Transcript Expressive Language Delay
LANGUAGE Cognitive Development
Failure to speak single words by
18 months
and phrases by
30 months
(Speech and Language Impairment)
•
10-15
%
of toddlers 3% are at risk of persistent speech and language problems and learning disability
•
4 –5 % beyond 3 years
•
Mental retardation
•
Hearing impairment
•
Autism
•
Emotional and Behavioral Disorders
•
Environmental deprivation
•
Developmental language disorder
•
Most common cause of language delay (> 50 % of cases)
•
Speech delay is “universal” among retardates
MENTAL RETARDATION
DEFINITION
A significantly
subaverage general intellectual functioning
which manifests itself during the
developmental period
and is characterized by
inadequacy in adaptive behavior.
INCIDENCE
About 3% of the population
ETIOLOGY OF MENTAL RETARDATION
A. Congenital syndromes, genetic
Chromosomal Single gene defect Major malformations Presumed genetic
B. Congenital syndromes, nongenetic
Intrauterine infection Maternal systemic disease Maternal drug ingestion Maternal gestational disorders
DOWN SYNDROME
Trisomy 21 Incidence: 1:800-1,000 babies Clinical features Medical problems
40-50% - congenital heart disease 50% - visual/hearing impairment
10% - intestinal malformations 15-20% - Alzheimer’s disease/dementia Increased risk of thyroid problems/leukemia Average life span: 55 years
ETIOLOGY … C. Perinatal and Postnatal Factors Prematurity and its complications Birth asphyxia Head trauma CNS infection Toxins Hypoxic events Chronic severe systemic disease Nutitional deficiencies Socioeconomic deprivation D. Unknown
Distribution of Classification of Mental Retardation
2.50% 2.00% 1.50% 1.00% 0.50% 0.00% MILD MOD-SEV PROFOUND
LEVEL OF MR Borderline Mild Moderate Severe Profound IQ SCORE 70-79 EDUC.
EQUIV Educable 50-55 to 70 35-40 to 50-55 Educable Trainable 20-25 to 35-40 Trainable Dependent Below 20 Custodial (life sup) ADAPTIVE BEHAVIOR ADL Independent Employable Employable in simple jobs LEVEL OF SUPPORT Intermittent Intermittent – prn basis Trainable Employed in sheltered env.
Trainable in some basic ADL Dependent in all ADLS Limited; more than prn Extensive; support at least 1/day Pervasive
Mental Retardation
•
Language problem: immaturity of overall language skills.
•
Language as well as the other developmental streams, particularly the visual-motor stream and adaptive skills are delayed.
Global developmental delay
DIAGNOSIS Neurodevelopmental Assessment: 1. Comprehensive history.
2. Complete physical and neurological examination.
3. Appropriate laboratory studies.
4. Developmental screenings.
5. Judicious referrals to supporting professionals.
MULTIDISCIPLINARY APPROACH
MANAGEMENT Role of the physician is limited; management is generally psychoeducational.
• •
most
deviant
degree of communicative disorder characterized by a triad of impairments Impaired social relatedness Impaired communication and play Stereotypic/ritualistic activities
PREVALENCE:
5-6 per 1000 births Congenital SNHL: 1/1000 births At age 5 years, 10-15% of children fail hearing screening
RISK FACTORS
1. A family history of hereditary childhood sensorineural hearing loss 2. Congenital infections known to be associated with hearing loss 3. Cranifacial anomalies 4. Birthweight less than 1500 gms 5. Hyperbilirubinemia at a serum level requiring exchange transfusion.
RISK FACTORS …
6. Ototoxic medications 7. Bacterial meningitis 8. Apgar score of 0-4 at 1 minute or 0-6 at 5 minutes 9. Mechanical ventilationfor 5 days or longer 10. Stigmata of a syndrome known to include hearing loss
DEGREES OF HEARING IMPAIRMENT Level of HL Description Etiology 25-30 dB hearing loss Mild hearing loss Serous otitis perforation, SNHL, tympanosclerosis Serous otitis perforation, tympanosclerosis, SNHL
DEGREES OF HEARING IMPAIRMENT Level of HL Description Etiology 30-50 dB 50-70 dB More than 70 dB Moderate hearing loss Severe hearing loss Profound hearing loss Chronic otitis, middle ear anomaly, SNHL SNHL or mixed loss from SN or middle ear dis Sensorineural or mixed loss
AVERAGE AGE OF IDENTIFICATION MILD SNHL – 3 to 4 years old MODERATE TO PROFOUND SNHL – 23 months UNILATERAL OR HIGH FREQUENCY LOSSES – 5 to 6 years old
Comprehension deficit leads to delay in the acquisition of speech and language forms
Most frequent complaints:
1. Lack of response to speech/noise 2. Poor speech development
Less frequent complaints:
1. Behavior problems 2. Balance problems/ear fingering
HEARING EVALUATION
METHODS:
•
Auditory brainstem evoked response (ABR, BAER, BERA)
•
Behavioral play audiometry
•
Otoacoustic emission (OAE)
•
Tympanometry
MANAGEMENT
•
MEDICAL
•
ASSISTIVE DEVICES - hearing aids - cochlear implants
•
EDUCATION
HYPERACTIVE; “DISTURBED” CHILD
Impaired comprehension and production of linguistic forms in relationship to social communicative abilities
Delay in speech as a result of lack of stimulation and attention
•
Inadequate acquisition of language in the absence of a hearing loss, documented neurologic lesion, mental retardation, or primary emotional disorder.
•
Prevalence ( DSM-IV ) : 3-5 % of children
DEVELOPMENTAL LANGUAGE DISORDER
PATHOGENESIS/ETIOLOGY:
•
unrelated to perinatal risk factors, early language deprivation, bilingualism
•
genetic contribution
is the only factor that has been implicated to any substantial degree “62% of DLD children studied had an affected parent”
Tallal, et.al
LANGUAGE ASSESSMENT
Difficult
Reasons: 1.
Most parents do not really focus on early language milestones.
2. Difficult to assess language directly in the well baby setting.
•
PARENTAL CONCERNS
•
Sensitivity of 72% Specificity of 83 %
SCREENING TESTS Middle-class community
1. Early language Milestone Scale (ELMS) 2.
Denver II 3. Clinical Linguistic and Auditory Milestone Scale (CLAMS) 4. Gessell Schedules of Infant Development
•
Audiological Evaluation
The first step is to rule out a hearing deficit. It is not enough to rely upon parents’ report or screening in pediatric office, because unilateral or mild hearing deficit, which can cause speech impediment is likely to be missed in the office.
Diagnostics …
•
Neuropsychological Assessment
•
Speech/Language Evaluation
•
Individualized
•