Comparison tables - SUBJECTS AND METHODS - Diagnosing Specific Language Impairment

4. SUBJECTS AND METHODS

4.3. Methods

4.3.4. Comparison tables

A special aim of the present study was to consider the merits of current clinical practice with children with SLI compared to the literature; see Tables in Appendices 2–7. Th e comparison was carried out by gathering ﬁ ndings and statements in the literature reviewed that are suggested to be insuﬃ ciently considered in present clinical practice. No statistical method was used to choose the ﬁ ndings and statements, and the ﬁ ndings and statements were sampled from studies based on variable methods. Further, the chosen items were gathered on the basis of conclusions drawn in the present work, based on the literature reviewed and analyses of the present data.

Appendix 2 consists a summary of the ﬁ ndings in the present study with regard to the ﬁ ndings and statements in the literature. Table in Appendix 3 is gathered on the basis of a topic (factors suggested to underlie SLI).

Tables in Appendices 4–7 are gathered on the basis of suggested insuﬃ cient correspondence between the literature and present clinical practice.

Th e present work studied children below school age. However, many of the ﬁ ndings and statements presented in the Tables in Appendices concern school-aged children. On the other hand, there are conclusions concerning possible social-emotional disorders of children with SLI, although marked social-emotional disorders were used as an exclusion criteria in the present study group. Th e conclusions given on domains that are not included in our sample are based on implicit suggestions made on the basis of the present data and the literature reviewed. Table in Appendix 7 also includes implicit conclusions made on the basis of the present data and the relevant literature.

5. RESULTS

Th e detailed results are presented in Tables 1–38, in Figures 1–29, and in Appendices 1–7.

5.1. Results regarding the risk factor analysis

In risk factor analysis (Appendix 1) it was common that boys demonstrated language disability about three times as often (sometimes even more) than girls. Th e eﬀ ect of gender often seemed to cover the eﬀ ect of other factors.

Variables behaving exceptionally in this aspect (gender not being a signiﬁ cant factor) were: age when uttering ﬁ rst words, age of starting to utter sentences, speech output in general, verbal praxia, phonology, morphology, and tiptoe walking along a line.

Th e values regarding the risk factor analysis or correlation analysis given below follow the computations for population combined unless otherwise stated.

5.2. Anamnesis

5.2.1. General history and development

With the exception of development of speech and language, the general history of the children did not diﬀ er between the LI and control groups.

Th e parents in both LI and control groups had mostly vocational or academic education. Th e most common education level was college for both LI and control groups´ mothers and control children´s fathers but vocational school for LI group´s fathers. 12 children´s mothers in the LI group had a university degree, while the mothers of 24 children in the control group had a university degree. Th us, mothers´ education level explained LI when

elementary school education was compared to academic education (OR 4.00 [95% CI 1.23 – 12.53], n=36 for university, n=21 for elementary school).

Fathers with vocational school education likewise showed a stronger risk of having a child with LI when compared to fathers with university degrees (OR 3.16 [95% CI 1.37 – 7.30], n=42 for university, n=58 for vocational school).

Of the children in the LI group 56% and almost all the control children (93%) were living in a city; 29 % of the LI group and 8% of the controls were living in a village. 14 % of the children with LI lived in a rural area.

Pregnancy, delivery and neonatal period had been normal for a great majority of both groups, and these factors did not explain LI. Prenatal irregularity was reported in 15 control children (15%) and 11 children (14%) in the LI group. Th ere had been some marks pointing to a threatening miscarriage before birth for four children in the LI group and two control children, but in the LI group only during the ﬁ rst trimester. Th ree study children’s but no control children’s mothers had had toxaemia in pregnancy.

Five mothers in the LI group and nine mothers in the control group had been prescribed antibiotics for an infection in the upper airways. One study child’s mother had been medicated during pregnancy for epileptic seizures, and one control child’s mother for diabetes. Th ree study children’s and ten control children’s mothers had been medicated for contractions.

Birth had been regular for 81 control children (80%) and 60 children (77%) in the LI group. Two study children and ﬁ ve control children had been born at gestation age 32 to 36 weeks, and one child in the LI group at 28 to 32 weeks of gestation. Two more control children had been born at about three weeks before the due date.

Presentation was reported to be normal for 56 control children (55%) and 59 children (76%) in the LI group. Two study children and three control children had been in breech presentation. Th ree study children and eight control children had been delivered with the aid of suction cup or forceps. Eight more children in the LI group and seven control children

had been born by an elective section, and two children in the LI group by an emergency section. Th e reasons for the emergency section had been the baby’s asphyxia and slow progress of the labour.

Apgar scores at the age of one minute were 8 to 10 for 81% of the control group and for 65 (83%) of the LI group. Six control children and seven study children had received seven points, and one study child six points. Five controls had scored two to ﬁ ve points at the age of one minute.

At the age of ﬁ ve minutes all children had scored seven to ten points.

Birth weight had been over 2500 grams for 96% of the control children and for 97% of the children in the LI group. Th e range of birth weight had been between 1510 and 4680 grams in the LI group and between 1680 to 4800 grams in the control group, the mean birth weight being 3636 and 3590 grams, respectively.

Five children in the LI group and seven control children had been nursed in the department for premature infants for some days after delivery. Two study children and one control child had been documented to have a brain haemorrhage (grade 1–2) as newborns, but the pathological ﬁ nding had disappeared in the follow-up, controlled by brain echo.

Four children in the LI group and ﬁ ve control children had been followed up after the neonatal period by a paediatrician, the others being followed up only by the municipal well-baby clinic system used in Finland.

General development was estimated to be, with the exception of the development of speech and language of the LI group, approximately normal for the great majority of both groups. Five children in the LI group and two children in the control group had started to walk at the age of 16 to 18 months.

Mean ages for walking were reported to be12 months in control children and 12.6 months in the LI group; the parents of one control child and eight study children did not remember the walking age. Motor development was reported to be normal for 95% of the controls and 71% of the LI group;

estimated by the parents, 19% of the LI children and 5% of the control children were described to exhibit some clumsiness or slightly slow motor development (Figure 1). 13 % of the LI children were noted to exhibit some diﬃ culty in learning to ride a bicycle, whereas only one control child had exhibited this kind of diﬃ culty. LI children were not as often interested in drawing as the control children.

FIGURE 1: Motor development in language impaired (LI; N=78) and in normally developing children (CG; N=101), assessed by parents.

(sw slow = somewhat slow motor development)

Only one control child and four study children were estimated by their parents to have babbled less than a normal child. Later development of speech and language diﬀ erentiated the groups clearly (Figure 2): Children in the LI group had started to utter single words signiﬁ cantly later than controls (OR 40.69 [95% CI 15.05–110.01] for later than 1.5 years; n=100 for about 12 months of age, n=56 for > 1.5years). However, having said the ﬁ rst words at the age of 16 to 18 months (n=8) was not a signiﬁ cant factor for LI. Of the LI group, 22% had uttered their ﬁ rst words at the age of 18 to 24 months, 28% at the age of two to three years, 13% at the age of three to four years,

and ﬁ nally, one child not until four years of age. Factors related to the age when uttering the ﬁ rst words are presented in Table 1.

FIGURE 2: Age at ﬁ rst word in language impaired (LI; N=78) and in normally developing children (CG; N=101), as reported by parents.

TABLE 1: Variables related to the age of the ﬁ rst words.

Variable Spearman correlation n p

Severity of the language disorder 0.612 153 <0.001

Auditory scoring in the ITPA test on average 0.590 120 <0.001

Discrimination 0.587 128 <0.001

Speech output in general 0.567 165 <0.001

Understanding in a natural context 0.550 154 <0.001

Auditory span (ITPA test) 0.544 161 <0.001

Verbal dyspraxia 0.517 151 <0.001

Dysphonology 0.516 162 <0.001

Concepts 0.507 131 <0.001

Motor skills in general 0.506 97 <0.001

Syntax 0.506 135 <0.001 First words at the age of

LI CG

Furthermore, as can be seen in Figure 3, only three children with LI had started to produce sentences at the age of about one and a half years. Four children talked in sentences below the age of two years. 19% started to produce sentences at the age of two to three years, and 40% at the age of three to four and a half years. Five children did not use sentences until about ﬁ ve years of age, and one child had so far used only one-word expressions.

Th e parents of 19 children in the LI group could not estimate or remember the age of the child when starting to produce sentences. Most parents reported that their children could express themselves and communicate adequately despite having delayed development of speech and language.

Of the control children 76% had started to produce sentences according to the normal schedule (about 18 months). Ten more control children were reported to utter sentences below the age of two years, while 14 childrens´

parents could not remember the age of the child when starting to speak in sentences.

FIGURE 3: Age when starting to produce sentences in language

impaired (LI; N=78) and in normally developing children (CG; N=101), as reported by parents.

1.5 yrs nearly 2 yrs 2-3 yrs 3-4.5 yrs about 5 yrs not yet missing Sentence age

LI CG

Th us, being late in starting to utter sentences was a signiﬁ cant factor (OR 143.73 [95% CI 37.81–546.36], n=66 for more than 2 years). Factors related to the age when uttering sentences are presented in Table 2.

TABLE 2: Variables related to the age of speaking sentences.

Variable Spearman

correlation

n p

Severity of the language disorder 0.873 139 <0.01

Discrimination 0.803 112 <0.001

Dysphonology 0.797 144 <0.01

Auditory skills in the ITPA test on average 0.789 106 <0.001

Understanding in a natural context 0.789 139 <0.001

Speech output in general 0.775 147 <0.01

Morphology 0.771 142 <0.001

Concepts 0.768 115 <0.001

Syntax (deviant word order, incomplete utterances) 0.725 118 <0.001

Word ﬁ nding 0.723 138 <0.001

Syntax 2 (simplicity of utterances) 0.689 116 <0.001

Verbal praxia 0.684 133 <0.001

Narration 0.671 136 <0.001

Grammatical completion (ITPA test) 0.667 139 <0.001

Reynell, the receptive part of the test 0.654 137 <0.001

Auditory span (ITPA test) 0.640 144 <0.001

Auditory closure (ITPA test) 0.639 142 <0.001

Vocabulary 0.620 142 <0.001

Motor skills in general (Stott) 0.595 88 <0.001

Verbal scoring on average 0.558 130 <0.001

5.2.2. Health

General health had been good for 86 % of the LI group and for 90 % of the control group. Seven study children and 11 control children were reported to have had recurrent respiratory tract infections and/or asthma, and four study

children were reported to have had recurrent infections fairly often. No child was described to have generally poor health.

Otitis media (OM) was not a prominent ﬁ nding in the LI group and did not explain LI. Eleven children with LI (14%) had had frequent OM;

tubes had been inserted in four of them. Th eir hearing was still found to be within the normal limits when studied. Only one child with LI had been set tubes because of secreting OM, and another one had been noted to have secreting OM but had not been set tubes. Four children were reported to have had longstanding problems despite having the tubes inserted. 78 % of the children had had some isolated OM infections at most.

Correspondingly, 17% of the control children had had frequent OM, and four children were reported to have had secreting OM. Two children had had longstanding problems with frequent OM instead of having tubes inserted.

Th ree study children had had a single epileptic seizure. EEG had been demonstrated to be normal for each of them, as well as the other etiological studies.

Of the LI children 77% had been examined in special health care solely because of delayed development of speech and language. One child had earlier been referred to a paediatric outpatient clinic because of slow development of motor skills, and three children because of the abovementioned seizures.

Fourteen children (18%) in the LI group had been in hospital because of infections in the airways, asthma or other somatic diseases. Of the control children even 37% had been treated or at least investigated in hospital because of infections, other somatic diseases, or some trauma.

5.2.3. Etiological studies

Etiological studies were made on the basis of clinical indications. Th erefore, if the child was estimated to show, most probably, normal ﬁ ndings in the etiological studies, they were not necessarily carried out. However, all the

children in the LI group were given audiograms, and none exhibited any hearing impairment. All the control children´s hearing had been tested earlier in the child welfare clinic by audiogram. Two of them were reported to have possibly exhibited a slightly lowered hearing level for some time due to secreting OM, and one control child was documented to exhibit a unilateral hearing impairment. Th e development of her speech, language and also cognition were still reported to be normal. Th e girl performed age-appropriately on the tests of the present work, too.

EEG was used to study 19 study children, mostly on the basis of poor reception of spoken language. Th ree children had had a single seizure.

According to the neurophysiologist, EEGs were found to be normal for nine children, “within normal limits” for six children, mildly deviant for one child and moderately deviant for three children. Th e children exhibiting deviant EEG showed very dissimilar performance proﬁ les in tests, so there did not seem to be any type of poor performance combined with a pathological EEG in this study.

Th e children with pathological EEG ﬁ ndings were examined by a child neurologist, too. No indication of other neurological pathologies was found.

Th e chromosomes were examined for 13 children in the LI group. Each of them was found to exhibit normal chromosomes.

Findings in other etiological studies such as fragile X, thyroid functions, and metabolic urine screen were also normal, carried out for ten children.

5.2.4. Delayed development in the family

Positive family history of delayed development of speech was more common in study children than in control children (OR 12.82 [95% CI 6.04–27.20], n=109 for no delay, n=62 for delayed relatives). Th e same concerns family history of language development (OR 16.31 [95% CI 7.03–37.86], n=103 for no delay, n=49 for delayed relatives), learning to read or write (OR 7.00 [95% CI 3.27–14.95], n=106 for no delay, 47 for delayed relatives) and

learning diﬃ culties (OR 2.63 [95% CI 1.05–6.59], n=131 for no diﬃ culty, n=22 for diﬃ culty in at least one relative).

According to the parents, 62% of the study children had delayed speech development in the family (Figure 4). Respectively, 14% of the control children were reported to have at least one close relative with delayed speech development. Furthermore, 49% of the children in the LI group were reported to have at least some relatives with delayed language development, whereas 11% of the control children were estimated to have such relatives (Figure 5).

FIGURE 4: Delayed speech development in family in language impaired (LI; N=78) and in normally developing children (CG; N=101), as

reported by parents.

29 85

14 14

0 4

9 1 0

10 20 30 40 50 60 70 80 90

no-one in 1 or 2 in some in many missing

Delayed speech development in family

LI CG

FIGURE 5: Delayed language development in family in language impaired (LI; N=78) and in normally developing children (CG; N=101), as reported by parents.

Dyslexia, or reading retardation, was reported to be exhibited by some relatives of 36% of the LI group. Respectively, dyslexia was estimated to be present in relatives of 16 % of the control children. Learning diﬃ culty was reported in some relatives in 14% of the children in the LI group. Ten control children were mentioned to be family-positive regarding learning diﬃ culty. AD(H)D had been diagnosed, according to the parents, in two study children’s and in three control children’s relatives. Finally, ﬁ ve children with LI and two control children were reported to have at least one relative with mental retardation, and one child with LI was reported to have an autistic relative.

23 84

11 8

0 3 0

0 10 20 30 40 50 60 70 80 90

no-one in 1 or 2 in some in many missing

Delayed language development in family

LI CG

5.2.5. Day-care

Of the LI group 51% and of the control group 67% were cared for in a day-care centre. Th e second commonest day-care form was home for both groups (33% of the LI children and 25% of the controls).

5.2.6. Rehabilitation given before examinations

Most children (85%) in the LI group had received therapy for speech and language development before the examinations of the present study; 33 children (42 % of the LI group) had been given therapy for at least 1.5 years. A small minority of the study children (19%) had received therapy for sensory integration (SI therapy, see Ayres, 1979, 1987; Fisher et al., 1991).

Two children in both groups had been given a period of physiotherapy during babyhood because of rather slow motor development.

5.3. Clinical evaluations

5.3.1. Expressive language

All the control children’s speech was easy to understand. 18% of them were estimated to be relatively short-spoken. Seven control children were found to show clear diﬃ culty in narration. 11 children had some diﬃ culty with naming objects, and 12 children were found to demonstrate subtle evidence of word-ﬁ nding diﬃ culty. Th ree children showed some deﬁ cit in phonology, and two children made some mistakes in the area of morphology.

Th e ﬁ ndings in the LI group regarding expressive skills were as follows:

50% of the LI group demonstrated slightly poor output, and 23% children rather poorer output. Five children expressed themselves verbally mainly by vocalizing. 16 LI children were reported to exhibit mainly receptive deﬁ cits.

Despite having marked LI, the expressions of the LI group were described to be mostly intelligible (with the aid of the context and nonverbal means) in 52% of the group. Th e speech of six children’s (8%) was estimated to be extremely diﬃ cult to understand, these children’s expressions being heavily dependent on nonverbal methods. Th e rest of the children spoke somewhat unclearly.

Oral motor skills were estimated to be within normal limits in at least 66% of the LI group. 21% of the children demonstrated some diﬃ culty with this area. For nine children there was no mention of oral motor skills, which may indicate normal performance.

Verbal praxia was found to be normal in only 23 children (29%) in the LI group. 60% of the children demonstrated some diﬃ culty, and 6 children´s verbal motor skills were rather poor. One more child was hardly able to express anything verbally.

If the child had substitutions in only two phonemes known to be the most diﬃ cult ones in Finnish language (/r/ and /s/), the articulation was classiﬁ ed as age-appropriate. Th us, as many as 64% of the LI children were found to demonstrate age-appropriate articulation, while 16 children

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