Communication Disorders

A communication disorder is an impairment that affects an individual’s ability to comprehend, detect, or apply language and speech to engage in discourse effectively with others. According to the Centers for Disease Control and Prevention (CDC), approximately 8% of children between the ages of 3 and 17 years have a communication disorder. Non-Hispanic Black children and males are more likely to be diagnosed with a communication disorder.

Children with communication disorders may demonstrate more challenging behavior, often due to frustration secondary to communication problems. They may also have a difficult time socializing with peers. Children with communication disorders are at increased risk of learning disabilities once they reach school age.

Percent distribution of types of communication disorders among children aged 3-17 years with a communication disorder during the past 12 Months, by age group: United States, 2012. (Source: Communication Disorders and Use of Intervention Services Among Children Aged 3-17 Years: United States, 2012. Center for Disease Control and Prevention, National Center for Health Statistics 2015.)

Risk Factors

• male sex

• family history of communication problems

• prenatal and perinatal complications (e.g., maternal stress, illness or infections during pregnancy, prematurity, low birth weight, or complications during delivery)

• recurrent otitis media with effusion

• cognitive problems

• genetic disorders

Terminology

An understanding of communication disorders requires the differentiation between speech and language:

• Speech refers to how speech sounds are created and formed for the purpose of communication. Speech involves:

  • articulation: how speech sounds are produced, involving the use of the mouth, lips, and tongue

  • voice: the quality, pitch, and volume of speech, involving the use of the vocal folds and breath support

  • fluency: the rhythm of speech

• Language refers to the words we use and how we use them. The two basic categories of language are:

  • receptive: understanding and receiving language

  • expressive: using and producing language

Types of Communication Disorders

Speech Sound Disorder

The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) defines a diagnosis of speech sound disorder as follows:

The American Speech-Language-Hearing Association (ASHA) further breaks down speech sound disorders as follows:

• Functional speech disorder: A functional speech disorder is one that has no known etiology. Most children diagnosed with a communication disorder have functional speech disorders.

  • articulation disorder — occurs when an individual distorts speech sounds or substitutes sounds, such as “wook” instead of “look”

  • phonological disorder — occurs when incorrect patterning is used, such as omitting final consonants when speaking

• Organic speech disorder: An organic speech disorder results from a neurological disorder or structural abnormalities or is a sensory/perceptual issue.

  • motor/neurological:

    • dysarthria — difficulty with execution of speech sounds caused by muscle weakness

    • apraxia — difficulty with motor planning of speech sounds

  • structural: related to a structural difference from a congenital abnormality (e.g., cleft palate) or resulting from trauma or surgery

  • sensory/perceptual: hearing impairment, auditory processing disorder

Childhood-Onset Fluency Disorder

The DSM-5 defines a diagnosis of childhood-onset fluency disorder as follows:

Stuttering is the most common fluency disorder. It can include the repetition of sounds, syllables and monosyllabic words, prolonged consonants when not used for emphasis, and speech blocks (the individual is inaudible or unable to initiate a sound). Disfluency can lead to avoidance of speaking and physical tension around speaking. Cluttering is characterized by a rapid or irregular speech rate, including pragmatic issues, and is important to distinguish from language-formulation difficulties and other disorders that affect speech production. Fluency disorders are also important to distinguish from word-finding difficulties associated with learning a new language.

Language Disorder

The DSM-5 defines a diagnosis of language disorder as follows:

According to ASHA, a language disorder is an impairment in comprehension and/or use of a spoken, written, and/or other communication system, such as American Sign Language. The disorder may involve the form of language (phonology, morphology, syntax), the content of language (semantics), and/or the function of language in communication (pragmatics) in any combination. Language skills are dependent on the acquisition of both expressive and receptive language skills.

Social (Pragmatic) Communication Disorder

The DSM-5 defines a diagnosis of social (pragmatic) communication disorder as follows:

Social (pragmatic) communication disorder differs from autism spectrum disorder (ASD). In contrast with children with social (pragmatic) communication disorder, children with ASD also have challenges with social play skills (e.g., imaginative play and interactive play). Additionally, children with ASD demonstrate repetitive behaviors and restricted interest. (See ASD in the Pediatric Mental Health rotation guide.)

Screening, Evaluation, Diagnosis, and Treatment

Screening

Hearing: All states have some form of universal hearing-loss detection programs, with the majority having universal newborn hearing screening. Early screening and intervention are associated with better speech and language outcomes in children. See Prevention and Screening in the Preventive/Well Child Care rotation guide.

Speech and language delay: Surveillance for speech and language delay should be part of all routine well child visits. Pediatricians should be monitoring acquisition of developmental milestones during visits and implementing standardized developmental screening tools at regular intervals, including evaluation of speech and language skills. Currently, no screening tools that are specific to speech and language disorders are available for use in the primary care setting. Speech and language screening is performed using validated general developmental screening tools (e.g., Ages & Stages Questionnaires, Third Edition [ASQ-3], Parents’ Evaluation of Developmental Status [PEDS]), which the American Academy of Pediatricians (AAP) recommends during well child visits at ages 6, 18, 24, and 30 months.

When there is concern for speech and language delay, the child should be promptly referred for a hearing evaluation (even if the child was screened as a newborn) and referred to a speech and language pathologist for definitive diagnosis or to receive early intervention services if younger than 3 years (see the Individuals with Disabilities Education Act [IDEA] in the section on Screening, Referrals, Evaluation, and Services in this rotation guide). Referral is advised whenever speech and language delay is a concern.

Evaluation and Diagnosis

Speech-language pathologists use a variety of tests for evaluation and diagnosis, based on a child’s age, level of functioning, presenting concern or problems, and parent and/or teacher observations. Various tools exist to test articulation, receptive vocabulary, expressive vocabulary, receptive and expressive language, written language, and/or reading. The speech and/or language diagnosis will reflect the results of testing.

Differential diagnoses and contributing factors of communication disorders:

• deaf/hard of hearing (a hearing test should be conducted in any child when there is concern for a speech and language delay)

• range of normal acquisition of skills

• motor impairment (e.g., dysarthria with cerebral palsy, verbal dyspraxia)

• selective mutism (selective mutism is an anxiety disorder; children with selective mutism should demonstrate normal speech and language in comfortable settings)

• Tourette syndrome (differential for stuttering; a speech-language pathologist can help to distinguish between the two)

• autism spectrum disorder (ASD; can be distinguished from social [pragmatic] communication disorder by the presence of restricted and repetitive patterns of behavior [see ASD in the Pediatric Mental Health rotation guide]).

• social anxiety (can be distinguished based on the timing; a child should have demonstrated a normal period of communication prior to experiencing social anxiety)

Treatment

Treatment for communication disorders can include any combination of the following interventions:

• speech therapy (speech sound production)

• language therapy (receptive, expressive, or both)

• social skills therapy (includes language pragmatics)

• fluency therapy (stuttering)

• voice therapy (voice quality such as hoarseness, hyper- and/or hyponasality)

• augmentative and alternative communication (AAC; pictures, communication device)

• sign language (manual signs)

• therapy for written language (spelling, reading, story writing)