My Child Doesn’t Talk!

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My Child Doesnt Talk!

• Mark Cohen, M.D., F.A.A.P.
• Developmental Pediatrician
• Exceptional Family Member Program
• Tripler Army Medical Center
• Honolulu, Hawaii

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Question

• What is the most common complaint among children
  who are referred for developmental pediatrics
  evaluation?

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Hint
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Answer

• Hes not talking.

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First word (not mama or dada)

• 50 by 12 months
• 90 by 15 months
• If a child is not saying any words at the 15
  month visit
• DONT WAIT -- EVALUATE!

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QUIZ

• Which of the following would be a good
  explanation of why a child is not talking by 15
  months of age?
• (Im not going to tell you how many of the
  choices are correct)

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He doesnt talk because

• Hes a boy
• His siblings all talk for him
• He gets everything he needs
• We speak two languages at home
• Hes lazy
• His father didnt talk until he was 3

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He doesnt talk because

• Hes a boy
• His siblings all talk for him
• He gets everything he needs
• We speak two languages at home
• Hes lazy
• His father didnt talk until he was 3

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He doesnt talk because

• Hes a boy
• His siblings all talk for him
• He gets everything he needs
• We speak two languages at home
• Hes lazy
• His father didnt talk until he was 3

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He doesnt talk because

• Hes a boy
• His siblings all talk for him
• He gets everything he needs
• We speak two languages at home
• Hes lazy
• His father didnt talk until he was 3

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He doesnt talk because

• Hes a boy
• His siblings all talk for him
• He gets everything he needs
• We speak two languages at home
• Hes lazy
• His father didnt talk until he was 3

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He doesnt talk because

• Hes a boy
• His siblings all talk for him
• He gets everything he needs
• We speak two languages at home
• Hes lazy
• His father didnt talk until he was 3

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He doesnt talk because

• Hes a boy
• His siblings all talk for him
• He gets everything he needs
• We speak two languages at home
• Hes lazy
• His father didnt talk until he was 3

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So, what are the real reasons?
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The Real Reasons

• Generalized developmental delay

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The Real Reasons

• Generalized developmental delay
• Hearing loss

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The Real Reasons

• Generalized developmental delay
• Hearing loss
• Speech and language disorders

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The Real Reasons

• Generalized developmental delay
• Hearing loss
• Speech and language disorders
• Autism

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The Real Reasons

• Generalized developmental delay
• Hearing loss
• Speech and language disorders
• Autism
• Other less common conditions (deprivation/abuse,
  cerebral palsy, central auditory processing
  disorder, Landau-Kleffner Syndrome, selective
  mutism, etc.)

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Developmental Delay

• Due to an abnormality of brain function
• NOT due to laziness, stubbornness, or poor
  parenting
• Terminology
• Developmental delay up to about age 4
• Mental retardation for older children

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Developmental Delay

• Delay in multiple domains
• Language
• Expressive
• Receptive
• Motor
• Gross
• Fine
• Cognitive/Adaptive (Thinking)
• Personal/Social

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Developmental Delay

• Multiple causes
• Chromosomal (Trisomy 21, Fragile X)
• Genetic, non-chromosomal syndromes
• Intrauterine toxin (Fetal alcohol syndrome)
• Metabolic (hypothyroidism)
• Infection (intrauterine or postnatal)
• Etc., etc., etc.
• WRDK

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• CAUTION
• Devel appears WNL

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• CAUTION
• Many children with significant delay are
  missed by medical professionals because they
  look good

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Take-home Lesson 1

• If a child is not talking, you MUST consider
  developmental delay as a possible cause.

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Hearing Loss
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Hearing Loss

• Infant screening has been a BIG help
• Family history
• Hearing loss
• Kidney disease
• History of meningitis or frequent otitis
• Ask the parents if theyre concerned
• Forget the hand clap!

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Hearing Loss

• Infant screening is not 100 reliable
• Hearing loss can be acquired postnatally
• Children with significant hearing loss can
  respond to visual cues, vibration, etc.
• So.

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Take-home Lesson 2

• Any child who is not talking needs a HEARING
  TEST!
• Refer to an audiologist with pediatric expertise
• For younger children, may need ABR (Auditory
  Brainstem Response)

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Speech and Language Disorders
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Quick Review Language vs. Speech

• Receptive language (brain)
• Expressive language (brain)
• Speech (brain muscles oral structures)
• May have a problem with any or all of these

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Developmental Language Disorder

• Expressive, receptive, or mixed
• Mixed delays are often associated with delayed
  cognitive development
• Motor skills and nonverbal cognitive skills may
  not be as severely delayed

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Expressive Language Delay

• Isolated delay
• Key receptive language is OK
• No delays in other areas
• May be familial
• Most will develop normal speech (with speech
  therapy)

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Developmental Phonological Disorder

• Distortions, omissions, substitutions of phonemes
  producing speech that is difficult to understand
• A language problem, not a motor problem
• Vowel sounds are usually OK
• Responds to speech/language therapy
• May have later reading problems (dyslexia)

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Developmental Apraxia of Speech

• Developmental Verbal Dyspraxia
• Apraxia of Speech
• Developmental Articulatory Dyspraxia
• Apraxia
• Dyspraxia

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Developmental Apraxia of Speech

• Primarily a speech problem
• (Some think its also a language problem)
• Impairment in the brains ability to plan and
  control motor patterns
• No weakness of muscles
• Apraxia may affect fine and gross motor skills as
  well as speech

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Signs of DAS

• Does not coo or babble as an infant
• Late to talk, and words are missing sounds
• Speech is slow, irregular, and there are
  inconsistent errors
• Errors in both vowels and consonants

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Autistic Spectrum Disorders
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Autistic Spectrum Disorders

• Pervasive developmental disorders
• Autistic disorder
• Aspergers disorder
• Retts disorder
• Childhood disintegrative disorder
• Pervasive developmental disorder, not otherwise
  specified (PDD-NOS)

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Autistic Disorder

• Impairment in social interaction
• Impairment in communication
• Restricted, repetitive, and stereotypic patterns
  of behavior, interests or activities
• Impairment in social interaction, social
  communication, or imaginative play

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PDD-NOS

• Child appears to be in the autistic spectrum but
  doesnt fit full criteria for autistic disorder
• More common in younger children
• Treatment approach same as autism
• Long-term prognosis uncertain

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MYTHS About Autism

• Parents cause autism
• MMR vaccine causes autism
• All autistic children are severely retarded, or
  savants like Rain Man
• Autistic children never make eye contact or
  express affection
• Autism is permanent and incurable

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More MYTHS About Autism

• All autistic children
• line up their toys
• spin around
• flap their hands
• walk on their toes
• turn light switches on and off

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FACTS About Autism

• Autism represents a spectrum, from mild to severe
• Autism is a brain disorder, probably due to
  genetics and other factors
• An autistic child can make eye contact and be
  affectionate

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More FACTS About Autism

• Not all autistic behaviors are due to autism
• Not all autistic children demonstrate autistic
  behaviors

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Early Intervention for ASD

• Speech/language therapy
• Social skills training
• Behavioral intervention
• Medication, in selected circumstances

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Red Flags for Autism

• Not talking, or loss of previously acquired
  language
• Does not respond when name is called
• Does not point for wants or to show
• Limited emotional reciprocity
• Does not respond to facial expressions
• No or minimal imaginative play

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Screening Tool M-CHAT

• Modified Checklist for Autism in Toddlers
• 18 months to 2 years
• Verbally administered questionnaire

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M-CHAT Key Questions

• Does the child
• Take an interest in other children?
• Use index finger to point, to indicate interest
  in something?
• Bring objects to show parent?
• Imitate parents facial expression?
• Respond to name when called?
• Look at something when parent points?

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Take-home lesson 3

• Be aware of the possibility of autism in a child
  with delayed speech.
• Not turning when name is called
• No pointing
• No imaginative or pretend play
• DONT WAIT REFER!
• under 3 years, H-KISS (0-3 Program)
• over 3 years, Dept. of Education

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Why is early diagnosis of autism so important?

• With early intervention (before age 3)
• Many children with ASD can have significant
  improvement in communication and social skills

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Detecting Problems Early

• Developmental screening
• Denver II (formerly DDST)
• PDQ (Prescreening Developmental Questionnaire)
• PEDS (Parents Evaluation of Developmental
  Status)
• ASQ (Ages and Stages Questionnaire)

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Detecting Problems Early

• Language screening
• ELM (Early Language Milestone Scale)
• CLAMS (Clinical Linguistic Auditory Milestone
  Scale)

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Helpful Resources

• American Speech/Language Hearing Association
  www.asha.org
• Autism Society of America www.autism-society.org
• NIDCD (National Institute on Deafness and
  Communication Disorders) http//www.nidcd.nih.gov/
  health/voice/speechandlanguage.asp

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Any questions?