Communication Disorders In Child Psychiatry

Communication impairments are frequently disregarded, particularly in kids who exhibit emotional and behavioral issues. There are mental and behavioral issues that coexist with these diseases. In clinical practice, these illnesses may be misdiagnosed, and theoretically, not much is known about them. These are a few of the most typical issues that young children present. 

The five categories listed in the Diagnostic and Statistical Manual-5 (DSM-5) correspond to these disorders: 

1. Language Impairment: There are two varieties of this disorder: expressive and mixed.
2. Speech sound abnormality
3. Childhood-Onset Fluency Disorder (Stuttering): Speech is a factor in each of these conditions.
4. Social (Pragmatic) Communication Disorder: This language use disorder.
5. An unidentified communication impairment

Language

There are four language domains:
1. Grammar 2. Semantics 3. Pragmatics 4. Phonology
The ability to generate the sounds that make up words in a language and the capacity to distinguish between different phonemes are referred to as phonology. 

Semantics is the structuring of concepts and the process of word acquisition; grammar is the organization of words and the rules for arranging words in a language in a way that makes sense. To put it another way, to build sentences, an individual takes the necessary information from their mental list of words. 

Therefore, challenges with semantics include: Difficulty learning new words, Difficulty organizing and storing new words, Difficulty retrieving words. The area of linguistics known as pragmatics focuses on language proficiency. It pertains to comprehending the speech context. Pragmatics facilitate communication and interactions. 

A youngster should normally know a few words to as many as 200 words by the time they are two years old. A youngster can communicate clearly and grasp the fundamentals of language by the age of three.

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Language Disorder

The impairment in language expression and reception is persistent and affects various modalities, including speaking, writing, and sign language. It can be classified into two categories:
1. Deficits in expressive language: There is a problem with language production, and comprehension issues might not be present. The prognosis is usually better for these conditions.
2. Complicated expressive and receptive deficiencies: Since receptive deficits do not happen in a vacuum, expressive deficiencies will typically accompany receptive deficits in most circumstances.

Expressive Language Deficits

Compared to normal receptive language skills and nonverbal intellectual skills, there is a selective deficiency in expressive language development.

Normal Expressive Language Development

 The child can coo and chuckle by six months. The youngster can speak syllables and babble by the age of nine months. By the time they are a year old, they can mimic vocalizations and frequently say at least one word.  The child can say a few words by the age of 1.5. 

The youngster can create simple sentences by the age of two.  The youngster can identify actions in pictures by the age of 2.5. Most kids can name one color and talk intelligibly by the time they are three years old.  The youngster can name four colors by the age of four. The developmental milestones differ before preschool. Development of expressive language is influenced by the type and volume of family interactions. As a result, the expressive language impairment is harder to identify prior to preschool and more noticeable during or following preschool. 

Deficits in expressive language can be -

Developmental: The most prevalent kinds of expressive language impairments are these ones. Most of the time, they are congenital and have no known cause.
In this class, only few cases are acquired during childhood. It may follow neurological illnesses and trauma. The primary clinical results are as follows:

When narrating stories, patients typically utilize phrases like "Thing" and are evasive. Age-appropriate expressive language development is impeded, while reception is often normal. 

There aren't many terms that aren't often improper for the age. After 18 months, they are limited to pointing our named items. By the age of four, kids are able to talk in brief sentences but find it hard to remember new words. Particularly in school-age children, a large number of these kids struggle with mental issues like depression and low self-esteem.

Mixed Receptive And Expressive Deficits

In this situation, children will struggle with linguistic expression and reception, or understanding and comprehension. Deficits in expressive language are comparable to the impairment of expression skills. Additional deficiencies in fundamental auditory processing skills, such as sound discrimination (difference between b and p), symbol-sound association (representation of the "B" sound), etc., are apparent in spoken language reception. 

Similar to expressive language difficulties, expressive impairments can sometimes be more severe. Receptive deficits usually manifest before the age of four years; mild cases may manifest after two years, and severe ones after seven years. Although there is a noticeable delay in verbal or sign language comprehension, verbal ability is age-appropriate. 

They might struggle with auditory and sensory issues, and their ability to follow visual symbols is diminished. They might also seem to be deaf. They may not be able to interpret pictures; there are deficiencies in the integration of both visual and aural symbols. For instance, it could be challenging to tell a toy bus from a toy car. They might react correctly to sounds in their immediate surroundings but not to spoken language.

• There could be mistakes in the speech, such omissions.
o Mistakes
o The replacement of phonemes
o A partial hearing impairment for real tones is present.
o The auditory arousal threshold has raised.
o They are unable to pinpoint sound sources. They could occasionally be unable to pinpoint the precise position of the sound.
o The family can struggle with reading difficulties and seizures.

Epidemiology

There is a significant variation in the prevalence, which could be brought about by variations in the clinical sample composition or diagnostic metrics. There is a 3–15% prevalence. Compared to receptive deficiencies, expressive deficits are more common. Males are more likely than females to have it (5:1) (2:1). Genes play a major influence in family aggregation, which is extremely characteristic.

Roughly 10–15% of kids under the age of three exhibit delayed language development that starts slowly. Between 50 and 80 percent of these kids go on to develop typical language abilities. Children who display language difficulties for more than four years are more likely to be at risk for language impairments. These deficiencies might not go away as adults. The particular problems could evolve over time.
For this reason, prompt diagnosis and management are essential in this regard.

Etiology

No known cause has been identified for language difficulties. Brain abnormalities, genetic factors, environmental issues, neurodevelopmental immaturity, general cognitive problems, and specific linguistic characteristics are a few of the potential causative factors.

Brain Abnormalities

Abnormalities can be observed on MRI scans, frequently in subcortical structures and the left hemisphere, two regions of the brain important for language processing. The frequency of mild neurological symptoms has increased. For example, mixed cerebral issues and fine motor impairments may be observed. These abnormalities could be the result of modest brain alterations. 

Reduced left and right brain asymmetry, particularly in the perisylvian and planum temporal regions, may be present in expressive language impairments. The asymmetry of the brain may be inverted, with more left than right. These deficiencies are more commonly linked to left-handedness or ambilaterality than to right-handedness.

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Genetic Factors

Research has demonstrated that monozygotic twins have a greater concordance rate than dizygotic twins, indicating the potential influence of genetics. Numerous loci on chromosomes 13, 16, and 19 have been found. Additionally, it's possible that chr 16 q is linked to more phonological short-term memory, while chr 19 q is linked to more expressive language. Research has shown that there may be genetic similarities or overlapping chromosome regions between autism and linguistic difficulties.

Environmental Factors

Children from lower socioeconomic backgrounds are more likely to experience linguistic difficulties. The following are a few associations with additional risk factors:
o Large family size; Single parent household; Lowered parental education;  Complications during pregnancy and childbirth
o Absence of relevant educational resources
o Neglect and abuse: Additional risk factors include malnourishment and other health issues.
Exposure to pollutants like lead and limited possibilities for social and educational growth 

Neurodevelopmental Immaturity

Slow myelinization of brain pathways or delayed neural structure maturation can result in neurodevelopmental immaturity and linguistic difficulties. Boys are more likely than females to have these.

General Cognitive Factors

These people may have slower cognitive processing speeds, which could impede language acquisition; phonological working memory impairments could potentially lead to language disorders.

Special Linguistic Factors

They could find it challenging to pick up some grammatical constructions, including pronouns.

Auditory Processes

 They might have otitis media or other auditory pathological diseases in addition to other conditions that cause transient hearing loss. The ability to perceive subtle changes in sound may be hampered by a possible impairment in the auditory perception centers.

Clinical Features

 The people may struggle with grammatical marking in tense, number, age, and gender. The hallmark is impairment in receptive and expressive language development. For instance, the people might struggle with pronouns (He, She), plurals (dogs, geese), and verbs (is, were). 

Comprehension issues arise in patients with receptive deficits: o Less familiar and abstract meanings, such as between, freedom, and when. Complex structures and sentences like "The toy lost in the bus was received under the bridge." Lengthy, complicated instructions and queries. These challenges would have a detrimental effect on their academic performance and interpersonal relationships.

Also Read: Exploring Trailing Phenomena: Perception Beyond The Ordinary

Diagnosis

The DSM-5 lists the following characteristics as requirements: Persistent problems learning and using language in spoken, written, sign language, or other modalities. Deficits in comprehension or production, such as a smaller vocabulary or difficulties with word usage and knowledge, may be the cause of this. Limited sentence structure: Grammar is used to form sentences. 

Discourse impairments include the inability to discuss any topic or carry on a conversation using vocabulary or sentence structure. Language abilities are significantly and quantitatively below age-appropriate levels, which leads to functional limits in social interaction, academic success, effective communication, and vocational performance. The early developmental stage at when symptoms first appeared.

Not better described by intellectual disability or global developmental delay, and not linked to motor dysfunction, hearing loss, or any other medical or neurological problem.

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Laboratory Examination

Audiogram: It can confirm or rule out auditory deficits or deafness.

Comorbidity

In 40–60% of preschoolers, speech sound abnormalities are the most frequent co-occurring disorders. Between 50 and 90 percent of school-age children with language difficulties have specific learning disorders.
Genetic research has shown that a family history of linguistic impairments can raise the chance of developing reading difficulties. Stuttering and developmental coordination impairments are more common. 

In around 30–60% of people with receptive language problems, attention deficit hyperactivity disorder is the most prevalent co-morbid mental illness. In terms of gender, girls will be more reclusive and boys will have more behavioral issues. The majority of these instances don't exhibit overt neurological symptoms like tremors and seizures. Despite this, there are noticeable increases in the rates of mild to moderate neurological symptoms such irregular reflexes or tiny movements. The intensity of the illness increases these symptoms as well. Though not particularly specific, some aberrant EEG and MRI findings can be seen. 

Differential Diagnosis

 Selective mutism is the initial differential diagnosis. Receptive language and nonverbal skills are significantly higher than expressive language in this circumstance. The patient in this situation speaks regularly in front of family members and is developing language normally. These patients are distant from their relatives and suffer from social anxiety. Anxiety disorders like this one exist. The intellectual disability differential diagnosis is the second one. In comparison to age expectations, there is a marked impairment in the receptive language, expressive language, and non-verbal performance. 

Impaired hearing is the third differential diagnosis. The expressive language and linguistic understanding are both abnormal. Both the articulation and the audiogram are abnormal. It's possible that the sufferer will only focus on loud or low-frequency noises. Autism spectrum disorder is listed as the fourth differential diagnosis. Both expressive language and linguistic understanding are dysfunctional. Additionally, it is unnatural to use gestures and social communication.

Language comprehension and expressive language are normal in speech sound problems, but articulation is deviant. Linguistic abnormalities can also result from environmental deprivation, but they may get better if the environment is changed. Remember that a healthy family atmosphere serves as a barrier against harm.

Acquired Language Problems

These could be brought on by assaults to the nervous system. Cerebral vascular accidents, such stroke.
o Infections like meningitis and encephalitis.
o Severe breathing difficulties can lead to anoxia or intraventricular bleeding.
o Near drowning
o Injuries to the closed or open head
o Toxins like lead
o Radiation therapy or tumors
o Convulsions
Acquired language disorders are also linked to Landau-Kleffner syndrome. This aphasia was acquired while having seizures. It is an uncommon illness that causes a sudden loss of language ability. In 80% of cases, it is linked to the start of seizures, or aberrant EEG findings may occur. Until the age of 3-7 years, the child is typically normal; beyond that, the disease becomes evident.

There are no evident causes for the abrupt or gradual emergence of expressive and receptive language difficulties. It's possible to observe behavioral issues, social hyperactivity, hostility, and depression.
The trajectory and outcome of acquired language disorders are typically unpredictable, with two thirds of instances resulting in the restoration of language skills.

Course And Prognosis

The path is typically unpredictable. The patient is less likely to experience major long-term mental health issues in mild to moderate cases. Higher verbal communication, receptive language, and nonverbal intelligence are linked to improved results. Additionally, the lack of disruptive behavioral issues and mental disorders is linked to improved results. 

Up to 50% of instances with minor expressive language difficulties resolve on their own. Overall, patients with combined receptive expressive deficits and expressive language abnormalities have a worse prognosis.

Treatment

Direct interventions by a professional (speech-language pathologist) may be part of the treatment. Parental, educational, and paraprofessional mediation. More meaningful language output is the aim of the treatment. One of the modalities used with patients who have an expressive language deficiency is Parent-Child Interaction Therapy (PCIT). Language therapy, which uses language to enhance interpersonal interactions. These consist of instruction, activities that are behaviorally reinforced, and therapy for phonemes, vocabulary, and sentence formation. 

The current recommendations for patients with combined receptive and expressive deficits are as follows: Both problems should be treated concurrently, or the expressive component should get care before the receptive component. Acquiring basic reading abilities is a crucial first goal in treatment for individuals with combined receptive and expressive difficulties. It might shield the youngster from the potential psychosocial effects of lacking these skills. Teaching a child basic reading abilities is essential for both academic and emotional success. 

Assessing social skills and self-image is crucial. Psychotherapy should be used to address emotional and behavioral issues that limit functioning. Furthermore, family therapy is crucial, and improving communication within the family reduces frustration for the family as a whole and for the child.

Hope you found this blog helpful for your Psychiatric Theory and Specialities Preparation. For more informative and interesting posts like these, keep reading PrepLadder’s blogs.