Speech and Language Disorders in Children

By Charbel on Apr 19, 2011 | In Health, Pediatric Primary Care: Well-Child Care

Ann W. Kummer

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Articulation (Speech) Disorders

Omissions occur if the child has so much difficulty with the motor requirements for speech that he leaves out sounds in words

Substitutions are noted when an incorrect sound is substituted for the correct one

Distortions occur when the child is attempting to produce the sound correctly, but an incorrect articulatory placement results in an altered sound

Some patients demonstrate oral/motor dysfunction that causes distortion of all speech sounds, particularly in connected speech

Apraxia of speech, also known as verbal apraxia, is another motor speech disorder

The causes of articulation disorders include structural anomalies, such as a history of cleft palate or velopharyngeal dysfunction

Contrary to popular belief ankyloglossia, commonly known as tongue-tie, usually does not interfere with speech production

A phonology disorder is much like an articulation disorder in that the patient demonstrates speech sound substitutions, omissions, and distortions, making the speech difficult to understand
Language Delays and Disorders

Children with a receptive language disorder demonstrate difficulty understanding the speech of others

Children with expressive language disorders may have limited vocabulary skills or may use words inappropriately

The content of language, called semantics, is the meaning of the words, phrases, and sentences that are used for communication

The form of language involves syntax and morphology

Finally, the use of language is referred to as pragmatics

Causes of language disorders include hearing loss, mental retardation, environmental deprivation, or neurologic damage or dysfunction
Screening for Communication Disorders
Referral for Treatment
Timetable for Intervention
Additional Reading

The ability to communicate, a critical human skill, affects the way that an individual functions in society and impacts most activities of daily living. Unfortunately, an estimated 6 million children under 18 years of age, as estimated by the National Institutes of Health, have a speech or language disorder. Boys make up about two-thirds of this population. Although some children who are identified as late or slow talkers at the age of 2 years begin to pick up communication skills, many continue to have speech and/or language problems at the age of 4 or 5.
A communication disorder can have a negative impact on the child's social and emotional development and can affect the child's ability to learn. Therefore the primary care physician should closely monitor the child's development of communication skills, particularly in the first 6 years. In addition, the provider should be prepared to answer questions of concerned parents regarding their child's development of these skills. Since in children “normal” changes with chronologic age, the physician must have a clear understanding of what is expected at each developmental stage. (For more information regarding normal developmental milestones, please see the Chapter 12, “Normal Speech and Language Development.”) Table 44.1 lists populations at high risk for speech and language disorders.

Table 44.1. Populations at high risk for speech and language disorders

The purpose of this chapter is to present an overview of the types of speech and language disorders that are commonly identified in children. This information should help the physician recognize communication disorders in children and gives the timeline for initiating a referral to a speech/language pathologist.
I. Articulation (Speech) Disorders
An articulation disorder is characterized by difficulty producing speech sounds in comparison to what is expected at the child's chronologic age. The difficulty in production typically occurs with consonants, although in severe cases, even vowel distortions can occur. When difficulties with articulation exist, the child may be forced to compensate by producing sounds in an easier way. As a result, the speech may consist of speech sound omissions, sound substitutions, or distortions. In addition, overall oral inactivity or slurring may be noted. As a result of these errors, the child's speech may be difficult to understand or even unintelligible. Poor speech intelligibility is a primary characteristic of an articulation disorder.

A.
Omissions occur if the child has so much difficulty with the motor requirements for speech that he leaves out sounds in words. Omissions occur most with the medial or final sounds in words and with consonants in blends. Examples of typical patterns of sound omissions are as follows:
I ri the bu to coo. (I ride the bus to school.)
Daey bo a cu. (Daddy broke a cup.)
My ca a do ah paying ousi. (My cat and dog are playing outside.)
In more severe cases, the child may omit all consonants, and only produce vowel sounds with a grunt (glottal stop) in place of the consonants. This causes speech to be essentially unintelligible.

B.
Substitutions are noted when an incorrect sound is substituted for the correct one. Most commonly, the child will substitute a sound that is easier to produce and developed earlier for a sound that is harder to produce and therefore developed later. Some common examples of sound substitutions are as follows:
t/k: I eat tate and tooties. (I eat cake and cookies.)
d/g: I'm a dood dirl. (I'm a good girl.)
p/f: I have pive pingers. (I have five fingers.)
t/s: I tee the tun in the ty. (I see the sun in the sky.)
w/l: I wike yewow wowwepops. (I like yellow lollipops.)
w/r: I have a wed fiuh twuck. (I have a red fire truck.)
When substitution errors are noted, they usually occur on many different sounds. In fact, the child may use only the early developmental sounds, or babbling sounds (p, b, m, t, d, n, k, g), as substitutions for the later-developing consonants. In more severe cases, the child may only use one or two consonants as a substitution for all other speech sounds.

C.
Distortions occur when the child is attempting to produce the sound correctly, but an incorrect articulatory placement results in an altered sound. A common distortion occurs with the production of the /r/ sound. Many children have difficulty with the motor requirements for producing this sound. If the tongue is not high enough or retracted enough, a distortion will result. Other common distortions are lisps, which occur on sibilant or “teeth sounds” (s, z, sh, ch, j). An anterior or frontal lisp is the result of the tongue articulating against or between the incisors during sibilant sound production. This causes a distortion that sounds almost like a /th/ sound. A lateral lisp occurs when the tongue tip or dorsum of the tongue articulates against the alveolar ridge or palate, stopping the anterior movement of the airstream. As a result, the airstream is redirected laterally, causing a slushy type of sound. At times, saliva can be seen bubbling at the sides of the mouth during speech.

D.
Some patients demonstrate oral/motor dysfunction that causes distortion of all speech sounds, particularly in connected speech. One motor speech disorder is dysarthria. Dysarthria is the result of neurologic dysfunction associated with cerebral palsy or acquired neurologic damage. Characterized by poor movement of all the articulators, it causes slow, slurred, and inarticulate speech. Respiration, phonation, and resonance may also be affected. As a result, dysarthric speech is usually hypernasal, and utterances can be short and choppy because of poor respiratory support.

E.
Apraxia of speech, also known as verbal apraxia, is another motor speech disorder. In this disorder, the patient has difficulty with motor planning and sequencing of movements. Although he or she may be able to move the oral structures normally for feeding and other nonspeech activities, difficulty in coordinating movements required for speech is demonstrated. As a result, the speech is characterized by many inconsistent substitutions, frequent sound omissions, sound and syllable reversals, and occasional struggle behaviors during speech production. Speech is best when producing single sounds or words but breaks down when the child is combining the sounds and words to produce the longer utterances of connected speech.

F.
The causes of articulation disorders include structural anomalies, such as a history of cleft palate or velopharyngeal dysfunction. If the velopharyngeal insufficiency causes a significant leak of air pressure into the nasal cavity during speech, inadequate air pressure in the oral cavity may prevent the normal production of sounds. Dental abnormalities, particularly anterior crossbite or class III malocclusion, often can affect speech sound production. For normal speech production, the maxillary arch should overlap the mandibular arch. If the anterior maxillary teeth are retrusive relative to the mandible or are inside the mandibular arch, they can interfere with the movement of the tongue during speech, causing faulty articulation. Hearing loss, especially a sensorineural loss, can affect speech sound perception and learning, thus affecting articulation production. Even chronic otitis media has been shown to affect speech development. Finally, oral/motor dysfunction, as mentioned previously, is a common cause of articulation disorders. Oral/motor dysfunction can be found as a result of neurologic damage, but it is also commonly found in patients with no other apparent neurologic problems.

G.
Contrary to popular belief, ankyloglossia, commonly known as tongue-tie, usually does not interfere with speech production. Whether the lingual frenulum has an anterior attachment on the tongue tip or is unusually short, the tongue tip is usually mobile enough for adequate elevation and protrusion for speech. The tongue only needs to elevate slightly to the alveolar ridge for the /l/ sound, and must protrude only to the back of the maxillary incisors for the /th/ sound. If ankyloglossia is noted in a patient with an articulation disorder, the problem is usually just coincidental. Most speech/language pathologists agree that a frenulectomy is usually not indicated for speech purposes. It may be indicated to improve feeding abilities, however, because the restriction of the tongue affects the ability to move a bolus in the oral cavity, particularly from the lateral sulci.

H.
A phonology disorder is much like an articulation disorder in that the patient demonstrates speech sound substitutions, omissions, and distortions, making the speech difficult to understand. The cause, however, is related not to structural or functional difficulties, but to a faulty “rule” that the child is using in producing speech patterns. For example, the child may always produce the /t/ sound as a substitution for sibilant sounds (s, z, sh, ch, j). Treatment would therefore focus not on the individual sounds but on correcting the rule for all the affected sounds.
II. Language Delays and Disorders
Verbal language requires the use of words, phrases, and sentences to convey information to the listener. In the course of normal development, various auditory, neurologic, and even environmental factors can affect the ability to acquire language normally, resulting in a language delay or disorder. A language delay is characterized by a normal, although unusually slow, progression of language acquisition. In contrast, a language disorder is characterized by deviant language skills or by language difficulties that are not typically seen during the course of normal development.

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