What an otolaryngologist should know about evaluation of a child referred for delay in speech development.

Clinical Review & Education

Review

What an Otolaryngologist Should Know About Evaluation of a Child Referred for Delay in Speech Development Christopher R. Tonn, MA; Kenneth M. Grundfast, MD

IMPORTANCE Otolaryngologists are asked to evaluate children who a parent, physician, or

someone else believes is slow in developing speech. Therefore, an otolaryngologist should be familiar with milestones for normal speech development, the causes of delay in speech development, and the best ways to help assure that children develop the ability to speak in a normal way. OBJECTIVE To provide information for otolaryngologists that is helpful in the evaluation and management of children perceived to be delayed in developing speech. EVIDENCE ACQUISITION Data were obtained via literature searches, online databases, textbooks, and the most recent national guidelines on topics including speech delay and language delay and the underlying disorders that can cause delay in developing speech. Emphasis was placed on epidemiology, pathophysiology, most common presentation, and treatment strategies. Most of the sources referenced were published within the past 5 years. RESULTS Our article is a summary of major causes of speech delay based on reliable sources as listed herein. CONCLUSIONS AND RELEVANCE Speech delay can be the manifestation of a spectrum of disorders affecting the language comprehension and/or speech production pathways, ranging from disorders involving global developmental limitations to motor dysfunction to hearing loss. Determining the cause of a child’s delay in speech production is a time-sensitive issue because a child loses valuable opportunities in intellectual development if his or her communication defect is not addressed and ameliorated with treatment. Knowing several key items about each disorder can help otolaryngologists direct families to the correct health care provider to maximize the child’s learning potential and intellectual growth curve. JAMA Otolaryngol Head Neck Surg. 2014;140(3):259-265. doi:10.1001/jamaoto.2013.6368 Published online January 16, 2014.

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oncerns arise when parents perceive that their child’s speech is not developing as expected, a natural reaction from comparison of their child with his or her peers. However, children do not develop speech at the same rate, with first word production ranging from before 1 year to 3 years of age. When a child seems to be delayed in developing speech, parents tend to get concerned about their child’s intellectual potential. We as caregivers can help to alleviate these fears if we are able to separate a speech problem from a communication problem. In considering the causes of and ways to manage speech delay in children, emphasis must be placed on the difference between speech and language. Language is defined as a set of shared rules guiding effective communication through speech, the written word, pictures, or gestures. Vocalization is the result of pushing turbulent air past manipulative vocal folds, producing audible vibrations. Speech is the synergy between language and vocalization—this expression of language requires intact neural language centers and properly coordinated muscle activity of the tongue, lips, jaw, and vojamaotolaryngology.com

Author Affiliations: Boston University School of Medicine, Boston, Massachusetts (Tonn); Department of Otolaryngology–Head and Neck Surgery, Boston University School of Medicine, Boston, Massachusetts (Grundfast). Corresponding Author: Christopher R. Tonn, MA, Boston University School of Medicine, 90 Wareham St, No. 307, Boston, MA 02118 ([email protected]).

cal tract. Children with speech delay vs language delay may present similarly; however, it is important to remember that a child who is delayed in speech may in fact have functioning communication centers with a deficit elsewhere in the speech production pathway. Alternatively, children with language disorders may retain proper articulation and grammatical sequencing with limits elsewhere in language comprehension. According to the US Preventative Service Task Force,1 approximately 5% to 10% of children in the United States fail to reach early language milestones and are diagnosed as having speech or language delay. Delay in speech development can have an impact on proper language acquisition and consequently impair the child’s ability to communicate, gain knowledge, and develop social connections. Accordingly, there is an impetus to identify as early as possible children with speech delay in order to implement early intervention and maximize the child’s potential. Language acquisition is an ongoing process; however, there is strong evidence that a critical period exists during the first 3 years of life when cortical scaffolding is still being heavily laid and molded. During this period, ex-

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Clinical Review & Education Review

Evaluation of a Delay in Speech Development

Table 1. Developmental Milestones for Speech and Language in Childrena Age

Receptive

Expressive

6 mo

Turns to rattling soundb

Laughsb

Turns to voicec

Vocalizes (cooing)b

NA

Babbles, single syllablesb

9 mo

Says mama or dada, nonspecificc Waves bye-byec 12 mo

Babblesa

Follows 1-step command

Imitates vocalizations and soundsb Says 1 wordc Waves bye-byec 15 mo

Says 1 wordb

NA

Says 3 wordsc Waves bye-byeb 18 mo

Says 3 wordsb

Points to at ≥1 body part

Says 6 wordsc 2y

Points to 2 picturesa

Combines words Names 1 picturec

Follows 2-step command 2.5 y

Points to 6 body partsa

Knows 2 actions

ters (ie, auditory or vocalization deficits) as well as global processes that contain speech/language pathology within their presentation (intellectual disabilities, acquired neurological damage, pervasive developmental disorders). The common subtypes of secondary causes are outlined in the Secondary Disorders section. Normal developmental milestones and indicators of normal hearing function are shown in Table 1.3 The National Institute of Deafness and Communication Disorders provides an extended checklist that can be used with parents to track proper hearing and language progress.2 Determining the cause of a child’s speech delay can be difficult, but the earlier a child is properly evaluated, the earlier an intervention can be initiated and the more likely the child will successfully overcome his or her deficit. In general, evaluation by a speech-language pathologist should be considered if a child consistently seems to be failing to meet milestones or the child manifests any of the warning signs listed in Table 2.3 Referral to a speech-language pathologist and/or audiologist may be all that is needed to assist young children with speech or language delay. Otolaryngologists are accustomed to working closely with audiologists and speech-language pathologists and therefore can assist primary care physicians in the evaluation and management of these children.

Names 1 pictureb Speech is half understandablec 3y

Knows 2 adjectivesc

NA

Names 4 picturesb Names 1 colorc Speech all understandablec 4y

Defines 5 wordsc

NA

Names 4 colorsc Speech all understandableb Abbreviation: NA, not applicable. a

See McLaughlin.3

b

More than 90% of children pass this item.

c

Fifty to 90% of children pass this item.

posure to language and properly functioning cortical language centers are required to build the groundwork for communication. Many language-processing deficits can be improved with early speechlanguage intervention.2 When a primary care physician becomes concerned that a child is not developing speech normally, the child is sometimes referred to an otolaryngologist to assess his or her hearing and oral motor coordination. Worried parents describing sparse word production or largely unintelligible speech from their child characterize the typical presentation of a speech delay referral. Thus, the otolaryngologist needs to know the major reasons why a child can be delayed in developing speech. Causes can be divided into primary and secondary in origin. Primary language disorders are defined by cortical function deficits specific for language production or comprehension. Thus, they are not speech disorders by definition but rather language disorders. Such deficits can be focal, affecting a specific aspect of language production or reception, or global, implying a complete detriment to language processing. These children may present with speech delay, but the root cause lies in their communication deficits. The category of secondary speech delay consists of problems receiving or producing speech despite intact language cen260

Primary Disorders Primary language disorders, as mentioned herein, are disorders in which language deficits are central, with speech delay as a common presenting sign. Expressive language disorder is characterized by normal comprehension and normal intelligence, but difficulty in speech content production suggests a focal cortical defect. These children may exhibit variable speech sound ability because they can exhibit speech difficulties on top of their language disorder. Early detection may be difficult because the signs are similar to those of other causes of speech delay; however, detection and intervention are crucial because speech-language therapy is often very beneficial.3 Receptive language disorder is defined by normal auditory function with disruption in comprehension centers resulting in problematic language acquisition. These children respond to auditory stimuli but have difficulty understanding and developing language skills based on reduced cognitive capacity for phonological memory and semantic encoding but have also been shown to benefit from speech-language therapy.3 Specific language impairment (SLI) is a developmental language disorder manifesting as delayed or impaired language progression in a child with normal comprehension, intelligence, and hearing with varied speech articulation. The presentation is variable but can affect expressive or receptive language. A common presentation of expressive SLI is characterized by verb syntax errors, such as mixing present and past tenses or excluding verbs from phrases, while an example of receptive SLI is seen with children who have difficulty comprehending complex verbal content, such as multifaceted directions or “wh” questions. Specific language impairment , by 1 account5 surveying 7200 American children, affects about 7% of kindergarteners in the United States and showed that parental education and socioeconomic status were correlated with SLI diagnosis. Although many biological theories have also been postulated—abnormal cortical architecture and exposure to aberrant




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prenatal hormonal milieu—unifying factors are not proven. Strong genetic links have been documented, however.6,7 These children are at risk for life-long language dysfunction and may later present with other language disorders. Again, intensive speech-language therapy is the most effective treatment modality for SLI. A child with constitutional language delay, also known as a “late talker,” is defined as a child whose receptive language abilities are within normal limits and who will develop language skills normally after a delayed onset of expressive language production. By definition, these children reach the average expressive language levels of their peers without therapy often by 5 to 7 years of age. When compared with children with typical language acquisition, late talkers consistently score lower in intelligence measures, such as word finding, working memory, and grammar, suggesting that causative factors may have a more global effect.6 The cause is likely multifactorial with genetic, social, and environmental influences undoubtedly playing significant roles. Differentiating between late talkers and pathological cases is not easily performed; thus, it would not be prudent to take a wait-and-see approach. Diagnosis of constitutional delay is therefore a retrospective diagnosis, and an argument can be made that constitutional delay may be a form of SLI that improves to a level of language function within the normal range. As with most cases of speech and language delay (approximately 50%-70% confirm a family history of delay2), constitutional delay is thought to have a strong familial component. Asking parents about their own speech and language development pattern as children, if this information is available to them, can validate the possibility of a constitutional case.7,8 Controversy exists as to whether bilingual environments precede a delay in language acquisition. Evidence suggests that bilingual language development does not consistently produce a delay, but it does increase the variability of milestone achievement rates. More commonly, these children present with differences in articulation or error-prone speech production early in acquisition; however, many of them normalize as they learn to master the differences in speech sounds of each language.9 Imaging studies have shown that separate language centers exist for primary vs secondary languages, with common cortical regions involved in both, prefacing the theory that bilingualism will naturally produce a variable speech production delay as the brain becomes more able to separate the 2 languages.9,10 Therefore, reassurance is appropriate for a child with modest language or articulation delay; however, close follow-up with a speech-language pathologist and assessing for signs of other causes are recommended.

Secondary Disorders The list of secondary language disorders can be subdivided into types of primary abnormalities, including hearing defects, anatomical abnormalities, intellectual disabilities, neurological insults, pervasive developmental disorders, and psychosocial issues (not directly discussed herein).

Auditory Defects Hearing impairment must always be ruled out as a cause of speech delay. A child with any level of congenital or acquired bilateral hearing impairment will not develop normal speech and will likely posjamaotolaryngology.com

Table 2. Red Flags in Children Suggesting Need for Immediate Speech-Language Evaluationa Age

Receptive

Expressive

12 mo

NA

Does not babble, point, or gesture

15 mo

Does not look at or point to 5 Does not use ≥3 words to 10 objects or persons when named by parents

18 mo

Does not follow 1-step directions

Does not say mama, dada, or other names

2y

Does not point to pictures or body parts when named

Does not use ≥25 words

2.5 y

Does not verbally respond or nod/shake head to questions

Does not use unique 2-word phrases, including noun-verb combinations

3y

Does not understand prepositions or action words Does not follow 2-step directions

Does not use ≥200 words

Does not ask for things by name Repeats phrases in response to questions (echolalia) At any age

NA

Has regressed or lost previously acquired speech/language milestones

Abbreviation: NA, not applicable. a

See McLaughlin3; adapted with permission from Schum.4

sess a level of speech delay. As described herein, language development relies on language stimuli exposure within the first several years of life. Approximately 12 000 infants (1-3 per 1000) are born with hearing defects in the United States per year.11 The current standard of care in the United States includes newborn hearing evaluation. Two modalities are commonly used in newborn hearing screening: the Auditory Brainstem Response (ABR) test and the Otoacoustic Emission (OAE) test. Briefly, the ABR test involves auditory stimulation and measuring the cortical electrophysiological response— reflective of the audio information pathway. Otoacoustic emission are sound waves produced by the cochlea on hair cell movement, which can be detected by probes placed in the external meatus assessing cochlear function. Performing both is integral to accurate detection and diagnosis of specific auditory abnormalities.11,12 As with all cases of hearing loss, early diagnosis and treatment intervention with auditory augmentation are the standard of care to prevent secondary language delay. Secondary to the implementation of the universal newborn hearing screening, a previously unrecognized disorder was documented. “Auditory neuropathy” or “auditory dyssynchrony,” now known as “auditory neuropathy spectrum disorder” (ANSD), is recognized at birth in infants with normal OAE and absent ABR results. The cause is a dysfunctional vestibulocochlear nerve preventing proper communication between the inner ear and brain. Recent studies have proposed potential risk factors such as prematurity, perinatal hypoxia or neurological insults, meningitis, and hyperbilirubinemia; however, the current volume of data is inconclusive. Prevalence data are also limited, but up to 15% of infants diagnosed as having hearing loss may have ANSD, and there is an overall incidence of 1 to 3 per 10 000 births.13 Most cases resolve spontaneously by 3 months of age; however, nonresolving ANSD can have deleterious effects on speech development with limited response to speech-language therapy.14




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Hearing loss after the critical acquisition time span presents as slowed vocabulary growth and gradual loss of articulation. In theory, recurrent bilateral otitis media during the critical period of language development could blunt acquisition; however, this is a controversial claim. Studies have shown that tympanostomy tube insertion does not noticeably affect developmental outcomes measured at age 4 years.15 Because prompt treatment does not correlate with improvements, questions arise in determining whether underlying physiological and/or social factors may be confounders contributing to both the recurrence of infection as well as poor speech development.15,16

Anatomical Defects Anatomic abnormalities can affect a child’s ability to speak in a normal way. Structural defects can also affect speech production and thus acquisition; however, these cases are much more easily defined owing to associated signs and symptoms. Obstructive lesions often present with respiratory symptoms, such as stridor, and thus are addressed long before speech difficulties become a problem. Ankyloglossia is another anatomical defect that is often implicated in speech pathology. Prevalence has been estimated at up to 10% in neonates; however, many are of mild character and spontaneously resolve.17 Research has both endorsed and discounted speech improvements after surgical correction.18,19 Kotlow’s20 classification divides cases into 4 categories based on range of tongue extension. Severe defects are often detected during the neonatal period owing to latching difficulties during breastfeeding—cases in which early intervention is essential. Intervention in milder cases is controversial because children classified having as type I defects often experience spontaneous correction.17 Owing to the relatively lowrisk nature of the procedural options, we advise correcting ankyloglossia in children younger than 3 months as referral to an otolaryngologist at this age suggests a functional defect. In contrast, children 2 years or older with speech pathologic deficits should be referred for speech evaluation before performing an operation because a short frenulum is most likely not the root cause of the delay. The ability to elevate the tongue tip to the alveolar ridge (to produce sounds /t/, /d/, /l/, /n/) and to protrude the tongue forward (/th/ sound) does not require extensive tongue range; thus, ankyloglossia is rarely the origin of a speech problem.

Intellectual and/or Cognitive Disabilities Intellectual and cognitive disabilities generally manifest with a global delay in cognitive development. The most commonly encountered causes are trisomy 21 and fragile X syndromes. While intellectual disabilities have the potential to precede language deficits, there is a wide range of language achievement in this population. Angelman syndrome is a rare genetic disease, classically resulting from a combination of chromosome 15 deletion and imprinting, mentioned in the context of speech and language pathology because language is uniformly severely impaired in these cases. The typical presentation is a child exhibiting developmental delay, balance dysfunction, excessive laughter, easily excitable, lack of stranger anxiety, excessive motor activity, and, most notably, little to no verbal communication.21 A small study of 7 children with Angelman syndrome and 4 control children using neural tract imaging showed that the arcuate fasciculus, an integral component in speech, is almost universally absent bilaterally in these cases.22 Although it is less likely 262

that these children will be referred to the otolaryngologist’s office, this is mentioned to reinforce the functional requirement of specific neurological regions in language development.

Neurological Insults The American Speech-Language-Hearing Association (ASHA) defines childhood apraxia of speech (CAS) as “a neurological childhood speech sound disorder in which precision and consistency of movements underlying speech are impaired in the absence of neuromuscular deficits” secondary to neurologic insults or neurobehavioral defects.23 Essentially, CAS is a neurological disorder resulting in poor intelligibility owing to the inability to coordinate the complex motor movements required in speech. The defect may extend to other motor movements as well. These children have normal intelligence, language comprehension, and language production; however, speech production is affected with varying severity. A Cochrane Review reveals a lack of proven diagnostic markers but points to 3 required features to make the diagnosis: (1) inconsistent error in consonant and vowel production when repeating the same syllables or words, (2) lengthened and impaired transition from syllable to syllable, and (3) impaired prosody (rhythm of speech). Although definite evidence of treatment efficacy is limited, speechlanguage therapy intervention likely precedes the best outcome.24 Cerebral palsy is a term describing a nonprogressive motor dysfunction syndrome due to neurological damage, often secondary to prenatal or perinatal factors. Up to 35% of children with cerebral palsy exhibit variable difficulty with language production, owing to damage to important central language centers. These children generally retain their speech and/or language defects throughout life. In this context, their speech disorder can be a mix of dysarthria from motor discoordination and central deficits. This is a more focused example of an acquired neurological insult resulting in speech and/or language delay. Again, intensive speech-language therapy is crucial to maximize the child’s speech outcome.25

Neurodevelopmental Disorders Developmental disorders make up an increasing proportion of language delay cases as the methods of detection have recently become more defined. The term “neurodevelopmental disorder” encompasses a variety of conditions characterized by abnormal neurological growth during a child’s developmental period. Neurodevelopmental disorders include intellectual disabilities (mentioned herein), communication disorders, autism spectrum disorder (ASD), attention deficit disorders, motor disorders, and specific learning disorders, all of which can present with speech delay. We have focused on ASD because of its epidemiology and the integral role language pathology plays in the presentation of a child with this disorder. Autism spectrum disorder often presents with speech delay owing to the pathological development of communication-limited acquisition and progression of abilities, affecting both verbal and nonverbal forms as well as social interaction. Since the release of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition,26 (DSM-5) in 2013, the ASD classification now encompasses and does not differentiate autistic disorder from Asperger syndrome and pervasive developmental disorder not otherwise specified. Instead, ASD is diagnosed with specifiers and graded severity (Box).27 Autism spectrum disorder, as defined by DSM-IV, follows an estimated preva-







Box. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Criteria for Autism Spectrum Disordera A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history (examples are illustrative, not exhaustive): 1. Deficits in social-emotional reciprocity, ranging, eg, from abnormal social approach and failure of normal back-and-forth conversation, to reduced sharing of interests, emotions, or affect, to failure to initiate or respond to social interactions. 2. Deficits in nonverbal communicative behaviors used for social interaction, ranging, eg, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication. 3. Deficits in developing, maintaining, and understanding relationships, ranging, eg, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers. Specify current severity: Severity is based on communication impairments and restricted, repetitive patterns of behavior. B. Restricted, repetitive patterns of behavior, interest, or activities, as manifested by at ⱖ2of the following, currently or by history (examples are illustrative, not exhaustive): 1. Stereotyped or repetitive motor movements, use of objects, or speech (eg, simple motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases). 2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior (eg, extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat same food every day). 3. Highly restricted, fixed interests that are abnormal in intensity or focus (eg, strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests). 4. Hyperreactivity or hyporeactivity to sensory inputs or unusual interests in sensory aspects of the environment (eg, apparent indifference to pain/ temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement). Specify current severity: Severity is based on social communication impairments and restricted, repetitive patterns of behavior. C. Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life). D. Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning. E. These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay. Intellectual disability and autism spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spectrum disorder and intellectual disability, social communication should be below that expected for general developmental level. Note: Individuals with a well-established Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) diagnosis of autistic disorder, Asperger disorder, or pervasive developmental disorder not otherwise specified should be given the diagnosis of autism spectrum disorder. Individuals who have marked deficits in social communication, whose symptoms do not otherwise meet criteria for autism spectrum disorder, should be evaluated for social (pragmatic) communication disorder Specify if: With or without accompanying intellectual impairment With or without accompanying language impairment Associated with a known medical or genetic condition or environmental factor Associated with another neurodevelopmental, mental, or behavioral disorder With catatonia a

See American Psychiatric Association.26

lence of 1 in 88 live births in 2008, which is almost a 2-fold increase since 2002 (1 in 150) per Centers for Disease Control and Prevention reporting.28 While the DSM-5 describes the onset of symptom presentation occurring within the first 2 years of life by definition, only 18% of cases are estimated to be reliably diagnosed by this age.26-28 Presentation of ASD follows wide variability in a child’s display of stereotyped behavior and intellectual ability but consistently includes communication and social deficits. Children with ASD can exhibit evident behavioral features including unremitting tantrums or prominent deficits in personal interaction, such as unwillingness to participate in physical contact, reduced or absent eye conjamaotolaryngology.com

tact with clinicians and parents, or a lack of responsiveness to verbal stimuli. These are the more textbook cases that are likely to be accurately screened in the primary setting. In milder cases, the child may not exhibit any classic signs.26 Because it is not uncommon for the earliest signs of ASD to manifest as language delay, the parents of a child with ASD may only complain of a delay in speech production, leading to an otolaryngology referral. Although there is a movement to screen for autism as early as 18 months with parent questionnaires and clinical exercises, this is not yet universal protocol. The Box shows DSM-5 criteria for ASD.26 While the DSM-5 criteria is comprehensive, a quick checklist may be




263



more beneficial as a screening tool. One validated option is the Modified Checklist for Autism in Toddlers (MCHAT) questionnaire which is a 23-question screening survey aimed at identifying the presence of typical developmental behaviors.29 Knowing several screening questions to ask parents in the physician’s office can help to more quickly identify children with ASD who require targeted therapies. Other screening tools can be found at http://www .commonwealthfund.org/Resources/2007/Dec/Part-II-Guides-to -Facilitate-Your-Choice-and-Use-of-Screening-Instruments.aspx. Although children with autistic spectrum disorder have difficulty with verbal and social communication, often they have the ability to communicate via nonverbal modalities. Subjective accounts of the use of electronic communication media, such as the use of touch tablets, are overwhelmingly positive. This follows the theory that people with autism likely have “altered wiring” of information processing and production centers such they may construct an alternative mental view of the world—for example, thinking in images rather than language—and may be better served with alternative means of communication. Growing up with autism is challenging for the patient as well as the family. Insight into the challenge and drive to overcome life with autism is beautifully displayed in the following acclaimed poem written by Scott Lentine,30 a person with high-functioning autism working to increase awareness of autism spectrum. Just a Normal Day Never knowing what to say Never knowing what to do Always looking for clues Just a normal day Feeling unsure Totally perplexed with everyday life

ARTICLE INFORMATION Submitted for Publication: October 14, 2013; accepted November 19, 2013. Published Online: January 16, 2014. doi:10.1001/jamaoto.2013.6368. Author Contributions: Both authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Grundfast. Acquisition of data: Tonn, Grundfast. Analysis and interpretation of data: Tonn, Grundfast. Drafting of the manuscript: Tonn, Grundfast. Critical revision of the manuscript for important intellectual content: Tonn, Grundfast. Study supervision: Grundfast. Conflict of Interest Disclosures: None reported. Previous Presentation: Some of the content of this review article was included in an instructional course presented by Dr Grundfast at the 2012 Meeting of the American Academy of Otolaryngology–Head and Neck Surgery; September 9-12, 2012; Washington, DC. Additional Contributions: Hope Dickenson, MS, CCC-SLP, and Kara Corley, MS, CCC-SLP, Division of the Speech-Language Pathology, Department of Otolaryngology, Children’s Hospital Boston,

264

Always on edge never certain I wish I could lift this curtain Needing to constantly satisfy my need for information Always online searching for new revelations Going from site to site Obtaining new insights every night Trying to connect with people my age Attempting to reveal my unique vision But ending up alone and unengaged Feeling like my life needs a total revision Just a normal day

Conclusions Otolaryngologists must remember that the perception that a child is delayed in developing speech could simply be determined to be an overly anxious parent who has an unrealistic expectation about the timing for onset of normal speech, or could be an early sign of significant disorders such as autism spectrum disorder The ability to speak is a significant milestone in child development, one that is much anticipated and celebrated by parents. Mastery of language skills, including speech, is important for normal communication and successful education. Otolaryngologists often are able to assist primary physicians in the complete evaluation of a child delayed in developing speech. To assist in this evaluation, otolaryngologists should be familiar with the milestones for early childhood speech development, know the common causes of speech delay, understand the difference between speech and language, and know the various treatment options available for assisting children with speech delay. Early intervention gives a child the best chance achieiving normal communication skills.

provided advice and gave suggestions that helped to improve the accuracy and relevancy of the article.

(updated March 2011). http://www.nidcd.nih.gov /health/voice/pages/specific-language-impairment .aspx. Accessed August 13, 2013.

REFERENCES

8. Rescorla L. Late talkers. Dev Disabil Res Rev. 2011;17(2):141-150.

1. US Preventive Services Task Force. Screening for speech and language delay in preschool children: recommendation statement. Pediatrics. 2006;117(2):497-501.

9. Hambly H, Wren Y, McLeod S, Roulstone S. The influence of bilingualism on speech production. Int J Lang Commun Disord. 2013;48(1):1-24.

2. National Institute of Deafness and Communication. Speech and language developmental milestones. http://www.nidcd.nih .gov/health/voice/pages/speechandlanguage.aspx. Accessed August 26, 2012. 3. McLaughlin MR. Speech and language delay in children. Am Fam Physician. 2011;83(10):1183-1188. 4. Schum RL. Language screening in the pediatric office setting. Pediatr Clin North Am. 2007;54(3):432.

10. Lucas TH II, McKhann GM II, Ojemann GA. Functional separation of languages in the bilingual brain. J Neurosurg. 2004;101(3):449-457. 11. Nelson HD, Nygren P, Walker M, Panoscha R. Screening for speech and language delay in preschool children. Pediatrics. 2006;117(2):e298e319. 12. Biernath KR, Montero DP, Mehl A, Toomey KE. Universal newborn hearing screening and beyond. Am Fam Physician. 2010;81(2):124-126.

5. Tomblin JB, Records NL, Buckwalter P, Zhang X, Smith E, O’Brien M. Prevalence of specific language impairment in kindergarten children. J Speech Lang Hear Res. 1997;40(6):1245-1260.

13. Bielecki I, Horbulewicz A, Wolan T. Prevalence and risk factors for auditory neuropathy spectrum disorder in a screened newborn population at risk for hearing loss. Int J Pediatr Otorhinolaryngol. 2012;76(11):1668-1670.

6. Kent RD. The MIT Encyclopedia of Communication Disorders. Cambridge, MA: Bradford Books; 2003.

14. Roush P. Auditory neuropathy spectrum disorder. Hearing Journal. 2008;61(11):36;38-41.

7. National Institute of Deafness and Communication. Specific language impairment

15. Paradise JL, Dollaghan CA, Campbell TF, et al. Otitis media and tympanostomy tube insertion






during the first three years of life. Pediatrics. 2003;112(2):265-277. 16. Feldman HM, Dollaghan CA, Campbell TF, et al. Parent-reported language skills in relation to otitis media during the first 3 years of life. J Speech Lang Hear Res. 2003;46(2):273-287. 17. García Pola MJ, González García M, García Martín JM, Gallas M, Seoane Lestón J. A study of pathology associated with short lingual frenum. ASDC J Dent Child. 2002;69(1):59-62, 12. 18. Messner AH, Lalakea ML. The effect of ankyloglossia on speech in children. Otolaryngol Head Neck Surg. 2002;127(6):539-545. 19. Suter VG, Bornstein MM. Ankyloglossia: facts and myths in diagnosis and treatment. J Periodontol. 2009;80(8):1204-1219. 20. Kotlow LA. Ankyloglossia (tongue-tie). Quintessence Int. 1999;30:259-262. 21. Williams CA, Beaudet AL, Clayton-Smith J, et al. Angelman syndrome 2005. Am J Med Genet A. 2006;140(5):413-418.



22. Wilson BJ, Sundaram SK, Huq AH, et al. Abnormal language pathway in children with Angelman syndrome. Pediatr Neurol. 2011;44(5):350-356. 23. American Speech-Language-Hearing Association. Childhood apraxia of speech (position statement). http://www.asha.org/policy/PS2007 -00277/. Accessed August 13, 2013. 24. Morgan AT, Vogel AP. A Cochrane Review of treatment for childhood apraxia of speech. Eur J Phys Rehabil Med. 2009;45(1):103-110. 25. Pennington L, Roelant E, Thompson V, Robson S, Steen N, Miller N. Intensive dysarthria therapy for younger children with cerebral palsy. Dev Med Child Neurol. 2013;55(5):464-471.

Prevalence of autism spectrum disorders. MMWR Morbidity Mortal Wkly Rep. 2012;61(SS03):1-9. 28. Centers for Disease Control and Prevention. Autism spectrum disorders. http://www.cdc.gov /ncbddd/autism/data.html#prevalence Accessed March 6, 2013. 29. Robins DL. Official M-CHAT website. http://www2.gsu.edu/~psydlr/DianaLRobins /Official_M-CHAT_Website.html. Accessed January 28, 2013. 30. Lentine S. Just a normal day. http://scottlentine.wordpress.com/. Accessed July 21, 2013.

26. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013:50-59. 27. Department of Health and Human Services, Centers for Disease Control and Prevention.




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[What rhinoplasty surgeons should know about body dysmorphic disorder (BDD)].

What midlife women should know about menopause and sleep.

What the pediatrician should know about pediatric trauma.

What Should the Cardiologist know about Lamin Disease?

What every radiologist should know about paediatric echocardiography.

Carbamazepine. What physicians should know about its hematologic effects.

Systemic amyloidoses: what an internist should know.

What should primary care providers know about pediatric skin conditions? A modified Delphi technique for curriculum development.

[Echocardiography - What you should know?].

What gastroenterologists should know about testing patients with eosinophilic esophagitis for food allergies.

What we (don't) know about what we know.

What a Dentist Should Know About Oral and Pharyngeal Cancer in Florida.

What Clinicians Need to Know about Bilingual Development.

ENT aspects in general (abdominal) surgery].