cognitive level, language related to the cognitive level, and other atypical features (sterotypies, poor socialization skills, sensory aversions)
• Speech and language pathologist
• Psychoeducational testing
• Hearing evaluations
• Screening audiometry: High false-negative rate and inappropriate for the younger child
• Formal audiologic testing including tympanometery and audiometry and possible brain stem evoked response testing for hearing loss
• Speech evaluation
• Videofluoroscopic speech study
• Nasometer: Microchip-based instrument to measure sound coming from the oral and nasal cavities; test to aid in the evaluation of resonance
• Language evaluation:
  • The Early Language Milestone (ELM) Scale (revised ELM 2 now available): Covers language development from birth through age 36 months and intelligibility of speech from ages 24–48 months
  • The Clinical Linguistic and Auditory Milestone Scale (CLAMS): Tests language development from birth through 36 months, confirming normal language in the 14–36-month age range, although less useful for confirming receptive language delay in 14–36-month-old children, or expressive language delay in children <25 months
• Metabolic and cytogenetic testing for disorders including fragile X syndrome
• Apex SNHL (sensorineural hearing loss) microarray for molecular diagnosis of genetic deletions in nonsyndromic SNHL
• Central nervous system (CNS) imaging is rarely helpful, except with autistic regression or Landau–Kleffner syndrome (epileptic aphasia)

Speech Problems - differencial diagnosis

• Infectious:
  • Prenatal: Toxoplasmosis rubella, cytomegalic inclusion, herpes (TORCH) infections
  • Postnatal infections, particularly bacterial meningitis caused by:
    • Neisseria meningitidis
    • Haemophilus influenzae
    • Streptococcus pneumoniae
  • Recurrent throat infections
  • Recurrent ear infections
• Environmental: Isolation and/or social deprivation
• Structural:
  • Cleft lip or palate
  • Notched uvula
• Genetic:
  • Waardenburg, Branchiootorenal, Stickler, Neurofibromatosis 2
  • Autosomal recessive (AR) inheritance
  • Refsum, Usher, Pendred, Biotinidase deficiency
  • X-linked recessive
  • Alports, Mohr–Tranebjaerg, mitochondrial syndromic hearing impairment
• Developmental:
  • Mental retardation
  • Autism/Autistic spectrum disorder
  • Apraxia
• Neuromuscular:
  • Cerebral palsy
  • Broca’s or Wernicke’s aphasia
  • Mobius syndrome
  • Landau–Kleffner syndrome
• Nutritional: Malnutrition
• Acquired hearing loss
  • Noise exposure
  • Aminoglycoside-acquired hearing loss
  • Hyperbilirubinemia
  • Trauma to the head and neck
  • Cholesteatoma
• Acquired voice loss/dysfunction:
  • Trauma to the head and neck
  • Tracheotomy
  • Adenoid enlargement
  • Chronic/Recurrent nose and/or throat infections
  • Nasal allergies
  • Voice abuse

Speech Problems - TREATMENT

Speech Problems - general measures

• Home-based programs through early intervention for preschool children up to 36 months
• Special education enrollment for children >36 months
• Audiologic assessment for all children with speech disorders is a must and should include hearing testing. Referral to an otolaryngologist to evaluate the function and structure of anomalies of the head and neck
• Referral to a speech therapist: Children who have oral–motor deficits (especially speech apraxia) and require intensive speech and language therapy
• Signing and/or picture card system may be helpful with severe speech and language problems to teach child how to communicate.
  • Use of signing by nonverbal children has been shown to be an effective bridge to spoken language. Picture exchange is another method of communicating.
• Referral to psychologist/child developmentalist
• Referral to an occupational therapist trained in sensory integration techniques: Can assist in management of children who show aversive behaviors.
• American Sign Language teacher

Speech Problems - FOLLOW UP

• The prognosis for most children with expressive language problems is excellent. Most will have normal language skills by the time they enter primary school.
• However, if there are persistent speech and/or language problems by 5 years of age, there is a 70–80% chance of continued communication difficulty and reading disorders.
• Pearls:
  • “Rule of 4s”: Divide the child’s age in years by 4; the quotient is approximately equal to the percentage of the child’s speech that should be intelligible to strangers:
    • A 1 year old should be intelligible to strangers 1/4 of the time
    • A 2 year old, 1/2 of the time
    • A 3 year old, 3/4 of the time
    • A 4 year old, essentially 100% of the time
    • The average 1 year old should be speaking at least 1 word (other than mama, dada, or family names), following at least a 1-step command not accompanied by physical gestures, and pointing with 1 finger to desired objects.
    • A 2 year old will be speaking 2-word phrases and following 2-step commands.
    • Between ages 2 and 3, the average child uses “telegraphic speech” (e.g., “go home now”).
    • The average 3 year old should be fluent in the present tense and have a speaking vocabulary of 500–1,000 words.
    • The average 5 year old follows 3-step commands, names 5 colors, has a vocabulary of >2,000 words, and makes up rhymes.

Speech Problems - bibliography

1. Coplan J. Normal speech and language development: And overview. Pediatr Rev. 1995;16:91–100.
2. Coplan J. Evaluation of the child with delayed speech or language. Pediatr Ann. 1985;14:203–208.
3. Simms M, Schum R. Preschool children who have atypical patterns of development. Pediatr Rev. 2000;21:147–158.
Smith RJH, Van Camp G. Deafness and hereditary hearing loss overview. Available at: http://www.geneclinics.org/profiles/deafness-overview/details.html.

Speech Problems - CODES

Speech Problems - icd9

• 315.30 Speech/language disorder
• 315.39A Developmental articulation disorder
• 784.40 Voice disturbance
• 784.69V Verbal apraxia

Speech Problems - FAQ

• Q: Does ankyloglossia make a difference in the emergence of language?
• A: The tongue has to move freely for speech with such sounds as /t/, /d/, /n/, and /l/, but misarticulation caused by ankyloglossia is quite rare.
• Q: Does “signing” delay speech?
• A: In fact, signing may promote speech development and progression due to the increased ability of the child to communicate.
• Q: Does birth order impact speech development?
• A: Later-born children produce single words and 2-word phrases at similar ages to their 1st-born siblings. Delayed speech carries the same significance regardless of birth order.
• Q: Does bilingualism make a difference in speech progression?
• A: Children born to bilingual parents may mix up phrases, vocabulary, and grammar of the 2 parents’ languages, but vocabulary size and length of sentences should be normal by age 2–3 years.

Book Source Details

• Book Title: The 5-Minute Pediatric Consult
• Author(s): M. William Schwartz MD; et al.
• Year of Publication: 2008
• Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: The 5-Minute Pediatric Consult Authors: M. William Schwartz MD; et al. Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7577-9

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