Recommendation biap 24/02

EARLY SCREENING FOR CHILDREN’S LANGUAGE DISORDERS

CT 24-02  RECOMMENDATION


 
 

In 1991, BIAP commission 24 published a single table entitled « towards language » listing the fundamental stages of hearing, visual, neuro-motor and language development of the child from 0 to 3 years old (recommendation 24-01).

BIAP (Bureau International d’Audio-Phonologie), aware of the importance of early screening for a language disorder in the child, proposes a clinical approach developed in recommendation 24-02.

Recommendation 24-02 completes the table by developing the following points :

Hearing, visual, neuro-motor, cognitive and relational difficulties may hinder or delay speech and language development.

It is crucial to listen to and take into consideration parental anxieties and to carry out as soon as possible the specific screening essential for confirming or invalidating the diagnosis.

The child will speak if those around it communicate with it, if it sees gestures, hears and understands the words of the speaker and if it can perform the movements that produce speech.

With early help, the child has every chance of developing favourably.

BIAP recommends to all professionals dealing with infants early diagnosis and care-taking of development disorders that might lead to language disorders.

 

 

EARLY SCREENING FOR LANGUAGE DISORDERS IN THE CHILD

CT 24 - BIAP - 1998

 

INTRODUCTION

Language development presupposes harmonious communication development.  Research into infantile development and a better knowledge of risk factors now allow, by means of sophisticated observation, early screening for and prevention of late language development.

Language involves reception-comprehension on one hand and expression on the other.  Comprehension development always precedes that of expression.  For comprehension, only a few weeks’ difference can be observed between one child and another, while for expression, inter-individual variation may be as wide as several months.

The child’s family and educational entourage are, together with the doctor, the privileged observers of language and of any impairment that may appear, whether visual, auditive, cognitive or relational.  When one or several anomalies are suspected, a clinical examination should be carried out : a medical, orthophonic, psycho-motor and psychological assessment with possible therapeutic treatment in view.

BIAP, aware of the importance of this subject, wishes to propose, after pluridisciplinary discussions, a clinical approach.

The following subjects will be dealt with : conditions for language development, the « Towards language » table, drawn up and diffused by BIAP, language development disturbances and their consequences, prevention and early screening of language development disorders.

 

I.  CONDITIONS FOR LANGUAGE DEVELOPMENT

A)  Child-related factors

For a child to develop language, it must, from birth, have normal neuro-motor, sensorial and mental structures and keep them throughout its development.

1.  HEARING FACTORS

Correct hearing capacity is essential for correct reception of the spoken message.

The non-appearance of babbling and of language at a certain age should systematically lead to suspicion of and screening for severe deafness (deafness in perception of 70 dB or above).
But any ear pathology (sero-mucous otitis,...) leading to a lasting bilateral hearing loss of 30 dB or above may have repercussions on the start and development of babbling and language (poor perception of phonemes, inaccurate articulation, slow acquisition...)
These repercussions are all the more important on account of related risk factors.  In order of  frequency, hearing damage due to common infections and inflammatory pathologies takes first place in front of perception or transmission deafness linked to congenital malformations of the ear.

2.  MORPHOLOGICAL FACTORS

Similarly, the morphological and functional integrity of the oro-facial entity is essential for correct language and speech development : a velar insufficiency, with or without palate division, a short velum, a bifid uvula, a deep pharynx, bucco-linguo-facial hypotonicity ... can retard and/or disturb elaboration of articulatory movements and distort voice quality.

3.  VISUAL FACTORS

Correct sight is essential to the organisation of communication.  Exchanged looks start up and maintain communication.  Facial expressions and gestures are the natural accompaniment of language.

4.  NEUROLOGICAL AND COGNITIVE FACTORS

Neurological health and sufficient intellectual capacity are essential to language development.

Cognitive abilities and linguistic skills are closely linked.  We can identify for example praxis difficulties in children with cerebral motor deficiencies / spastics  , language structuring difficulties in encephalopathic children, cognitive disorders in language-retarded / dysphasic children...

B)  FACTORS RELATED TO PARENT-CHILD INTERACTION QUALITY :

The infant communicates well before it can speak (expressions, smiles, voice, crying).  This aptitude is particularly important in that if prefigures the social function of language.

From the first weeks of life, the mother regards her baby as a real interlocutor with, as she sees it, the intention to communicate.  Cries, baby sounds, expressions and non-verbal movements are interpreted by the mother as having a meaning.  The mother is very receptive to all such behaviour and answers it verbally or with miming and gestures.  The effect of this is to encourage certain attitudes in the baby, attitudes which, taken up by the mother, become part of a « conversation » in which the baby experiments alternately with speaking and listening periods.  From the first months, the infant multiplies perceptive experiences through what it sees, hears, touches, feels and tastes.  Its parents, by commenting on these experiences help it to organise its environment, its relationship with people, objects and actions.  As the child improves its motor capacity, new interactive and mental modes of behaviour appear.

 

Among the non-verbal modes of behaviour shown by babies, pointing appears at about 9 months.  Around 12 months, this behaviour has acquired a social communication function.  At this age, the child points with the intention of drawing its mother’s attention to certain elements in the environment.  She replies by naming the object or event pointed to by the child (« Yes, it’s the dog, what is the dog doing ?, Oh, the dog’s eating, the dog is hungry », etc.)

This procedure, which gives the mother and child the opportunity to be « on the same wave-length » is the basis for all future dialogue because, for it to take place efficiently, the two interlocutors have to fix their attention on a common object or event to be able to « talk » about it together ; this is what is known as joint attention.

In the course of its development, the child is able to experiment with more and more wide-ranging and sophisticated modes of social behaviour on the motor, relational and cognitive levels.

The processes of maternal adaptation to infant behaviour are largely unconscious, thus allowing, at all stages of development, a progressive adjustment.

At this stage, the mother’s role is essential, for it is on her ability to let herself be guided by the infant that prelinguistic communication depends.  Here is a framework favourable to language development, for it is in this privileged context of dialogue and shared pleasure that the first baby sounds will be interpreted by the mother and take on a meaning.

 
 

Early interactions are a pre-requisite for language development but are not in themselves sufficient to lead the child to the acquisition of a linguistic system.  Language development supposes the existence of healthy sensorial and cognitive capacities in the infant.  The first words appear between 18 and 24 months and, at about 24 months, most children begin to combine two words to form their first sentences.

 
 

II.  DEVELOPMENT  INDICATORS

PRESENTED IN THE « TOWARDS LANGUAGE » TABLE  (cf. Annex 1)

Research work in the last few decades has shown the importance of the first years of life for language development.  The key stages from 3 months to 3 years old are shown in this table.  For each age-group, certain items have been selected.  They are easily observable and should be acquired by the age of 3.  For each age, they show the upper limit for acquisition beyond which there is cause for concern.

The top section of the table indicates three areas to be explored :

Any hearing disorder, however mild, has an influence on language development, which is why the exploration of hearing capacity has been linked to the first section.  For instance, at 6 months : reception, the child turns towards a noise or voice ; expression, it babbles ; interaction, when it is talked to, it responds by baby-sounds.
The lower section of the table indicates two areas to be explored :
Certain disorders in these areas can hinder language development.  The relational aspect, another important element, is not fully explored as it may be equally the cause or the consequence of a problem with verbal or non-verbal communication.
 

III.  LANGUAGE DEVELOPMENT DISTURBANCES AND THEIR CONSEQUENCES

 

A)  Disturbances

Parents and other adults surrounding small children more often detect difficulties in expression than those in language comprehension.  « He talks badly, he does not articulate properly, he does not understand what he’s saying, .... »

Language development, however, can be disturbed in its comprehension and/or expression aspects on the phonological, morphosyntaxic, lexical or pragmatic level.

1.  Comprehension

The child’s comprehension capacity is the basis of language development and precedes expression capacity.  As the infant grows older, its understanding possibilities continue to precede its ability to express itself.  Comprehension observation is thus of primary importance.

It is essential  to check if comprehension depends on the verbal or the non-verbal.  We call « non-verbal » the gestures and miming that accompany speech as well as the situation (or context) of communication.

From 12 to 18 months, the child should be able to take notice of verbal messages without relying exclusively on the non-verbal.

Comprehension level can easily be misleading or illusory.  The child seems to understand a simple order but in fact, it only understands the situation and not the linguistic message.  Ex. « Come on, we’re going » : in fact, it sees its mother putting on her coat.

2.  Expression

Temporary distortions normally exist in a child’s language during its development (he says « tut » for « shut »).  They must be differentiated from major disorders which must, of course, draw attention and motivate exploration.

· Major articulation disorders : non-acquisition of certain phonemes, reduced intelligibility of speech, ...
 
· Speech disorders : words are simplified, deformed or unfinished (substitutions, omissions, elisions, ...)
     These disturbances may co-exist with satisfactory language development.

· Retarded language development : language development may be considered as retarded when a child at a given age is unable to understand and/or express itself by words and sentences in comparison with the generally described chronology.

     The retardation may affect comprehension and/or expression to varying degrees.
     The use of jargon or stereotypes should suggest a specific language pathology.
B)  Consequences
 

The extent of the consequences of retarded language development is related to :

· the nature of the difficulties : speech, language, comprehension, expression ...
· the origin of the problems : hearing, mental, cerebral dysfunction, affective ...
· specific family repercussions :
The family may sometimes compensate for comprehension and expression difficulties by certain types of behaviour (family code, miming, key-words ...).  This will avoid or retard behavioural disorders and the isolation of the child.  The continuation of such methods may, however, aggravate the language retardation.  Inappropriate attitudes towards a child’s difficulties of expression might fix a pathology (stammering for example, ...)
1.  Effect on communication and relationship
If the child does not understand what it is told, it does not act or reply in the way expected by its interlocutor and its response is inappropriate.
The syntactic and semantic aspects of the discourse offered by the adult are not integrated.  The child then has difficulty in expressing itself and the communication link is not established.
Communication problems also affect relationships : the child’s language efforts or the parents’ initiatives meeting no suitable response, manifestations of frustration are likely to appear on both sides ; the child may show inhibition, instability or hyperactivity ...
2.  Effect on the child
The child is aware of limits to its self-expression and of its mistakes through corrections by others ; if the latter are too frequent, a block may arise, with refusal and anger.
The reception of partial information will slow cognitive development.  The child cannot make the adjustments necessary for the use of concepts, the development of cognitive skills, memorisation and evocation.
At school, from kindergarten on, language difficulties distort communication with other children.
Moreover, without appropriate help, these difficulties are likely to have a negative influence on written language.

IV.  PREVENTION AND EARLY SCREENING FOR A LANGUAGE DISORDER

 

            The doctor faced with this risk is confronted by different types of situation :

*  THE CHILD PRESENTS A KNOWN CONGENITAL OR ACQUIRED PATHOLOGY   (embryo-foetopathy, neo-natal anoxia, meningitis, polymalformative

    syndrome ...)
 In this case, the doctor
- makes sure that the initial assessment was complete ; hearing, visual and neuro-motor assessments for detecting related pathologies (deafness, amblyopy ...)
- checks that the follow-up and in particular the parental guidance (cf. BIAP CT 25) have been correctly undertaken.
* THE CHILD IS HEALTHY, BUT PRESENTS LANGUAGE-RISK FAMILY ANTECEDENTS :  deafness, language retardation, elocution disorders, unfavourable socio-affective context).
 In this case, the doctor
- makes sure that an initial assessment has been carried out
- checks that sensorial examinations are repeated (cf. late appearing deafness)
- follows up language development until complete acquisition.  In the case of a development disorder (cf. items of the table), he requests a specialised language assessment even if this does not lead to re-education.
* THE CHILD IS APPARENTLY HEALTHY AND HAS NO KNOWN PERSONAL OR FAMILY ANTECEDENT BUT THE DOCTOR DETECTS DEVIANCE FROM THE NORMS LAID DOWN IN THE TABLE.
He must, in this case, first eliminate definitely and systematically, whatever the child’s age, any sensorial and especially hearing disorder.  A deafness diagnosis is in fact possible from birth.  Other aetiologies should be considered only after this verification.  A language development assessment is systematically included in these assessments whatever the child’s age.
The diagnosis must be directly followed by pluridisciplinary parent-child care.  The quality and state of advancement of language development depends - whatever the aetiology - on the age at which the child is first taken in charge.

In all cases, the doctor centralises the results and makes sure that a follow-up appropriate to the aetiology and the extent of the language disorder is put in place.

 

C O N C L U S I O N

Hearing, visual, neuro-motor, cognitive and relational difficulties may hinder or retard speech and language development.

It is crucial to listen to and take parental anxieties into consideration.

Specific examinations essential for confirming or invalidating the diagnosis should be undertaken at once.

A child will speak if those around it communicate with it, if it sees gestures, hears and understands the words addressed to it, if it can perform the movements that lead to speech.

 

Taken in charge early, the child has every chance to develop favourably.

Nivelles (B), 1st May 1999

 

 

 

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