Communication Disorders in Pediatrics

Abstract

Communication centered on the concept of exchanging information and ideas. Communication considered disordered if the individual’s ability to receive, send, and process is impaired. Communication disorder may be evident in the process of speech, language, and/or hearing. Children acquire speech and language skills naturally without formal instruction; however, some children experience difficulties in their acquisition that vary in severity. It is currently acknowledged that at least 8% of children aged 3–17 years had a communication disorder and approximately 55% of those children received an intervention service (Centers for Disease Control and Prevention, Communication disorders and use of intervention services among children aged 3–17 years: United States, 2012, 2015).

Medical practitioners are expected to be familiar with speech and language disorders types, levels and classifications to make the best possible clinical decisions and appropriate referrals as needed. The medical practitioners namely pediatric specialists is often the first one consulted about speech and language difficulties and the doctors should avoid wait and see approach as simplistic explanations by saying ‘he’ll grow out of it’ based on subjective examination.

In the light of lacking resources in developing countries the doctors may find themselves in position to make clinical judgments about speech and language disorders that should not exceed detection and monitoring progress. However, we should always remember that assessing and treating speech and language disorder needs a highly advanced and specialized training represented only by the well trained speech-language pathologist.

With all these challenges and complexities in mind, I hope to share all possible information about speech and language disorders in the pages that follow to help the doctors reaching successful management considering their scope of practice.

9.1 Communication and Communication Disorders

Communication refers to the interactive exchange of information, ideas, feelings, needs, and desires. It involves encoding, transmitting, and decoding messages. Each communication interaction includes three components: (1) message, (2) sender who expresses the message, and (3) receiver who responds to the message. Communication can include both verbal and nonverbal means (i.e., spoken words, naturalistic gestures, or signs). The primary component of human communication is language, and speech is the primary means of language expression for most individuals. However, using the terms “speech” and “language” implies they are not the same which is truly the case. They are separate but related process in a longer process that is called communication.

Communication disorders are defined by the American Speech-Language-Hearing Association as impairment in the ability to receive, send, process, and comprehend concepts or verbal, nonverbal, and graphic symbol systems. The communication disorder may be evident in the process of hearing, language, and/or speech [1]. It may be categorized on the basis of whether reception, processing, and/or expression is affected. Etiology of communication disorders may be due to environmental or faulty learning, neurological impairments, developmental disabilities, anatomical or physiological abnormalities, cognitive deficits, hearing impairment, or damage to any part of the speech system. Communication disorders may be caused by congenital or acquired problems, and it may range from borderline to significant (see Table 9.1). It is currently acknowledged that at least 8% of children aged 3–17 years had a communication disorder and approximately 55% of those children received an intervention service [2].

Table 9.1 Possible criteria of classification in communication disorders

According to the American Speech-Language-Hearing Association (ASHA), the speech-language pathologist and audiologist are trained professionals who can serve individuals with communication disorders. Speech-language pathologist (SLP) is the professional who provides a variety of services that relate to communication disorders. SLP is the specialist who can identify, assess, treat, and prevent communication disorders in all modalities including spoken and written. Also, SLP provides services for disorders of swallowing. The audiologist is the specialist who can measure hearing ability and identify, assess, manage, and prevent disorders of hearing and balance. Both SLP and audiologist are independent professionals who practice without a prescription from any other healthcare provider [1]. As in other professions, SLPs and audiologists use evidence-based practice to provide the best services possible (Table 9.2).

Table 9.2 Typical communication development

9.2 Language Disorders

Language is a socially shared code or conventional system that represents ideas through the use of arbitrary symbols and rules that govern combinations of these symbols [5]. Language has been usefully described as having three levels: “Form”, “Content,” and “Use”. In this approach, “Form” is described as including phonology, morphology, and syntax; “Content” describes semantics; and “Use” describes pragmatics [6, 7]. See Fig. 9.1. During early child development years, if one or more of these levels does not develop properly for any reason, the language will be considered disordered [8].

Fig. 9.1

Language levels

Children acquire language naturally without formal instruction; however, some children experience difficulties in their acquisition that vary in severity. These children are typically described as language disordered [5]. It is important to have a clear distinction between language delay and disordered language . Nicolosi et al. [9] defined language delay as the failure to comprehend or produce language at the expected age that may be due to slow maturation. Regarding language disorder, it is described by Accardo and Whitman [10] as a developmental disorder involving disabilities of reception integration, recall, and/or production of language. According to the ICD-10 [11], language expression and comprehension disorder is described as assessed on a standardized test, within the 2 standard deviation limit for the child’s age. Added to that, the DSM-5 [12] describes the language disorder as defined by the scores obtained from standardized, individually administered measures of expressive language development. These will be substantially below those obtained from standardized measures of both nonverbal intellectual capacity and receptive language development. The DSM [12] uses two classifications to describe language disorder: first expressive language disorder and, second, mixed receptive-expressive language disorder , in recognition of the fact that receptive language problems rarely occur in isolation without accompanying expressive problems [13]. Language disorder may include impaired comprehension and/or expression in the use of spoken but also extended to written and/or other symbol systems [3, 5]. The disorder may involve (1) the form of language (phonology, morphology, and syntax), (2) the content of language (semantics), and/or (3) the function of language in communication (pragmatics) in any combination (Table 9.3).

Table 9.3 Five dimensions of language

9.2.1 Form Disorders

As discussed previously, language form includes phonology, morphology, and syntax . When we speak, we combine sounds (phonemes) into words (morphemes) which in turn combine into phrases and sentences using syntactical rules (syntax). Errors in sound use represent a disorder of phonology. Incorrect uses of appropriate tense or plural markers represent example of a disordered morphology. Incorrect word order and run-on sentences represent disordered syntax.

9.2.2 Content Disorders

It represents the inability to use, understand, and comprehend the meanings of words in their particular arrangement. When the child presents with misuse words or word-finding difficulties, that may be described as a disorder of content or semantics. The limited ability to understand and use abstract language as humor, metaphors, and proverbs indicates semantic disorders. Finally, the overuse of empty words such as “this” to avoid naming objects is another indication of a disorder of content.

9.3 Use Disorders (Pragmatic Disorders)

Pragmatic issues are being increasingly addressed in clinical practice . This has led to a growing number of studies that are concerned with difficulties and problems some children may experience at the level of language use [14]. However, the relationship between pragmatic theory and clinical practice is not as strong as it should be compared to practice in syntax and semantics, according to Perkins [15]. With such heightened interest and research activity, there is a great need for more and more efforts to increase our understanding of pragmatics in different diagnostic categories.

According to Nilson et al. [16], successful communication requires more than knowledge of words and grammar; it requires an understanding of how language is used for social and functional purposes. Gleason [17] defined it as the system of rules that dictates the way language is used to accomplish social ends and Silverman [18] to the ability of a speaker to use language for accomplishing goals or intentions while interacting with others. Mey [19], Owens [3], and McKibbin and Hegde [20] add the concept of inappropriacy. Their definition of pragmatics includes who is talking to whom, in which way [how], in what situation [where], and at what time [when] [20].

Pragmatics is commonly divided into three domains: firstly, discourse management that includes how to initiate, maintain, and end a conversation; secondly communicative intention that includes how to request and inform; and thirdly presupposition that includes assumptions about the interlocutor and the context [21, 22]. The child’s pragmatic competency is associated with a group of developing skills including eye contact, requesting information, taking turns in conversations, topic initiation, topic maintenance, speech acts, adjusting what is being said according to the listener’s linguistic ability, and responding to requests for clarification and cohesion. Children with poor pragmatic skills often misinterpret another person’s communicative intent and have difficulty responding appropriately either verbally or nonverbally [13].

In 1987, Prutting and Kirchner described pragmatic aspects of language as including verbal utterances, paralinguistic aspects, and nonverbal behaviors. According to Prutting and Kirchner [23], the nonverbal aspect of pragmatic skills includes eye contact, facial expression, physical proximity, and gestures; paralinguistic pragmatic skills are defined as the mechanics of speaking that include intensity, intelligibility, tone, and rhythm (considering the conversational impact of these characteristics). A possible exemplifying scenario for a disruption on the nonverbal level in the pragmatic domain would be when a conversation is disrupted due to the child’s failure to give eye contact with the interlocutor during conversation which may mean the topic of the conversation is shifted to the child’s inappropriate behavior instead of the subject in hand. Verbal pragmatic deficits may include inappropriate turn taking (e.g., not responding to the interlocutor), interruptions, and failure to track and respond to topic shifts. Camarata and Gibson [24] conclude that pragmatic deficits are evident when disruptions occur at a level that significantly interferes with the child’s ability to successfully converse. Pragmatic disorder is a descriptive term that refers to difficulties with using language to convey and understand intended meaning, and it includes any disruptions in the social interaction that do not arise from deficits in structural aspects of language [20,21,26], although a lack of structural complexity can lead to pragmatic ambiguity [15]. So pragmatic difficulties can be observed as a secondary feature of any developmental language impairment due to the limitation in communication abilities [23, 27]; however developmental pragmatic disorders are not restricted to any particular diagnosis such as attention deficit hyperactivity disorder or autism spectrum disorder [25].

Pragmatic disorders are evident when disruptions occur at the level of language that significantly interfere with the individual’s ability to successfully converse [28, 29]. These levels include verbal linguistic behaviors, including speech act, topic initiation, topic maintenance, topic shifting, turn taking, lexical (word) selection, and stylistic variations; paralinguistic aspects including the mechanics of speaking including intelligibility, vocal quality, intensity (loudness), prosody, and fluency; and nonverbal aspects including eye contact and body language [23, 24, 30]. The DSM included language disorders under a broader category of communication disorders, which are defined as any disorder in the production and/or comprehension of speech and/or language. It should be noted that the pragmatic aspect of language is not directly included, but is indicated in the expressive language difficulty description (315.31) by pointing out that the language difficulty interferes with social communication. Camarata and Gibson [24] stated that “the DSM criteria appear to require pragmatic analysis for accurate diagnosis” [24, p. 210].

9.4 Formalists Versus Functionalists in Speech-Language Pathology

The formalists view pragmatics as one of five equal and interrelated aspects of language [3]. These aspects are syntax, morphology, phonology, semantics, and pragmatics that are organized and controlled by a set of formal systems and rules [31]. Prutting [32] argued that this approach is inadequate. In contrast, the functionalistic point of view is a more holistic approach that views pragmatics as an overall organization of these aspects of language [3].

Prutting [32] discussed the shift that had taken place in speech-language pathology, as result of the focus on the pragmatic aspects of language. The discussion of the formalists and functionalists illustrated the differences in definition, function of language, competency, and framework. At the level of definition, the formalist approach was described as referring to a linguistic view of language, while the functionalist approach referred to the pragmatic perspective. Added to that, the advocates of the formalist approach defined language as a set of sentences, whereas the functionalists advocated defining language as an instrument for social interaction. At the level of language function, the formalists view it as mainly the expression of thoughts; however the functionalists believe that the primary function of language is communication, which the author believes is more practical for clinical purposes. At the level of competency, the formalists view it as the ability to produce, comprehend, and judge grammatical structures; however the functionalists see competency as a communicative competence, which is rooted in social interaction.

From a clinical perspective, Owens [3] mentioned that speech-language pathologists replaced the formalists’ model with a more functionalistic approach due to the increasing recognition (by speech-language pathologists) of the influence of pragmatics on the structure and content of verbal output. This view of language led to a different approach for intervention: from the approach that covers isolated bits of language (entity approach) to the holistic approach (functionalistic approach) that targets language within the overall communication process [33].

9.5 Speech Disorders

Speech is the oral expression of language. Sometimes the terms “speech” and “language” are used interchangeably, but they are clearly not. If the assumption of interchangeability is correct, one could not exist without the other because they would be one and the same thing. In actual fact, both “speech” and “language” can and does exist in the case of absence of the other. Speech is not the only mode of expressing language (e.g., gestures, pictures), but it is the fastest and most efficient method of communicating by language. Hulit and Howard [34] described speech as a product of four separate but related processes as follows:

• 1. Respiration (breathing that provides the power supply for speech).

• 2. Phonation (the production of sound when the vocal folds of the larynx are drawn together by the contraction of specific muscles, causing the air to vibrate).

• 3. Resonation (the sound quality of the vibrating air, shaped as it passes through the throat, mouth, and sometimes nasal cavity).

• 4. Articulation (the formation of specific, recognizable speech sounds by the tongue, lips, teeth, and mouth).

Owens et al. [4] described speech as the acoustic representation of language. They added that features such as articulation (the way in which speech sounds are formed), fluency (the smooth forward flow of communication), and voice (the sound produced by the larynx) interact to influence the speech production signal. The final product reflects the rapid coordination of movements associated with each of these features.

The three basic types of speech disorders includes articulation disorders (errors in the production of speech sounds), fluency disorders (difficulties with the flow or rhythm of speech), and voice disorders (problems with the quality or use of one’s voice).

9.5.1 Articulation Disorders

Speech requires neuromotor coordination to actually produce speech sounds, called articulation. The correct use of speech sounds within a language requires knowledge about the sounds of that language and the rules that govern their production and combination, termed phonology.

The articulation disorders are impairments of production that means a child is not able to produce a speech sound physically (e.g., /k/). Disorders of articulation are typically characterized with four typical types of errors:

• Substitution

• Distortion

• Omission

• Addition

Substitution occurs when a phoneme is replaced with another, as in saying “tar” for “car.” Children with substitution problem are often convinced they have said the correct word and may resist correction. It may cause a considerable confusion for the listener. Distortion occurs when a nonstandard form of the phoneme is produced as in saying “thun” or “schun” for “sun.” Some children have a whistling /s/, and others a lisp. Omission occurs when the child deletes a phoneme as in saying “tain” for “train.” Addition occurs when the child adds extra sounds that makes comprehension difficult as in saying “clar” for “car.”

The phonological disorders are impairments of conceptualization or language rules [4]. The child may be able to produce a given sound correctly in some instances; however he/she fails to produce the same sound correctly at other times. Children with phonological disorders are apt to experience difficulties in academic areas (e.g., reading and writing) [37, 38]. Differential diagnosis between articulation disorders and phonological disorders is highly needed due to the difference in the treatment goals, producers, and strategies of intervention (Table 9.4).

Table 9.4 Differences between articulation and phonological disorders

The causes behind articulatory and phonological disorders in most children are not easy to be identified which are usually termed as functional disorder. Functional disorder is the term used to describe when no cause is known. Accordingly, researchers in the field of speech and language pathology have directed more attention to comorbidity or co-occurring conditions. Comorbidity means that two or more conditions occur together but one does not necessarily cause the other(s). The possible comorbid conditions with articulatory and phonological disorders include but not limited to general developmental delay, intellectual disability, language difficulties, hearing impairment, history of frequent otitis media during the first few years of life, neuromotor disability, poor oral-motor skills, atypical tooth alignment and missing teeth, eating problems, and family history of speech and language delay.

9.5.2 Fluency Disorders

Fluent speech is the consistent ability to use the speech organs in an effortless, smooth, and rapid manner which consequential in continues uninterrupted forward flow of speech. Dysfluent speech includes prolongations, pauses, hesitations, interjections, and repetitions that interrupt the smooth flow of speech. According to [1], “fluency disorder is an interruption in the flow of speaking characterized by atypical rate, rhythm, and repetitions in sounds, syllables, words, and phrases. This may be accompanied by excessive tension, struggle behavior, and secondary mannerisms.”

Children are not born as fluent speakers. Fluent speech requires physical maturation and language experience, but it does not develop linearly as the child matures. According to Yairi’s longitudinal studies (1981 and 1982), children at 25 months of age are more fluent than they will be at 29 months and 37 months of age.

Dysfluency disorder is a problem of 1% of the general population. About 85% of stuttering cases start during the preschool years, and 98% of cases begin before the age of 10 years [39]. According to [40], 4% of children stutter for 6 months or more and that 70–80% of children 2–5 years old who stutter recover spontaneously. It is more common in males than females, and it tends to run in families [41]; but we are not certain if it is a result of genetic connection or environmental factors or a combination of both. The causes behind stuttering remain unknown, although the problem has been studied extensively (Table 9.5).

Table 9.5 Onset and development of stuttering based on Bloodstein’s four phases

The most common form of stuttering is called developmental stuttering, and it begins in the preschool years. The second form of stuttering is neurogenic stuttering which is typically associated with neurological disease and trauma. The difference between developmental stuttering and neurogenic stuttering is represented in several behaviors (see Table 9.6).

Table 9.6 The difference between developmental stuttering and neurogenic stuttering

Dysfluency disorder is of two types; the first is known as stuttering, and the second type is called cluttering. Cluttering is characterized with very rapid speech and mispronounced or adding sounds which highly affects speech intelligibility. The difference between stuttering and cluttering can be summarized in two main points. The first is related to the problem awareness—stutterers are more aware of their fluency problem; however individuals with cluttering may be unconscious to his/her disorder. The second is related to paying more attention to his/her speech—stutterer is likely to exhibit more dysfluency episodes; however clutterer more often improves his/her fluency by monitoring his/her speech.

9.5.3 Voice Disorders

Voice disorders involve deviation in voice quality, pitch, loudness, and flexibility that may indicate illness and/or interfere with communication. The American Speech-Language-Hearing Association (2000) described voice disorders as the abnormal production and/or absences of vocal quality, pitch, loudness, resonance, and/or duration, which is inappropriate for an individual’s age and/or sex. The voice reflects age, gender, personality, personal habits, and general condition of health. Although voice disorders can affect individuals at any age, it is more common in adults than children, and in adult population, males are more commonly affected than females [4, 43]. Voice disorders in children are usually related to vocal abuse or misuse and in most cases are temporary. Colton and Casper [44] considered the perceptual signs of voice into five categories:

• 1. Pitch

  • (a) Monopitch

  • (b) Inappropriate pitch

  • (c) Pitch breaks

• 2. Loudness

  • (a) Monoloudness

  • (b) Inappropriate loudness (soft, loud, uncontrolled)

• 3. Quality

  • (a) Hoarseness/roughness

  • (b) Breathiness

  • (c) Tremor

  • (d) Strain/struggle

• 4. Nonphonatory behaviors

  • (a) Stridor

  • (b) Excessive throat clearing

• 5. Aphonia

  • (a) Consistent

  • (b) Episodic

Voice disorders are divided into two types: phonation and resonance. When the phonation is disordered, the voice will sound hoarse, breathy, husky, strained, or no voice at all (in severe cases). Phonation disorders can be caused by organic origin such as growths or irritations on the vocal cords. Hoarseness frequently comes from chronic vocal abuse (i.e., yelling). Misuse of voice causes swelling of the vocal cords, which in turn can lead to growths known as vocal nodules, nodes, or polyps. When the resonance is disordered, it is either hypernasality (too many sounds coming out through the air passages of the nose) or hyponasality (not enough resonance of the nasal passages). The etiology of resonance problems may be either organic (e.g., cleft palate, swollen nasal tissues, hearing impairment) or functional (e.g., learned speech patterns or behavioral problems).

9.6 Children at Risk for Speech and Language Disorders

For the purpose of prevention, the medical field focused on identifying the at-risk infants. There are two types of risk: biological and environmental. Biological risks originate from genetic conditions in addition to teratogenic factors. The biological risks include illegal substances (i.e., cocaine, methamphetamines, and marijuana) as well as the commonly used teratogens (i.e., alcohol, nicotine, and caffeine). Regarding environmental risks, it is referring to the impact of the surroundings on the child such as socioeconomic status, maternal influences, lead, nutrition, and diet. The possible outcomes for risk factors may include but not limited to prematurity, low birth weight, shorter body length, smaller head circumference, tremulousness, cognitive/social/behavioral difficulties, congenital abnormalities, neurological impartment, intellectual disability, and learning disorders. Finally, we should consider that a single risk factor alone cannot clearly predict a specific outcome.

9.7 Medical Conditions Associated with Speech and Language Disorders

Some medical conditions may be reported by parents or caregivers during a typical initial interview. It is very crucial for physicians to know what each condition is and how it may affect the child’s speech and language abilities bearing in mind that most illnesses or conditions have potential implications for speech and language development (see Table 9.7).

Table 9.7 Some medical conditions and its effect on speech and language disorders

9.8 Identification

To decide whether a child has a speech and language problem , the physician should ask the parents or caregiver the following questions:

• Does the child’s verbal production call attention to itself?

• Does the child’s speech and language level affect his/her social communication and interaction?

• Is the child’s speech appropriate for his/her chronological age?

• Is the child’s speech and language a concern to his/her parents?

In case the answer is yes for any of the previous questions, the referral to speech-language pathologist for assessment and management of these problems is the best clinical decision to make. Also, the physicians are encouraged to observe the child’s speech and language abilities during their routine visits to make needed referrals (Table 9.8).

Table 9.8 Red Flags for referrals of speech and language problems to a speech-language pathologist

The communicative impairment may involve speech, language, hearing, and/or processing or, more likely, some combination of these. During assessment, the speech-language pathologist is trying to investigate the specifications of the individual’s speech and language abilities. That includes identifying the strength and the weakness of communicative abilities. As a conclusion, the speech-language pathologist should provide the child’s family with a report that includes all detailed information about all aspects of the child’s communicative disabilities and abilities (see Fig. 9.2).

Fig. 9.2

Sample of generic speech and language assessment report

9.9 Online Resources

• American Speech-Language-Hearing Association (ASHA)—www.asha.org

• National Institute on Deafness and Other Communication Disorders (NIDCD)—www.nidcd.nih.gov

• Royal College of Speech and Language Therapists (RCSLT)—www.rcslt.org

• The worldwide organization of professionals and scientists in communication, voice, speech language pathology, audiology and swallowing (IALP)—www.ialp.info