Verbal Communication Difficulty
Verbal Communication Difficulty: Excerpt from The Diagnostic Approach to Symptoms and Signs in Pediatrics
Impairedverbal communication affects normal development, social relationships, andlearning in school.Basic components of verbal communicationare language, speech, and voice.On each well-child visit, a child'sability and skill in verbal communication should be assessed. Anyproblem needs to be recognized and evaluated properly, so that necessaryhelp can be given. Principal Causes of Verbal Communication Difficulty
- Receptiveand expressive language disorders
- Maturational delay
- Hearing loss
- Neurologic disorders
- Psychologic disorders
- Speech disorders
- Articulationdisorders
- Phonology disorders
- Fluency disorders
- Voice disorders
- Phonationdisorders
- Resonance disorders
Clinical Features and Diagnosis
Receptive and Expressive Language Disorders
Languageis the understanding and use of meaningful speech. Receptive languageis the ability to understand the language of others, whereas expressivelanguage is the ability to choose and combine words into meaningfulspeech.Children with receptive language disorderhave difficulty understanding speech of others and answering questionsappropriately.Those with expressive language disorderhave limited vocabulary and experience difficulty in forming sentencestructures and using words appropriately.Causes of receptive and expressivelanguage disorders include maturational delay, hearing loss, neurologicdisorders, and psychologic disorders, including psychosocial deprivation. Maturational Delay
Although maturational language delay is common,the cause remains unknown. The language is normal, but its developmentis unusually slow. There is no evidence of hearing, cognitive, orpsychologic problems.
Hearing Loss
Normal hearingis necessary for normal language development.Hearing loss, especially sensorineural,can affect perception and learning of speech sounds. Even mild hearingloss may contribute to delayed language development.Children with delayed or impaired languagedevelopment should have their hearing tested.Causes of hearing loss and types ofage-appropriate hearing tests are discussed in Chap. 26, Hearing Loss and Deafness. Neurologic Disorders
Mental retardationis common cause of impaired language acquisition. Affected childrenhave delayed and impaired language at any age. See Chap. 13, Developmental Delay.Cerebral malformations may affect languagedevelopment if they involve the language area in dominant hemisphere.Acquired language disorders also mayoccur from focal cerebral lesions in the dominant hemisphere. Theselesions may be due to head trauma, infection, neoplasm, vasculardisease, and degenerative diseases of the nervous system. Psychologic Disorders
Severe psychologicproblems can cause disturbed or bizarre communication patterns inwhich affected children do not behave or relate to other peoplein normal ways.Autism, most extreme form of disturbedcommunication, involves severe disturbances in attention, cognition,and behavior.Psychosocial deprivation is anothercause of delayed or impaired language development.Intellectual and language stimulationis critical during early language development, which occurs duringfirst 3 yrs of life. If such stimulation is absent or inadequate,delayed and impaired language development may occur. Speech Disorders
Speech is the physical production of soundsin sequence to form spoken words. A speech disorder is characterizedby defective production of individual speech sounds in comparisonwith one's peers. Speech may be difficult to understandor even unintelligible.
Articulation Disorders
Causes of articulation problems include anatomicconditions (cleft palate, dental malocclusion, macroglossia) andneurologic insult or dysfunction (cerebral palsy).
Phonology Disorders
Phonologyconcerns rules that govern the production of speech sounds.A phonology disorder is characterizedby speech sound errors due to difficulty in applying a rule forthe production of a class of speech sounds (e.g., child may substitute /t/ for /s/, /t/ for /sh/,and /d/ for /z/). In this case,child is using the process of "stopping" to producethese sounds.Therapy involves teaching the childthe common feature of production, so that this feature can be generalizedto the entire class of sounds. Fluency Disorders
Fluency disorder, commonly known as stuttering,is a type of speech disorder with abnormal number of repetitions,hesitations, blocks, and prolongations in normal flow or rhythmof speech. Stuttering seems to be learned behavior and often beginsat 2–4 yrs.
Voice Disorders
Voice maybe defined as sound produced by vocal cords (phonation), which isaltered when it vibrates in oral and nasal cavities (resonance).Voice disorders can be classified into2 major types: phonation disorders and resonance disorders. Phonation Disorders
Hoarseness,abnormal pitch, inappropriate loudness, severe pitch breaks, andaphonia characterize phonation disorders, which are usually causedby laryngeal pathology.Common causes include laryngitis, vocalnodules, papillomas, and vocal cord paralysis. Most common causeof persistent hoarseness in children is vocal nodules, which maydevelop on vocal cords due to overuse, misuse, or abuse of voice.See further discussion of these disorders in Chap. 31, Hoarseness, and Chap. 63, Stertor, Stridor, and Airway Obstruction. Resonance Disorders
Abnormalvibration of sound in oral, nasal, and pharyngeal spaces of respiratorytract produces hyponasal or hypernasal voice that characterizesresonance disorders.Lack of adequate nasal resonance produceshyponasal voice, which is due to obstruction in posterior nasalpassages or nasopharynx. Most common cause is enlargement of adenoidglands, which is usually due to recurrent viral URI or allergicrhinitis.Escape of too much sound from nasalcavity and nasopharynx produces hypernasal voice, which is oftenaccompanied by nasal air emission during consonant production. Thisis due to incomplete closure of velum against posterior pharyngealwall (velopharyngeal insufficiency). Cleft palate, submucous cleftpalate, short palate, wide nasopharynx, adenoidectomy, and poorvelar mobility can produce velopharyngeal insufficiency. Diagnostic Approach
Problemin verbal communication often presents as delay in language development orinadequate use of speech. Table72.1 describes normal sequence of receptive and expressivelanguage development.Children at high risk for problemswith verbal communication include those with cleft palate, mentalretardation, cerebral palsy, hearing loss or deafness, deprivation,or psychologic disturbance.Complete history, physical exam, anddevelopmental assessment should be performed when a child exhibitsverbal communication difficulties. Physician can listen to childrentalking in natural conversation and have them repeat specific wordsor sentences to assess use of consonants, vowels, pronouns, vocabulary,syntax, and intelligibility of speech. Communication disorder shouldbe suspected if any indications listed in Table 72.2 are observed.Children with delayed language or inadequatespeech should have their hearing tested and language and speechskills evaluated by speech-language pathologist. Children with voicedisorders should be referred to otolaryngologist or speech pathologistif voice is chronically hoarse or of poor quality, pitch is inappropriatefor age or sex, pitch brakes occur often, or voice is hypernasalor hyponasal.Child with stuttering should be referredto speech-language pathologist if parents have expressed concernabout the condition; if child has abnormal number of repetitions,hesitations, prolongations, blocks, or disruptions in natural courseof speech; or if child is concerned and becomes anxious or tenseduring speech, or avoids speaking due to fear of stuttering. Table 72.1. Indications of the Normal Sequence of Language Development
| Age | Indication |
| Receptive language |
| 2 mos | Startles or cries with a loud noise |
| 4 mos | Orients to a voice |
| 6 mos | Turns to a bell |
| 9 mos | Activity stops when told his or her name |
| 12 mos | Responds to simple requests (e.g., "bring me" or "give me" with gesture) |
| 15 mos | Follows simple commands (e.g., "bring me" or "give me" without gesture) |
| 18 mos | Identifies familiar objects in a picture book |
| 2 yrs | Listens to stories with some understanding |
| 3 yrs | Follows directions and 2-step commands |
| 4 yrs | No difficulty understanding and following directions |
| Expressive language |
| 3 mos | Coos in response to voice |
| 5–6 mos | Uses vocal sounds to get attention |
| 7–8 mos | Babbles |
| 10 mos | Says "mama" and "dada" |
| 12 mos | Begins to use single words |
| 15 mos | Says 4–6 words and jargon |
| 16–18 mos | Extensive jargoning with some true words |
| 18–20 mos | Says 20 words |
| 21–24 mos | Puts 2–3 words together |
| 2 yrs | Speech about 75% intelligible |
| 3 yrs | Uses pronouns I, me, you; uses sentences with frequent grammatical errors; speech90% intelligible |
| 4 yrs | Can produce all vowels and most consonants |
| 5 yrs | Speech is understandable and fluent; can produce all voweland consonant sounds |
Table 72.2. Clinical Indications of Suspected Abnormal Verbal Communication
| Age | Indication |
| By 3–6 mos | Failure to consistently respond to sound |
| By 9–12 mos | No babbling or any words |
| By 12–18 mos | Failure to use >1–2 words and to follow simplecommands |
| By 18–24 mos | Failure to say any words or put 2 words together; has vocabulary of <20 words |
| By 30 mos | Failure to understand without gestures; speech not understandableby family |
| By 3 yrs | Failure to speak in sentences; small vocabulary; speech difficultto understand by nonfamily members |
| By 4 yrs | Difficulty in producing several speech sounds (e.g., s, sh,ch, j, and l) |
| By 5–6 yrs | Difficulty in producing any speech sounds |
| By 4–6 yrs | Inability to converse with others and adequately express oneselfverbally |
References
- Crosley CJ. Speech and language disorders.In: Swaiman KF, Ashwal S, eds. Pediatric neurology: principles andpractice, 3rd ed. St. Louis: CV Mosby, 1999:568–575.
- Kummer AW. Assessment of speech and language disordersin children. In: Cotton RT, Myer CM III, eds. Practical pediatricotolaryngology. Philadelphia: Lippincott-Raven, 1999:59–74.
- Rudolph, AM, ed. Rudolph's pediatrics, 20thed. Stamford, CT: Appleton & Lange, 1996.
- Schwartz ER. Speech and language disorders. In: SchwartzMW, ed. Pediatric primary care: a problem-oriented approach, 2nded. Chicago: Year Book Medical, 1990:696–700.
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Book Source Details
- Book Title: The Diagnostic Approach to Symptoms and Signs in Pediatrics
- Author(s): Paul S. Bellet
- Year of Publication: 2006
- Copyright Details: The Diagnostic Approach to Symptoms and Signs in Pediatrics, Copyright © 2006 Lippincott Williams & Wilkins.
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