Speech and language impairment in children: Evaluation, treatment, and prognosis

INTRODUCTION — 

Speech and language disorders are two major types of communication disorders. Speech impairment involves disorders of articulation, voice, or fluency. Language impairment involves disorders of comprehension and systems (oral, written, sign) used to convey language. Developmental language disorder/impairment is the most common developmental disability of childhood, occurring in 5 to 10 percent of children [1-3].

Children learn to speak and use language in early childhood; later they use these skills to learn. Children with speech and language disorders are at increased risk for difficulty with reading and written language when they enter school [4-12]. These problems often persist through adolescence or adulthood. Early intervention may prevent the more serious consequences of later learning disabilities. (See "Specific learning disorders in children: Clinical features".)

The evaluation and treatment of speech and language impairment is discussed here. Other issues related to speech and language impairment are reviewed separately:

●(See "Speech and language impairment in children: Etiology".)

●(See "Speech and language impairment in children: Case study".)

●(See "Expressive language delay ("late talking") in young children".)

GOALS — 

Speech and language evaluation in children has three objectives:

●Determine whether an impairment in communication skills exists

●Specify the nature of any impairment

●Initiate appropriate intervention strategies

ROLE OF THE PRIMARY CARE CLINICIAN IN IDENTIFICATION AND INITIAL EVALUATION — 

The primary care clinician may identify speech and language disorders as part of routine medical, developmental, and behavioral surveillance. Routine medical screening may identify underlying conditions that can result in speech and language deficits (table 1).

In younger children, routine developmental screening includes the use of validated developmental and behavioral screening tools which can help to identify communication and other developmental problems (eg, motor and cognitive deficits, or behavioral conditions, such as autism spectrum disorder). (See "Developmental-behavioral surveillance and screening in primary care" and "Autism spectrum disorder in children and adolescents: Surveillance and screening in primary care" and "Expressive language delay ("late talking") in young children", section on 'Screening'.)

In older children, speech and language problems may also be identified as part of discussions prompted by concerns about behavior or school performance.

Identification of speech or language impairment should prompt further evaluation, as described in the following sections of this topic, and treatment.

MEDICAL EVALUATION — 

All children with speech and language impairment should have a comprehensive history and physical examination and formal audiologic testing to detect medical conditions or hearing loss that may contribute to the impairment. Speech and language impairment can be a manifestation of congenital or acquired disorders such as structural anomalies, neurodegenerative disorders, infections, or traumatic injury. A comprehensive medical evaluation can help to distinguish different forms of speech and language impairment from associated causes and guide the formulation of a treatment plan.

History — The medical history should include the birth history, history of prior illnesses, environmental exposures, and developmental and family history. Specific elements of the history can have clinical implications (table 1). For example, a history of preterm birth suggests the possibility of developmental language delays (eg, learning disabilities) associated with prematurity. Prematurity and recurrent or persistent ear infections may also predispose to hearing loss, which can result in speech and language disorders. A diagnosis of autism spectrum disorder may identify risk for associated language disorder, while a history of language delay in family members may point towards a genetic cause.

It is important to differentiate lack of progression in developmental milestones from a loss of milestones. Lack of progression of milestones may be indicative of global or cognitive developmental delay, while a loss of milestones may indicate a degenerative neurologic disorder. (See "Speech and language impairment in children: Etiology", section on 'Speech disorders' and "Speech and language impairment in children: Etiology", section on 'Language disorders'.)

Physical examination — The physical examination should include an assessment of overall appearance and specific physical components that may indicate conditions resulting in speech and language impairment (table 1). For example, the head and neck examination may identify a structural anomaly that can interfere with speech, such as ankyloglossia or cleft lip. Neurological abnormalities may suggest cerebral palsy, which can result in dysarthria, or degenerative neurological conditions, which can result in loss of language skills. Poor growth or dysmorphic features may suggest a syndrome such as mucopolysaccharidosis or fetal alcohol syndrome. (See "Speech and language impairment in children: Etiology", section on 'Speech disorders' and "Speech and language impairment in children: Etiology", section on 'Language disorders'.)

Audiologic and other testing — Formal audiologic testing is important as undetected hearing loss can lead to cognitive, speech, and language delays and requires early intervention. (See "Hearing loss in children: Screening and evaluation".)

Screening for iron deficiency and lead toxicity should be considered as these conditions can result in neurocognitive delays. Indications for iron deficiency and lead toxicity screening are discussed in detail separately. (See "Screening tests in children and adolescents", section on 'Iron deficiency' and "Screening tests in children and adolescents", section on 'Lead poisoning'.)

Genetic testing in consultation with a specialist may be useful if global developmental delay, intellectual disability, or a neurodegenerative disease is suspected. (See "Intellectual disability (ID) in children: Evaluation for a cause" and "Speech and language impairment in children: Etiology", section on 'Degenerative neurologic disorders'.)

INDICATIONS FOR REFERRAL — 

When a specific medical etiology can be determined, the primary care clinician can initiate an appropriate intervention strategy. For example, a child with hearing loss can be referred to an audiologist for a hearing aid, and a child with a resonance disorder secondary to nasal polyps or enlarged adenoids can be referred to a surgeon. Referrals to other medical specialties and developmental support services may be required to further evaluate or address problems identified on initial medical evaluation.

In many cases, however, the etiology cannot be clearly identified. In these cases, referral to a speech-language pathologist (SLP) is warranted for an in-depth assessment of speech and language.

Children with any of the criteria listed in the table (table 2) should be referred for a speech and language assessment.

SPECIALIST ASSESSMENT OF SPEECH AND LANGUAGE — 

An in depth evaluation of speech and language involves quantitative and qualitative assessments that are typically performed by a speech-language pathologist (SLP) who has undergone extensive training in an accredited speech-language pathology program. The goals of this assessment are to identify and describe the impairment and recommend a plan for intervention [13].

A case illustrating the major features of the speech and language evaluation is presented separately. (See "Speech and language impairment in children: Case study".)

Initial assessment of speech and language skills — The adequacy of the child's speech and language skills should be assessed in relation to the norm and to their cognitive ability. This information should be acquired from various sources. Information about the child's cultural and linguistic background is necessary to appropriately assess and treat speech and language impairment [14,15]. Information regarding medical history, family history (including speech and language impairment), and parent/caregiver characteristics (eg, low socioeconomic status, directive rather than responsive interaction style) can identify factors contributing to impairment and inform the formulation of a treatment plan [15-17].

●Use of questionnaires – A comprehensive history can be obtained from the parent/caregiver with a questionnaire that includes detailed developmental, medical, social, behavioral, and school histories and a description of the parents'/caregivers' perception of the problem (form 1A-D). The clinician asks the parents/caregivers questions that clarify or enhance information that has been submitted on the questionnaire. The responses on the questionnaire and the interview provide data that help to determine whether the child has had a favorable, stimulating environment in which to develop speech and language skills at a level consistent with their chronologic age and overall potential.

For school-age children, information provided by teachers regarding performance in language, social, academic, and behavioral areas is helpful (form 2A-B). The results of previous evaluations (eg, hearing, vision, intelligence, emotional development) should be obtained if available.

●Use of interpreters – Children who are more proficient (dominant) in a language other than English should have at least part of their evaluation conducted in their dominant language. Children who speak a language other than English should be tested in their primary language; evaluations should be performed by an SLP who is fluent in the child's primary language whenever possible.

An interpreter must be employed if a fluent SLP is not available. Potential problems in the use of interpreters include errors in interpretation, failure of the interpreter to share information from the case history interview, and interpreter minimization of the parent's/caregiver's concerns. The occurrence of such problems can be reduced by thoroughly training interpreters in the diagnostic process [18].

Measurement of speech and language skills

Standardized tests — The child's performance in specific speech and language areas (eg, phonologic ability, vocabulary comprehension, and grammatical usage) is measured objectively using the most recent standardized, norm-referenced tests for a particular age group. No uniformly applicable test battery for this assessment exists; clinicians must use their expertise to select from among a large number of available tests.

The value of standardized tests as the sole tool for the assessment of communication problems is controversial. Standardized tests require the isolation and measurement of a particular aspect of communication without accounting for others, and do not capture the social-interactive nature of communication [19]. However, some objective tests do provide quantitative measures of a child's specific skills. In addition, objective scores often are necessary for placement in special education programs and are useful for subsequent comparison. Standardized assessment tools that are chosen carefully and used appropriately provide worthwhile information.

Observation — Observation of the child's performance supplements objective test results and is essential for establishing a diagnosis and devising a treatment plan. Approach varies depending on the age and abilities of the child:  

●Very young or uncooperative children: In younger children or those who cannot cooperate with examination, parent/caregiver report and observation of the child at play provide the information necessary to make judgments about the precursors of speech and language development which include:

•The adequacy of speech and language

•Nonverbal cognition

•Social interaction

Specific abilities in children that illustrate the precursors of normal speech and language development include:  

•Meaningful play with toys

•Appropriate interactions with others

•Demonstration of understanding the world around them

•Imitation of body gestures, movements of the articulators, sounds, and syllables

•Comprehension of simple verbal directions

●Older and cooperative children: In older and cooperative children, the SLP can gather data about the child's ability to communicate in conversational situations by informally talking with the child or observing the child's interaction with their parent/caregiver or sibling.

Qualitative analysis — As with observation of the child's performance, qualitative analysis also supplements objective test results and is essential for establishing a diagnosis and devising a treatment plan. In the qualitative analysis, the skilled SLP assesses how the child arrived at the answer, instead of whether the answer was right or wrong. The SLP should note the kinds of test modifications that were helpful to the child, such as repeating instructions and stressing key words, shortening the length of the stimulus, prodding or encouraging to take risks, requiring eye contact during oral instruction, or encouraging repetition of instruction before proceeding.

As an example, does the child:

●Require repetition or shortening of the question to understand it?

●Use gestures excessively or grope for words during responses?

●Run out of breath while talking?

●Become dysfluent or hypernasal in speech as the length of the stimulus increases?

●Demonstrate appropriate problem-solving strategies?

●Show poor ability to respond to suggestions?

●Require excessive time for comprehending and/or responding?

Assessment of swallowing and voice functions — Computers, fiberoptic instruments, and radiologic studies augment the evaluation of swallowing, voice, and resonance disorders. As examples, computers are used to analyze the acoustic properties of voice and speech; the vocal folds can be viewed directly with fiberoptic instruments; and videofluorography assists in the examination of the oral mechanism during speaking and swallowing [19]. These studies can be performed by an SLP who has received extensive training in consultation with medical professionals [20].  

Reporting results — The final assessment report should include the following information:

●The nature of the problem

●A description of how the problem affects the child's function

●The strengths of the child that will enable them to compensate for their weaknesses

●Recommendations for management

●A program for implementing the recommendations

The SLP should communicate this information to the child's parents/caregivers at a conference and in writing. The SLP can choose to have the child present at this meeting or to have a separate conference with the child to present the information at a level that the child will understand.

Next steps for children without a definitive diagnosis — A definitive diagnosis cannot always be made after the initial speech and language assessment. In these cases, the initial assessment provides a baseline for comparison with follow-up assessment (monitoring). Diagnostic therapy may be recommended for those children for whom more observation is necessary before arriving at a diagnosis or determining a management plan (eg, children who are frightened or overly anxious in the clinical setting) [21].

TREATMENT

Importance of early intervention — Early intervention appears to improve speech intelligibility in children with speech disorders and language skills in children with delayed language development. Thus, it can lower frustration for the child and family and maintain the child's self-esteem. However, evidence is limited:

●In a randomized trial, 30 preschool-age children with severe phonologic disorders were assigned to receive four months of therapy followed by four months of no treatment, or four months of no treatment followed by four months of therapy [22]. The children in the early therapy group had greater improvement in speech intelligibility at both four and eight months.

●In a randomized trial, 21 toddlers with delayed language development were assigned to early versus delayed treatment groups. Children in the early treatment group showed improvement in each of five linguistic outcomes: mean length of utterance, total number of words, number of different words, lexical repertoire, and percentage of intelligible utterances [23]. These children also had improved socialization skills and decreased levels of parent/caregiver stress.

●In a randomized trial, 19 children between 6 and 24 months of age with moderate to profound hearing loss received parent/caregiver-implemented communication treatment or usual care [24]. Children who received caregiver-implemented communication treatment improved speech prelinguistic skills were demonstrated by those who received parent/caregiver-implemented communication treatment.

●Early intervention for delayed expressive language (ie, late talkers) may not change the long-term outcome for this group. In a study examining the narrative language skills of untreated children with and without a history of delayed expressive language as toddlers, children with normal language skills had better narrative language skills in kindergarten and first grade than those with expressive language delay. No difference was found among the groups by second grade [25]. However, early intervention for children with delayed expressive language may be recommended in selected cases. This is discussed in more detail elsewhere. (See "Expressive language delay ("late talking") in young children", section on 'Approach to referral'.)

Candidates for intervention — Children with the following baseline characteristics and risk factors for language impairment are good candidates for intervention because they are at greater risk of having an impairment that will not improve spontaneously, and intervention can improve language development [15-17]:

●Smaller vocabulary – Children with a smaller vocabulary and a less diverse vocabulary composition (particularly for verbs) than expected for their age.

●Delayed language comprehension and production – Children who are delayed in both comprehension and language production and have a larger comprehension-production gap.

●Limited phonologic repertoire – Children with fewer prelinguistic vocalizations, more limited phonetic (speech sound) inventory, and more restricted syllable structure.

●Limited word imitation – Children who do not imitate word combinations.

●Delayed play skills – Children with delayed play behaviors, as play is the foundation for the content of first words and word combinations.

●Limited use of gestures – Children who convey complex thoughts by exhibiting fewer gestures and sequences of gestures in addition to single words.

●Limited social skills – Children with socialization challenges (eg, reluctance to initiate and participate in conversations).

●Other risk factors – Children with delayed language development and a history of persistent otitis media, a family history of language and learning problems, or parents/caregivers with low socioeconomic status or a directive rather than responsive interaction style.

Specific interventions — The treatment plan for a child with speech or language disorder is tailored to their individual needs, but all treatment plans have common components, including therapeutic interventions and outcome goals. Management of speech and language impairment may include one or more of the following:

●Enrollment in individual or group speech and language therapy

●Therapy through an early intervention program, the public school system, or a private facility

●Attendance at a specialized school for children with speech, language, and learning differences

●Further assessment in specific areas (eg, oral motor function, general motor function, psychological or cognitive function)

●Application of assistive technology

●Periodic monitoring without direct therapy

Behavior modification strategies — Behavior modification establishes consistency in behaviors by using facilitation strategies (eg, tactile, verbal, visual, or gestural cues) to elicit specific changes in the child's behavior. A combination of high- and low-structure approaches may be appropriate, depending upon the type of impairment and the stage of the therapeutic process.

Examples of structured approaches include:

●High-structure approach, which includes stimulus-response-reinforcement and requires strict behavior modification.

●Low-structure approach, which uses a less structured intervention that is more child-led and may be more beneficial in younger children. For example, "enhanced milieu teaching" is an intervention that occurs in play-based interaction sessions [26]. Similarly, in corrective conversational recast therapy, an adult repeats some or all of what the child says, correcting a grammatical error [27].

Interventions suitable to the school setting — Parents/caregivers should be counseled on how to advocate for receipt of services and other accommodations in the school setting. (See 'Counseling caregivers' below.)

Emphasis on the practice of inclusion in public schools has been increasing; children with special health care needs (eg, speech and language impairments) can receive services within the classroom rather than being pulled out for treatment. Some types of intervention are more suited to inclusion settings such as schools than others. The carryover practice for a learned skill, as an example, works well in an inclusion setting. In contrast, new skills may be better acquired in individual therapy. However, evidence demonstrating improved progress for children with language disorders in inclusion settings has not been consistently demonstrated [28,29].

Applying the interventions — Short-term and long-term functional goals are determined based on baseline data gathered from the speech and language assessment.

Functional goals are outcomes that can be measured in terms of experience in the child's life; they extend beyond the individual treatment session to the real world environment [30].

Children differ in their abilities to apply what is learned in one context to other contexts. For example, children often have difficulty using new speech or language skills in situations other than the treatment setting. Functional goals can thus help to apply learned skills to different environments. It is also important to counsel parents/caregivers and others on how to assist the child with applying these skills. (See 'Counseling caregivers' below.)

Efficacy — Therapeutic efficacy has been described in a variety of patient populations, including children with speech disorders (eg, articulation, voice, fluency) and language disorders. Some examples include:

●Children with speech disorders:

•Children who received phonologic treatment have demonstrated changes in their sound systems that improved overall intelligibility and communicative functioning [31].

•In 41 children with cleft palate who received direct or indirect speech services, normal oral-nasal resonance balance and articulation was achieved by age 5 years in 93 percent of cases [32]. In a small randomized trial of children with cleft palate, improvements in cleft speech characteristics and consonant proficiency were greater with the linguistic-phonologic than the motor-phonetic approach [33]. Both approaches improved the participant's quality of life.

•Individuals with severe physical disability and dysarthria (eg, secondary to cerebral palsy) demonstrated significant improvement in their ability to communicate by using augmentative communication systems [34].

•In a controlled trial including children (ages 9 to 14 years) who were treated for stuttering, those who received intensive smooth speech therapy, caregiver-home smooth speech therapy, or intensive electromyography feedback demonstrated improvement in fluency compared with the control group at 3 and 12 months posttherapy (less than 1 percent of syllables stuttered versus no improvement) [35]. The treatment gains were maintained after an average of four years posttreatment [36].

●Children with language disorders:

•Children who were exposed to enhanced milieu teaching in their preschool classroom increased their use of targeted language skills; these changes were maintained when the treatment was discontinued [26].

•In children with developmental language disorder, explicit (direct) grammar instruction has been associated with improvement in expressive language [37].

•In preschool children, conversational recast therapy is effective in treating morphologic targets [27]. In a small case series, six of seven children showed clinically meaningful gains in the use of grammatical forms targeted for treatment using Enhanced Conversational Recast via telepractice [38].

Unproven therapies — Facilitated communication, auditory integration training (AIT), sensory integration (SI) therapy, and Fast ForWord are examples of practices that have not been validated in large, controlled trials [39-43]. We do not recommend these practices.

COUNSELING CAREGIVERS — 

A key factor in treatment success is collaboration with parents/caregivers, other family members, and educators in helping the child exercise new skills. Parents/caregivers, teachers, and others involved in the child's care should be given specific suggestions for appropriately stimulating language, such as:

●Using language appropriate to the child's linguistic development (eg, sounds, single words, phrases, simple sentences, more complex sentences).

●Talking to the child during daily activities rather than overusing direct questioning that may decrease verbal output from the child.

●Accepting less than perfect productions (eg, word approximations) when the child's intent is clear.

In a systematic review, better language outcomes were achieved when parents/caregivers were taught specifically how to stimulate language in their children [44].

In addition, parents/caregivers should know how to advocate for their children in the school system by ensuring that they receive the services they need and that their conditions are monitored through periodic reevaluation. Children with speech and language disorders are at high risk for developing learning disabilities (eg, academic problems) when they enter school [4-11,45,46].

In the United States, children 36 months of age or older with language impairment may be referred for special education services through the public school district as part of the Individuals with Disabilities Education Act (IDEA). IDEA also supports ongoing services for children younger than 36 months of age through early intervention (EI) programs available in each state. A list of early intervention programs by state is available through the Centers for Disease Control. IDEA and other laws pertaining to services for learning disorders in the United States are discussed in more detail elsewhere. (See "Definitions of specific learning disorder and laws pertaining to learning disorders in the United States".)

PROGNOSIS — 

The long-term outcome for children with isolated speech disorders is better than for children with both speech and language impairment. Signs of persisting difficulty may exist in both populations, particularly in children who have continuing impairment after age four to five and those whose speech is characterized by atypical error patterns at age four [6,45,47,48]. Atypical error patterns are those that occur in <10 percent of the typical population at any age; examples include initial consonant deletion (eg, "og" for "dog"), additional consonants (eg, "dunk" for "duck"), and replacing groups of sounds with a favorite sound (eg, "hy heddy" for "my teddy").

Speech and language disorders may persist through childhood and adolescence. Although a six-year-old child's conversation may sound mature, language development continues through adolescence with the understanding of subtle changes and reciprocity between oral and written language. The absence of overt speech or grammatic errors does not necessarily mean no problems are present [4-6]. School language, or the language of instruction, is different from home language; problems can exist in one sphere but not the other.

SUMMARY AND RECOMMENDATIONS

●Goals – Speech and language evaluation in children has three objectives (see 'Goals' above):

•To determine whether an impairment in communication skills exists

•To specify the nature of any impairments

•To initiate appropriate intervention strategies

●Identification and medical evaluation – Speech and language disorders may be identified as part of the routine medical, developmental, and behavioral surveillance by the primary care clinician. All children with speech impairment should have a complete history and physical examination and formal audiologic testing to detect medical conditions or hearing loss that may contribute to the speech impairment (table 1). (See 'Role of the primary care clinician in identification and initial evaluation' above and 'Medical Evaluation' above.)

●Speech and language evaluation

•Referral indications for speech and language evaluation are listed in the table (table 2). (See 'Indications for referral' above.)

•Components of the speech and language evaluation include assessment of the adequacy of the child's speech and language skills; norm-referenced standardized tests to provide quantitative measures of the child's skills; qualitative analysis of the performance; and assessment of swallowing, voice, and resonance disorders (as indicated). (See 'Specialist assessment of speech and language' above.)

•The report of the evaluation should include a description of the problem, assessment of the effect on the child's function, and recommendations for management. Follow up assessment and diagnostic therapy may be recommended for children without a definitive diagnosis. (See 'Reporting results' above and 'Next steps for children without a definitive diagnosis' above.)

●Treatment – The treatment plan for a child with speech or language disorder is tailored to their individual needs. It is important to intervene early. The child's baseline abilities and specific risk factors for language impairment can be used to determine if the child will be a good candidate for intervention. Common components include setting short-term and long-term functional goals and using facilitation techniques (eg, tactile, verbal, visual, or gestural cues) to elicit specific changes in the child's behavior. The success of treatment is dependent on collaboration with parents/caregivers and educators. (See 'Treatment' above.)

●Counseling caregivers – Parents/caregivers, teachers, and others should be given specific suggestions for appropriately stimulating language and information on how to advocate for services within early intervention programs and/or the school system. (See 'Counseling caregivers' above.)

●Prognosis – The long-term outcome for children with isolated speech disorders is better than for children with both speech and language impairment. Signs of persisting difficulty may exist in both populations, particularly in children who have continuing impairment after age five. (See 'Prognosis' above.)