Case illustrating the evaluation of speech and language impairment in children

INTRODUCTION — Children learn language in early childhood; later they use language to learn. Children who have oral language disorders are at increased risk for difficulty with reading and written language when they enter school [1-9]. These problems often persist through adolescence and into adulthood. Early intervention may prevent or diminish the more serious consequences of later learning disorders. (See "Specific learning disorders in children: Clinical features".)

Speech and language evaluation in children has three components:

●To determine whether an impairment in communication skills exists

●To specify the nature of any impairment(s)

●To initiate appropriate intervention strategies

A case to illustrate the evaluation of a child with a language impairment is presented here. The etiology, evaluation, and treatment of speech and language impairment are discussed separately. (See "Etiology of speech and language disorders in children" and "Evaluation and treatment of speech and language disorders in children".)

CASE

Concern — "Jacob" was two years and five months old when brought for a speech and language evaluation because he was saying only a few recognizable words. His comprehension of spoken language was reported to be good.

History — The history, obtained from the caregiver through a questionnaire and subsequently in an interview, revealed no difficulties during pregnancy or delivery, immediately following birth, or during early infancy. Gross and fine motor milestones were achieved at appropriate times, but speech and expressive language were delayed. He used a few single words by 18 months but had not added many since then and was not yet combining words. He ate well and seemed well coordinated for a child his age. He interacted appropriately with adult family members and children and enjoyed playing with toys. Jacob had recurrent middle ear infections prior to the age of 18 months. Pressure-equalizing tubes were inserted, and there were no subsequent infections. Hearing sensitivity had not been formally assessed during the time he had recurrent ear infections, as he appeared to respond well to environmental sounds and oral language comprehension was developing appropriately. There was no family history of speech, language, or learning difficulties.

Evaluation — The assessment was conducted with Jacob's caregiver present in the room. He would not cooperate for formal, objective (norm-referenced) testing, so caregiver report measures and observational data were used.

Caregiver report — Jacob's caregiver reported that he could follow directions, identify pictures, and point to body parts, but his ability to express himself was limited to very few words. He managed to communicate by supplementing words with gestures and by taking a person to what he wanted. Some of his words were conventional (eg, "bye-bye," "no," and "more"), while others were idiosyncratic (eg, "haha"/"train"). Attempts to get him to imitate tongue or lip movements, speech sounds, or words had been unsuccessful. He reportedly had no difficulty sucking, chewing, or swallowing. He was described as a "very mechanical" child who liked playing with cars, trucks, and trains. He was also noted to enjoy being around other children.

Observation — Jacob played meaningfully with toys, interacted appropriately with his caregiver and the examiner, and demonstrated good problem-solving skills. His eye contact and affect were good. He demonstrated appropriate comprehension by following instructions and responding to conversation. As he played, he used several words that had been reported by his caregiver, such as "mammom"/"mommy," "dadam"/"daddy," "haha"/"train," "more," "bye-bye," "no," and "boo"/"blue." He produced no word combinations. He gestured on occasion. He made no attempt to imitate tongue/lip movements, speech sounds, or words, even though he looked at the examiner when she attempted to elicit these. The structure and function of the peripheral speech mechanism could not be directly observed; however, he did not drool and had no difficulty eating crackers. It was determined based on developmental norms that his receptive language skills were between the 33- and 36-month levels and that his expressive language fell between the 12- and 15-month levels, with a notable difficulty in speech sound production. These results confirmed the presence of Language Disorder and Speech Sound Disorder, which required a home program and intervention from a speech-language pathologist.

INTERPRETATION AND APPROACH — This case highlights some important features of the speech and language evaluation:

●Concern by the caregivers or teachers regarding a child's speech or language should prompt referral for a speech and language evaluation.

●Information provided by caregivers is useful and important because it suggests areas that require particularly close investigation. Examples in this case include the focus on ability to formulate words. Also, the history of ear infections is notable because this may play an important etiologic role in language disorder. Jacob was referred for an audiologic assessment and found to have normal hearing sensitivity. Repeat audiologic assessment should be performed annually if language concerns persist. (See "Hearing loss in children: Screening and evaluation", section on 'Screening for hearing loss in children'.)

●Observation and qualitative analysis of the child's performance supplement, and sometimes must substitute for, objective test results; they are essential for making a diagnosis and devising a treatment plan.

●Jacob was reported and observed to have impaired expressive language and speech sound production. His caregiver was taught modeling techniques that she could use at home to encourage speech and language production, and was encouraged to enroll him in weekly speech-language therapy, which continued until he entered kindergarten. It was recommended that upon dismissal from therapy, Jacob's progress in academics, speech, and language were monitored through early elementary school to make sure development in each area proceeded appropriately.

●Children with early speech and language disorders should be closely monitored when they enter school. Although he became an effective oral communicator, Jacob did encounter some difficulties with reading and spelling which required additional intervention.