School Problems and the Family physician - Part I

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Speech and Language Disorders in Children

School problems and the Family Physician

Dr. Latha Ravichandran, DCH, DNB(Pediatric Medicine)


Speech and language although closely related are not synonymous. Language is a symbol system used to develop concepts and allow understanding. It is expressed through speech, but it can also be conveyed through other means such as sign language and musical notation. Linguistically proficient children have a distinct advantage in school because much of what is taught is delivered in literate language. All the basic academic skills are largely conveyed through language. Therefore it is not surprising that children with language dysfunction usually have troubled educational career.

Classification of speech and language disorders;
1. Developmental disorders
A. Speech
(a) Dysrhythmia- stuttering
(b) Phonological delay (dyslalia)
(c) Articulatory (verbal) dyspraxia
B. Language
(a) Receptive and expressive language delay
(b) Verbal auditory agnosia / Central deafness
(c) Semantic
2. Neurological and/or acquired disorders
A. Speech
(i) Dysphonia Recurrent laryngeal nerve palsy/brain stem lesion
(ii) Dysrhythmia Cerebellar
(iii) Dysarthria Anatomical
Cleft palate
Neurological : bulbar palsy
(iv) Acquired articulatory dyspraxia
B. Language
(i) Dysphasia Expressive
(ii) Acquired auditory agnosia
3. Secondary speech and language disorders
(i) Peripheral deafness
(ii) Mental handicap
(iii) Autism
(iv) Psychological deprivation
(v) Miscellaneous
Definition of Terminology:
a. Developmental language disorder is a delay in the development of comprehension and the use of a spoken, written or symbolic system of communication.
b. Dysrhythmia eg. Stuttering, fluency disorder, where there is intermittent difficulty in producing a smooth flow of speech that is characterized by repetitions, hesitations, or blockage of speech.
c. Phonological delay (dyslalia): This is characterised by constant delay in the onset of various stages of speech, but the most striking feature is their unintelligibility of speech.
d. Dyspraxia is an inability to use voluntarily the muscles needed for articulation.
e. Receptive Disorder is impairment in the ability to comprehend language.
f. Expressive disorder is impairment in the ability to express thoughts.
g. Verbal auditory agnosia/Central deafness. This condition where the peripheral hearing mechanics are normal, but there is word deafness due to bilateral involvement of primary auditory cortex in the temporal lobes (the cortex fails to recognise signals).
h. Semantic : These children may be chatty, and articulate but on keen observation reveal echolalia, perseverations, circumlocution and errors. Their comprehension is delayed compared to their expression and they fail to understand their own speech.
i. Dysphonia; These children have abnormalities in the tone of the voice.
j. Autism : It is characterised by a qualitative impairment in verbal and non verbal communications, in imaginative activity and in reciprocal social interactions.

A. History : In children > 3 years of age - ask
  • Whether he or she talks spontaneously and if speech is intelligible.
  • If she/he becomes frustrated when asked questions and/or fails to ask questions spontaneously.
  • Whether dislikes listening to stories, had difficulty in understanding stories, and cannot relate events correctly.
  • Cannot learn simple song or nursery rhymes
  • Has difficulty in playing with peers
    In children < 3 years ask,
  • How many words spoken
  • Able to follow small instructions (comprehension)
  • Also ask for family history of disorder of hearing, language, attention deficit, learning articulation and stuttering.

B. Physical Examination
Perform pneumatic otoscopy to identify otitis and middle ear effusion.
Note signs of neurologic disorder, especially altered, generalized muscle tone, abnormal reflexes and abnormality of muscle movements related to speaking, chewing, sucking or swallowing. Note abnormalities of palate and oral structures (tongue tie, cleft palate)

C. Audiological evaluation
This is mandatory in all cases of language disorders.

D. Identify hearing loss and congenital syndromes.
In many congenital disorders, hearing loss is associated with mental retardation and produces marked language problems. Wherever possible treat hearing loss (eg) Downs syndrome, Treacher Collins, Congenital infections.

E.The Diagnostic criteria for developmental language disorders in children is when the problem causes interference with home and educational activities in the absence of global developmental delay, hearing loss and neurologic disorders.

F. Repetition of words and phrases is common for children of 2 to 5 years of age. A small proportion of these children progress to chronic stuttering. The features that indicate a persistent problem include part-word repetition rather than full word or phrase, multiple rather than single repetitions and irregular, abrupt (jerky) repetitions. The children with obvious problem exhibit struggle and avoidance behaviour. They avoid speaking to strangers. Children should be referred to speech therapist if the problem inhibits the child or continues longer than 6 months.

G. The effect of mild to moderate conductive hearing impairment related to persistent or recurrent otitis media on language development makes it important to do an otological examination of any child with language disorder.

H. The home environment. Inadequate stimulation at home can be a result of insufficient care and attention or overprotection, especially from siblings who do and get everything of a younger child. Children living in multilingual environment is simultaneously hearing more than one language may have transient delay.

Speech and language disorders are contributors to poor school performance.The role of Family Physician in children with language disorder is to identify rectifiable causes such as hearing loss, otitis media, anatomical defects (cleft-palate, tongue tie); assess for underlying neurologic problem, mental subnormality or lack of stimulation and appropriately refer conditions such as stuttering for speech therapy.

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