Out of the mouths of babes

"I`ll get you, you wascally wabbit!" "Th-th-th-th-that`s all folks!" "Thufferin` thuccotath!" "I taught I taw a putty tat!" I`ll bet you know exactly what famous cartoon characters are known for these uniquely spoken, comical sayings. However, these same speech problems aren`t so funny in real life, especially when a child is struggling to communicate. Often speech disorders are missed, even by a child`s physician or pediatrician. Concerned parents are often pacified by well-meaning friends or r

Feb 1st, 1999

Are you spotting communication disorders in children?

Cathleen Terhune Alty, RDH

"I`ll get you, you wascally wabbit!" "Th-th-th-th-that`s all folks!" "Thufferin` thuccotath!" "I taught I taw a putty tat!" I`ll bet you know exactly what famous cartoon characters are known for these uniquely spoken, comical sayings. However, these same speech problems aren`t so funny in real life, especially when a child is struggling to communicate. Often speech disorders are missed, even by a child`s physician or pediatrician. Concerned parents are often pacified by well-meaning friends or relatives with the cliché that he or she will "grow out of it."

Unfortunately, many children do not grow out of it. Hundreds of children are brought to each one of us for dental care. We are in a unique position to detect possible speech and language difficulties and can refer the parent to get help for their child. Why is this important? How do we recognize these problems? How do they happen? What do we say to the parent?

The evidence is convincing regarding the impact that a speech-language problem can have on a child`s academic development. According to Dr. Diane Paul-Brown, director of Speech-Language Pathology Practices/Clinical Issues at the American Speech-Language-Hearing Association (ASHA) in Rockville, Md., "If a preschooler has trouble with language, it`s highly likely that he or she will have a problem with written language, such as reading and writing, as he or she grows. Language is also used as the child advances in school and begins social studies and math. Underlying academic problems are often first a language problem."

The classifications of speech or language disorders are: articulation problems, fluency, voice problems, language use, language content, and language form. The disorders affect the way a person talks or understands, ranging from substituting sounds to not being able to speak at all. Speech-language pathologists are most qualified to make a specific diagnosis of these disorders, but hygienists who understand the basics can notice problems and make an appropriate referral.

Articulation is the pronunciation of sounds. An articulation problem is when sounds or words are pronounced incorrectly, interfering with communication. These problems can be due to physical causes, such as cleft palate or hearing loss, or they can be due to incorrect placement of lips or tongue while speaking. Lisping and tongue-thrust problems are very noticeable to the dental professional because of the tongue movement during speaking. The teeth often will reflect incorrect tongue placement because there may be an open bite or a large overbite.

Dr. Paul-Brown adds that articulation problems are typically not the result of a "lazy child," as some people mistakenly believe.

Fluency is the smoothness of speech flow. Stuttering is a common fluency disorder, as is excessive use of "uh" when speaking. Dr. Paul-Brown says that a certain amount of stuttering is normal at any age. However, if a child appears to be struggling to get words out, appears to be self-conscious, or repeats sounds in words often, there could be a fluency problem.

If a child receiving dental care is stuttering, Dr. Paul-Brown suggests that hygienists not call attention to the stuttering. Do not say, "slow down," "stop and start over," or "think before you talk." Don`t look away or fill in the words. Instead, she suggests we listen carefully and patiently to what the child is saying and then talk to the parent about a referral.

A voice problem is when you are more aware of the vocal quality than the content. Any vocal extreme is suspect. It may be too loud or soft, too high- or low-pitch, hoarse, breathy, or nasal. It could also mean pain or discomfort when speaking. "If a child is hoarse," says Dr. Paul-Brown, "and the parent says he`s been hoarse for more than a week, encourage the parent to have it checked out." If a child talks loud all the time it could damage the vocal cords.

Language use or vocabulary problems can be indicated when a child relies on gestures or other nonverbal ways of communicating. It`s as if they lack the vocabulary to express their feelings. The child may say the same words over and over again or point to simple objects instead of saying the name. They may not ask questions or take turns in a conversation.

Dr. Paul-Brown says children may have a language problem when they do not seem to understand when it is appropriate to talk and when it is not. "This is the social use of language; you talk differently depending on where you are or who you are talking to. For example, a child is not expected to shout in the dental office. He would be expected to use more formal language and talk appropriately to those in authority. The child may appear to be disrespectful, but he may not know how to use appropriate social conventions in speech."

If a child seems to have difficulty in the way hy put his words together, - for example: "Juice want me" instead of "I want juice" - this may indicate a language form problem. Dr. Paul-Brown says that if the word order is unusual or mixed up at any age, we should bring it to the parent`s attention. This classification also includes omission of the last sound in a word (how for house) or substituting one sound for another (toup for soup). Often these children are understood by their parents or family, but others cannot understand the child without a family interpreter.

Disorders of language content are when a child can`t convey ideas; their expressive language words are spoken correctly, but they don`t make sense. They may substitute one word for another with a similar sound, but a dissimilar meaning.

There are expected language behaviors for different ages. Dr. Paul-Brown said, as a general rule, you should expect to be able to understand a child most of the time by age 3 or 4. If a preschool child is mispronouncing words or sounds, or can`t be understood, a visit to a speech-language pathologist (also called a speech therapist) may be in order. Children are individuals and develop at different rates, but, as a rule, there should be continuous growth in speech skills.

The causes of these problems vary. Sometimes, it`s a hearing problem, requiring the help of an audiologist to diagnose. There could be a genetic predisposition, especially with a fluency dysfunction. Or, it could be a "developmental delay of unknown cause," according to Dr. Paul-Brown.

How do you approach a parent when you believe a child may have a speech or language disorder?

Dr. Paul-Brown suggests, "I would ask the parent in private, not in front of the child, if the parent has any concerns about the child`s speech. Have they noticed anything unusual about their child`s speech? Or you could ask if the parent had noticed how the child speaks and then explain what you noticed. Give them a chance to respond in case the parent is aware and the child is already in treatment for the problem. If the parent is unaware, then describe the behavior of the child: `He mispronounces this sound,` `He frequently repeats a word,` `His voice is unusually loud or hoarse,` `He didn`t seem to understand me,` etc. If the parent says the pediatrician said he`d outgrow it, that is an alert! Don`t say to the parent that the doctor is wrong; just suggest maybe they should have it checked out by a speech-language pathologist - just in case."

Early intervention is very important, according to Dr. Paul-Brown. "The earlier the treatment, the less likely there will be long-lasting effects in academic and social areas."

Some parents feel they can fix a child`s speech problem by diligently correcting the child. Children who stutter often will be told to slow down, even though "speed" is only part of the problem. Besides, Dr. Paul-Brown points out, it is difficult for a child to slow speech down. Often, the child feels more pressured to speak correctly and this increased pressure leads to decreased fluency. A child who shouts frequently can`t stop the habit easily; he or she needs more help than being shushed by a listener. Swallowing and tongue-thrusting problems need professional guidance to overcome. Besides, some speech and language problems are just the tip of the proverbial iceberg for other more serious health difficulties.

If a parent is being dismissive about a child`s speech problem, Dr. Paul-Brown proposes that you ask the parent, "Would you like for me to call and have information about this sent to you?" Then you could call an organization such as the American Speech-Language-Hearing Association and have brochures mailed directly to the home. If nothing else, you can plant a seed in the parent`s mind that there may be a valid concern about the child`s speech or langauge use. Perhaps the parent will begin to notice the problem as well.

Some parents depend on schools to detect and report any communication dysfunction. While many children are routinely screened for speech and hearing problems in school, it is considered a cursory screening. Health conditions such as fluid in the ear or seasonal allergies influence the results at a screening. Once a child falls behind in speech or language, he will find it difficult, if not impossible, to catch up on his own.

Schools can, however, be a valuable resource for the child if speech and language evaluation is needed. Most children, including toddlers and preschoolers, can receive testing and treatment, if recommended, at no cost in the school system. The parent, though, really has nothing to lose by having the child professionally evaluated and gains piece of mind knowing that everything is OK.

Other parent resources are the community health agencies, hospital or university speech-language-hearing clinics, and speech-language-hearing centers.

Another good resource for information and referrals for speech-language pathologists or audiologists is the American Speech-Language-Hearing Association (ASHA). This professional organization offers free brochures and other literature on all facets of speech and hearing difficulties. They can also refer parents to speech and hearing professionals in their geographic area who can investigate speech, language, or hearing concerns. They also have a newsletter which contains helpful articles and lists of self-help consumer groups for people with communication disorders. Dental hygienists are encouraged to call for free individual brochures on hearing, language, and communication problems. If you want larger quantities to have available at the office for parents, they can be purchased from ASHA. You can reach ASHA at (800) 638-8255 or via e-mail: irc@asha.org.

With some careful listening, evaluation, communication with parents, and appropriate referrals, we can help keep the speech disorders in the mouths of TV cartoon characters and out of the mouths of our Obabes.O

Cathleen Terhune Alty, RDH, a frequent contributor to RDH, is based in Rochester Hills, Mich.

Indicators of developmental language disorders

* Absence of words by age 18 months

* Absence of two-word phrases that have a message by age 2 years

* Inappropriate responses to questions

* Echoing of speech

* Poor intelligibility (unclear speech)

* Undeveloped play skills

* Poor understanding or use of adjectives (descriptive words) and prepositions (in, out, under, etc.)

* Word-finding problems

* Dependent on gestures to follow directions

* Requires frequent repetitions of directions

* Poor social interaction with peers (does not get along with other children)

* Poor school performance

by Sharon Willig, Georgetown University Child Development Center

Additional resources

* "How Does Your Child Hear and Talk?" - helps parents identify possible speech, language, and hearing problems (includes checklist of developmental milestones).

* "Early Identification of Speech-Language Delays and Disorders" (Let`s Talk No. 32) - addresses importance of evaluation and identification.

* "Activities to Encourage Speech and Language Development" (Let`s Talk No. 42) - describes activities for ages 0-2, 2-4, and 4-6 years.

* "Late Blooming or Language Problem?" (Let`s Talk No. 66) - discusses parental concerns about children`s development, factors the parents can look for, and the role of professional evaluation.

The above are available from ASHA at (800) 638-TALK.

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