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Trastornos del Lenguaje:¿Cuándo un retraso en el lenguaje
convertido en un problema?
Heidi M. Feldman MD PhD
Stanford University School of Medicine, Stanford CA
Resumen
• Definitions
• Normal development birth to 7 years
• Red flags of slow/abnormal (see Handouts)
• Differential diagnosis as guide to assessments for language or speech delays
• Appropriate community services
• Approaches to treatments for children as guide to management and follow‐up
Definitions
• Communication: The activity of conveying, transmitting, exchanging information using a common system though not necessarily intentionally
• Language: A distinctly human communication system with two defining features– Uses symbols– Rule governed
• Speech: The usual output of the language system, using respiratory and oral‐motor systems
Communication
Communication
Verbal Written
Receptive Expressive
Non‐Verbal
Symbolic Non‐Symbolic
Language
LANGUAGE SKILLS(Receptive/Expressive)LANGUAGE SKILLS
(Receptive/Expressive)
Phonology:SoundsRules
Pragmatics:Social
FunctionsMorpho-Syntax: Grammar
Semantics:Meanings
Language Sub‐Systems
• Phonology: Speech sounds in a language with reference to distribution, patterning, and tacit rules of pronunciation
• Morpho‐syntax: Regularity in grammatical features, such as word order, and internal structures of words, such as prefixes and suffixes that affect meaning
• Semantics: meaning (literal and figurative) at the levels of words, phrases, sentences, and discourse
• Pragmatics: social functions of language– Using language for different purposes– Changing language according to the needs of a listener or
situation– Following rules for conversations and storytelling
Speech
SPEECHSPEECH
Motorplanning, execution
Voice and Resonance Fluency
Coordinating breath &
movements
Articulation
Speech Sounds
Requirements for Speech
• Plan and organize respiratory and oral motor mechanism
• Control breath and muscles
• Produce speech sounds in isolation and context
• Regulate voice and resonance
• Speak fluently
SPEECH&
LANGUAGE SKILLS(Receptive/Expressive)
SPEECH&
LANGUAGE SKILLS(Receptive/Expressive)
Motorplanning, execution
Voice and Resonance Fluency
Coordinating breath & movements
Articulation
Speech Sounds
Phonology:SoundsRules
Pragmatics:Social
Functions
Morpho‐Syntax: Grammar
Semantics:Meanings
Communication
Los primeros hitos de la comunicaciónAge Receptive Skills Expressive Skills
Newborn Attends to voiceRegards face
Cries
3 months Differentiates cryCoos
6 months Recognizes name Begins to babbles
9 months Responds to “No”, Learns routines, such as “Wave bye‐bye”
PointsSays “mama” or “dada” non‐
specifically
12 months Follows simple commands with gestures*
Says “ma‐ma” or “dada”specificallyJargons
Says first words*
*Onset of true language development
Hitos del Lenguaje
Age Receptive Skills Expressive Skills
15 months Points to body partsFollows single command
without gesture
Acquires words slowly Uses simple and idiosyncratic forms
18‐24 months Understands sentences Vocabulary reaches 50 wordsVocabulary explosionTwo‐word phrases
36 months Follows 2 and 3‐step commands
Short sentencesUses increasing complex grammar
48‐60 months Understands concepts, such as same/different
Grammar is matureConstructs scripts and narratives
72 months Mature speech soundsApplies language skills to reading
Mecanismos de Aprendizaje
• Observation and social learning, without instruction or rewards
• Biological factors– Human brain is self‐organizing system– Infants link speech perception to motor output
• Environmental factors– Children learn language of their environment– Quantity and quality of input affects rate and maturity of output
Explanations for changing rates
• Biological– Increased myelination
– Synaptic pruning
Myelination of Language Pathways
Pujol, et a., 2006
Pathways:Sensori‐motorTemporal language
Frontal language
Explanations for changing rates
• Biological– Increased myelination
– Synaptic pruning
• Computational– Organization of a neural network
– Based on degree and nature of
input
Developmental Delay• Definitions vary (see Tables for Red Flags o Alertos)
– 1.5 standard deviations below mean – 25% delay
• Functional definition: fail to meet criteria of 50 words and 2‐word phrases at 24 months (15%)
• Trajectory– Late talkers: ~ ½ children delayed at 2 years remain delayed at 3 ‐4 years +
– Late bloomers: Catch up by 3 to 4 years• Favorable prognosis for improvement
– Age 2: appropriate receptive skills and symbolic play– Age 3: use of verbs and prepositions, increasing sentence length
Conceptos erróneos***Meaning that delays will resolve without intervention*Meaning that delays will resolve without intervention
• Boys are very delayed (>6 months)
• Second‐ and third‐borns let their older sibling speak for them
• Children from bilingual households are significantly delayed
• OME causes language delay
• Boys are slightly delayed (1‐2 months)
• Children have strong motivation to speak when they can
• Children from bilingual households may show mild delay and early mixing
• OME associated with language delay
MisconceptionMisconception FactsFacts
Trastornos del Habla y Lenguaje
• Heterogeneous category• Limit age‐appropriate understanding and/or production of human communication
• When does delay become disorder– If delays in preschool era are severe– When mild to moderate delays persist to school age – If delays that limit age appropriate functioning in learning, communication and social skills
– When pattern of development shows qualitative differences in course
Alta Prevalencia
Type of disability Total White Black
3 to 5 years
Any disability 693,245 454,638 103,332Specific learning disability 13,279 6,723 1,770Speech or language impairment 326,606 223,185 42,352
Mental retardation 22,468 13,596 3,830
Emotional disturbance 5,809 4,331 961Autism 25,664 16,128 3,322
Hearing impairment 7,702 4,675 1,007
Visual impairment 3,268 2,008 400
SOURCE: U.S. Department of Education, Office of Special Education Programs, 2004.
El Diagnóstico Diferencial 1
FunctioningHealthy & Normal
IntactChild‐centered
Supportive
Oral mechanisms
Human brain & cognition
HearingVerbal InputSocial interactions
El Diagnóstico Diferencial 2
Low SES, parents
with limited education
Inadequate,
adult‐centered
Verbal input
Abnormal structure or function
Genetic or Neurologic
Disorders
ImpairedUn‐supportive
Cleft palate, velo‐
pharyngeal insufficiency
Cognitive Disability, Neuro,
Autism, SLI
Sensori‐neural
hearing loss
Child abuse or neglect, orphanage
Oral mechanisms
Human brainHearingSocial interactions
SPEECH DISORDERS&
LANGUAGE DISORDERS(Receptive/Expressive)
SPEECH DISORDERS&
LANGUAGE DISORDERS(Receptive/Expressive)
PhonologicalDisorder
PragmaticDisorderLanguage
ImpairmentSemanticDisorder
Childhood Apraxia
Of Speech Hypo- and Hyper-
Nasality Stuttering
Dysarthria
ArticulationDisorder
Motor Speech Disorder
Disorders of Social Communication
Características del Autismo
• Qualitative impairment of social interaction– Impairment in eye to eye gaze, gestures, posture
– Lack of social reciprocity
• Qualitative impairment of communication– Delay in development of spoken language– Stereotyped, idiosyncratic vocalization
• Restricted and repetitive behaviors– Stereotyped, repetitive mannerisms
Autismo
• Represents failure to learn basic communication and social skills from observation learning
• Spectrum of impairment of communication – Severe: lack of communication (verbal, written, sign language or gestures); rare or non‐symbolic communication; communication about wants and needs
– Moderate: limited vocabulary and grammar skills, poor pragmatic skills, and stereotyped, repetitive or idiosyncratic uses of language.
– Mild: ability to use vocabulary and grammar but limited ability to initiate or sustain a conversation with others, flat intonation and poor pragmatic skills
Características delChildhood Apraxia of Speech
• Limited repertoire of vowels & vowel errors
• Variability of errors or unusual, idiosyncratic error patterns
• Errors increase with length or complexity of utterances, such as in multi‐syllabic or phonetically challenging words.
• More difficulty with self‐initiated utterances as compared to over‐learned, automatic, or modeled utterances
• Disturbances of prosody
• Groping or observable physical struggle
• Not explained by Weakness, paresis, or paralysis of the speech musculature
Los Tratamientos
• Children with language and speech disorders have failed to learn through observation and social participation. More time is usually not enough!
• Treatment involves– Increasing opportunities
– Increasing salience of elements in verbal environment
– Direct instruction of language or speech
– Operant conditioning, rewards and consequences
– Augmentative or alternative communication
Los Tratamientos
• Usually in relaxed, play environment• Parent participation key for leveraging therapist time
• Therapy in natural environments avoids the problems of generalization
• Inclusive education benefits children’s communication by providing peer role models
Tratamiento del Autismo
• For children who have failed to learn value of communication– Intensive approach– May need successive approximations to goals– Must provide motivation – Initial progress often through augmentative techniques (picture exchange or sign language)
• For children with mild variant– Attention to pragmatics and social interaction– Operant techniques not appropriate to increase initiative and creativity in language expression
Tratamiento de la CAS
• Verbal motor learning component teaches sounds and syllables, increasing in complexity
• Oral movement (sucking, puckering) do not generalize to verbal movements
• Requires mean of 151 sessions of speech treatment to have a significant effect
• Recommendation for SLP 4 sessions/week
Mensaje Clínica
• Prevention: Encourage families to interact with children and provide rich verbal input environment
• Screen early and often• Do not dismiss wait when you see delays in boys, second‐
born children, children in bilingual household, or children with persistent MEE
• Create differential diagnosis; dissect the problem• Conduct hearing assessment on all children with delays
and further assessment as appropriate• Contribute to the management of delays and disorders
with early intervention or speech/language therapy; assess frequency and approach
• Follow‐up closely
ReferencesAcademic sources:• Feldman, H. M. (2005). Evaluation and management of language and speech disorders in preschool
children. Pediatrics in Review, 26(4), 131‐142.• Feldman, H. M. (2007). Using the language characteristics of clinical populations to understand
normal language development. Pediatric Clinics of North America, 54(3), 585‐607.• Goldstein, B., & Kohnert, K. (2005). Speech, language, and hearing in developing bilingual children:
current findings and future directions. Language, Speech & Hearing Services in the Schools, 36(3), 264‐267.
• Moeller, M. P., Tomblin, J. B., Yoshinaga‐Itano, C., Connor, C. M., & Jerger, S. (2007). Current state of knowledge: language and literacy of children with hearing impairment. Ear & Hearing, 28(6), 740‐753.
• Paradise, J. L., Feldman, H. M., Campbell, T. F., Dollaghan, C. A., Rockette, H. E., Pitcairn, D. L., et al. (2007). Tympanostomy tubes and developmental outcomes at 9 to 11 years of age.[see comment]. New England Journal of Medicine, 356(3), 248‐261.
• Spinath, F. M., Price, T. S., Dale, P. S., & Plomin, R. (2004). The genetic and environmental origins of language disability and ability. Child Development, 75(2), 445‐454.
• Tomblin, J. B., Records, N. L., Buckwalter, P., Zhang, X., Smith, E., & O'Brien, M. (1997). Prevalence of specific language impairment in kindergarten children. Journal of Speech Language & Hearing Research, 40(6), 1245‐1260.
• Tomblin, J. B., Zhang, X., Buckwalter, P., & O'Brien, M. (2003). The stability of primary language disorder: four years after kindergarten diagnosis. Journal of Speech Language & Hearing Research, 46(6), 1283‐1296.
Information for parents:• Feit D with Feldman HM. The Parent’s Guide to Speech and Language Problems. New York:
McGraw‐Hill, 2007, 276 pages
Gracias.
AlertosAlertosAge Finding
Lack of response to sound
Lack of interest in social interaction
2-6 m
No urge to communicate
6-12 m Loss of cooing or babbling
12 m Failure to understand routines, produce mama/dada specifically
AlertosAlertos
Age Finding
Failure to use or understand pointing
Poor understanding of words
15–18 m
No expressive vocabulary
Limited symbolic play18-24 m
Loss of ability to communicate
““Red flagsRed flags”” in 2in 2‐‐3 year olds3 year olds
Age Finding
Lack of ability to follow commands
Productive vocabulary < 35-50 words
No 2-word utterances
24 m
Rote memorization without novel phrases
AlertosAlertosAge Finding
Lack of ability to follow 2-step commands
Limited vocabulary
No simple sentences
< ½ - ¾ intelligible
36 m
Excessive repetition
AlertosAlertosAge Finding
Lack of ability to follow 3-step commands
Poor sentence structure
No complex sentences
> ¼ unintelligible sentences
48 m
Stuttering
AlertosAlertosAge Finding
Inability to express ideas60 m
Persistent stuttering
Errors in sound production
Inability to manipulate the sounds of words for rhyming
72 m
Poor reading skills
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