The delays in Development

by Ann-Marie C. DePalma, RDH, BS

We treat a variety of patients — young, old, and everything in-between. With adult patients, intra-extra oral exams, tobacco cessation information, and blood pressure screenings are all part of daily clinical hygiene practice. We also now know the relationships between periodontal disease and systemic diseases. But with younger patients, we can also be of valuable assistance to them and their families. This is especially true of the recognition of developmental delays.

The American Academy of Pediatrics and the American Academy of Pediatric Dentistry recommend that the initial dental visit be at one year of age. This visit is not a "maintenance" visit, but rather a counseling session for the parent/caregiver. It can be used to evaluate the risk of ECC (early childhood caries), pacifier use, thumb sucking, nutritional issues, and any other dental related issues or concerns. It can also be a valuable experience for the parent, giving them a "dental home" if recent dental experience has been relocated or minimal. But what should hygienists be aware of in the recognition of childhood developmental delays? This article will review some of the signs and symptoms of delays.

Each child is a unique individual and progresses through various stages at his/her own pace. However, there are general areas with which a child can be expected to be at various times in cognitive, speech, and motor skills.

One detail to understand prior to determining if a child may be developmentally delayed is the concept of chronological age vs. adjusted age. With normal births at full gestation, the chronological age is the actual age of the infant — three months, six months, eight months, etc. However, if a child is a premature infant, then his/her age is adjusted to the age they would have been if born at full gestation. For example, a child born at 34 weeks gestation (given that normal gestation is 40 weeks) may be considered two months premature. Therefore, at age four months (chronological age) the child will have an adjusted age of two months. The child will then be only expected to be doing activities that a two-month-old would rather than a four-month-old.

This age difference usually lasts until approximately age two, when the adjusted age "catches" up to the chronological age and there is very little difference in children, if both are healthy and without any other serious medical issues.

But if a four-month-old normal birth child is performing at a two-month-old level, then a delay or disorder may be present. A child experiencing a delay is defined as a child whose skills are developing at a slower rate than normal; the skills are present but slow to emerge. Children who present with a disorder, though, will be developing skills abnormally or not at all.

Speech and language

Many delayed children experience speech/language and motor delays. As hygienists our realm of practice deals with the oral cavity. Speech is a natural product of that environment. In order for the hygienist to begin to understand the complexities of delays, one must first understand the differences between speech and language.

Speech is the motor act of sound production, while language is the tool by which experiences are symbolized and communicated to others. Language is governed by a rules system (syntax and grammar).

Speech is governed by phonation, resonation, and articulation. Phonation involves the way sounds are used to pronounce words; resonation involves the voice qualities and sound; and articulation involves the rapid and precise movements of the teeth, tongue, lips, and mandible — the oral environment about which the hygienist is knowledgeable.

Any problem with either speech or language constitutes a communication disorder. Also, limited control of the muscles of speech (motor) can also present problems for the child. These muscles may be ineffective or weak depending on the particular situation.

An area of speech and language that is often overlooked involves the hypo and hyper nasality of the child's voice. Nasality is part of the resonation of the voice and occurs when too much or too little air passes over the vocal cords. Children who have hyper-nasal voices experience a high-pitched voice, while those with hypo-nasal voices sound muffled.

A major reason for hypo-nasality (beyond the normal "cold" symptoms) is enlarged adenoids and, to a lesser degree, enlarged tonsils. Children who have enlarged adenoids not only exhibit a hypo-nasality, but also a number of other non-speech related problems. These children often exhibit episodes of sleep apnea, with related lack of sleep. Children who have sleep apnea often are more frustrated and tired than children of the same age. They may also experience repeated bed-wetting episodes, beyond the age-appropriate stage. Because sleep apnea can result in a lack of oxygen, children who experience repeated episodes are at risk for developing delays.

What should parents, caregivers, and hygienists be aware of in recognizing developmental delays? There are broad ranges of "normal," but if children do not reach certain milestones, then evaluation by appropriate sources is needed. As hygienists, we can only discuss what we find in our evaluations; diagnosis of delays is beyond our scope of practice. But we can be instrumental in pointing parents to the appropriate sources, thus alleviating frustration for both the parent and child.

Early warning signs of children who may have a communication delay or disorder include:

• No babbling as an infant
• No single words by 18 months of age
• No simple phrases by age two ("more juice," "ball go")
• Inappropriate responses to questions asked and poor intelligibility for a particular age.

As children mature and develop, sound phonemes (sound sequences) also grow and develop. At age two, for example, a child may say "wabit" for "rabbit" and this is considered appropriate. However, a four-year-old saying the same thing would be inappropriate because the four-year-old should have the necessary phoneme to pronounce the "r" in rabbit. The consonant blends (sh, ch), and the letter "l" are more difficult phonemes to master and may not be clear even as late as ages 6 or 7.

Another area for concern is hearing. If a child cannot hear the appropriate sounds correctly, how is he/she going to make them correctly? Therefore, hearing is another avenue within communication disorders/delays that must be evaluated. Warning signs for hearing problems which are more subtle than profound hearing loss include:

• For infants, startling/crying/turning to new noise

• A four- to six-month-old should respond to the word "no" (may not know what it means but knows it means something)
• One-year-olds should be able to name simple body parts
• Two-year-olds should be able to follow simple commands
• Three- and four-year-olds should be able to answer simple who/what/when/where/why questions.

If a parent or caregiver note any concerns or issues in any of the communication areas, a referral to appropriate sources is encouraged. Speech and language pathologists deal with any speech related issue, while audiologists are involved in hearing. Both often work in conjunction with one another and the child's medical team.

In older children, evaluations deal more with learning and social skills. A kindergartener should be able to make the appropriate sounds for beginning reading and, if not know, then at least recognize the letters of the alphabet and numbers 0-9. A first grader should be able to understand that reading progresses left to right, and that sounds make up words, and words make sentences. They should also be able to recognize common "sight" words (I, me, my, see). As a child progresses through grades, how he/she interacts with other children is also an important indicator of communication problems. Children who avoid basic eye contact or tend to seem distracted during conversation tend to miss some of the important non-verbal cues that occur during speech. Therefore, these children are often mislabeled as "problem" or have trouble with their peers, when in actuality they may have a communication problem.

Speech and language delays can affect a child's life from the earliest communication to social and school activities. Early recognition of delays and the appropriate treatment can go a long way in altering the child's outlook in life. As hygienists we are committed to enhancing our patient's lives, and by recognizing delays and using appropriate referrals to treatment sources we are enhancing both our professional lives and those of whom we treat.

It is estimated by state Early Intervention programs that a significant portion of children will experience some type of speech/language, motor or cognitive delays, which may severely impact the child's social, emotional, and academic life. Early Intervention is a federally mandated program under the auspices of the Americans with Disabilities Act in all 50 states that can provide services for children who have or are at risk for developing delays or disorders. Each state can determine actual eligibility requirements (based on national requirements) but services can be for children from birth to age three or, in some instances, age five. EI programs are usually found under the Department of Public Health.

Each state's requirements are different, but Massachusetts EI program requirements involve the child and/or family possessing four or more specific characteristics or having a diagnosed medical condition(s) that are known to involve delays or disorders.

Examples of medical conditions would include, but are not limited to cerebral palsy, Down syndrome, cleft lip/cleft palate and seizure disorders.

Child and family characteristics include (and again are not limited to):

• Birth weight less than 2 lbs, 6 oz
• Gestational age of less than 32 weeks
• Total hospital stays of greater than 25 days in six months
• Maternal age less than 17, or three or more children prior to age 20
• Multiple losses or traumas, and substance abuse or domestic violence in the home.

Upon reaching the "age-out" age, the child, if services are still needed, becomes part of the Special Education department of the local school system. Under SPED, President Bush's "No Child Left Behind" act is in place. This act signed in January 2002 is meant to enhance public school systems around the country, as well as provide for SPED needs. Funding is a major source of problems for these programs, and therefore SPED departments are often unwilling to place children in SPED unless it is absolutely necessary.

Differences between EI and SPED exist primarily in the mode of services. EI is very family-centered, while SPED is school-based and it is often difficult for families to adjust to the SPED programs. However, SPED can accomplish significant goals in the delayed child's life. Depending on actual needs and services, children can obtain in-class or out-of-class programs either one-on-one or in group settings. Depending on the state rules and regulations governing SPED programs, evaluations can be held monthly, quarterly, yearly, or of longer duration.

What can parents/caregivers do to improve and encourage a child's speech and language development? Depending on a particular child and the life stage the child is in, a variety of strategies can be utilized. Talking naturally to children, even from the youngest age, stimulates the communication process.

A parent/caregiver can discuss what is going on during the day's activities, even though the child may not understand the meaning. This activity stimulates the child to understand the beginning concepts of language. As the child grows, imitation of sounds occurs and this should be encouraged in the back and forth communication process.

Maintaining eye contact, altering the pitch and tone of voice, and directly listening to the child can also enhance the overall skill of the child. The use of "baby talk" should be discouraged. For the older child, gradually increasing the sentence length and structure as the child grows and matures is also important. Not constantly repeating the child's speech errors but rather "modeling" the correct sounds and words is appropriate for children of any age.

If a younger non-verbal child shows signs of frustration at the lack of communication skills, simple sign language can be used. It can be the parent/caregiver's own "made-up" signs or simple forms of American Sign Language (ASL).

Other oral motor stimulators include: bubble blowers, party favors, specially designed toothbrushes and rubber tubing, the use of seltzer water (the bubbles stimulate muscles). These can aid in the development of the structures needed for speech production and are used quite often in speech therapy, along with a variety of other resources.

Ann-Marie C. DePalma, RDH, BS is a practicing hygienist in a periodontal-implant practice.She is a graduate of the Forsyth School for Dental Hygienists, is active in the Massachusetts Dental Hygienists' Association, and is a Fellow of the Association of Dental Implant Auxiliaries and Practice Management.Ann-Marie has written articles and presents programs on dental implants, TMD, and developmental delays and can be reached at [email protected].