Something to Talk About

Courtney
McGrath
Early Interventions Can Bring Out the Chatterbox in Children

Madelyn Dennis with Her TherapistFew experiences thrill a parent more than the first time they hear their child say "mama" or "dada." Those words, often a baby's first, are usually followed by a flurry of new ones, and eventually phrases, thoughts, questions and observations that give parents constantly new glimpses of the unique person their child is becoming.

But for many children, speech and language development doesn't come so easily. Between 10 and 30 percent of preschool-age children, those between the ages of 2 and 5, do not develop speech and language skills as expected. Such delays can keep children from saying their first words, or can cause their speech to be unintelligible or their vocabularies limited to just a few words. Speech and language problems can occur alone, or can be "symptoms" of learning, attention, social, emotional, genetic or motor disorders.

Left untreated, speech and language disorders can have significant, negative consequences on a child's social, emotional and academic development. "Communication, usually in the form of speech, is how we connect with each other as human beings," says Dr. Jan Turner, director of the Speech-Language and Assistive Technology Department at Kennedy Krieger. "For a young child, it's part of the bonding process with a parent or caregiver. As children begin to move outside the home into other environments, it's how they interact with and learn to make sense of the world." If this ability to connect with others and comprehend the world around them is limited, a child's ability to make friends can be compromised, and the foundations of reading and even math may be harder to grasp.

As parents well know, each child is unique and they all develop differently. In spite of these individual differences, most children learn speech and language in a predictable order and at roughly similar chronological ages. We know, for example, that babies 3 to 6 months old make nonsense speech sounds, called babbling. They engage others in the earliest forms of conversation by vocalizing, laughing and making eye contact. One-year-olds can already say a word or two, though they probably don't pronounce them the same as adults. By 2 years, children's expressive power increases as they begin to combine words into short phrases, such as "more milk." Parents and professionals often know whether these milestones, or the precursor skills of these milestones, are present, even in very young children. When skills are slow in coming, having a professional evaluation is the first step in meeting a child's needs.

Kennedy Krieger operates several programs where children suspected of having speech or language disorders can receive evaluations or treatment. Speech-language pathologists (SLPs) evaluate children's communication and feeding-swallowing skills through observation, play and structured activities. Parents' insights provide critical information about their children's strengths and needs. SLPs might ask whether a child pantomimes or gestures to convey wants and needs. Children who do might have a solid understanding of language concepts, but lack the motor control for speech. Audiologists check hearing, even in very young children, because of its importance in speech and language development and learning.

For a broader perspective on development, more than 500 families bring their preschool-age children to Kennedy Krieger's Center for Development and Learning each year for medical and developmental evaluation. Youngsters receive a full physical examination and parents provide detailed medical histories, helping the program's staff of neurodevelopmental pediatricians and nurse practitioners determine what factors might be affecting a child's development of speech-language skills.

Then, says CDL Director Dr. Paul Lipkin, "we look at how far behind a child is in the development of language milestones compared with other areas, which helps us understand if a language delay is tied to other delays. We'll examine how well a child follows commands, can name or point to objects, or understand words. We also look at how the child performs on non-language based tasks like completing puzzles, stacking blocks and drawing." These observations provide a more in-depth picture of the child's development than a typical well-child visit could.

Toddlers (children below age 3) diagnosed with speech, language or feeding/swallowing difficulties are eligible for therapy provided by their state's Infants and Toddlers or similar program. Children age 3 to 5 can receive services through their school districts. Many parents also seek private therapy at places like Kennedy Krieger. Kennedy Krieger's Speech and Language department treats more than 150 children each year, more than half of whom are under the age of 5. "The years before a child starts school are the big explosion years in terms of language development, so that's the best time to address a speech or language disorder," says Barbara Hartshorn, a Kennedy Krieger speech-language pathologist who specializes in treating young children. "That's not to say we can't help an older child, but it's a lot easier to complement what is being developed in the usual timeframe than to go back and have to re-teach the concepts." Children can also receive community-based services through Kennedy Krieger's Child and Family Support Program or the PACT program.

Madelyn DennisSpeech-language pathologist Dana Mason began treating late-talking 2-year-old Madelyn Dennis in the summer of 2003. Madelyn's older brother had been a late talker, too, but mom Kimberly attributed his delay to the chronic ear infections requiring tube placement and slight hearing problems he'd had as an infant. He soon caught up and began chatting up a storm. But at 2, Madelyn couldn't say any words at all. Madelyn has received therapy at Kennedy Krieger to help with a gross motor delay, and her physical therapist suggested that Mrs. Dennis have a Kennedy Krieger speech-language pathologist work with Madelyn.

During an early session, Mason noticed that Madelyn constantly mouthed her toys, sucked on cloths and sought other means of stimulating her mouth. Suspecting the true cause of Madelyn's speech problems, she watched as Madelyn tried to manipulate a lollipop with her tongue. Madelyn had almost no control over the lollipop's movement. Mason realized that the same low muscle tone that weakened Madelyn's legs had affected her mouth as well. Since then, Madelyn's therapy sessions have focused on strengthening the muscles in her mouth and jaw to allow her to form words. Mason massages the inside of Madelyn's mouth for the first 10 minutes of each session.

"Madelyn loves it," says Mrs. Dennis. "Then, to work Madelyn's muscles even more, they'll use a chewy tube and play what looks like tug-of-war."

With Madelyn's oral muscles getting the extra attention they needed, Mason has moved on to other activities like reading books to Madelyn, playing games, role-playing and singing.

In just a few months, Madelyn has gone from saying no words at all to putting together multiple word phrases. Her progress has amazed her mother. "She still has trouble saying "j" sounds, so calling for her brother Jonathan is still tough," says Mrs. Dennis. "But when she really wants something, it comes out clear as day."

The play-oriented activities Mason has tried with Madelyn are tailor-made for preschoolers, says Hartshorn. "Kids that age just can't be expected to sit behind a desk and do drill work," she says. "It has to involve a game or real-life activity."

At Kennedy Krieger, a speech-language pathologist might ask a child to pretend that they're playing store and have the child ask for items that include the sound being worked on that day. They could also re-tell a story where the main character's name begins with that sound. "You pick an activity or toy of interest to the child and use new sounds, forms and phrases related to it," says Dr. Turner. "If a child likes animals, you might play with a barn set and talk about how the cow went outside the fence' and let the child see the language paired with something meaningful to them."

Three-year-old Brian High's speech language pathologist Nancy Solomon uses vibrantly colored Play-Doh to engage him. "They'll both work with it," says mom Maria. "She shows him what all sorts of words mean: snake, ball, push. Then he uses the Play-Doh to show her he understands." When he began speech therapy this past summer, Brian had just a few words, and many of those he'd say just once and never repeat. Now, he adds new words to his vocabulary every day.

When speech-language difficulties are indicative of autism, other pervasive developmental disorders or intellectual disabilities, early identification and intervention can make interaction with others easier for children with these disorders, too.

When her son Robert was 16 months old, mom Laura began noticing that his language skills, which had been developing normally, were deteriorating. He had even lost the ability to say "mama." Kennedy Krieger's Dr. Rebecca Landa recognized Robert had an autism spectrum disorder in July 2003, just before he turned 2. This diagnosis means that Robert meets some, but not all, of the criteria for autism. Since then, Robert has received speech therapy one to three times each week. The speech-language pathologist does a lot of oral motor work to help increase Robert's awareness of his mouth and his breathing patterns, and has taught sign language techniques to help Robert communicate when he has trouble speaking. Now, Robert's vocabulary is up to 50 words far higher than it was before his communication abilities began to decline.

In order to increase their children's chances for success at school and in other settings, all three families are continuing the lessons learned in therapy sessions at home. Many of these techniques can enhance communication skills in all children, not just those with speech and language or feeding/swallowing difficulties.

Brian High"One of the first things all parents should do is make sure they're providing adequate opportunities for their child to learn language through normal, everyday interaction and conversation," says Dr.

Lipkin. "Reading to your child, asking questions and introducing new objects and activities can all reap remarkable improvements in the tools a child has to understand his environment."