Children’s speech and language difficulties
Judy Clegg
Introduction
Speech and language difficulties have a significant impact on the lives of children and their families. This chapter will give an overview of the types of speech and language difficulties children present with and how these are generally classified and diagnosed. Specific Language Impairment (SLI) and speech and language difficulties associated with child psychiatric disorder, specifically disorders of attention and selective mutism will be a focus. The life course of children with speech and language impairments will be described through childhood, adolescence, and adult life. Current management approaches will be presented and evaluated and strategies for effective communication considered.
Clinical features
Typical speech and language development
It is remarkable how quickly and easily most children progress through the typical stages of speech and language development to become competent communicators by the age of 5 years. Much is known about how children acquire speech and language and when these skills are achieved.(1) Children need to be competent communicators prior to starting school, as learning is dependent on adequate speech and language abilities. At school entry age, children are expected to be able to speak clearly, to understand and use complex grammatical structures, to use language for a range of communicative reasons from requesting to negotiating and predicting, to take part confidently in conversations with both children and adults and to have a knowledge of letter names and sounds and to read some single words. The acquisition of these speech and language skills will enable the child to access the
educational curriculum where learning is dependent on both verbal and written language. If children are not competent in these skills then they will experience significant difficulties in their learning from the start of their school career.
educational curriculum where learning is dependent on both verbal and written language. If children are not competent in these skills then they will experience significant difficulties in their learning from the start of their school career.
Features of speech and language difficulties
Speech and language development can be affected by hearing impairment, visual impairment, general learning disability, epilepsy, and specific syndromes of learning disability such as Down’s syndrome, and Fragile X syndrome. In these examples, speech and language difficulties are usually attributed to and explained by an aetiological cause. However, speech and language difficulties do occur in the absence of an obvious identifiable cause and are therefore considered as a specific impairment, e.g. SLI.
Prevalence rates of speech and language difficulties vary and are dependent on the criteria used to define and classify them. Law et al.(2) report prevalence rates in children as high as 24.6 percent whereas rates for SLI are much lower between 3 and 7 per cent.(3) Importantly, speech and language difficulties can persist over time and often have a negative impact on the child’s education and general well-being.
(a) Speech difficulties
A speech difficulty reduces a child’s intelligibility and may result in speech sounds being omitted, substituted with another sound or distorted. Speech difficulties can be evident when a child says single words, sentences, and participates in conversation. The physical articulation of speech sounds is affected by physiological and structural abnormalities, such as cleft lip/palate, and neurological impairments leading to dysarthria characterized by weakness and/or in-coordination of the speech musculature system. There is another group of children who have phonological speech difficulties. These children have an intact speech musculature system but have not managed to acquire all the speech sounds of their language and so can only use a limited range, which subsequently limits their intelligibility.
(b) Language difficulties
Language difficulties can involve problems in the development of both comprehension and production.
(i) Vocabulary difficulties
Restricted word knowledge and poor development of the understanding of word meanings result in small vocabularies. Some children have impoverished vocabularies but other children can have specific word finding or retrieval difficulties. Here, the child knows the word he wants to say but is unable to retrieve it accurately and quickly. This is usually evident by ‘searching’ behaviours where the child may substitute the word for a related word, use a filler word such as ‘thingy’ or ‘stuff’, gesture the word instead of saying it or say the first sound of the word but not the rest. For example,
ICE SKATING: ‘I can’t do that thing … erm … you know … where you put sharp shoes on … I always fall over’. PLUM: ‘well, I don’t really like that one which smells like soil and is purple and juicy’
These problems may not only be due to lexical difficulties but also problems retrieving the right phonological sounds of the word. Cognitive impairments in information processing, specifically short-term and phonological working memory have been associated with problems in vocabulary learning.(4)
(ii) Syntax difficulties
Children often have difficulties in their understanding and use of syntax and as a consequence find it very difficult to not only understand language but also to construct sentences in order to use language to communicate effectively, for example giving a narrative where past events are described and future events predicted. Common problems are learning how to use inflections to mark different tenses and understanding as well as constructing complex sentences such as passives. The child in the following example has lots of syntax difficulties as well as word finding difficulties and it is clear how this affects his ability to convey verbal information. The correct forms the child is attempting are shown in brackets.
‘They erm … was … erm … goed to make (made) some vegetable circles (pizzas) and rolls (they rolled) it (the dough) out because that’s what you do first and he was reading the menu (recipe) as well and then they is erm … erm … erm … printing (cut) them out and then they put them in the oven because they’ll taste crunchy (to cook) and then erm … then they took them out of the oven so they be … er … get … cool down (could cool down) and then you would take (ate) them’.
(iii) Social communication difficulties
Children with speech and language difficulties often show associated problems in social communication behaviours, also referred to as pragmatics. These can be both verbal and non-verbal and include difficulties with eye contact, initiation, turn taking, interaction, sharing, requesting, and responding. Higher level social communication abilities can also be affected such as inferring information, giving the listener adequate information and self-monitoring. Ultimately, these can all hinder effective communication between the child and others and also expose the child to negative social experiences, particularly with their peers. For some children, the social communication difficulties may be an intrinsic part of a developmental disorder where speech and language difficulties are evident, for example children with autistic spectrum disorders. In other children, it is important to note that these behaviours can develop as a secondary consequence of poor communication skills due to the speech and language difficulty.
Classification
Speech difficulties can occur in isolation without the presence of language difficulties. Language difficulties can also occur without the presence of speech difficulties but often speech and language difficulties co-occur together. Children can have difficulties with both language comprehension and language production.
Within child psychiatry, both the ICD-10(5) and DSM-IV(6) systems categorize developmental speech and language difficulties. However, there is little robust empirical evidence to support the subtyping of speech and language difficulties. Children are usually classified according to whether the speech and language difficulty is specific, i.e. cognitive development is age appropriate and if there are any co-morbid aetiological or functional explanations. Descriptions of the type of speech and language difficulty involve identifying how the speech and language system is disrupted, describing the levels of impairment, and how this is impacting on the child’s communication and their access to learning.
Diagnosis and differential diagnosis
Descriptions of developmental speech and language disorders
Children’s language is said to be ‘delayed’ when their language abilities are behind those expected for their chronological age and ‘impaired’ or ‘disordered’ when a language delay does not resolve and the child continues to experience significant and severe problems. Several established diagnoses of developmental speech and language disorders are described below:
(a) Cleft lip and palate
A cleft/lip palate results from the incomplete fusion of the hard or soft palate in the embryonic stages of development. A cleft palate can be accompanied by a cleft lip or either one can occur independently. In the United Kingdom, cleft lip/palate is repaired in the first few months of life. However, some children can be left with fistulas and velopharyngeal incompetency, which significantly affects speech development and intelligibility. Children with cleft lip/palate receive speech and language therapy from birth onwards. At birth the focus of attention is primarily on feeding and then the development of speech and language.
(b) Dysarthria
Dysarthria is a speech disorder due to neurological impairment which affects how the speech musculature system functions. Children with cerebral palsy often have dysarthria, which makes their speech slow, weak, and uncoordinated. There may be a mild, slight slurring of speech to profound dysarthria where a child cannot produce any intelligible sounds or words. Children with moderate and severe dysarthria have shallow breathing which is insufficient to sustain speech and/or a low-pitched voice, nasal speech, and a reduced range of vowels and consonants that can be produced accurately.
(c) Developmental phonological disorder
Unlike cleft lip/palate and dysarthria, phonological speech disorders involve the child’s developing speech sound or phonological system. The child’s speech is difficult to understand because the child makes speech sound errors which are either due to the speech sound system developing more slowly or in an atypical way and this is not a result of obvious structural, sensory, or neurological impairments. Often, there are systematic patterns of errors in the child’s speech, for example the child always replaces the ‘s’ sound with a ‘d’ sound. Auditory processing and discrimination skills have been implicated in the development and maintenance of this disorder. Over time, phonological disorders often resolve with speech and language therapy input. However, for some children they are severe and do persist into adult life.
(d) Childhood apraxia of speech (CAS)
This developmental speech disorder is characterized by both speech and non-speech behaviours. The speech sound errors are inconsistent and are accompanied with oral movement difficulties in drooling, feeding, and blowing. Reduced early verbal behaviours such as babbling are often evident. CAS often co-occurs with motor apraxia but for some children, only speech and oral movements are affected. There is some debate as to the existence of CAS as there is no obvious cause although both neuromotor planning and the organization of the child’s phonological system have been implicated. CAS is often a label given to children where the speech disorder has persisted despite intervention and oral non-speech movements are affected. See Dodd(7) for a detailed review of children’s speech disorders.
(e) Fluency disorders
Although classified under speech disorders, stuttering is not an articulatory or phonological difficulty. There are no structural abnormalities and the child usually has a typically developing phonological system. Core stuttering behaviours include part-word or whole-word repetitions, revisions, pauses, blocks, sound prolongations, and obvious struggling behaviours such as jerky head movements. Secondary behaviours result from the stuttering and generally help the individual to avoid stuttering. For example, circumlocution where the speaker substitutes a word he knows he will stutter on for an easier word and environmental control such as avoiding the use of the telephone or talking to certain people. Fluency disorders are often identified in young children before the age of 5 years although many children experience a period of normal non-fluency usually between the ages of 2 and 5 years, which is not severe and resolves spontaneously.
(f) Learning disability
Level of cognitive ability is the strongest predictor of language ability and therefore language development is certainly affected in learning disability. The sequence of language development is similar to that found in typical development but with mild to moderate to severe and profound delay. A child with a profound learning disability may never develop an intent to communicate whereas another child may have established an intent but no verbal language and uses some signs or symbols to communicate instead. For children with mild and moderate learning disability, language abilities plateau with no further improvement, usually in adolescence at a level below the child’s chronological age.
It should be noted that specific patterns of speech and language development have been identified in specific syndromes of learning disability. Down’s syndrome is characterized by superior vocabulary development to grammatical development and children with William’s syndrome often appear as competent communicators but do have significant language learning problems. Speech and fluency problems are common in learning disability and vary according to the aetiology of the learning disability. For example, conductive hearing loss and articulatory speech problems occur where there is cranio-facial involvement.
(g) Acquired childhood aphasias
Acquired aphasias refer to a loss or deterioration in language ability after a period of typical language development. The child acquires language but then loses these language abilities, usually between 3 and 7 years of age. Causes of childhood aphasia include open and closed head injury, cerebrovascular lesions, cerebral infections, cerebral tumours, and epilepsy. Landau Kleffner (first described by Landau and Kleffner in 1957)(8) is an acquired aphasia where language deteriorates after a period of typical language development and the deterioration in language is usually, although not always accompanied with a seizure disorder. Receptive language is severely affected with expressive language problems as well, often word finding difficulties. See Lees(9) and Deonna(10) for a complete review.
Specific language impairment (SLI)
Specific language impairment (SLI) is a term used to describe language impairment (and additional speech impairment) where there is no identifiable medical, neurological, sensory, or functional cause and where cognitive ability measured by non-verbal intelligence (IQ) is within the normal range. Therefore, there is a discrepancy between language and cognitive ability with the exclusion of any obvious causes for the language impairment. Diagnosis of SLI according to exclusionary and discrepancy criteria is dependent on standardized language and cognitive psychometric assessments. However, there is continuing debate regarding which criteria to use to establish a meaningful discrepancy between language and cognition. ICD-10,(5) for example adopt a strict criteria of language skills at least two standard deviations below the level expected for the child’s chronological age and language skills at least one standard deviation below the child’s level of non-verbal IQ. More liberal criteria advocates a non-verbal IQ of 75 or above with language abilities often only one SD below the mean. Proponents of liberal criteria claim that more stringent criteria may fail to identify children who are at risk of poor long-term outcomes. However, liberal criterion may identify children who simply perform at the lower end of the normal distribution of language ability. It should be recognized that different criteria are used. Although the diagnosis of SLI stipulates good cognitive ability, some specific cognitive deficits in phonological memory, verbal, and visuo-spatial memory and symbolic play are evident and thought to underpin the language impairment.
SLI is considered to affect 3-7 per cent of all children.(3) The use of the exclusionary and discrepancy criteria to define SLI means that as a group, children with SLI are very heterogenous with impairments in many areas of language. Although useful, attempts to subtype SLI(11) have not yet proved clinically robust. However, children with SLI are considered to show disproportionate difficulties in vocabulary and syntax compared to other aspects of language.
(a) Aetiology of SLI
Research in SLI primarily focuses on trying to establishing a cause. SLI is a heritable disorder and much research is underway to try and establish the genetic basis.(12,13) SLI is of particular interest to researchers because of the unusual dissociation between cognitive and language ability and whether this dissociation is explained by innate modular theories of language acquisition or more general cognitive processing deficit theories. Some attempt has been made to identify genetic markers of SLI such as a phonological memory deficit(12) which stems from the research into general cognitive processing deficits as underlying SLI and a specific tense marking deficit(14) or a syntax representational deficit(15) which argues for the disruption of innate modular components of language.
(b) Diagnostic overlaps between SLI and autistic spectrum disorders (ASD)
(i) Pragmatic language impairment
Autism and autistic spectrum disorders (ASD) are discussed extensively in Chapter 9.2.2 of this text. Language and communication difficulties are central to both SLI and ASD. However, the fundamental difference between these disorders is the severity and pervasiveness of the social communication impairment. In SLI, social communication difficulties are considered secondary to the language impairment where children with speech and language difficulties will have problems in developing appropriate social communication skills. In ASD, the social communication impairment is an intrinsic part of the disorder and does not develop as a secondary consequence of a speech and language impairment. Due to the increase in the identification of ASD and the use of the autistic spectrum many more children with milder difficulties are being diagnosed with ASD. This has led to some researchers proposing that there are overlaps between SLI and ASD.
Semantic-pragmatic disorder was first described in the 1980s as a subtype of SLI(16,17) and was a label used to describe children with comprehension problems, echolalia, behaviour difficulties, and difficulty with non-literal language, semantics and pragmatics. At the time, these children were not considered as autistic. However, the increasing use of the autistic spectrum led to debates about whether semantic-pragmatic disorder exists as a separate category of SLI or whether it should be included on the autistic spectrum.(18,19) The crucial issue was whether the social impairment was intrinsic to the language disorder or a secondary consequence of the language disorder. To address this, researchers have attempted to show differences in pragmatic abilities between children with SLI, ASD, and typically developing children. For example, Bishop and Norbury(19) identified a subgroup of SLI children who show a profile of Pragmatic Language Impairment (PLI). These children showed inappropriate behaviours across aspects of social communication including initiating conversations, understanding subtle aspects of language such as humour and sarcasm, adapting their communication to different contexts, understanding and using non-verbal communication, and engaging in conversations about specific interests. Importantly, these children did not show the non-verbal repetitive behaviours typically characteristic of autism. Overall it is argued(19) that there are continuities between autism and specific language impairment but not all children with pragmatic impairments have autism. Therefore, pragmatic language impairment alone should not be used to make diagnoses of autistic spectrum disorders. It is recognized that there are conflicting opinions about the increasing evidence that indicates continuity between disorders that have traditionally been regarded as distinct from one another. However, assessment should consider whether a child’s social communication difficulties are being compounded by language difficulties as amelioration of the language difficulties may improve the child’s social communication.
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