Evaluation and treatment of speech and language disorders in children

INTRODUCTION — Developmental language disorder is the most common developmental disability of childhood, occurring in 5 to 10 percent of children [1-3]. Children learn language in early childhood; later they use language to learn. Children with 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".)

Speech and language evaluation in children has three objectives:

●To determine whether an impairment in communication skills exists

●To specify the nature of any impairments

●To initiate appropriate intervention strategies

The evaluation and treatment of speech and language impairment are reviewed here. The etiology of speech and language impairment and the approach to the young child with expressive language delay are discussed separately. (See "Etiology of speech and language disorders in children" and "Expressive language delay ("late talking") in young children".)

MEDICAL EVALUATION — All children with speech impairment should have a complete medical evaluation and formal audiologic testing to detect medical conditions or hearing loss that may contribute to the speech impairment. Caregivers should be encouraged to follow through with the speech and language evaluation and management recommendations. (See "Hearing loss in children: Screening and evaluation".)

CRITERIA FOR SPEECH AND LANGUAGE EVALUATION — Children with any of the criteria listed below should be referred for a speech and language assessment:

●Concern by the parent or caregiver, teacher, professional, or other caregiver about the child's speech or language

●Slowed or stagnant speech and language development

●Excessive drooling

●Difficulty sucking, chewing, or swallowing

●Difficulty coordinating movements of lips, tongue, and jaw

●No babbling by nine months

●No first words by 15 months

●No consistent words by 18 months

●No word combinations by 24 months

●Speech is difficult for caregivers to understand at 24 months

●Speech is difficult for strangers to understand at 36 months

●Dysfluencies (stutters) consist of more than tension-free whole-word repetitions

●Child is frustrated by communication difficulty

●Child is teased by peers for "talking funny"

●Child avoids talking situations

●Child acquires vocabulary and sentence structure but does not use language appropriately for communicative purposes

●Language is unusual or confused, or ideas are not expressed clearly

●Child cannot follow instructions without supplemental visual cues

●Loss of milestones

●Poor memory skills at five to six years

SPEECH AND LANGUAGE EVALUATION — In some cases of speech and language impairment, an etiology can be determined and an appropriate intervention strategy can be initiated. A hearing aid, as an example, can be prescribed for a child with a language disorder resulting from hearing loss, whereas surgery may be considered for a resonance disorder secondary to nasal polyps or enlarged adenoids. By comparison, for many speech and language disorders, the etiology cannot be clearly identified, or the disorder is one manifestation of a larger condition. In these cases, the goals of the assessment are to 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 "Case illustrating the evaluation of speech and language impairment in children".)

History — The adequacy of the child's speech and language skills should be assessed in relation to the norm and to their cognitive ability. The speech and language pathologist uses data gathered from various sources to perform this assessment:

●History obtained from the child's caregivers

●Medical history

●School history

●Previous evaluations (eg, hearing, vision, intelligence, emotional)

●Test results and observations derived from contact with the child

A history can be obtained from the caregiver with a questionnaire that includes detailed developmental, medical, social, behavioral, and school histories and a description of the caregivers' perception of the problem (form 1A-D). For school-age children, having information from teachers regarding performance in the language, social, academic, and behavioral areas is helpful (form 2A-B).

Initial evaluation — The clinician asks the 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.

Information about the child's cultural and linguistic background is necessary to appropriately assess and treat speech and language impairment [14]. 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 native language; evaluations should be performed by a speech language pathologist who is fluent in the child's native language. An interpreter must be employed if a fluent speech and language pathologist is not available. Potential problems in the use of interpreters include errors in translation, failure of the interpreter to share information from the case history interview, and a tendency of the interpreter to minimize problems. The occurrence of such problems can be reduced by thoroughly training interpreters in the diagnostic process [15].

Standardized tests — The value of standardized tests as the sole tool for the assessment of communication problems has been challenged because "standardized tests destroy the fundamental social-interactive quality of communication. Many of the tests attempt to isolate and measure particular aspects of communication" without considering the others [16]. 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.

The child's performance in specific speech and language areas, such as phonologic ability, vocabulary comprehension, and grammatic usage, is measured objectively using the most recently standardized, norm-referenced tests for a particular age group. No uniformly applicable test battery for this assessment exists; the clinician uses their expertise to select from among the large number of tests available.

Observation and qualitative analysis of performance — Observation and qualitative analysis of the child's performance supplement objective test results and are essential for making a diagnosis and devising a treatment plan. In the very young or uncooperative child, caregiver report and observation of the child at play provide the information necessary to make judgments about the precursors of speech and language development: the adequacy of speech and language, nonverbal cognition, and social interaction. Precursors of normal speech and language development are listed in the table (table 1).

For older children, the clinician can gather important data about the child's ability to communicate in conversational situations through close observation during informal interaction with the child or watching the child's interaction with their caregiver or sibling. In the qualitative analysis, the skilled clinician looks at how the child arrived at the answer, instead of whether the answer was right or wrong. As an example, does the child:

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

●Use their hands excessively or grope for words during responses?

●Run out of breath while talking?

●Become dysfluent or hypernasal 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?

The clinician 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. These subjective observations provide valuable information for making the diagnosis and for devising a management plan.

Instrumented observation — 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 [16].

Reporting results — The final 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 the weaknesses

●Recommendations for management

●A program for implementing the recommendations

The clinician should communicate this information to the child's caregivers at a conference and in writing. The clinician 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 they will understand.

A definitive diagnosis cannot always be made during the initial assessment. In these cases, the 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 in the clinical setting) [17].

Specific suggestions for appropriately stimulating language should be given to caregivers, teachers, and others involved in the child's care. As an example, providing a language model that is appropriate to the child's linguistic development (eg, sounds, single words, phrases, simple sentences) is important. Caregivers may be advised to comment about daily activities rather than overusing direct questioning that may decrease verbal output from the child. Caregivers are encouraged to accept less than perfect productions (eg, word approximations) when the child's intent is clear. In a systematic review, better language outcomes were achieved when caregivers were taught how, specifically, to stimulate language in their children [18].

Children with speech and oral language disorders are at high risk for developing learning disabilities (eg, academic problems) when they enter school [4-12,19]. Caregivers should know how to advocate for their children in the school system by making sure they get the services they need and ensuring the condition is monitored through periodic reevaluation.

TREATMENT — The treatment plan for a child with speech or language disorder is tailored to their individual needs, but all treatment plans have common components. Baseline data are used to set short-term, long-term, and functional outcome goals [20]. The speech and language pathologist then employs facilitation techniques to elicit specific changes in the child's behavior. Some clinicians use a highly structured approach in which the principles of behavior modification (stimulus-response-reinforcement) are strictly followed; others use a less structured intervention that is more child-led. For example, "enhanced milieu teaching" is an intervention that occurs in play-based interaction sessions [21]. Similarly, in corrective conversational recast therapy an adult repeats some or all of what the child says, correcting a grammatical error [22].A combination of high- and low-structure approaches may be appropriate, depending upon the type of problem and the stage of the therapeutic process.

Functional outcomes 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 [20]. Children differ in their abilities to apply what is learned in one context to other contexts. As an example, children often have difficulty using new speech or language skills in situations other than the treatment setting. Collaboration with family members, caregivers, and educators in helping the child exercise these new skills is a key factor in the success of the treatment.

Emphasis on the practice of inclusion in public schools has been increasing; children with special health care needs (eg, speech and language impairments) are served within the classroom rather than being pulled out for treatment. However, evidence demonstrating improved progress for children with language disorders in inclusion settings has not been consistently demonstrated [23,24]. In addition, some types of intervention are more suited to inclusion settings than are 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.

Specific interventions — 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 a private facility or the public school system

●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)

●Application of assistive technology

●Periodic monitoring without direct therapy

Timing of intervention — Predictors and risk factors to consider when making the decision to initiate intervention are listed in the table (table 2) [25]. Though few studies have examined the effect of timing of intervention on outcome, early intervention usually is recommended. This preference was illustrated in a study in which 30 preschool-age children with severe phonologic disorders were randomized 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 [26]. The children in the early therapy group had greater improvement in speech intelligibility at both four and eight months.

Early intervention also improves language skills in children with delayed language [27]. In one study of 21 toddlers with delayed language development who were randomly assigned to early versus delayed treatment groups, 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 [27]. These children also had improved socialization skills and decreased levels of caregiver stress. In another small randomized trial, caregiver-implemented communication treatment improved speech prelinguistic skills in children between 6 and 24 months of age with moderate to profound hearing loss [28].

However, early intervention for delayed language may not change the long-term outcome, as illustrated in a study that examined the narrative language skills of untreated children with and without a history of delayed expressive language (ie, late talkers) as toddlers [29]. Children with normal language skills had better narrative language skills in kindergarten and first grade than did those with language delay, but by the second grade, no difference was found among the groups.

Although many variables must be considered, and criteria may be difficult to objectify, the positive effects of lowering frustration for the child and family and maintaining the child's self-esteem render early intervention worthwhile in many cases.

Efficacy — Therapeutic outcomes have been described in a variety of patient populations, including children with articulation, voice, fluency, and language disorders. Some examples include:

●Children who received phonologic treatment have demonstrated changes in their sound systems that improved overall intelligibility and communicative functioning [30].

●Normal oral-nasal resonance balance and articulation was achieved by age 5 years in 93 percent of 41 children with cleft palate who received direct or indirect speech services [31]. In a small randomized trial in children with cleft palate, improvements in cleft speech characteristics and consonant proficiency were greater with the linguistic-phonologic than the motor-phonetic approach [32]. Both approaches improved the participant's quality of life.

●In a controlled trial for the treatment of child stuttering, children 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) [33]. The treatment gains were maintained after an average of four years posttreatment [34].

●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 [21].

●The field of augmentative communication has tremendously improved the ability of individuals with severe physical disability and dysarthria (eg, secondary to cerebral palsy) to communicate [35].

●Explicit (direct) grammar instruction has been associated with improvement in expressive language in children with developmental language disorder [36].

●Conversational recast therapy is effective in treating morphologic targets in preschool children [22]. 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 [37].

Investigational therapies — Facilitated communication, auditory integration training (AIT), sensory integration (SI) therapy, and Fast ForWord are examples of controversial practices that have not been validated in large, controlled trials [38-43].

AIT has been advocated for children with autism and a variety of communication, behavioral, and emotional disorders, although this practice lacks a reasonable theoretic basis [39] and has been denounced by the American Speech-Language-Hearing Association [44]. (See "Autism spectrum disorder in children and adolescents: Complementary and alternative therapies", section on 'Auditory integration training'.)

The research supporting the effectiveness of SI therapy in children with language-learning disorders is limited and inconclusive at best [40]. (See "Autism spectrum disorder in children and adolescents: Behavioral and educational interventions", section on 'Sensory integration therapy'.)

Fast ForWord is a computer-assisted intervention program for language disorders [41]. The effectiveness of this intervention has not been validated through independent experimentation and replication, and a meta-analysis of published reports concluded that there was no benefit for oral language or reading disorders from this therapy [42,43].

PROGNOSIS — 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.

The long-term outcome for children with isolated speech disorders is better than for children with both speech and language impairment, but 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 [6,7,45,46]. 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").

SUMMARY

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

•To determine whether an impairment in communication skills exists

•To specify the nature of any impairments

•To initiate appropriate intervention strategies

●Medical evaluation – All children with speech impairment should have a complete medical evaluation and formal audiologic testing to detect medical conditions or hearing loss that may contribute to the speech impairment. (See 'Medical evaluation' above.)

●Speech and language evaluation

•Indications for speech and language evaluation are listed in the table (table 3). (See 'Criteria for speech and language evaluation' 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 'Speech and language evaluation' 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. (See 'Reporting results' above.)

●Treatment – The treatment plan for a child with speech or language disorder is tailored to their individual needs. Common components include setting short-term, long-term, and functional outcome goals and the use of facilitation techniques to elicit specific changes in the child’s behavior. (See 'Treatment' above.)

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