Learning Objectives
By the end of this section, you will be able to:
- Outline the different types of communication disorders
- Describe the principles used to treat communication disorders
Approximately one in ten American children have a communication disorder, one of a group of neurodevelopmental disorders that affect speech and language development (Psychology Today, 2022). While there is not one specific etiology for communication disorders, some risk factors include medical problems, motor skill problems, and genetics (Law et al., 2017). Early intervention is the best way to treat communication disorders. Children with language disorders may feel frustrated when they cannot understand others or make themselves understood and, as a result, may act out, act helpless, or withdraw. Language or speech disorders may also be present with other disorders, such as ADHD, anxiety, or autism (CDC, 2021b). Table 23.1 lists some key signs of speech, language, and hearing disorders by age.
| Age | Presentation |
|---|---|
| Birth to 3 months | No smiling or playing with others |
| 4 to 7 months | No babbling |
| 7 to 12 months | Minimal vocalization; no gestures |
| 7 months to 2 years | No understanding of spoken words |
| 12 to 18 months | Saying only a few words |
| 1½ to 2 years | Not putting two words together |
| 2 years | Saying fewer than 50 words |
| 2½ to 3 years | Struggles with early reading and writing; shows no interest in books or drawing |
| 2 to 3 years | Struggles with playing and talking with other children |
Defining Communication Disorders
Persistent difficulty with language and/or speech is considered a communication disorder. There are set developmental milestones that mark a healthy progression on the speech-language trajectory, and individuals with communication disorders may not meet them. Problems with articulation, quality, pitch, loudness, and repetition of speech sounds (stuttering) may characterize issues with speech. Overall causes of communication disorders include “hearing loss, neurological disorders, brain injury, vocal cord injury, autism, intellectual disability, drug abuse, physical impairments, emotional or psychiatric disorders, and developmental disorders” (Psychology Today, 2022, para. 15). There is an increased risk for communication disorders if there is a family history of these disorders. Communication disorders are more common in boys aged three to seventeen than their female counterparts (NIH, 2016).
Early intervention is the best treatment. Nurses should recommend that parents follow pediatric developmental milestones and can refer to the CDC website (CDC, 2023d). The nurse can also recommend that the parents talk to the pediatrician when concerns arise regarding their child not reaching speech-language age-related milestones, such as making squealing sounds by age six months or saying mama or dada by age twelve months. Each age group listed on the CDC website has specific things that a child should be able to do or say by that age. Treatment may involve seeing a speech-language pathologist.
Life-Stage Context
Stages of Communication Development in Childhood
During the first five years of a child’s life, they are developing critical skills that assist them with learning verbal and reasoning skills, how to socialize with others, and growing their independence. Developmental milestones help both parents and health-care professionals to recognize any deficits a child has that may indicate a communication disorder. Nurses working with pediatric clients can ask the parent questions about family history, when a child’s symptoms were first noticed, and provide support to the parents.
(Psychology Today, 2023)
The DSM-5 breaks communication disorders into five categories: language disorder, speech sound disorder, childhood-onset fluency disorder (stuttering), social communication disorder, and unspecified communication disorder, which can be caused by a medical or neurological condition and will not meet the DSM-5 criteria.
Language Disorder
A language disorder is when an individual has difficulty learning and using spoken, written, or signed language. They can physically make the sounds but cannot use language correctly. Their language ability is below what is expected for their age. A person with language disorder is unable to adequately express and receive communication (Psychology Today, 2022). Expressive communication involves making the verbal or nonverbal signal and receptive communication is understanding the language that is taken in from another person.
Language disorders caused by a medical or neurological condition are not diagnosed with DSM-5 criteria. These may include brain injury, a problem that occurred during pregnancy—such as maternal stress, folic acid and vitamin D insufficiency, and smoking and alcohol use (D’Souza et al., 2019)—a birth defect, or have an unknown cause. Other language disorders have a strong genetic factor; many children who develop them have a familial history. Treatment for language disorders is primarily through speech-language therapy. There may also be the need for psychotherapy in cases where the individual has behavioral issues.
Speech Sound Disorder
A speech sound disorder is the inability to articulate words or sounds in order to communicate with others. While this disorder may be the result of a physical complication, such as cleft palate, it may be related to a hearing impairment, a genetic component, or can be related to a neurodevelopmental problem in which the brain fails to correctly deliver impulses to muscles involved in making the sounds (Psychology Today, 2022).
Symptoms observed in children with a speech sound disorder include stuttering, lisping, using shorter words and syllables past the age of seven, having a nasal quality to their voice, and running out of air when talking. Referral to a speech-language pathologist for assessment and diagnosis is a common beginning of treatment. Treatment will involve speech and language therapy to identify and correct articulation problems. Speech therapy helps 75 percent of children resolve their speech sound disorder by the time they turn six (Psychology Today, 2022).
Child-Onset Fluency Disorder
Children between the ages of two and five can sometimes stutter, but this is just part of learning to speak. It usually goes away on its own, but there are some individuals who have chronic stuttering that persists into adulthood (Mayo Clinic, 2021), which is considered child-onset fluency disorder. Symptoms that may occur include repeating a word or a sound, difficulty beginning to say a word, adding extra words like “um,” facial tightness or tension in the face and upper body, anxiety when talking, and decreased ability to communicate. Interestingly, people who stutter usually do not stutter when talking to themselves or while singing a song (Mayo Clinic, 2021). Treatment by a speech-language pathologist might be needed if the stuttering lasts more than six months, gets worse with anxiety, and is affecting school, work, or social situations.
Social Communication Disorder
A person with social communication disorder has difficulty using verbal and nonverbal communication within a social situation. This may cause problems with making and maintaining friends. The individual might not understand how to effectively carry on a conversation or understand nonliteral language meanings or grasp the rules of conversation. The exact cause of social communication disorder is unknown, and it is often connected to another condition, such as intellectual disability or a traumatic brain injury (American Speech-Language-Hearing Association, 2023). A speech-language pathologist is the primary treatment provider and is responsible for screening, assessment, and diagnosis. It is within the scope of practice of the speech-language pathologist to provide “clinical services, education, advocacy, research, and administration” (American Speech-Language-Hearing Association, 2023, Roles & Responsibilities section, para. 1). The Individuals with Disabilities Education Improvement Act of 2004 (IDEA) requires that children and adolescents with social communication disorders be provided speech-language services in schools.
Unspecified Communication Disorder
When a child exhibits some symptoms of communication disorders, but the symptoms do not fall into a pattern according to the DSM-5, then they are described as having unspecified communication disorder. There is no particular cause noted in the DSM-5 for this disorder. The age of onset is typically early childhood (Porter, 2023). There are no specific treatments specified by the DSM-5 for this disorder, but speech-language therapy may be helpful.
Treatment of Communication Disorders
Treatment for communication disorders generally begins with a parent telling their child’s health-care provider about concerns for their child’s language development. The provider then may make a referral to a speech-language pathologist for assessment, diagnosis, and treatment. Early intervention, some of which may be free or low-cost, is considered to have the best outcomes.
The speech-language pathologist (SLP) follows four basic principles for the provision of services: “(1) Family centered and culturally and linguistically responsive; (2) developmentally supportive promoting children’s participation in their natural environments; (3) comprehensive, coordinated, and team based; and (4) based on the highest quality evidence available” (Paul & Roth, 2011, p. 320). These four principles are used to focus on the individual needs of each child and their family.
There are three main goals of treatment for communication disorders. The first is helping children work on and improve their communication. The second is to teach children coping skills and alternative ways to communicate when they are having difficulty with communication. The third is encouraging children to use and practice their communication skills at home, at school, and with friends (MentalHelp.net, 2023).
Nursing Implications
With those goals in mind, treatment of communication disorders is collaborative, meaning that different professionals and caregivers work together to assist the child in learning how to communicate better. These roles can be shared by the speech-language pathologist, school nurse, peers, parents, and classroom teachers (American Speech-Language-Hearing Association, 2023). A treatment plan is agreed upon with different parts of that plan being implemented by identified members of the team. School nurses can work individually with clients or in group settings (e.g., special education).
Nurses need to remember that just because a client cannot communicate in the same way as the nurse, it is important to include them in the care that is being provided. This quote from a nurse who was part of a focus group in Mimmo et al. (2022) highlights the importance of treating the client with respect and dignity: “talking to the patients whether or not they can talk back to me . . . treating them as though they can listen so talk to them . . . just say, hi, . . . treat them with dignity” (“Know the Child” section).
Types of Interventions Used to Treat Communication Disorders
The types of intervention recommended to treat a communication disorder is based on the child’s age, the severity of the disorder, and whether or not it is connected to another disorder. Interventions are intended to assist the child in developing their language skills and remove barriers to social participation (Law et al., 2017). Direct interventions are those that focus on the child as an individual or in a group. Indirect interventions are those that involve the parents interacting with their children as a way of modeling speech and language behavior. Indirect interventions are used less as the child ages. Rewards, such as stickers, are often used as reinforcement for the child following the directions of the therapy by repeating sounds, vocabulary, and sentence structures (Law et al., 2017). As children get older, the therapy focuses on teaching skills that encourage the use of judgment to determine the correct phonics and grammar to use in the moment. Considerations for therapy focus on who is going to deliver the therapy, where it will take place, the frequency/intensity/duration of the therapy, and the expected outcomes.