Language Disorders in Children David Johnson, M.D.Identification of Language Delay # Language delay is the most common developmental disorder of childhood: • 15% prevalence at 3 years • 5% prevalence at school entry # Early intervention in language disorders results in successful outcomes. Speech and language problems are the most common developmennta disorder of childhood. They are seen almost every day if you have a busy practice. It is estimated that 15% of threeyeearolds have some sort of speech or language disorder. The good news is that by the time they start school, about two-thirds of them have resolved spontaneously. The bad news is that 1 out of 3 has not. It is quite difficult when they present to your office at age two or three to know which category they are going to fall into. The other reason I think it is important to identify this is that early speech and language therapy works. However, if we don't identify these disorders at an early stage, they will usually go undiagnosed. As pediatricians, we are the ones who see these children and we are the ones who need to intervene. Nomenclature # Language: A system of symbols constructed to communicate information. # Speech: The mechanical aspects of language production. # Expressive language: The generation of symbolic output (spoken or written). # Receptive language: The ability to decode and extract meaning from the language of others (listening or reading). I want to go through with you a little bit about the nomenclaturre' definition of language and language disorders, first of all. The words speech and language are actually quite different. Remember, language is a system of symbols constructed to communicate or store information. Language is purely a symbolic system for labeling objects. Speech, on the other hand, refers to the mechanical aspects of language production, not the content. So a child who has delayed language doesn't necessarily have a speech problem. Speech problems are more like stuttering, lisping and so on. So don't confuse speech and language or use them interchangeably. Whenever you are assessing a child with a language problem, you have to make a very early distinction. Is this an expressive language disorder? Is this a receptive language disorder? Expressive language is the generation of the symbolic output. It can be auditory or visual, in the case of sign language, but it's how language is expressed. Whereas receptive language is the ability to decode and extract meaning from the language of others by listening or reading. This is going to be a key point in defining a differential diagnosis of the etiology of a speech and language disorder. Whether it is purely a receptive language problem, an expressive language problem, or both.Grammatical Terminology # Phonology: How sounds (phoneroes) are combined into words. # Syntax: How words are put together into phrases and sentences. # Semantics: The meaning of words. phrases, and sentences. # Pragmatics: How words, phrases, sentences and gestures are used to communicate. Grammar is the rules that we learn when we learn language. The young child is learning grammar as one of the first developmeenta challenges that he or she faces. First of all, phonology is how sounds, or phonemes in a language, are combined into words. So, if I said to you, could the word “blick” be a word? You'd say, "Well, 'blick' could be a word. It's not a word, but it could be a word." If I said to you or I said to a five-year-old child, "Could 'bnick' be a word?" The five-year-old would say, "Silly. 'Bnick' is not a word. 'Bnick' can't be a word." You don't think it could be a word either because of the phonological rule in English that "n" never follows "b". Now none of you knew that rule existed consciously, but once you say the word "bnick", you know that that's true. That's because you learn the phonological rules of your language in the first years of life. Syntax is how words are put together into phrases and sentennces If I said to you the sentence, "I finances green sleep saturate.", that would make no sense to you. If I said to you, "Green eyes saturate sleep finances", it would still make no sense, but you would say syntactically that could be a sentence. That is the way we put words together in the English language. Yet, if I were to ask you what syntactical rules were violated in the first sentence you wouldn't know. Again, because this is something you learn in the first years of life as a young child. Semantics is the meaning of words, phrases and sentences. And finally, pragmatics is how words, phrases, sentences and gestures are used to communicate. Pragmatics is very important -how we gesture, how a young child points. When you're making the diagnosis of autism, for example, that is one of the main features to look at. Does the child gesture? Does the child point? Even if there is no language, perhaps the child communiccate very well, except nonverbally. Sequence of Language Acquisition # 0-3 months: Random noises # 3-6 months: Babbling # 6-9 Months: Expressive babbling # 9-12 months: Jargoning # 12-18 mos: One word stage # 18-25 months: Two word stage # 24-36 months: Telegraphic speech # 36-48 months: Grammatical refinement Sequence of language acquisition. It starts out that a newborn is just making random noises. A newborn's vocal tract actually is like a non-human mammal. It is almost like a periscope. The larynx is incapable of making the sounds that they can make just a few months later. So there are a lot of random noises and babbling and "ga-ga" but there is certainly no meaning attached to them. Around three to six months, the baby's vocal cords descend and the baby is able to make sounds and starts playing phonologically with sounds, "ba-ba-ba-ba," and starts babbling and babbling and babbling incessantly. Expressive babbling starts at around six to nine months and this is when the baby starts babbling in the tenor and the tone and in the intonation of their own language. You can really tell the difference between a Chinese baby, who has a more tonal sound, and an American baby, that has the intonation of the American language. But again, this is not language, this is just sounds. This is phonological work--making sounds and playing with sounds. Around nine to twelve months jargoning begins and this is where the child then begins to spend more time playing with sounds. Instead of just going "ba-ba-ba", it starts going "ba-boobbaba-boo-ba", making all sorts of noises. This is the age where the kids sound like they are making sentences. They go "Ba-babbaba?" and they look at you as if to ask a question. This is expressive jargoning. They are speaking with intonation, they are playing with sound, but again there is no language. This is just speech without language. Somewhere around nine to twelve months, the child realizes that this sound that I'm hearing is actually a metaphor, a symbol, for something that I know and love, whether it's "bottle" or "mama" or "dada". This sound actually stands for something else. This is the beginning of symbolic thought and it happens somewhere around nine to twelve months of age. When the holophrostic one-word stage begins one word has a whole range of meanings for children, and they only use this one word. What is interesting about this, is that it takes about six months before each child learns to put two words together. The two-word stage is actually the same in all languages, in all cultures, in all countries. It's always the same thing, an adjectiiv and a noun, or a noun and a verb and it always follows the same order, which leads people to believe that the deep structure of language is the same for all human beings. The two-word stage then goes on for at least another six months or so. There is no three-word stage. Beyond the two word stage begins so called telegraphic speech where the child begins to talk with putting many words together. After the telegraphic speech stage, then comes grammaticalLanguage Delays # Impairment can occur anywhere in the Language Process: • Input: Impaired sensory input (hearing) • Processing: Impaired decoding, word identification, or meaning formation (related to IQ, vocabulary, reasoning, concept formation) • Output: Impaired oral-motor ability, expression refinement, somewhere around three to four. So that by the time the child is four years old, he or she is a full-fledged member of our linguistic community. Their grammar is impeccable. Their language is superb. They use complex sentences. Language delays originate in one of three areas. One is input, two is processing and three is output. If the child is falling behind in language or in speech, the first question to ask, "Was there a problem with the input?" This could be something as simple as a hearing problem, a sensory problem. What about processing language? Language may be being heard from the environment, but the child is unable to make sense of it for some reason. They can't decode the symbols. They hear the word “microphone” but they can't understand it. The identificatiio and meaning of words that can be related to IQ, to vocabulaary reasoning and concept formation. Any of these areas can cause processing language disorders. Then, finally the problem could be on the output side. The child is unable to generate the words that he needs to speak. He or she can understand the words, can make sense of them, but cannot generate the output, whether that is on the output side, Broca's area or an oral-motor problem. Language is the final common pathway of probable developmenntalemotional/behavioral problems in young children, which is why it's so important. It is exquisitely sensitive to input from a whole range of areas. First of all, language delays can be caused by endogenous problems. Problems completely within the child, such as a hearing disorder. A hearing test should be completed on all children who are not speaking and who are falling behind in the milestones. The child may have mental retardation, and often the best indicator of early mental retardation is going to be language delays. Learning disabilities. We know that children who later have problems decoding language (reading and spelling), often first present with language disorders. They go on to learn language but then have a harder time with learning higher concepts in school later on. Again, when they are seen at three years of age, you are not going to know whether the child is going to grow up having a learning disability or not, but it is certainly something to keep in the back of your mind. Any neurological deficit obviously can lead to a language disorder especially if the language parts of the brain have been damaged through some organic insult. And then there are pure developmental language disorders that seem to be getting more and more common in children. There are more and more children who seem to have purely language disorders, but the other areas of developmennta behavioral functioning seem relatively intact. Language Delays # Endogenous Problems • Hearing impairment • Mental retardation • Learning disabilities • Neurological deficits • Pure developmental language disorder # Exogenous Problems • Linguistically impoverished environments • Lack of parenteral reinforcement of speech and language • Language not integrated with other sensory input • Parenting dysfunction Language delays are also a final common pathway for exogenoou problems. A linguistically impoverished environment. When two parents are asked to diaper a child, one of the parents who was from more advantaged circumstances, would say, "Oh, you need your diaper put on. Oh, isn't that wonderful. Let's wipe you off. Does that feel okay? Are you cold? Let's put it on now. Is that fitting okay? What should we do now when we're done?" In ten seconds, more advantaged parents will provide one hundred words of stimulation. Whereas the disadvantaged parent who was asked to diaper the child, put on the diaper with zero words. The study that was just published looked at how much parents talk to their young children and found an astounding difference by a year of age of parents who talk a lot to their children, generally related to a higher socioeconomic status, than of those who didn’t. That by one year, the higher socioeconomic status babies had heard six million words. The lower socioeconoomi status babies heard one million words. The difference is staggering. The child’s developing brain needs stimulation. It affects the actual structure of the brain. If the child does not receive the significant linguistic stimulation from a very early age, they're simply not going to make as many synaptic connectiion in the language parts of the brains as other kids. So it is very concerning to think about the quality of linguistic environmeen of children who are not being talked to and to children who are. The most common cause of language disorders in children living in impoverished circumstances is inadequate verbal stimulation. Non-reinforcement of speech and language. A wonderful family once came in with their two-month-old, and the older children were giggling and saying the two-month-old knew how to speak. And I said, "What do you mean? Two-month-olds don't know how to speak." They said, "Yeah. She knows how to speak. She can say 'ah-goo'." And they say, "Watch." The baby is making random noises and then it goes, "Ah-goo." Everyone goes nuts and starts laughing and tickling the baby and saying, "See. She says 'ah-goo'." The baby looks kind of startled and looks up. The two month old, has very little ability to affect the environment except for perhaps crying. Here was a child who had an utterance that really got reinforced by the environment. And that baby just started saying "ah-goo" all the time because it was one way to change the environment. If he baby that says "ah-goo" and nothing happens, there is no reinforcement from the environment. It is critically important to reinforce utterances to increase the frequency of those utterances. Some environments reinforce what children say and others don't. Language not integrated with other sensory input. Where there is sound completely divorced from anything else. A monitor goes off -nothing happens visually, nothing happens tactilely.Theories of Language Acquisition Nature (Chomsky) vs. Nurture (Skinner) There is no integration of the senses with the sound. And that seems to be a risk factor for later language problems. We know that preemies frequently have language delays. Some people believe that the reason is an environment where different senses are not integrated well. Where sounds just occur devoid of environmental context. Parenting dysfunction clearly can be a cause of a language problem. So if you see a child with a language disorder early on, all of these things should go through your mind. Human beings seem to be born with a language acquisition device of something in our brains that allows us to learn language. What is very interesting is that if you learn a second language in the first years of life, certainly within the first ten years of life, it is stored in the part of the brain that stores your primary language. So you are very fluent, you don't have an accent. If you move somewhere else in the first ten years of life, you are fluently bilingual. If you are unlucky, like most of us, products of the American school system that didn't start learning language until high school, that part of language is stored in the memory part of your brain, completely separate from language. After taking four years of Spanish in high school, you still can't ask how to get across the street when you go to Mexico. We know that learning language early on is really important for children and it seems to be because the brain is wired to learn language. But that wiring does not exist forever.Red Flags for Serious Language Delay Age Expressive Red Receptive Red Flag Flag 0-3 months No noises or Signs of hearing sounds loss. 6 months No babbling Signs of hearing loss. 12 months No jargoning, imitatiion indication of wants with simple gestures Doesn't understand simple commands or words ("no", "bottlee") 15 months No single meaningffu words 18 months Not at least 6 Can't follow oneworrds doesn't imi-step commands tate words ("get the ball”). 24 months No two-word Can't point to body phrases, negatives, parts, not underpossesssives loca-stand "more ," postiion sessives 30 months No telegraphic Can't follow twospeeech can't name stage commands, pictures including "on", "undeer. 36 months No 4 word sen-Doesn't understand tences no ques-three stage comtioons no past or future tense mands. 48 months No full sentences Can't differentiate with proper adult big/little,"What do grammar we do when hungrry? Red flags for language problems. This is sort of a bottom line of when should you worry about a child's language developmeent Most kids are doing much better than this and there may be some children who are doing better than this who you would still say have a language delay. By fifteen months, there should be single meaningful words. Remember, meaningful words -not just saying "ma-ma-ma-ma" or "da-da-da-da" randomly. But does "ma-ma" mean mother, does "da-da" mean father? Is it language? Does it stand for something else? By two years of age, the child should have a two-word phrase. Remember "bye-bye" is not a two-word phrase. "All gone" is not a two-word phrase. The child has to put two ideas together. "Bye-bye" is one idea. "Milk all gone" is a two-word phrase. So, don't be confused if the parents say that the child is putting two words together when it really only has one meaning. It is putting two ideas together. The child should have at least fifty words by two years of age. Most children will, of course, have hundreds of words by two years of age. By three, there should be at least four word sentences. The child should be asking questions. Using the past and future tense correctly. Stringing sentences together generally. And by four years of age, the child should be a full-fledged member of the linguistic communiity speaking in grammatically correct sentences, able to have a conversation, able to relate what happened in a very meaningffu complex way. Signs of receptive language problems. You certainly worry about hearing loss in the first months of life. You look for onestte commands by at least eighteen months of age and serial one-step commands by eighteen months of age. You should be able to tell a child, "Go do this." That is a one-step command and they'll do it. By thirty months, two and a half years old, the child should follow two-step commands and by thirty six months, three-step commands and so on. When you are taking your history, think to yourself, "Does this child have a language disorder?" If you think the child does have a language disorder, here's what you can do in the office. Again, as we always do in pediatrics, history is far and away the most important. You want to probe for organic vulnerabilities: Was the child premature? Were there other prenatal and perinatal risks? And just to remind you that some chromosomal syndromes, like Klinefelter's and Turner's syndrome, that are associated with language delays. Medical risks, frequent otitis media or meningitis are going to make you think about some sort of brain dysfunction manifesting itself, at least early on, as a language disorder. Hearing. You'll always want to ask the parents, "Do you think the child can hear well or not?" Oral-motor functioning. Are there any feeding problems, problems with drooling and so on.Office Assessment of Language Delay # History • Organic vulnerability (eg, prematurity, other prenatal and perinatal risks, Klinefelter or Turner syndrome) • Medical risks (eg, otitis media, meningitis) • Hearing • Oral-motor function (e.g., feeding, drooling) • Language milestones • Developmental milestones • Socioemotional functioning • Quality of linguistic environment • Family history # Observation • Verbal interactions with parents • Spontaneous language output • Relationship between child and parents • Developmental functioning You want to get the language milestones of the child. When did the child say his or her first word? Remember again that it has to be a meaningful word and parents notoriously overestimate their child's language output and the child's receptive language. So you have to be very careful and ask very probing questions about whether the child actually means something with their expressive output. Certainly look at developmental milestones, because the language delay may be a manifestation of mental retardation and other problems. Socioemotional functions. Does the child seem depressed, unhappy, miserable in other ways? Is language again just a marker or a more global, environmental problem? The quality of the linguistic environment. Again, you usually see this in your office. Unconsciously, when you see the mother and father talking to the child all the time or just using words in a very proscriptive way, "Do this. Don't do that." Not asking the child to respond in any way and not talking to the child so much. In some cultures they don't believe it's worthwhile to talk to a child in the first year of life. Observation clearly is important as I mentioned. The verbal interaction of the parents is something you'll be watching as you are taking the history and doing your exam. The spontaneoou language output of the child is your best marker. You don't need to do language testing if the child is talking up a blue streak while you're beginning your exam or while you're engaged in history taking. You are looking at the relationship between the parent and child all the time. Developmental functioning. Do you think language is just one part of a more global problem?Office Assessment of Language Delay # Physical Examination • Ears: Presence of fluid, mobility • Palate: submucous cleft, normal mobility • Oral-motor Function: Drooling, low tone • Neurological Status • Hearing and vision # Language Assessment • Spontaneous is best • ELM scale # Developmental assessment Physical exam, especially focusing on the ears is important. You want to decide if there is any problem with hearing early on. Looking for fluid and mobility of the tympanic membranes. Looking for the palate. Especially feeling for submucous clefts, which can cause language disorders especially expressive language disorders and speech problems. Oral-motor functioning. Again looking for drooling and so on. Neurological status and, of course, hearing and vision should be evaluated. Language assessment. Spontaneous language utterances are the best. But the ELM scale is a nice one. It is very quick. It is a nice general screen that you can do in your office. The Denver is not a good screening of language development. I would say to you that at two years of age, if you want to do a developmentta assessment on the child, focus on language. Because if the language is normal, you are probably okay cognitively in all the other aspects of at least cognitive development and the ELM scale may be helpful for you. It is based on the Denver and it is easy to do.Differential Diagnosis # Never caused by laziness, birth order, tongue tie # Bilingualism may slow down expressive (not receptive) a little until age 3 # Based on history and physical, decide if exogenous, endogenous, or a transaction between the two # Decide if expressive delay only versus expressive and receptive delay Differential diagnosis. We are wired to talk. Our neurological systems are made to talk. It's like saying a child won't walk because they are lazy. That is never true. Birth order probably has very little to do with it. Maybe it slows things down a little bit, but a frank language delay, no. Not on the basis of birth order. Tongue-tied, or tight frenulum, cannot cause a language delay. Bilingualism may slow down expressive language a little bit but not receptive language, until about age three. But certainly, we should be encouraging bilingualism, especially given the knowledge of where it is processed in the brain and of how important and wonderful it is to be bilingual in our culture. You are going to base your differential diagnosis obviously on your history and physical and decide if you think the problem is exogenous, that is in the environment; whether it is endogenoous something with the child, or the input processing or output part of the language sequencing; or if it's a combination of the two, which is very common also. You also should always decide if this is an expressive language problem purely, with normal receptive language, or is it both? You feel much better about the child who has a purely expressive language delay but who understands everything, versus the child who also has receptive language delay. It has a much better prognosis. Remember again, though, that parents overestimate their child's receptive language. Usually what they will do when you ask them, "Does he understand two-step commands?", they will tell you, "Yes." at age 2. But really what they are doing is a lot of gesturing, a lot of pointing and giving serial one-step commannds “Go do this and then go do that.” And that is an eighteen month level to follow one-step commands. So the two-year-old that is doing serial one-step commands is still delayed if he can't do two-step commands. Parents will frequently overestimate that. So that is the most important decision point in the differential diagnosis. Is it purely expressiiv or is it expressive and receptive?Differential Diagnosis of Purely Expressive Language Delay # Constitutional # Developmental language caused by output impairment (eg, word finding, ability to construct sentences) # Oral-motor dysfunction (eg, verbal dyspraxia) # Hearing loss # Non-reinforcing linguistic environment If it is purely expressive language, probably the most common thing I saw in middle-class practice is constitutional. Some kids are just slower than others. Especially boys, because girls learn language faster than boys. Boys are slow in expressive languaage but they have perfectly normal receptive language. There certainly is a significant subset of children whose wiring in their brains just takes a little bit longer to develop. It will take longer for expressive output. Again, remember we are talking about normal receptive language. It is never constitutioona just to have delayed receptive language. It could be a developmental language disorder just on the output side. For instance, if the child is having, and this is often related to learning disabilities, word finding problems. Many of you, like myself, may be having more and more word finding problems as we get older, it is not so easy always to think of the word. Some children are born with an inherent disadvantage coming up with the right word. Even though they can have the idea of what they want to say, and that will show up as a purely expressive language problem or the ability to construct sentennce -to syntactically put sentences together. Oral-motor dysfunction. Verbal dyspraxia. Children who just can't seem to make the sounds correctly. The most complex fine motor activity of the human being is speech. It is exquisittel complex the way we make sounds. It concurrently uses all those oropharyngeal muscles, like the tensor veli palatini. All of those little ones that you hated to remember. Putting those together in a coordinated way during speech to make sounds. Coordinating your tongue, your breathing and so on. It is extremely difficult to make language. It is far and away the most difficult fine motor task we are asked to do and some kids just can't seem to do it. They want to and they are frustrated because they have verbal dyspraxia. They just can't make the sounds. Very interesting when you see these kids, they are quite frustrated and may present initially with temper tantrums because they are so frustrated. Hearing loss can sometimes cause a purely expressive language delay when it is only a minor hearing loss, not a severe, profound hearing loss. And again a non-reinforcing linguistic environment as I talked about. Differential Diagnosis of Receptive and Expressive Language Delay # Developmental language delay with more global impairment (eg, processing) # Learning disability # Significant hearing loss # Severe psychosocial neglect # Significant linguistic impoverishment # Mental retardation # Autism/pervasive developmental disorder If it is a receptive and expressive delay, we think of a more global developmental language disorder. The child cannot process language as well as cannot make the output. He just doesn't understand it, but the problem seems to be mostly in the language areas. It could be indicative of a learning disability that probably goes along with developmental language disordeers significant hearing loss, severe psychosocial neglect, significant linguistic impoverishment where the child really isn't spoken to too much at all. And then mental retardation and autism. Mental Retardation # Language development is the best predictor of mental retardation # Prevalence = 25/1000 # Mild= 1.25% of population, IQ 50-70, familial, polygenic or sociocultural in origin # Moderate = IQ 35-50 # Severe = 0.3% of population, IQ 20-35 # Profound = IQ <20 Mental retardation. Remember that the best predictor of mental retardation is going to be language development, not gross motor development. That may be the first way you get an inkling that the child is going to have mental retardation. The prevalence is about 25 out of 1000. Remember that most mental retardation, more than two-thirds, is mild mental retardation which is least 1.25%, maybe more, of the populatiion IQ of 50-70. Generally, if you are looking for an etiology of mild retardation, you only find it in about 1 out of 3. It is very often environmentally mediated. In fact, two-thirds of all people with mild mental retardation grew up poor and the problem is felt to be possibly on the basis of a nonstimulating environment. It is usually diagnosed late, at about three and a half years, when we first diagnose mild mental retardation. Remember mental retardation is not diagnosed by IQ alone, there have to be deficits in other areas of the child's function. Some of these other areas include activities of daily living, vocational ability. You look for areas--is the child able to care for him or herself, social skills, ability to direct him or herself, work, leisure activities, health, safety. So we do not make the diagnosis of mental retardation purely on IQ, although it's a good measure. You also look at so-called activities of daily living, the child's social skills. Moderate mental retardation has an IQ of about 35-50. You can see in the handout that the child may read or write. It is very limited at the first or second grade level. Mild mental retardatiio is more like a fourth or fifth grade level. Severe mental retardation is a much lower IQ of 20-35. If you look hard, you will often find an etiology of severe or profound mental retardation. Certainly, in about two-thirds, you can find the etiology of the more severe the mental retardation. Remember again that most mental retardation is going to be mild. And profound mental retardation is an IQ of less than 20.Autism and Pervasive Developmental Disorrde # Prevalence: 1/1000; 3-4 times more common in boys; no socioeconoomi status or racial differences # Etiology unknown (?limbic dysfunction, genetic) # Family propensity # Broad spectrum of severity (Asperger's syndrome...PDD...Autism) # Treatment is psychoeducational, not pharmacological Autism and pervasive developmental disorder (PDD). Everybood is talking about how they are seeing more autism and pervasive developmental disorder. The prevalence is about 1 in 1000. It is 3 to 4 times more common in boys than girls. There seems to be no differences for socioeconomic status or racial differences. The etiology basically is unknown. There is a lot of fascinating research looking at the brains of these kids and people are talking about deficits in the limbic system and cerebellar dysfunction. There is probably some genetic predisposition, where at least you get a history of severe language problems and/or autism, sometimes in a first or second degree relative. So there is a family propensity, but not all the time. There is a broad spectrum of severity. You probably know now that pervasive developmental disorder is the term that is used, but it is a bad term because autism is not a pervasive developmennta disorder. It is a specific developmental disorder. Mental retardation is a pervasive developmental disorder, but people sometimes use autism for the most severe part of PDD and PDD for less severe. That is probably what you should remembbe if you are going to take the boards. We use the term autistic spectrum disorder to give the idea that there is a whole spectrum in functioning in autism. From severely autistic to the mildest which is called Asperger's syndrome. If you saw Rain Man, Dustin Hoffman qualifies for Asperger's syndrome. The treatment is psycho-educational, not pharmacological. There is no pharmacological treatment of autism. There is pharmacological treatment of the behaviors associated with autism, although they don't work very well. But unfortunately there is no cure. Parents are looking right and left and there is always a new cure for autism coming down the pike. Autism is a biologically based impairment. They have a lack of social interaction and this is really what differentiates autistic kids from children with significant developmental language disorder. It is the social interaction deficit that you should really be mindful of. That is why the child is going to be different. That's when you are going to say, "Maybe this isn't just a language problem. This is autism." They have a lack of or poor or atypical interactions with people. There is something not right. They don't seem to regard you as a person. They don't look you in the eye very much, or if they do, just a little bit. Again, there is a whole spectrum. But, there is something where they don't seem to be there. They are in their own world. Very isolated. There is a lack of shared attention. They don't use the pragmatics. They don't point and say, "Look at that. I want that." If they want something from the refrigerator they may take the parent with them to the refrigerator and that is it--they won't point, they won't open the door, they won't even make sounds. There is a lack of shared attention. Some people think that autistic children don't have a concept of a "mind".Autism and Pervasive Developmental Disorrde # Biologically-based Impairments: • Impaired Social interaction. Lack of (or poor or atypical) eye gaze, shared attention, reciprocity, imitation, or peer relations • Impaired Language Ability. Lack of (or poor or atypical) expressive and receptive language, abstraction ability, imaginatiion prosody, pragmatics, or echolalia. • Impaired Behavior. Insistence on routines and rituals, restriicte interests, resistance to change perseveration, preoccupattio with parts of things, sterotypies, sensitivity to sensory input, hyperactivity, splinter skills That I have a mind and you have a mind and that we can communicate with each other. People are more objects to them to get their needs filled. There is a lack of reciprocity. They don't imitate at all. They don't have peer relations. They are clearly in their own world. That is the key differentiating point of autism from a severe developmental language disorder. They do have language problems also. They may have no language or atypical language, where they repeat things over and over again. They use words in idiosyncratic ways and so on. Their expressive and receptive language may show a significant deficit. With Asperger's syndrome, however, the mildest form of autistic spectrum disorder, their language may be close to normal, although a little bit atypical. They can be very bright. I take care of one child who is trilingual now and very smart in some areas, but socially, again, very atypical and unusual. They have problems with their ability to abstract and think symbolically with imagination and prosody. This is the way they talk. Sometimes they just talk with no normal intonation and inflection that we expect to hear with normal language. They may have problems with pragmatics. They may not use gestures or other ways to communicate. Echolalia is a common feature of autistic kids, where they just repeat whatever is said to them. Sometimes that is all they say. For some reason, many of them seem to like commercial jingles, and they will do the whole jingle. An autistic child will just rattle it off over and over again. Finally, the behavior that is unusual if you are thinking about autism is that there is an insistence on routines and rituals and sameness. They don't like things to change. They have restriicte interests. Some are interested only in telephone books or in cars--things like that. There is a resistance to change, perseveration, a preoccupation with parts of things, instead of the whole, Stereotypies. They may have self-stimulating behaviors -hand flapping, and head banging sometimes. They are very hypersensitive to sensory input. Sometimes they hate sounds, other times they like sounds. Sometimes they hate to be touched, other times they like to be touched. And splinter skills, as in Rain Man, they may have Savant skills. One child could read at age two. Now, he didn't have a clue what he was reading, which is actually a bad prognostic sign, but he was able to read in an amazing way. It was as if one part of the brain hypertrophies because of the deficits in the others. Treatment of Language Disorders # Treatment is based on the underlying etiology # Early intervention program or specific speech-language pathologist Language disorders. You should decide what you think the reason for the language disorder is and let the treatment match the etiology.Methods of Improving Language Developmeen # Expand "caretaker speech" (high pitched, exaggerated intonation, simple amplification of whatever is said) # Narrate day to day events # Positively reinforcement any utterance by the child # Provide the child with listening experiences (eg, reading aloud, telling stories) # Ask a lot of questions # Name everything # Discourage others from speaking for the child # Accompany words with gestures # Don't criticize language errors # Find a pal at a slightly higher level # Spend more time together; have fun # Don't punish the child for not talking If you think that it is the linguistic environment that is the problem, you may not do anything else except give the parents information. Just tell them to expand their caretaker speech. Caretaker speech is when you take what the child says and add a word or two to it. Make it a little bit more complex. You don't talk to the child in very complex sentences like you do with an adult. If the child says, "Bye-bye." You say, "Oh. You want to go bye-bye." And "Give me milk." "Oh. You want some milk?" You expand a little bit on what they say, grammatically correct. Narrate concrete day to day events. The child needs to hear a lot of language positively reinforcing any utterance that the child makes. Providing the child with listening experiences -reading aloud is a wonderful one. Telling stories. Ask a lot of questions. Children do not learn to talk by watching Sesame Street. It has to be elicited from them. You have to ask them to talk back to you. It can’t be just all input, it has to be output also. It has to be an interactive kind of language stimulation, which most parents do. That is what you are going to decide. They may already be doing that and this may be unnecessary. Label everything. Discourage others from speaking for the child. Words with gestures make language exciting. Don't criticize the language errors. Children will learn correct grammar in their own time. You don't need to teach them correct grammar. Finding a pal at a slightly higher level is a wonderful way to do it. Spending more time together having fun. Don't punish the child for not talking. "I'm not going to give you a cookie until you ask for it." Language needs to be a positive experience. And finally, don't worry so much about the language delay that you don't have fun together. Just spend your normal time interacting. Other children need to go to speech and language therapists as I mentioned before. Early intervention programs are very helpful if you think the problem is more than a non-reinforcing linguistic environment or you don't think it is a constitutional delay. Speech Disorders # Articulation problems: Rule of 4s • Refer to speech therapist at 3-4 years # Work-up as with language # Play close attention to other fine motor skills Speech disorders, remember, are just articulation problems and so on. An easy one to remember is the Rule of 4s. By age four, a stranger should understand four-fourths of what a child says. By age three, three-fourths, by age two, two-fourths. So you can grossly assess a child's intelligibility right there in your office by the Rule of 4s. If you can understand three-fourths of what the three-year-old is saying, they're fine. By four, you should understand everything the child is saying and if you can't, you need to refer him to a speech therapist, somewhere along the age of four, for speech problems. For language delays, you can refer as early as you want to, but for speech problems, articulatiio disorders and so on, not until age four. Pay closest attentiio to other fine motor skills because this could be a verbal dyspraxia. Speech Disorders: Stuttering # Prevalence =1% in school-aged, overall incidence =5% (therefore 80% recover) # Male to female ratio is 2:1 # Probably biological predisposition, sometimes worsened by environmental demands # Transient dysfluency is common at 2-4 years # Speech therapy is recommended if stuttering persists Speech disorders. Stuttering especially is a common one. One percent of school-aged kids have speech disorders. Five percent have had it earlier than that. So most kids do recover while they are in school. Males seem, again, to get the short end of the stick. There is probably a biological predisposition to stutterinng but what I want you to remember too is transient dysfluency at two to four years of age. Many kids, some people estimate up to 75% of young children, will have transient problems in speech output, at age two, age three. It is basically because their brains are working faster than their mouths. They just can't get things out. They repeat things and they'll get frustrated. It is often very bright children. So transient dysfluencies are quite common in kids, and it is probably too early to worry about stuttering and other kinds of speech disorders at age two or even three. At four is when you can really tell and then you use speech therapy if it persists. References Coplan J. Language delays. in: Parker S and Zuckerman B (eds): Behavioral and developmental pediatrics: A handbook for primary care. Boston, MA: Little, Brown and Co. 1995, pp 195-199. Rapin I, Allen D, Dunn M. Developmental language disorders. In: Segalowitz S and Rapin I (eds): Handbook of neuropsychology, vol. 7. Amsterdam, Elsevier, 1992, pp 111-137. Bashir A, Scavuzzo A. Children with language disorders: Natural history and academic success. J Learn Disabilities 25:53, 1992.