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Definition

Communication disorders, or speech and language problems, are among the most common problems of childhood. These problems may involve verbal comprehension, vocabulary, grammar, articulation, voice, fluency and understanding of the social rules of communication.

A communication disorder can be an isolated problem resulting from a delay in specific areas of development or can be part of a more general developmental delay.

Language can be defined as a set of symbols used for communication. These symbols are used to organise thoughts and new learning and to communicate with others. Language may be spoken or take a visual form such as through gestures (as in sign language), or written language. Language involves the understanding and use of sounds, words and the rules for combining their use. It involves both receptive and expressive processes.

The Development Of Oral Language

Oral language (speech) involves the understanding and use of:

• Phonology, which refers to the understanding and use of speech sounds. Recent research has shown that by the age of six months, infants have learned to differentially respond to the sounds of their native language.
• Semantics, which refers to the meaning of language and involves understanding and use of words (vocabulary).
• Syntax or grammar, which involves rules for combining words and appropriate word endings into meaningful sentences.
• Pragmatics, which refers to the use of language for communication in a manner appropriate for a specific social situation. Pragmatics may involve the tone of voice used, rules for turn-taking in conversation, facial expressions and gestures used to accompany speech.

The infant possesses or develops the following cognitive and interactional skills that assist in the form and meaning of conversation, prior to becoming an effective communicator:

• Eye contact.
• Joint attention: attending to an activity with another person.
• Turn taking: taking turns in an activity together with another person.
• Object permanence: knowing that an object still exists if it disappears from sight.
• Cause-effect: realising that performing one action will lead to a consequence.
• Meaningful use of objects.
• Pointing.
• Making a choice between objects or people.
• Babbling: experimenting with combinations of speech sounds.
• Imitation of actions or sounds.
• Motivation to be involved in communication with another person.

Language develops rapidly and easily in most children despite variation in environment and intelligence. Children at risk of developmental delay of language are those with intellectual disability, hearing loss, central nervous system impairment affecting the speech production mechanism, autism spectrum disorder, emotional disturbance or extreme environmental deprivation.

In addition there is a group of children with specific developmental speech/language disorders where the cause is thought to be atypical pre-natal brain development.

Many children with communication disorders have a family history of speech, language and learning disorders.

Prevalence

Published prevalence rates for communication disorders in children vary from 2–3% to about 20% depending on the age of the children studied and the definition of disorder. However, most studies agree that about 10% of children will have a moderate to severe speech and/or language delay at the time of school entry. More males are affected than females. Children with communication disorders frequently have significant behaviour problems that may be related to the frustration involved in communicating, or to factors inherent in the child's developmental delay, eg. children who have an autism spectrum disorder.

Related Conditions

Communication disorders may be one aspect of the following conditions. A full assessment by a team of professionals is necessary to determine the cause of the communication disorder. Children with any of these conditions may be eligible for a Child Disability Allowance.

Hearing loss

Hearing loss may be permanent or transient. Transient loss is usually due to otitis media with effusion and causes a mild to moderate hearing loss. Both transient and permanent hearing loss may be associated with delayed language development. Sensorineural hearing loss is permanent and ranges from mild to profound. It can be unilateral or bilateral, congenital or acquired. It can be caused by anatomical abnormalities, genetic disorders, prematurity with low birth weight and other perinatal complications, drugs, trauma or diseases.

It may mean that the child requires hearing aids and special assistance for the child and family from parent counsellors, special education facilities or visiting teacher services. Initial assessment should be carried out by a team including a paediatrician, ear, nose and throat specialist, and audiologist.

Intellectual disability

Intellectual ability is conventionally measured in terms of developmental milestones and reactions to cognitive tasks. It can be difficult to separate speech and language development from intellectual ability in the young child, however it is generally true that children with intellectual disability will be delayed in their development of speech and language. If intellectual disability is suspected, the child should be assessed by a paediatrician and clinical psychologist.

Autism Spectrum Disorders

Children with autism spectrum disorders commonly have difficulty in developing speech and language and in understanding the social use of communication. They may also be disordered in the non-verbal aspects of communication, such as eye contact, use of gesture and facial expression. Many children with autism spectrum disorder have severe problems in understanding language, but may also have any other type of speech and language problem seen in non-autistic children. Most children with autism spectrum disorder can be diagnosed by the age of three. The diagnostic process generally involves a paediatric and developmental cognitive assessment, a psychiatric assessment and a speech and language assessment.

Emotional Disturbance and Environmental Deprivation

Mother-child interaction, the mother's level of education and support available to her within the family and the stimulation provided for the child in the home have all been identified as predictors of language skill. Intervention for children with speech and language delay will therefore involve consideration of the child in the context of the family. Many community mental health teams for children and adolescents have speech pathologists who work as part of a team for those children with speech and language delays as a symptom of broader problems within the family.

Developmental Speech and Language Disorders

After discounting factors such as hearing loss, intellectual impairment, central nervous system impairment affecting the speech production mechanism, autism spectrum disorders, emotional disturbance or extreme environmental deprivation, there is still a group of children who have speech and language disorders of unknown origin. It is likely that these children have atypical pre-natal brain development.

Language/Learning Problems

Children with developmental speech and language disorders often have difficulty in developing skills in other language-based learning activities, such as reading and spelling. Problems with reading and spelling may be traced back to poor auditory processing skills and difficulty in understanding how words can be broken down into components (phonemic knowledge). Assistance with phonemic knowledge in the kindergarden (pre-school) and early school years may minimise later learning problems.

When To Refer For An Assessment To A Specialist Service

Table 1 outlines the indicators of moderate to severe communication disorder that necessitate referral to specialists dealing with communication disordered children, such as speech pathologists, audiologists and paediatricians.

In addition, any child who consistently loses previously developed words or is considered to have regressed in language development, speech clarity, or intellectual development, should be promptly referred to the specialists indicated above.

Table 1: Indicators of Moderate to Severe Communication Disorder.

Six months.	No response to sound. No cooing, laughing, vocalisation, eye contact in interaction with a familiar adult.
12 months.	No localising of sound, no babble.
20 months.	No meaningful words.
24 months.	Fewer than 20 words. Not pointing to items on request.
30 months.	No two-word combinations. Not understanding simple instructions without gesture. Less than 50 words.
36 months.	Not understood within the family. Not using early grammatical constructions, eg. verb endings (runn-ing), plural 's' (cat-s). Stuttering with signs of tension, particularly if there is a family history of stuttering.
48 months.	Not understood outside the family. Not using complex sentences.
52 months.	Not understanding prepositions (in, on, under, beside, behind).
60 months.	Speech not fluent ,and not complex. Not reasonably clear.
84 months.	Has not acquired correct production of late developing speech sounds, - "s", "l", "r", "th"
Adapted from "Indicators of Moderate Language Delay", Speech Pathology Department, Royal Children's Hospital, The Australian Paediatric Review Training Program, 1996.

Stuttering

Stuttering is a common communication disorder that generally starts in the pre-school years. It can be defined as a temporary loss of control of the ability to continue speaking, and is characterised by disfluencies such as repetitions, hesitations, prolongations or blocking on sound, syllables or words. It is more common in males than females. Stuttering may be a source of frustration, anger and bewilderment for children, particularly if there is a rapid onset. Stuttering has an incidence of 5%, however 65%–75% of children who stutter will regain fluent speech without formal intervention. Intervention is shorter and more effective if it occurs in the pre-school years. Presence of the following indicate the need for a prompt referral to a speech pathologist:

• Many disfluencies.
• Disfluencies involving tension:
• part-word repetitions (ca ca ca cat);
• prolongations (ca_____t);
• blocks (no sound);
• blinking; grimacing; body movements.
• Parent reports of the child avoiding speech, or stating they can't speak.
• More than six months since onset of stuttering.
• Co-occurrence with speech/language delay.
• Family history of stuttering.

Role Of Primary Health Care Professionals

Primary health care professionals play a valuable role in:

• Advising parents of the importance of talking to their child at the earliest age to encourage language development.
• Assessment of language development.
• Referring a child as early as possible if there are concerns about language.
• Referring the child for an audiology assessment when a referral to a speech pathologist is made.
• Reviewing the child's progress and maintaining the communication with the speech pathologist.
• Supporting and empowering parents to gain the information necessary to make informed decisions.

Early Intervention

Early referral is important for children with communication impairment, and is welcomed by the specialists involved. There may be long waiting lists for services such as speech pathology and audiology, so this must be taken into consideration. Early intervention can help prevent behaviour problems related to frustration, and assists the child in keeping up with appropriate developmental milestones.

In treatment of speech/language disorders, the current view is that in most cases improvement is not due to maturation, but rather the child learns to use alternate strategies to achieve functional communication. Early intervention allows the child more time to develop communication skills before commencing formal education.

Assessment and Treatment by a Speech Pathologist

Assessment of communication impairment is time-consuming, and is carried out using standardised tests, analysis of the child's language during play and interaction with parents or other familiar people, and a history of the child's development as provided by parents or carers.

The intervention offered may be through home visits or be centre based. It may be in a group setting, or the child may be seen in individual sessions with parents. The intervention (speech therapy) is based on the child's individual pattern of strengths and weaknesses in speech and language areas. Sometimes an alternative communication system such as signing will be suggested. Signing is easy to learn, doesn't stop the child from speaking and diminishes frustration. It provides more information for the listener if the child is hard to understand and seems to increase the rate of vocabulary development in some children with restricted vocabularies. Signing is generally used only for a short period, and parents are not required to learn large numbers of signs.

Long-Term Outcomes For Children With Communication Disorders

The long-term outcomes for children with communication disorders varies according to the type and severity of the disorder. Earlier points have emphasised:

• Early intervention targeted to improving the child's communication skills, minimises behavioural problems due to frustration and prepares the child for formal education.
• Intervention for stuttering is shorter and more efficient if it occurs in the pre-school years.
• Children with developmental speech and language disorders often go on to have difficulties with reading and spelling.

References
Law, J. The Early Identification Of Language Impairment In Children. Chapman & Hall, London, 1992

Parents' References
Mulvaney A. Look Who's Talking. Simon & Schuster, Australia, 1991
Clark, C., Ireland, A. Learning To Talk, Talking To Learn, Bay Books, Sydney, 1994

For Further Information
General Practitioners and Paediatricians

For Children Under Six Years
Speech pathologists in:

• Community Health Centres.
• Early Intervention Centres.
• Department of Education and Early Childhood Development, Specialist Children's Services Teams. Tel. 1800 783 783
• Specialist facilities associated with disabilities such as hearing impairment, visual impairment, autism, and physical disabilities.
• Private practice.

For School-Aged Children
Speech pathologists in:

• Department of Education and Catholic school systems.
• Private practice.
• Training clinics at La Trobe University (School of Communication Disorders) and Monash University (Krongold Centre).
  School nurses in:
• Department of Education and Early Childhood Development, School Nursing Program (in your region).

Other Community Resources

SPEECH. Parent Support Group:- Ph. (03) 9531 4106

Written and Developed by the Centre for Community Child Health & Ambulatory Paediatrics, Royal Children's Hospital, Melbourne for the Victorian Government Department of Human Services.

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