[banner_0ld.htm]

back to Jacksonville Medicine (March 2000)

Early Intervention Strategies In Communication Disorders

Sheila Daly Russo, M.Ed./CCC-SLP and David W. Bailey, M.D.
Sheila Daly Russo, M.Ed./CCC-SLP and David W. Bailey, M.D. are with the
Early Intervention Program at the University of Florida Health Science Center/Jacksonville.

Introduction

Both authors participate in the Early Identification Program (EIP) in Jacksonville, Florida (Dr. Mary Belkin's article elsewhere in the issue provides a detailed description of EIP). We have observed over the past decade that the proportion of children (all under 3 years of age) referred to that agency primarily for speech/language concerns has risen from about 20 to well over 50 percent. Whether this reflects an apparent or a real increase in the prevalence of communication disorders in the very young is conjectural, but it is clear that primary care providers (PCP) who care for this population will confront the problem not infrequently.

Lawmakers at both the federal and the state level have passed legislation strongly supporting early identification, assessment and intervention in communication and other developmental delays. In 1996, the US Department of Education reported that 12% of school age children (over 5) were receiving special education services, 4.4% of preschool children (3 to %) were in special services, and only 1.4% of children under 3 were receiving early intervention services.1 These numbers suggest that the infant and toddler group is under-identified by a factor of 9.

Florida has intensified its efforts to identify these young children. In 1998, the University of Florida Department of Communication Science and Disorders published The Infant And Toddler Communication Inventory2 which is used by speech/language pathologists. The Florida State University Department of Communication Disorders has introduced two instruments that PCP's can use to identify infants and toddlers in their practice with communication delays. The first is a fact sheet for parents, which can be given out at well baby visits (Figure 1).3 The second is the Infant /Toddler Checklist For Communication And Language Development (Figure 2 - html version or PDF file).4 It is filled out by the caregiver and quickly scored by a health professional. Its use in Leon County, Florida has promoted early identification of communication disorders, and has helped PCP's determine which children need formal speech/language evaluations.

Etiological Classifications

Young children with communication disorders fall into one or more of four main categories, based on etiology:

  • Moderate/Severe Hearing Loss
  • Cognitive/Global Delays
  • Autism Spectrum Disorder
  • Specific Speech/Language Disorders

Moderate/Severe Hearing Loss

Infants with hearing loss show early signs of communication delays. Early detection can make learning to communicate easier. Hearing aids, instruction in sign language and possible cochlear implants are some of the strategies employed by the physician/audiologist/speech pathologist team. During the first two years hearing impaired children will exhibit some or all of the following behaviors:

  1. • Awakens to touch but not to voice - from birth;
  2. • Not startled by loud sounds - from birth;
  3. • Responds to comforting only when held - from 3 to 4 months;
  4. • Does not respond to speech, foot steps or noisy toys - 4 months;
  5. • Does not babble, imitate sounds or engage in vocal play - 6 to 10 months;
  6. • Seems startled to look up and see a person in the room - 12 months;
  7. • Pays attention to loud noises but not to speech - 12 months;
  8. • Does not follow verbal requests without a cue - 16 months;
  9. • Does not talk - 16 to 24 months.

Cognitive/Global Delays

Children who exhibit communication delays secondary to cognitive/global deficits will have a history of late onset of motor and cognitive milestones. The speech pathologist helps develop a communication system that allows the child to express his needs. Motor and cognitive deficits are seen in conjunction with some or all of the following behaviors in children who have communication delays related to global delays: 5,6

  • Does not recognize bottle or breast - by 3 months;
  • Does not make cooing sounds or smile - 3 months;
  • Does not babble - 6 to 8 months;
  • Does not play social games (pat-a-cake or peek-a-boo) - 12 months;
  • Does not wave bye-bye - 12 months;
  • Does not follow simple requests - 18 months;
  • Does not have two to three word sentences - 24 months;
  • Does not have three to five word sentences or imitate rhymes - 36 months.

Autism Spectrum Disorder

Infants and toddlers who are high risk for persisting language disabilities secondary to autism spectrum disorders show delays across the communication spectrum. Specifically, they have diminished use of emotion, eye gaze, sounds, words, object use and understanding of spoken language. The speech pathologist develops joint attention, social interactions, use of gestures and expressive/receptive language.7 Young children with autism spectrum disorder will have some or all of the following:

  • Limited ability to share emotion and attention - 8 months;
  • Limited ability to draw others attention to interesting objects - 12 months;
  • Not pointing to objects - 12 months;
  • Not using six of the following gestures: giving, pushing away, raising arms, showing, reaching, waving, shaking head "no" or nodding "yes" - 12 months;
  • Poor eye contact with speaker - after 4 months;
  • Echolalia - after 24 months;
  • Lack of intonation or inflection - if speech is present;
  • Use of phrases out of typical context.

Specific Speech/Language Disorders

Specific speech/language disorders are divided into expressive and receptive disorders. Expressive speech disorders in the young child are verbal apraxia and dysarthria of speech. Verbal apraxia is a motor programming disorder affecting the muscles used in speaking. It exists in the absence of a specific motor disorder affecting the muscles of speech.8 Young children with verbal apraxia will point and use vowel sounds when their typically developing peers are speaking in short phrases. Dysarthria of speech is an oral motor weakness that results in slow, labored and often nasal sounding speech attempts. Speech therapy for children with these problems teaches sound placement in conjunction with oral motor exercises. Children with early signs of expressive language disorders will show some or all of the following:

  • Diminished cooing or babbling as an infant;
  • Pointing and grunting when first words should be emerging - 12 to 24 months;
  • Delayed first words with many sounds omitted or replaced by easy to pronounce consonant sounds;
  • Saying only the easier sounds (b, m, p, t, d, and h) - 2 to 3 years;
  • Saying sounds in isolation but unable to use them in words - 2 to 3 years;
  • Not using two word phrases - 24 months;
  • Speech is unintelligible even though single words are often clear - 2 to 3 years;

Young children who have difficulty understanding spoken language, in the absence of severe hearing or cognitive, deficits may have a central auditory processing disorder (CAPD). Children with CAPD have difficulties decoding and sorting auditory information. They do not discriminate spoken language and appear to have a hearing loss. Children with a history of frequent ear infections may evidence persistent receptive language delays.9 Intervention for receptive language deficits builds competence in sound/word discrimination and attention to spoken language. Children with receptive language disorders will have some or all of the following:

  • Reduced ability to follow verbal directions - 2 to 3 years;
  • Repeating words or phrases without comprehension - 2 to 3 years;
  • Inappropriate responses to yes/no, what, where and who questions - 2 to 3 years;
  • Reduced attention to spoken language - 2 to 3 years.

Summary

Communication disorders in infants and toddlers appear to be increasing in prevalence. There are tools available to the PCP, which can be used in the office setting to enhance the precision of screening or initial assessment of these young children. Timely referral to appropriate resources in the community for more in depth assessment can lead to early intervention, if necessary, for the child along with reassurance and support for the family.

REFERENCES

  1. U.S. Department of Education. Eighteenth Annual Report to Congress on the Implementation of the Individuals with Disabilities Education Act. (Prepared by the Division of Innovations and Development, Office of Special Education Programs). Washington, DC. 1996;U.S. DOE.
  2. Lombardino L, Vaudreuil K. Infant-Toddler Communication Inventory. FL J Communication Dis. 1998;18:20-38.
  3. Weatherby A. First Words Project, How can we find children who need services earlier? Developmental milestones.(http://firstwords.fsu.edu)
  4. Wetherby A, Prizant B. Communication and Symbolic Behavior Scales Development Profiles Research Edition. Chicago, IL: Applied Symbolix.
  5. Bzoch R, League R. Receptive-Expressive Emergent Language Scale. Gainesville, FL:Tree of Life Press.
  6. Zimmerman I, Steiner v, Pond R, Preschool Language Scale-3. Orlando, FL: The Psychological Corporation.
  7. McAuthur D, Adamson L. Joint attention in preverbal children-autism and developmental language disorders. J Autism and Dev Dis. 1996;26:481-496.
  8. Apraxia-kids. Frequently asked questions from parents. (http://www.apraxia-kids.org)
  9. Friel-Patti S. Otitis media with effusion and the development of language. Topics in Lang Dis. 1990;11:11-22.

Jacksonville Medicine / March, 2000

What's New · Northeast Florida Medicine Journal · Know Your Physician · Legal & Legislative
· DCMS Alliance · Academy of Medicine · Member Websites · Community Health
About the DCMS · Meetings Calendar · Member Benefits · Employment Connection · Home

Duval County Medical Society   ·   555 Bishopgate Lane  ·   Jacksonville, FL  32204
Phone: (904) 355-6561   ·     FAX:  (904) 353-5848   
General Email: dcms@dcmsonline.org    ·   Webmaster's Email: mdoran@dcmsonline.org
Privacy Policy and Disclaimers