|Clinical Practice Guideline:
Report of the Recommendations, Communication Disorders, Assessment and Intervention for Young Children (Age 0-3 years)
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Communication is the process used to exchange information with others and includes the ability to produce and comprehend messages. Communication includes the transmission of all types of messages, including information related to needs, feelings, desires, perception, ideas, and knowledge. Communication also occurs through a variety of modalities, including nonlinguistic, verbal, and paralinguistic processes. All of these processes influence an individual's ability to communicate with others.
Language, an integral part of human communications systems, is also a mechanism to control and mediate one's own actions, thoughts, and behaviors. Although language and speech are sometimes thought of as inseparable, they are, in fact, different.
Communication is integral to overall developmental progress in young children, particularly in the cognitive, social-emotional, and adaptive development. Human newborns enter the world with limited but functional repertoires of behaviors that serve as communication signals to attentive caregivers.
Communication begins in the earliest days of infancy when babies and caregivers "take turns" in their first "conversations" of looking, vocalizing and gesturing. For example, an infant's cry is usually a sign of distress; smiles and coos signal pleasure; and hand sucking may signal hunger.
A number of studies of young children identify important milestones in communication development that are typically obtained in the first 36 months of a child's life. Typically developing young children demonstrate many rich gestural and social prelinguistic (before verbal language production) communication routines prior to the onset of first words. Important prelinguistic behaviors and interchanges include:
The production and use of words emerges later in development, usually during familiar routines and with familiar adults (such as saying "bye-bye," "mama"). As young children move into the "intentional language stage" both language comprehension (what the child understands) and language production processes become evident. Typically in young children developing language skills, comprehension skills exceed language production skills.
There is a systematic progression of vocal and language development that characterizes the first two years of life. During the first year, the child's vocalizations gradually become more refined, better controlled, and more focused on the sound characteristics of the language in the environment. Also during the first year, children begin to exhibit language understanding (comprehension) of words and some phrases, language production (words), and the beginnings of communicative abilities (such as turn-taking; requests for objects or actions and statements using vocalization, eye contact, and gesture).
During the second year of life children's comprehension and production abilities expand rapidly. Production vocabulary increases, gradually at first, and then rapidly at around 18 months. Comprehension vocabulary expands rapidly. Comprehension and production of syntax (words combined in phrases) both emerge during this period. Communicative skills also expand so that children initiate communicative exchanges and readily participate.
By three years of age, children have acquired the rudiments of language. Their average sentence length is approximately four words, with many longer, far more complex sentences. They are sophisticated conversationalists, able to maintain a topic of conversation, add information, and initiate topics. They also can describe complex events and past experiences.
Research indicates that young children who are raised in bilingual or multilingual households are not at a disadvantage when learning language. Nonetheless, the very early expression of language as it is being learned by the young child in a bilingual/multilingual household may vary somewhat from those children who are raised in a monolingual environment.
There are many variations of a bilingual/multilingual household that might impact the language learning process in the very young child. For example:
It is possible that receptive and expressive language skills may develop at different rates across the various languages in a child learning language in a bilingual/multilingual environment. A young child in a bilingual/multilingual environment may also mix languages for a period as language skills are being acquired.
A difference in language development is not a deficit.
Differences in language development, however, present one of the greatest challenges in appropriately assessing for communication disorders in young children from a bilingual or multilingual home. While children learning Spanish develop their sound system at a rate similar to that of children learning English, Spanish phonology is different from English phonology, and the complexity of the Spanish morphological system makes the development of Spanish different from the development of English. Many features that develop relatively early in children learning English (such as gender and number agreement) do not develop until as late as six years of age in children learning Spanish. Because some of the differences in language structure impact the way in which children learn the language, it may appear that a child learning English influenced by Spanish is delayed in his language development when, in fact, it may be a normal variation in the learning process.
In addition to linguistic differences across languages, cultural differences in communication and learning exist. These differences are found in verbal and nonverbal communication, communicative and narrative style, rules for adult-child discourse, conversational roles of young children, and culturally based learning style preferences. Even within one language, there may be one or more dialects accepted by its community of speakers. A regional, social, or cultural/ethnic variation of a language system is not considered a disorder of speech or language.
A major concern in language development relates to those children where Standard American English (SAE) is not used in the home. Many young children live in homes where a variation of English, such as African American English (AAE) or Spanish-influenced English is used. The language variation may occur in language form, language content, and/or language use. As with any child, when considering the possibility of a communication disorder in a child who speaks a variation of Standard American English, it is important to distinguish between features of language attributable to language variation, those attributable to development, and those indicative of a disorder.
The available data indicate that children in the 0-2 age group learning language in environments where AAE is the predominant language can be expected to follow the same course of development in syntax, morphology, semantics, and phonology as children developing Standard American English (Cole, 1980). The features that typically distinguish AAE and SAE involve phonological and morphological features that do not typically develop until after age 4 or 5 years. Blake (1984) and Stockman (1986) have shown that the morphological development of young children who speak AAE is similar to that of children who use SAE to the age of 3 years, including the development of the mean length of utterance (MLU). At the age of 3 years, children learning AAE have developed the use of well-formed multi-word sentences, use appropriate question form, and use a few complex utterances with appropriate subjects, verbs, and complements (Stockman, 1986; Stockman, 1996).
The American Speech and Hearing Association (ASHA) defines communication disorder as:
"An impairment in the ability to receive, send, process, and comprehend concepts or verbal, nonverbal and graphic symbol systems. A communication disorder may be evident in the processes of hearing, language, and/or speech. A communication disorder may range in severity from mild to profound. It may be developmental or acquired. Individuals may demonstrate one or any combination of the three aspects of communication disorders. A communication disorder may result in a primary disability or it may be secondary to other disabilities" (ASHA, 1993).
Communication disorders may range from sound substitutions to the inability to use speech and language. Young children with a communication disorder may show delays or atypical development in one or more of the following areas:
The American Speech-Language-Hearing Association (ASHA) estimates that 42 million Americans have some type of communication disorder. Persons of all ages can be affected by a communication disorder resulting from a variety of causes (for example: stroke, trauma or other injury to the brain, injury to facial structure or muscles, etc.).
Communication disorders can occur in isolation (specific language impairment) or they may co-exist with other developmental disorders such as mental retardation and autism. In young children, communication disorders represent the most common developmental problem. As broadly defined by ASHA, it is estimated that between 15 and 25% of young children have some form of communication disorder.
Frequently, the specific cause of a communication disorder is unknown. Some common problems which co-exist with communication disorders include cerebral palsy and other nerve/muscle disorders, traumatic brain injury, stroke, viral diseases, mental retardation, effects of certain drugs, structural impairments such as cleft lip or palate, vocal abuse or misuse, or inadequate speech and language models (ASHA, 1998). A list of medical conditions that are commonly associated with communication disorders in young children is given in the section on risk factors in Chapter III (Table III).
Children begin to develop the communicative skills that form the foundation of language in very early infancy, long before they begin to produce their first words and sentences. The most severe communication disorders in young children are usually associated with other developmental disabilities or severe hearing loss/deafness and are usually noticed as part of delayed development during infancy. These children may be delayed in cooing and babbling, be generally unresponsive to communication routines with their caregivers or may have severe feeding problems which may be associated with later difficulty with oral-motor coordination necessary for speech sound development. Other speech and language disorders (such as specific language impairment, stuttering, voice dysfunction, problems with articulation, or lesser degrees of hearing loss) typically cannot be observed until after the child begins to talk. Delayed production of words may be the first indicator of a communication disorder in some children.
The American Speech-Language-Hearing Association (1993) categorizes communication disorders into three categories: language disorders , speech disorders , and hearing disorders.
A language disorder refers to impaired comprehension and/or use of spoken, written and/or other symbol systems. Language disorders include any delay or disability affecting the child's ability to comprehend (receptive language) and/or appropriately use words or gestures (expressive language).
The disorder may involve any of the following in any combination:
Phonology is the sound system of a language and the rules that govern the sound combinations.
Morphology is the system that governs the structure of words and the construction of word forms.
Syntax is the system governing the order and combination of words to form sentences and the relationships among the elements within a sentence.
Semantics is the system that governs the meaning of words and sentences.
Pragmatics is the system that combines all of the previous language components in functional and socially appropriate communication.
In general, language disorders can be grouped in the following categories of coexisting conditions:
Young children with cognitive delays, autism, and other general developmental disabilities almost always experience general delays in their language development. The severity of these language disorders usually varies according to the severity of the child's primary disability.
In contrast to the general delay or disorder associated with a co-existing condition is the phenomenon of specific language impairment (SLI) . SLI is "a significant limitation in language ability, yet the factors usually accompanying language learning problems - such as hearing impairment, low nonverbal intelligence test scores, and neurological damage - are not evident" (Leonard, 1998).
In some young children with SLI, only expressive language seems to be affected, whereas others show impairments in both receptive and expressive development. The severity of these impairments ranges from a mild delay in the emergence of spoken words or the use of specific grammatical forms to very severe delays and language learning disabilities that persist throughout the child's school years and significantly influence both academic and social success.
Beyond consensus on these general definition and descriptive statements, it is difficult to find much agreement among experts on the exact nature and etiology of SLI. One of the most basic issues yet to be resolved in studies of SLI is whether this type of impairment is best characterized as a delay or a deviance in the language development process.
It will come as no surprise that there is also little consensus on the etiology of SLI. It seems likely that there are multiple risk factors, including chronic otitis media, genetics, socioeconomic status, and speech perception deficits, that act in cumulative fashion to increase the likelihood that any one child will experience SLI. It also seems likely that the degree and pervasiveness of any impairment may be associated with the number of risk factors involved. Studies have shown that children with persistent language disorders in the later preschool years continue to have language-learning problems and are also at significant risk for both academic and social failure when they enter school. They have difficulties with reading and writing that, in turn, have an impact on academic achievement in other subject areas as children get older. In addition, these children often have impairments in the skills associated with appropriate conversational uses of language (Brinton and Fujiki, 1989) in that other children are likely to avoid conversation with such children and to leave them out of social interactions (Rice, 1993; Watkins, 1994).
A speech disorder is an impairment of the articulation of speech sounds, fluency, and/or voice. All disorders affecting the child's ability to produce clear, intelligible spoken language are considered speech disorders. Of the preschool age children served by speech-language pathologists in the United States, it is estimated that about 60% have a primary language delay or disorder and 40% have some type of speech disorder (Peters-Johnson, 1992).
In general, speech disorders include:
A voice disorder may be defined as any deviation in pitch, intensity or quality which either consistently interferes with communication in such a way as to adversely affect the speaker or the listener, or is inappropriate for the sex, age, or cultural background of the individual.
The most obvious communication signal used by an infant is its voice through crying, cooing, and vocal play. The infant's cries are interpreted by parents/caregivers and act as an important agent in bonding. Appropriate vocal patterns are essential to effective communication and the child's relationships to others.
Dysfluency or stuttering is an involuntary repetition, prolongation, or blockage of a word or part of a word that the child is trying to say. There are many patterns of speaking that are recognized as stuttering in young children, including repetitions of phrases, words, syllables and sounds, sound prolongations, unexpected pauses, revisions, and interjections.
Most young children show some degree of dysfluency in the normal course of speech and language development. In a child whose speech and language are otherwise developing normally, it is not uncommon for characteristics of early stuttering to appear over a period of several days, sometimes almost overnight. These periods of stuttering may be associated with unusual excitement and/or uncertainty in the family, for example, birthdays, holidays, moving to a new home, visits by relatives, the birth of a sibling, or the like. The behavior may last for a few days or weeks and then without warning or any explanation, disappear just as quickly as it appeared.
Most often true dysfluency begins in the early years when speech and language development are at a period of fast development. For most children, stuttering usually does not persist into the later preschool years. As many as 50-80% of the children who show dysfluency in the early years develop normal speech without assistance.
Disorders of articulation and phonology
Articulation refers to individual speech sounds, and phonology refers to groups of sounds. Articulation involves the actual motor production of those speech sounds. Articulation affects the clarity with which a child produces individual speech sounds (phonemes) that make speech intelligible and meaningful to a listener. Phonology is defined as the sound system of a language and the rules that govern sound combinations in that language.
The term "articulation disorder" refers primarily to speech sound disorders in which the underlying problem appears to be in the motor-speech production mechanism. In such cases, sound errors take the form of distortions, omissions or substitutions, and the child is unable to correctly produce the affected sounds, even when provided with an imitative model (Shriberg and Kwiatkowski, 1988).
The term "phonological disorder" refers to sound errors that affect a class of sounds or a sound sequence. Examples include deleting the final consonant in words or replacing one sound type for another, such as t's or d's for s, z, sh, etc. (tee for see).
Many different phonological processes have been documented. One way to characterize these patterns is by a set of phonological processes or rules. Normative data identify the ages at which such error patterns typically disappear and mature sound production is observed. When a child persists in using these processes at later ages or uses phonological processes not observed in typical development, the child is said to have a phonological delay or disorder.
A hearing disorder is the result of impaired auditory sensitivity of the physiological auditory system. Hearing disorders are classified according to difficulties in detection, recognition, discrimination, comprehension, and perception of auditory information. Individuals with hearing impairment may be described as deaf or hard of hearing.
The focus of this guideline is primary communication disorders that are not the result of hearing loss or other specific developmental problems.
Communication is essential to learning, playing, social interaction and can affect every aspect of a child's life. Impaired communication may impact development of a child's social and emotional skills, cognitive skills, and later academic skills such as reading and writing. Even if a delay is transitory, a communication delay at a young age may have an impact on the child's ability to form relationships with peers and adults and, therefore, may impact the child's overall development. Additionally, a child who demonstrates communication delays as a toddler and during preschool is at greater risk for later language-based learning disabilities, including reading disabilities.
Children who have a problem correctly processing the sounds of speech (phonemes), will manifest a communication disorder early in life. It is now believed that later on, this same problem with processing (understanding, perceiving, being able to retrieve the speech sounds from one's store of information), is likely to manifest as a reading disability (a language-based learning disability) (Schaywitz, 1998).
Children who are delayed in the acquisition of speech and language skills usually follow a typical pattern of development but at a slower rate than children who are not delayed. Any marked regression or loss of language or other communication skills requires a comprehensive medical, neurological, psychological, and audiological evaluation to rule out possible contributing factors such as seizure disorders,degenerative syndromes, progressive hearing loss, or other brain-based abnormalities, or severe social-emotional trauma.
There is a subgroup of children who experience a period of typical language development followed by a regression in communication skills. This regression may be characterized by appropriate use of first words (e.g. "mama", "dada") and sudden loss of acquired words and failure to progress further linguistically (usually between 18 and 30 months). Apparent regression in communication skills can occur in young children with certain conditions such as Rett's disorder or Landau-Kleffner syndrome.
Young children who demonstrate communication disorders secondary to developmental disorders, syndromes, or other specific medical conditions do not typically "outgrow" their communication disorders. Appropriate interventions for these children may help them to improve their language skills, but it will likely not completely eliminate the disorder.
Some young children are described as "late talkers." These are children who have no delays in other areas of skill development but demonstrate delays in expressive language for unknown reasons. Some of these children appear to "catch up" to their peers in developmental status by preschool and early school years.
The last three decades have been an active period for research concerning the nature of typical and atypical language acquisition. Although a great deal of information has been accumulated, many areas, particularly those important for early assessment and for early intervention, are not yet fully understood, identified, or documented. Although it is clear from the outcome measures used (successful communication) and from a set of efficacy studies that early intervention is effective, we do not yet have comparative studies of different approaches or information concerning the best approaches to the intensity, frequency and duration of intervention.
Few studies with large numbers of children within the target age range have been conducted. Furthermore, of the studies conducted to date, most have involved children in other areas of the country and many involve only a small number of children. There may be important variations attributable to geographic location, socio-economic class, and other factors. Among the research needs are:
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|Revised: June 2002|