Key learning points:
– Find out whether the child or adult with a communication disorder has been referred for a speech and language therapy assessment
– Ask the individual with the communication disorder how you can help them to express their needs and wants in your discussion with them, ie openly acknowledge the difficulty
– Give the person time to get their message across and check that you have understood
Communication is often defined as the ability to impart or exchange information by speaking, writing, gesture or other medium. Such a definition overlooks the importance of communication in being able to express one’s personality, engage with friends and family and its centrality to personal development. Communication is key to the development of homo sapiens and thus it is strange that speech and language disorders are often overlooked or not seen as pivotal to a person’s quality of life.
There are many medical, surgical, psychological and environmental causes that underlie the various impairments of speech, language and communication. It is likely that such difficulties will have a profound effect on the child or adult by limiting ability to participate in a full life, causing anxiety and frustration to the individual, their friends and family, and limiting educational, recreational and work opportunities.
Speech, language and communication problems in children
Speech, language and communication are the most common special educational need observed in children during the primary school years (age five to 11).1 But the problems that children experience aren’t confined to that age group. Approximately 7% of 12 to 14-year-olds2 will also have a significant speech and language impairment, affecting their ability to communicate, and many preschool children show delays in development of speech, language or communication skills.
It is well known that there is wide variation in the rate and pattern of typical development in young children and that is true also of speech, language and communication. However, when children’s problems persist into early school years, they are at greater risk of problems with educational attainment,3 behaviour and bullying4 and are more likely to be unemployed or have low employment status later in life.5,6 Research has also shown that these children are also more likely to have mental health problems as adults7 and a greater risk of becoming involved with crime8 or entering a cycle of poverty and dependence on the state. In other words, when children have problems with speech, language and communication that don’t resolve, they can become a major cost to society as well as having limited life options themselves.
Determining who will have persistent problems can be difficult for health professionals. Nurses in primary care have frequent contact with families and may be the first to identify a possible problem. Children will typically show problems with one or more aspects of speech, language and communication. Some will show difficulties with the development of their speech, which can make them difficult to understand or lacking in fluency (eg stammering). Other children may show a limited vocabulary or seem to struggle to put words together in sentences. These problems may often co-occur so that children who use a limited range of speech sounds also talk in short sentences and have a smaller vocabulary.
Some children might have normal-sounding speech and language production, but may not be communicating normally. Examples would include: poor eye contact, not responding to questions, use of repetitive phrases, lack of engagement and interest. Such behaviours suggest a child has a social communication disorder and might be on the autistic spectrum. While there is wide variation in the way this presents, with every child having unique abilities and challenges, it is generally agreed that early identification is effective, and a speech and language therapist can assist parents to stimulate communication.
For some children, there may be an obvious structural or neurological cause for their difficulties, such as cleft palate, cerebral palsy or hearing impairment. In other cases, there may be a global developmental delay or a learning difficulty. In most cases, no clear cause is identified.
While not all children who show impairment in their speech, language and communication development will require speech and language therapy, it is important that identification of needs is responded to promptly. We know that delayed vocabulary development in children as young as two is associated with low scores on school entry assessments,9 so any advice we can provide to parents and carers in the early years to help boost language skills could have a positive impact later in school.
Speech and language impairment is also associated with problems acquiring literacy – because the skills are related to those for speaking and understanding. Some children who appear to grow out of their speech and language problems may show greater difficulty than their peers in learning to read and spell. Other children may appear to develop speech and language along typical lines in their early years but then have difficulties progressing at school. Detailed speech and language assessment may reveal that such a child has difficulty with language processing and in understanding what is said to them. These children can often go unnoticed in a busy classroom but the child may present either with social, emotional and behavioural needs or may be quietly failing without adults noticing.
The nurses role
The key role of the practice nurse is to encourage parents and carers to communicate with their baby from day one. The more language that a two-year-old hears, the more rapidly they will add words to their vocabulary.10 The richer the vocabulary and more complex sentences the child hears, the more quickly their language will develop.10,11 Helping the child by explaining the meaning of a word, for example when reading a book or watching television, makes a real difference to the child’s language development.11 It is particularly helpful if the language that the child hears relates to their interests and is in response to their vocalisations and attempts at interaction. In this way, children learn more language from an individual who can interact with them directly and follows their lead. The practice nurse should be alert for children who are not developing speech and language in the usual manner. They should notice if immature sounds are abnormal in production or when vocabulary is severely restricted and not developing at the usual rate. Referring to an audiologist for a hearing test and to speech and language therapy for assessment is essential. If a parent is worried about their child’s development it is important to take these concerns seriously as parents might be detecting subtle clues to real problems.12
The role of healthcare professionals in supporting families who have children with speech, language and communication disorders cannot be underestimated. The Communication Trust (see Resources), an organisation for those who work with children and young people with speech, language and communication difficulties, reports that parents have frequently been concerned about their children’s development but have not been able to access assessment, intervention and advice. They have frequently been incorrectly assured that the child ‘will grow out of it’.
Some handy tips to give to parents of young children are provided in Box 1, but do consider whether referral to speech and language therapy may also be appropriate. If you need help to identify whether a child is having difficulties, or more information on advice to give parents, visit Talking Point (see Resources) for an online checklist and downloadable resources.
Speech, language and communication problems in adults
Speech and language disorders in adults are frequently acquired after a stroke or head injury, or as a symptom of a progressive neurological disease. The most common language disorder acquired after stroke or head injury is aphasia – difficulties in both expression and comprehending language. This leads to problems with speaking, listening, reading and writing. Aphasia can be mild, with the person having difficulty finding words to express an idea. Or it may be severe, and the person may be unable to understand anything or to even indicate ‘yes’ or ‘no’. Aphasia may not be related to any intellectual decline and often causes severe emotional upset, depression and frustration.13
Dysarthria is a motor speech disorder that may make the person difficult to understand. Speech may be slurred, less precise, low in volume, uncoordinated, irregular or at an abnormal pitch.
Some individuals may have a persistent voice disorder (trouble with phonation such as huskiness) associated with impairment of the larynx or vocal cords. This might be associated with a range of ENT problems or vocal abuse (frequent shouting). Again, it should be investigated if it is persistent. There is a higher prevalence of voice disorders in professions where there is heavy use of the voice and people have to project over noise (eg teaching).
Some adults may be dysfluent (they stammer), and may benefit from speech and language therapy, even if they did not earlier in their life (Speech and language therapy for dysfluent children has good evidence of effectiveness).
An increasing number of adults may have a social communication disorder, which is frequently associated with dementia or other mental health conditions. An assessment by the speech and language therapist, identifying retained abilities and areas of difficulty, can help the health and social care team to work with the individual. Such an assessment can also assess mental capacity and determine the best way of checking whether an individual has understood a course of action or choice.14
The practice nurse has opportunities to raise the issue of a speech, language and communication problem with an individual or parent in a casual fashion, which can lead to disclosure of difficulties that have been avoided or suppressed. The nurse can refer directly to speech and language therapy or to a GP, and can also guide the patient to information to help them take things forward themselves.
For more information on speech language and communication disorders and how to access speech and language therapy, go to The Royal College of Speech and Language Therapy (see Resources).
Resources
The Communication Trust –communicationtrust.org.uk
Talking Point –talkingpoint.org.uk
ICAN –ican.org.uk
The National Aphasia Association –aphasia.org/aphasia-resources/communication-tips
The Royal College of Speech and Language Therapy –rcslt.org/
References
1. Department for Education. Special Educational Needs in England, 2014.
2. Law J, Boyle J, Harris F, Harkness A, Nye C. Prevalence and natural history of primary speech and language delay: findings from a systematic review of the literature. International Journal of Language & Communication Disorders 2000;35(2):165-188.
3. Stothard SE, Snowling MJ, Bishop DVM, Chipchase BB, Kaplan CA. Language-impaired preschoolers: A follow-up into adolescence. Journal of Speech, Language, and Hearing Research 1998;41(2):407-418.
4. Knox E, Conti-Ramsden G. Bullying risks of 11-year-old children with specific language impairment: Does school placement matter? International Journal of Language and Communication Disorders 2003;38:1-12.
5. Felsenfeld S, Broen PA, McGue M. 1994. A 28-year follow-up of adults with a history of moderate phonological disorder: educational and occupational results. Journal of Speech and Hearing Research 1994;37(6):1341-53.
6. Clegg J, Ansorge L, Stackhouse J, Donlan C. Developmental Communication Impairments in Adults: Outcomes and Life Experiences of Adults and Their Parents. Language, Speech, and Hearing Services in Schools 2012;43(4):521-535.
7. Voci S, Beitchman J, Brownlie E, Wilson B. Social anxiety in late adolescence: The importance of early childhood language impairment. Journal of Anxiety Disorders 2006;20:915-930.
8. Bryan K, Freer J, Furlong C. Language and communication difficulties in juvenile offenders. International Journal of Language & Communication Disorders 2007;42(5):505-520.
9. Roulstone S, Law J, Rush R, Clegg J, Peters T. Investigating the role of language in children’s early educational outcomes. Department for Education, 2011.
10. Hoff E, Naigles L. How children use input to acquire a lexicon. Child Development 2002;73:418-433.
11. Weizman ZO, Snow CE. Lexcal input as related to children’s vocabulary acquisition: Effects of sophisticated exposure and support for meaning. Developmental Psychology 2001;37:265-279.
12. Hall D, Elliman D. Health for all Children. Oxford University Press, 2006.
13. Jordan LC, Hillis, Argye E. Disorders of speech and language: aphasia, apraxia and dysarthria. Current Opinion in Neurology 2006;6:580-585
14. Nicholson T, Cutter W, Hotopf M. Assessing Mental Capacity: The Mental Capacity Act. British Medical Journal 2008;336(7639):322-325.
