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Spe e ch a nd L a ng uage Development a nd Disorder s in Children

Helen M. Sharp, PhD*, Kathryn Hillenbrand, MA


KEYWORDS  Child language  Developmental disabilities  Articulation  Apraxia  Cleft palate  Autism  Speech-languate evaluation  Speech therapy

Communication is the exchange of information using a socially accepted system of symbols and behaviors. Although humans communicate with gestures, posture, and facial expression, most human communication relies heavily on converting ideas into language that is written or spoken. Spoken communication is received by the listener through hearing. Language is a socially agreed on, rule-governed system of symbols that is used to represent ideas about the world. Language includes shared understanding of what words mean (semantics); the capacity to change words in systematic ways, such as adding s to the end of a noun to make it plural (morphology); and rules that govern word order in a sentence (syntax).1 The use of language as a social tool (pragmatics) involves a complex set of rules about using eye contact, interpreting nonverbal messages together with words that may have a different literal meaning, structuring requests that are polite, and sustaining conversation topics. Language disorders are identified when a person has difficulty with expressive language (sharing his or her thoughts and ideas), receptive language (understanding what others say), or pragmatic language (the social use of language).1 Speech is the oral means of communicating language. Speech is produced through the complex coordination of respiration and laryngeal, velopharyngeal, and articulatory movements. Respiration provides the air pressure to initiate sound production through vocal fold vibration at the larynx. Sound from the larynx together with airflow are then directed nasally or orally by the velopharynx and shaped by the other articulators (eg, tongue, lips, teeth, and jaw) to create speech sounds. When these sounds are sequenced together, listeners are able to recognize words and sentences. Speech production can be categorized into three main areas: voice, fluency, and speech intelligibility, which includes articulation and speech resonance.1 Voice quality reflects the sound produced by the vocal folds, a function that is influenced by respiratory support. Fluency refers to the rhythm and rate of speech, whereas articulation refers
Department of Speech Pathology and Audiology, Western Michigan University, 1903 West Michigan Ave., MS 5355, Kalamazoo, MI 49008, USA * Corresponding author. E-mail address: helen.sharp@wmich.edu (H.M. Sharp). Pediatr Clin N Am 55 (2008) 11591173 doi:10.1016/j.pcl.2008.07.007 pediatric.theclinics.com 0031-3955/08/$ see front matter 2008 Elsevier Inc. All rights reserved.

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to the coordinated movement of the articulators to produce the consonants and vowels we recognize as speech. For example, children must learn how to combine laryngeal and articulatory control to differentiate sounds such as b from m, which use lip closure, but m is produced nasally, whereas b involves stopping and releasing airflow through the oral cavity. Speech disorders are identified when a persons voice, fluency, or articulation call attention to the speaker because his or her speech is sufficiently different from the norm.1 Hearing is the conduction of sound from the environment through the outer, middle, and inner ear to the brain where the signal is interpreted. Hearing is an essential element in the development of oral speech and language. Those who have hearing loss can be expected to have difficulty developing and maintaining speech and language skills for oral communication (see the article by XX found elsewhere in this issue).
TYPICAL DEVELOPMENT OF SPEECH AND LANGUAGE

Infants recognize parents voices and respond to adult speech from birth. Infants produce voice when they cry, and gradually begin to gain voluntary control over respiratory and laryngeal function to produce prespeech sounds. As oral, laryngeal, and respiratory control develop, babies begin to produce vowel-like sounds (cooing) between 1 and 4 months of age, and this progresses to production of definitive vowel sounds along with other oral productions such as raspberries typically between 3 and 8 months of age. Babbling or the sequential production of a consonant and vowel (eg, babababa) occurs between 5 and 10 months of age.2 The speech sounds m, b, and p are often produced early because they are produced anteriorly in the mouth and are therefore easy to imitate. Before true words emerge, infants string together longer sequences of consonants and vowels and begin to add the inflections of their native language. This pattern of output is called jargon.3 While the infant is learning to exert control over the respiratory, vocal, and articulatory mechanisms, she is also listening to and perceiving the language spoken around her. Infants who have normal hearing thresholds respond to the human voice and reinforce caregivers by attending to their speech and smiling. Adults adopt a higher pitched voice with greater inflection and prolongation of vowel sounds when speaking to infants, and this style of speech is referred to as motherese4 and, in some contemporary literature, as parentese. Infants are also reinforced by hearing their own prespeech cooing, babbling, and jargon. When infants are severely hearing impaired, early vocal behaviors are often present but may stop developing or extinguish.5 Language comprehension nearly always precedes language expression.3 For example, an 8-month-old infant may turn his head and look at his father when asked, Where is Daddy? but will not yet be able to say Daddy. A true word is produced when an infant uses the same sound sequence consistently to refer to the same thing, but this word may be recognizable only to the parent; for example, baba is bottle and ba is ball. Most infants produce at least one true word between 10 and 15 months of age. After the infant begins to say true words, her expressive vocabulary should expand steadily. By age 2 years, toddlers should have an expressive vocabulary of at least 50 words and should start to combine words together in two-word phrases such as Mommy up. The typical milestones for the development of language comprehension and expression are summarized in Table 1.
DELAYS AND DISORDERS OF SPEECH AND LANGUAGE

Many congenital, genetic, and environmental conditions are known risk factors for speech and language delays and disorders. Some conditions, such as cleft palate,

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are identified at birth and yield clear opportunities to initiate early intervention. For many disorders of speech (eg, stuttering) and language (eg, autism), however, there are some familial and environmental links but, at this time, no definitive risk factors or clearly understood underlying etiologies. Therefore, most speech and language delays and disorders are not evident until the child reaches a developmental point at which typical milestones are noted to be absent. Thus, many speech and language disorders are identified during the toddler years by parents and pediatricians. For purposes of simplicity, the authors divided the discussion of specific disorders into disorders of speech production and disorders of language, but it is important to note that for many children, this distinction is blurred. For example, cleft palate is a disorder of a structure that is integral to speech production. Although production of speech is the primary concern for most children who have cleft palate, these children have an increased likelihood of impaired language performance and reading problems.68 Similarly, children who have Down syndrome often have a principal delay in language acquisition that is accompanied by delayed learning of speech sounds.9 Children who have Down syndrome may also demonstrate distorted speech sound productions related to oral structural differences. When there is overlap between disorders of language and speech, the authors discuss the issues in the context of the primary domain (ie, speech or language) and discuss overall communication function, as well as feeding and swallowing disorders.
DISORDERS OF SPEECH PRODUCTION

Any change to the structures or physiologic function of the speech mechanism can result in disorders of speech. Most speech disorders in children relate to functional mislearning or are caused by organic anomalies that affect oral, pharyngeal, or laryngeal structures or neuromuscular functions. Oropharyngeal anomalies include macroglossia, asymmetries related to hemifacial microsomia, or cleft palate. Laryngeal changes include alterations to the vocal folds, such as laryngeal papilloma or intubation trauma. Vocal pathology is relatively rare in children, so laryngeal changes are not discussed here. Any child who has an unusual voice quality should be referred to otolaryngology to rule out structural disorders of the larynx. Speech disorders occur when there is disruption in the neuromotor coordination of respiration, laryngeal, and articulatory functions, seen, for example, in muscular dystrophies and in many forms of cerebral palsy. Because speech is a representation of a language system, some disorders or disruptions of speech may actually be symptoms of an underlying language learning problem, particularly when the disorder relates to learning the rules that guide the sound system of the childs primary spoken language (phonology).
Cleft Lip and Palate

Clefts of the lip and palate are among the most common congenital anomalies, occurring in approximately 1 in every 600 live births.10 Intact palatal structures are critical for the development of normal speech because the hard palate and soft palate (velum) act to separate the oral cavities from the nasal cavities. The velopharynx closes to direct airflow orally for most speech sounds and opens to permit nasal resonance on nasal speech sounds (in English: m, n, and ng). When dynamic function of the velopharynx is disrupted, speech is hypernasal in quality. Samples of hypernasal speech are available through the American Cleft PalateCraniofacial Associations Web site.10 One of the most commonly identified syndromes in individuals who have cleft of the secondary palate is velocardiofacial syndrome (also called 22q;22q1113,

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Table 1 Summary of prespeech, speech, and language milestones in the first 5 years of life Age Birth3 mo Language Comprehension Skills Startles to loud sounds Quiets or smiles to familiar voice Increases or decreases sucking behavior in response to sound Localizes to sound Reacts to changes in tone of voice Is aware that toys that make sounds Attends to music Expressive Speech and Language Skills Coos to indicate pleasure Uses different cries for different needs Smiles when sees familiar people Begins to produce clear vowel sounds Imitates adult mouth movements, vowel sounds, and nonspeech movements (eg, raspberries) Babbles alternating consonants and vowels (eg, bababa), often with b, p, and m Uses voice to communicate excitement and displeasure Gurgles when alone and when playing with an adult Babbles with short sequences Adds sounds k, g, t, and d Uses speech or noncrying sounds to get and keep attention Uses one or two true words such as bye-bye or mama

48 mo

714 mo

Listens to speech and localizes to sound Discriminates between speech sounds in native language Recognizes words for common items such as daddy or juice Responds to some requests such as Want more? Enjoys social turn-taking games such as peek-a-boo Identifies at least a few body parts Follows simple commands in context such as Throw the ball. Understands simple questions in context such as Wheres your sock? Listens to stories, songs, and rhymes Points to familiar pictures in a book

12 y

Uses at least 10 words by 18 mo Uses many different consonant sounds at the beginning of words Simplifies adult speech by dropping a syllable, consonant blend, or word ending Steadily increases vocabulary, particularly from 18 to 24 mo Begins to combine words into two-word phrases and questions Girls tend to be slightly more advanced at this stage

23 y

Follows two-part commands such as Get your shoe and give it to me. Consistently identifies body parts

Speech is understood by caregivers most of the time Has a word for almost everything Uses two- to three-word phrases to ask questions or to describe events Uses speech to get attention or to make a request May repeat starting phrases or words (eg, I, I, I, I want) but should not get stuck or frustrated Unfamiliar listeners can understand most of the childs speech Can describe events that take place away from home or parent Uses longer sentences of four or more words Usually talks fluently without repeating syllables or words Voice sounds clear Uses sentences that give a lot of details (eg, I like to read my books) Tells stories that stick to a topic Communicates easily and clearly with other children and adults Says most sounds correctly (exceptions are th, ch, r, l, s, and z, which may not yet be accurate) Uses regional or familys rules of grammar

34 y

Understands easy wh questions and gives appropriate response to who, what, where, and why forms Learns vocabulary and sentence structure from adult conversation and being read to Attends to and understands short stories Can answer questions about a story Understands most of what is said in home, preschool, and school environments

45 y

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Data from Refs.

13,21,51

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Shprintzens syndrome, or DiGeorge syndrome).11 This syndrome is characterized by a triad of symptoms: velopharyngeal dysfunction (with or without a frank palatal cleft), cardiac anomaly, and learning difficulties including language delay. Any child who has a cleft and any history of cardiac involvement, from a mild murmur to cardiac surgery, should be evaluated for this syndrome.12 Other genetic and craniofacial disorders are addressed in this issue (see the article by XX found elsewhere in this issue). Although most clefts are recognized at birth, some microforms of cleft palate may go unnoticed or unreported, particularly if they are not symptomatic during feeding. Any infant who has persistent nasal leakage associated with feeding and any child who has persistent hypernasal speech should be evaluated for submucous cleft palate.13 Careful evaluation of palatal structure is also advisable before a child undergoes adenoidectomy because velopharyngeal closure for speech often occurs at the level of the adenoid. Any child who has persistent hypernasality 4 to 6 months after adenoidectomy should be referred to a speech-language pathologist affiliated with a cleft palate team to determine whether the child is physically able to achieve velopharyngeal closure. When physical closure is evident on some speech sounds, the child is a candidate for behavioral intervention, but if the child can never achieve closure, then other physical management strategies must be explored.
Speech Disfluency or Stuttering

Stuttering is a disruption in the expected rate or fluency of speech that can include prolongations of sounds in words, use of filler words such as um, difficulty with starting to speak (blocks), and repetitions. Repetitions may vary from repeating one speech sound (often in word initial position, such as s-s-sunny), syllables, words, or phrases (I want, I want, I want an ice cream). Stuttering occurs more often in boys than in girls and appears to have an underlying genetic component.14 Some disruptions in the fluency of speech are expected in all speakers because speech is an immensely complex coordinated motor activity. Effortless repetitions of syllables, words and phrases are observed to increase in young children during the time at which they begin to produce complex utterances and may persist for a period of a few months. In a typically developing child, this period of developmental disfluency occurs between 2 and 3 years of age.15 Referral for a speech evaluation should be made when a child has a positive familial history or demonstrates any of the following characteristics: prolonged disfluency (>6 months), self-awareness of talking difficulty, avoiding talking, tense pauses in speech, blocks, or extraneous facial or body movements while talking or when trying to initiate speech.16
Childhood Apraxia of Speech

Childhood apraxia of speech (CAS) is characterized by impaired volitional motor programming for speech production in the absence of paralysis or weakness of the oral musculature.17 It may be associated with known neurologic impairment or may be idiopathic. A cardinal sign of CAS is inconsistency in speech production: a child may be able to produce a speech sound or a sequence of sounds one moment and then be unable to do so the next. The childs connected speech is likely to be limited to vowel sounds and speech that appears to be effortful. Children who have CAS are often described as groping for accurate placement of the articulators when they try to produce consonant speech sounds. The difficulty executing oral movements for speech often corresponds with a significant delay in speech development in a child who has intact auditory comprehension skills. Children who have CAS may develop methods of communication that do not rely on speech to express themselves, for example, pointing, grunting, and idiosyncratic

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gestures or manual sign language.17 Parents of children who have CAS often describe the frustration that the child experiences related to the inability to express his or her needs. Caregivers also become frustrated as they work to decipher what the child is trying to communicate. As a result, communication may not be a positive experience for children who have CAS, and some children may resort to using negative behaviors (eg, hitting) to communicate. When a child demonstrates inconsistent production of consonants and vowels on repeated productions of syllables or words, lack of smooth transitions between sounds and syllables, or inappropriate inflection patterns (prosody), he should be referred for a full speech and language evaluation.17
Speech Delay or Disorder

It is typical for a child who is learning to speak to simplify adult productions of words and speech sounds. For example, a child might say efun instead of elephant. Many of these simplifications should begin to reduce by 24 months of age and be eliminated by 36 months of age among children who do not have musculoskeletal anomalies.18 Most children should be attempting most speech sounds by age 36 months, but many sounds such as s, th, ch, sh, f, v, l, and r continue to be perfected in conversational speech beyond age 4 years.19,20 Children should be 50% intelligible by age 36 months and about 75% intelligible by age 48 months.21 Persistent speech production problems may reflect difficulty with learning or coordinating articulatory placement for individual sounds (eg, th for s), which is called an articulation disorder. Alternatively, children may have mislearned the rules that guide the sound system (phonology) in their native language. Children who have a phonologic disorder tend to demonstrate recognizable patterns of speech errors such as omitting syllables in multisyllabic words (banana becomes nana), using front sounds (t and d) to substitute for speech sounds usually produced at the back of the mouth (k and g), or deleting all final consonant sounds in words.22 Formal assessment and detailed analysis of speech sounds are often necessary to differentiate articulation problems from phonologic disorders of speech production or from CAS. Children who have persistent difficulty with speech intelligibility beyond age 36 months should be referred for a comprehensive evaluation of speech and language.

DISORDERS OF LANGUAGE Autism

Autism is one of the most frequently diagnosed communication disorders, with estimates that 1 in every 150 children is affected.23 The wide range and severity of symptoms within the autism spectrum disorders (ASD) include classic autism, Aspergers syndrome, Rett syndrome, childhood disintegrative disorder, and pervasive developmental disorders. Autism is a complex condition characterized by a wide range of symptoms that can include communication problems such as lack of expressive eye contact with caregivers, reduced interest in vocal exchange with caregivers, lack of recognition of and response to caregivers voices, onset of babbling after age 9 months, decreased or absent prespeech behaviors such as social waving, alterations in speech rate and rhythm, and failure to develop speech.24,25 The most common characteristic across individuals who have autism is difficulty in the social use of communication and language (pragmatics). Pragmatic problems may include impairment in understanding and using nonverbal communication, reduced understanding of spoken or symbolic

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communication, and problems interpreting metaphoric language. Children who have autism may also demonstrate problems with reading and writing.24 The American Academy of Pediatrics published several clinical reports related to the pediatricians role in the early identification, evaluation, and management of autism.25,26 As part of its Autism Listen Act Refer Monitor screening program,23 the American Academy of Pediatrics recommended screening starting at the 9-month visit, with autism-specific screening at the 18-month visit using the following red flags to initiate comprehensive evaluation: Lack of babbling, pointing, or other gestural communication by age 12 months Lack of the use of single words by age 16 months Lack of two-word novel phrases by age 24 months Loss of language or social skills at any age Greenspan and colleagues27 recommended a broader functional framework for identifying children at risk for ASD that focuses on a childs ability to initiate and sustain engagement, demonstrate social reciprocity with caregivers, and solve social problems with caregivers through use of gestures to communicate and negotiate getting desired items. The goal of early identification is to initiate early intervention, which has been shown to improve outcomes for children who have ASD.28
Specific Language Impairment

Specific language impairment (SLI) is a delay in the acquisition of expressive language in a child who has no known hearing, neurologic, or physical problems and occurs in the presence of normal nonverbal intelligence.29 Children who have SLI exhibit smaller vocabularies, use shorter utterances, omit grammatical endings and function words, and demonstrate more grammatical errors than their same-aged peers. An epidemiologic study identified a prevalence of 7.4% (8% boys; 6% girls) among children in kindergarten.29 Of those who had SLI, parental awareness of a speech or language problem was 29%.30 SLI appears to have a genetic component, because children who have SLI are more likely than typically developing children to have a relative who has a language disorder.30,31 SLI is also linked to parent education and income.29 Early identification of SLI in young children is important because the language deficits are associated with academic problems, particularly the acquisition of literacy skills.32
Central Nervous System Injuries

Focal brain injuries such as intracranial hemorrhage can occur in infants, toddlers, and throughout childhood. Diffuse injuries may occur through blunt head trauma, penetrating injuries, or abuse. Any damage to the developing brain can negatively affect cognition, memory, attention, learning, language comprehension, language production, and pragmatic language and can disrupt motor control and motor programming for speech and swallowing.3336 Although it has been suggested that young children have greater neural plasticity for mapping new learning, the evidence suggests that earlier age of injury is associated with poorer long-term outcomes.33 Communication problems associated with brain injury can range from a minimal reduction in speech intelligibility to profound impairments of language and cognition that limit communication in activities of daily living. The long-term outcome of very early injury to the cortex is often classified generally as cerebral palsy. Depending on the timing, site, and extent of cerebral damage, speech intelligibility is likely to be affected because of imprecision and discoordination of the respiratory, laryngeal, and articulatory movements for speech. As a result, speech may be limited to a few

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syllables per breath, with inconsistent loudness and inflection, and vocal quality may sound strained or breathy. Speech resonance may sound hypernasal, which is related to poor coordination of the velopharyngeal mechanism. Children who have difficulty producing speech due to central nervous system damage will likely also have problems manipulating food for chewing and bolus control and may have difficulty coordinating laryngeal closure for airway protection during swallowing.37 In addition to oral motor difficulties that affect speech and swallowing, some children who have cerebral palsy have hearing loss and others have cognitive impairments that impact auditory comprehension and language development. Children who have sustained focal or diffuse injury to the brain in infancy or early childhood should be monitored by an interdisciplinary team that can evaluate the child across a spectrum of skills related to cognitive, speech, language, and motor skill development.
Social Environmental Risks for Language and Cognitive Development

Children need a stimulating home environment from early in life, and the language learning environment has the potential to affect a childs capacity to acquire language. Children who experience traumatic events are known to be at risk for disrupted development.38 Children who have postnatal traumatic stress combined with prenatal alcohol exposure have lower intelligence scores and more significant neurodevelopmental deficits, greater oppositional defiant behavior, and greater problems with attention and social interaction than traumatized children who do not have alcohol exposure.38 Children who are known to have been neglected or abused are candidates for a comprehensive evaluation of cognition, development, language, and social development, ideally through an interdisciplinary pediatric team that specializes in working with children who have this history.
International Adoption

When children are adopted internationally, they most often experience an abrupt change in language exposure from their native language to the language of the adoptive family. This sudden change has been termed arrested language development.39 Language acquisition theories suggest that the older a child is at the time of adoption, the more likely it is she will have difficulty acquiring the new language. Age at adoption may also be mediated by the length of time a child was cared for in an institution.40 Glennen41 reported that older children catch up with their peers more slowly than a cohort of children adopted at younger ages, whereas other researchers have found that age at adoption is less predictive than time since adoption.42 Parents who adopt children internationally often have questions about what to expect with respect to language acquisition. A speech-language pathologist can consult with the family to review these expectations, particularly when the child has a known medical condition such as cerebral palsy or cleft palate. When a child is at significant risk for ongoing speech and language difficulties, therapy may be initiated shortly after adoption; however, when a child appears to be following a typical developmental trajectory, an evaluation of speech and language skills conducted within the first 3 to 6 months after adoption is likely to be inconclusive. Parent-report and completed inventories such as the MacArthur-Bates Communicative Development Inventory are strongly correlated with other clinical assessment techniques, at least during the first year post adoption.42 Sequential administration of this parent-report of receptive and expressive language skills can provide a child-specific baseline and measure of acquisition of language skills over time and offer the advantage of monitoring speech and language skills without repeated appointments at the speech clinic.

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SPEECH-LANGUAGE EVALUATION

Speech-language evaluations vary in scope depending on the reason for referral but should provide a comprehensive assessment of speech production and receptive and expressive language skills. A comprehensive audiologic evaluation is ideal, but a hearing screening meets the minimal requirement to rule out hearing loss as a contributing factor to speech sound disorders or language impairments. Examination of oral structures and functions also serves to rule out structural contributions to speech sound distortions and weakness or paralysis of the tongue or soft palate that would contribute to speech disorders and swallowing difficulty. Speech and language skills in children must be assessed within a developmental framework; thus, information from the parents and pediatrician about the childs overall development is critical. The childs medical, developmental, and psychosocial histories are obtained before the evaluation by chart review, parent interview, or both. Interdisciplinary team contexts often allow a richer understanding of the childs development, the family system, and any medical or dental issues. The goal of the evaluation is to assess the childs speech and language function relative to age and developmental expectations. Each evaluation is tailored to the familys concern and the childs needs, although a child who has a speech problem may exhibit decreased speech intelligibility as a sign of an underlying language impairment, so all domains should be evaluated using observation or structured assessment tasks. The evaluation begins in the waiting room as the speech-language pathologist notes the childs eye contact, use of social greetings, shyness, or willingness to engage in play. Assessments may include observing the parent-child interaction, involving the child in play activities to elicit a spontaneous speech and language sample, and administering a standardized test of articulation, comprehension, and expressive language use. Requests made in play or structured activities, such as Put the balls under the bucket, allow assessment of the childs understanding of nouns (ball and bucket), plurals (more than one ball), and prepositions (under). Similarly, structured tasks allow assessment of the childs use of language concepts. For example, pointing to a picture and asking, Whose shoes are those? should elicit a response such as The boys that demonstrates use of the possessive form. Articulation tests allow the speech-language pathologist to elicit all the speech sounds in the language in each word position, within a few minutes. This process yields an inventory of speech sounds that the child uses and those on which she makes errors. These data can then be evaluated to identify common features across the speech sounds and allow comparison with normative data. The speech-language pathologist evaluates all the data obtained and should review the findings with the parents at the time of the evaluation or at follow-up. Recommendations may include no further assessment or treatment, waiting and re-evaluating, giving parents some tips for facilitating communication at home, or direct service intervention.

TREATMENT

When therapy is recommended, the primary goal is to give the child a reliable way to exchange ideas and information in his daily social and educational environment. Treatment is tailored to the specific communication needs of each child, which vary with disorder type and severity, the childs age, and the etiology of the problem. Any speech or language intervention requires that the childs family and educators be involved to provide ongoing support for the child outside of the clinical setting.

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Therapy for Speech Disorders

Treatment for articulation impairments targets the correct production of specific consonant or vowel sounds, whereas treatment for systematic mislearning of the phonologic system in the language addresses the patterns of error, rather than teaching each sound individually.43 After production of target sounds is achieved in structured contexts, treatment addresses generalization of sounds into more natural speaking tasks. Treatment for CAS differs from the approaches used for articulation or phonologic problems and often requires intensive treatment over a longer course of therapy than treatment for children who have other speech sound disorders.44 Isometric oral-motor exercises have often been recommended to strengthen and increase range of movement in the oral mechanism. Because few speech production disorders relate to muscular weakness or reduced range of motion, the finding of limited efficacy of oral exercises is not surprising.45
Therapy for Language Disorders

Children can exhibit language problems in a number of areas including expressive language, receptive language, written language, and social (pragmatic) language. The goals of language therapy and the approaches used are based on the results of a comprehensive language evaluation. Children up to age 3 years are likely to benefit from a focus on language using play-based therapy in which the child and a parent participates as the speech-language pathologist creates an environment rich in opportunities to communicate.46 As the child is reinforced for using new behaviors to communicate in this semistructured play setting, the child begins to learn the social power that these new behaviors bring. This setting also is valuable in demonstrating to the parent language stimulation activities to use at home. Older preschoolers and school-aged children can benefit from individual or group therapy that focuses on their specific language needs (ie, vocabulary, longer word combinations, or the use of more grammatically complex utterances). It is critical that structured language intervention be extended into functional contexts for children, including the school curriculum, to promote generalization of skills into natural communication settings. When the goal of therapy is to increase social language skills, children are often enrolled in group therapy, which provides natural opportunities for supported interaction with peers when working on language and written communication.47
Therapy for the Child who is Nonverbal

When a child is not able to use speech to communicate, the primary goal of speechlanguage therapy is to establish a reliable means of communication using the childs capacity for communication skills, which may include the use of gestures, idiosyncratic signs, more formal baby signs, or an established manual sign language. It is important that treatment provide the child opportunities for communicative success, irrespective of the communication modality used. As the child develops a reliable way to communicate basic needs, nonspeech techniques are expanded to allow for maximal expressive language development. Speech models are given simultaneously as the child works on nonspeech communication to continue to provide opportunities for developing speech production skills; most children demonstrate increased speech production as their communication skills increase.48 Some children do not develop functionally adequate speech communication due to neuromotor, structural, or cognitive impairments. Children who have severe impairments in speech production may benefit from the use of communication

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technology, ranging from the use of a picture communication board to a speechgenerating device to a computer-based system that features access to word processing and voice output.49 A speech-language pathologist can provide evaluation and intervention for the use of alternative communication systems to determine the level and type of technology that best fits the childs daily communication needs.
THERAPY APPROACHES AND SETTINGS

Early intervention services are available to at-risk children from birth to age 3 years. Many programs in county-based school systems provide interdisciplinary evaluation and treatment teams through center-based or in-home services. Children in preschool through high school are most often served by speech-language pathologists in the community or through the school system. School services may be defined for those children identified as having a speech or language deficit (or both) that would interfere with their education. Based on the evaluation findings and recommendations, an Individualized Education Program (IEP) is written, which specifies the goals and frequency of therapy to be implemented through school services.46 In the school setting, children receive services individually or in small groups, based on the IEP. Children aged 0 to 26 years who have severe communication or cognitive impairments may receive services through a center-based program operated by a regional school district. These centers provide comprehensive educational day programs that integrate therapy services in an interdisciplinary team model. Many communities have independent speech-language and hearing centers through hospitals, rehabilitation centers, outpatient clinics, and private practices. In addition, universities with speech-language and hearing training programs may have a clinic on campus that serves as a training site for students in their preprofessional education and can serve as a resource for patients who have limited insurance coverage or other resources for services not covered through other agencies.
ENSURING AN EVIDENCE BASE

In addition to broad efforts to conduct outcomes research in the field of speechlanguage pathology, many clinical sites participate in the American SpeechLanguage-Hearing Association National Outcomes Measurement System, which is a centralized system designed to track changes in functional communication skills between admission to and discharge from speech and language services. Scales to measure patient performance across speech and language domains are available to clinicians in a variety of clinical settings. For example, the preschool scales include specific measures across the domains of articulation/intelligibility, cognitive orientation, pragmatics, spoken language comprehension, spoken language production, and swallowing.50 Aggregate outcomes data are used to examine the value of speech-language services for policy makers, third-party payers, and consumers and to provide members information about best practices.
SUMMARY

Speech and language development should be consistent with the childs overall development and can be tracked using typical milestone markers for comprehension of language and for expressive speech and language skills. Differential diagnosis allows for the distinction between overall language delay, language impairments limited to the expressive domain, and speech production difficulties. Differential

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diagnosis is critical to designing appropriate intervention. Intervention for voice, speech, and language problems should be tailored to the parents goals along with the childs clinical and educational needs. Early identification and intervention assist in educational planning and are often associated with better long-term outcomes. Any speech-language therapy plan should be designed with measurable goals and consistent monitoring of progress toward those goals.
ACKNOWLEDGMENTS

Erin McGraw, MA, contributed research and writing of the section on international adoption. Amy Esh, BA, contributed to the introductory paragraphs and the table of language development milestones.
REFERENCES

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