Abstract
To find the status of age of suspicion and identification availed for children with different communication disorders. This cross-sectional survey study was conducted on 2081 children aged 0.5 to 15 years (mean: 5.41; S.D.: ±3.77) who came to the speech-language diagnostic department of AYJNISHD(D), RC, Kolkata for availing rehabilitation service at the institute. The information was gathered from the parents and caregivers of the children. After detailed evaluation by the interdisciplinary team, the developed 14-item questionnaire was administered, and data were recorded and tabulated. Findings suggested that average age of suspicion of presence of communication problem is 2 years (SD: ±0.98). The suspicion rate increased with increasing age with a saturation in suspicion rate after 5 years. Consultation of a medical professional, primarily an ENT specialist was availed by 2.8 years (SD: ±1.89) of age and 32% of the doctors during the first visit assured the parents not to worry as the child would learn language with age and only 43.4% were referred for rehabilitation. Among them, 42.8% of children were found hearing loss, 24.5% found to have autism spectrum disorder, 20.66% of children were diagnosed with developmental delay, 6.4% were diagnosed with intellectual disability, 4.7% were diagnosed with late language emergence and 0.86% were diagnosed with cerebral palsy. From the findings we can conclude perceived cause of delay in identification is lack of awareness, lack of proper guidance from the primary consultants, and tendency to follow wait-and-watch policy.
Keywords: Communication disorders, Age of suspicion, Age of identification, Age of intervention
Introduction
Communication is the process of sending information from one person to another [1]. The development of communication skills for young children encompasses the acquisition of skills to comprehend and express thoughts, needs, and information. The understanding of communication commences prior to birth and persists throughout life, as children perceive and interpret information from other individuals. Communication development is guided by the need for relevance, which involves communicating necessities, the principle of discrepancy, wherein individuals seek the initiation of a constant flow of information, and elaboration, which involves acquiring more complex language skills [1]. The significance of speech and language development in the early stages of a child's life cannot be overstated. This developmental phase serves as a critical foundation for future academic, social, and cognitive growth. The acquisition of proficient communication skills empowers children to express their thoughts, feelings, and needs effectively, laying the groundwork for successful interactions with peers, family, and educators. Language development is closely intertwined with cognitive advancement, as it enables children to comprehend complex ideas, enhance problem-solving abilities, and develop logical thinking [17]. Furthermore, strong language skills foster a child's reading readiness, opening doors to educational success. Beyond academic aspects, the ability to communicate proficiently from an early age nurtures self-confidence and self-esteem, enabling children to participate actively in various social contexts [18]. Early intervention and support in speech and language development not only contribute to a child's well-rounded growth but also play a pivotal role in mitigating potential learning difficulties later in life [16].
During the early childhood years, parents and family members play an integral role in providing rich stimulation for the proper acquisition of children's speech, language, and communication skills. Appropriate stimulation contributes to all aspects of children's development [2]. Conversely, limited stimulation can significantly hinder a child's development [5]. Additionally, parents and families should be the primary individuals to comprehend the child's communication needs and delays.
Communication disorders encompass a range of developmental conditions characterized by persistent challenges related to language and speech. These disorders encompass a broad spectrum of issues in hearing, speech, and language development, which can arise from environmental influences or stem from other conditions like learning disabilities, cerebral palsy, and intellectual disabilities. While data specific to India is limited, evidence suggests that untreated speech and language delays can persist in approximately 3.63% of children, placing them at a heightened risk for social, emotional, behavioral, and cognitive difficulties in adulthood [6].
The occurrence of speech delays has historically been downplayed due to a belief that delayed speaking might run in families and is not inherently concerning. However, it's important to note that communication disabilities can have enduring effects on social interactions, education, and employment. The United Nations Educational, Scientific and Cultural Organization [4] reported that three-fourths of children with disabilities at the age of five lack access to formal education, and one-fourth of the population aged 5–19 faces similar barriers. Moreover, a study indicated that more than 40% of individuals with communication difficulties are unemployed [23].
In the Indian context, the significance of addressing communication disorders is underscored by findings from the National Sample Survey [7]. The NSS survey covered a total of 576,569 people, with 402,589 residing in rural areas and 173,980 in urban areas. The report reveals that the prevalence of disability in India was 2.2%, with 2.3% in rural areas and 2% in urban areas in 2018. Additionally, the prevalence of disability was noted to be higher in males than females, impacting 2.4% of males and 1.9% of females. Among individuals aged 3–35 years with disabilities, 62.9% were enrolled in ordinary schools, while 4.1% received specialized education or therapy related to their disabilities, such as speech or behavioral therapy. Notably, a significant proportion of persons with disabilities received government aid, with over a fifth benefiting from various forms of assistance such as education, employment, corrective surgery, or disability pension. Conversely, 76.4% did not receive any form of support, highlighting the potential gaps in accessibility and assistance for this population.
The implications of these findings underscore the urgency of addressing speech and language delays, particularly in early childhood. Early intervention not only mitigates potential lifelong challenges for individuals with communication disorders but also contributes to a more inclusive and equitable society. By focusing on timely identification, appropriate support systems, and accessible education, societies can work toward reducing the barriers faced by those with communication disabilities.
It is crucial to understand the multifaceted factors associated with the delay in the development of speech and language skills and the barriers impeding the initiation of speech, language, and aural rehabilitation in children [20]. The complexity of communication disorders demands a comprehensive exploration of underlying causes, encompassing not only biological and neurological factors but also socio-economic and environmental influences [24]. In a rapidly evolving society like India, where diverse cultures, languages, and social disparities intersect, a nuanced understanding of these factors is imperative to formulate effective interventions. By pinpointing the challenges that hinder the timely acquisition of communication skills, researchers, policymakers, and healthcare practitioners can collaborate to design targeted strategies that address the specific needs of children with communication disorders.
Alleviating these factors holds the potential to substantially reduce the prevalence of delays in speech and language development within a developing country like India. Early intervention and rehabilitation programs guided by empirical insights can ameliorate the trajectory of communication disorders, leading to improved overall quality of life for affected individuals [19]. The economic implications of such interventions are also significant. Hence, the primary aim of this study is to investigate the factors contributing to the delay in speech and language development among children in India. By examining the factors, the study seeks to provide a comprehensive understanding of the challenges that hinder the timely acquisition of communication skills. The research aims to shed light on the socio-economic, cultural, and environmental influences that impact the initiation of speech, language, and aural rehabilitation in children with communication disorders. Ultimately, the study aspires to inform targeted interventions that can effectively reduce delays in speech and language development, thereby improving the overall well-being and prospects of affected children within the context of a developing country.
Methods
Participants
This cross-sectional survey study was conducted on 2081 children aged 0.5 to 15 years (mean: 5.41; S.D.: +3.77) who sought rehabilitation services at the speech-language diagnostic department of AYJNISHD, RC, Kolkata, over a 2-year period spanning from January 2019 to December 2020. Primary caregivers provided the information for the study.
Ethical Clearance and IRB Approval
The ethical integrity of this study was upheld through stringent adherence to ethical standards and the attainment of Institutional Review Board (IRB) approval. Prior to the commencement of the research, formal written consent was diligently acquired from the participating primary caregivers. These caregivers were thoughtfully informed about the study's objectives, procedures, and the importance of their involvement. Assurances were provided regarding the confidentiality of all collected demographic information. The study was conducted in accordance with the established guidelines and protocols of the IRB, ensuring the rights, safety, and privacy of all participants.
Data Collection and Measures
Data collection for this study encompassed a comprehensive approach involving both audiological and speech-language evaluations. Initially, a brief case history was obtained from the caregivers, laying the groundwork for subsequent assessments. The audiological evaluation commenced with otoscopy and tympanometry utilizing the GSI TYMPSTAR PRO instrument. The probe tone frequency was set at 1000 Hz for children under 6 months and at 226 Hz for children above 6 months.
Subsequently, a click-evoked brainstem response audiometry was administered, employing the DUET-INTELLIGENT HEARING SYSTEMS' SmartEP module. This assessment was preceded by Otoacoustic Emissions (OAE) screening, conducted using the SANTIERO ADVANCED S0H07 OAE System. Additionally, for children below 2 years of age and those above 2 years unable to participate in conditioned play audiometry, visual reinforcement audiometry was employed. For children aged 2 to 5 years capable of following instructions for conditioned play audiometry, the Resonance R37A dual-channel Audiometer was employed, and sound stimuli were presented through supra-aural headphones. Lastly, for children aged 5 years and above who could follow instructions, standard conditioned play audiometry guidelines [10] was employed.
Assessment Services
For the evaluation of speech and language skills, receptive language age and expressive language age was assessed using formal and informal language assessment tools including Assessment of Language Development [14], Brown’s Mean length of utterance [3] and Communication DEALL Developmental Checklist [12] to estimate the children’s receptive language age, expressive language age, mean length of utterance and information regarding other developmental milestones. Subjects were referred for psychological evaluation, assessment of occupational therapy and physiotherapy, as per the requirement.
Procedure
Data Collection
A detailed interview process was undertaken, utilizing a carefully developed 14-item questionnaire specifically designed for this study. The questionnaire served as an essential tool for gathering information from caregivers. It consisted of open-ended questions, covering a range of topics including the child’s demographic details, medical history encompassing prenatal, natal, and postnatal factors, auditory behavior, cognitive and social skills, educational background, the individual who initially observed the communication difficulty, the age at which it was first noticed, and specifics regarding professionals consulted for assistance. This questionnaire underwent a stringent validation process to ensure its reliability. Five experienced Audiologists and Speech-Language Pathologists (ASLPs) with a minimum of eight years of expertise in pediatric aural and speech-language rehabilitation were involved in the validation process. They were tasked with rating each individual question on a three-point scale: 0 for "inappropriate," 1 for "needs modification," and 2 for "appropriate." The internal consistency of the questionnaire was verified, yielding a satisfactory Cronbach-α score of 0.84.
The information collected encompassed a wide array of data points, including the chronological age of the child, the age at which the problem was first suspected, the caregiver who suspected the problem, the age at which the first medical recommendation was sought, the age of formal identification of the communication difficulty, presence of family history, parental consanguinity, risk factors related to the prenatal, natal, and perinatal periods.
Statistical Analysis
The responses were recorded stored in excel sheet [15] and descriptive statistics were implemented to obtain the descriptive data of age of suspicion, identification, and intervention, risk factors, and percentage breakdown of various types of communication disorders.
Results
The statistical findings suggested that average age of suspicion of presence of communication problem is 2 year (SD: ±0.98) in which 67.7% of children were male and 32.3% were female. The age-wise distribution was done, where the subjects were divided into different age groups from 0–1.5 years, 1.6–2.5 years, 2.6–3.5 years, 3.6–5 years, 5.1-10 years 10.1-15 years. Visiting the doctors for first consultation, regarding the problem was minimal below 1.6 year that increased in percent from 2.5 years as depicted in Table 1. The graphical representation of chronological age of the child, the age at which the problem was first suspected, the caregiver who suspected the problem, the age at which the first medical recommendation was sought, the age of formal identification of the communication difficulty is represented in Fig. 1.
Table 1.
Age of suspicion, identification, and intervention for children with communication disorders
| Age- group (years; during the data collection) | Suspicion of communication difficulty | First visit to doctors (ENT specialist, paediatrician, general physician) | Commencement of rehabilitation for speech and language |
|---|---|---|---|
| 0–1.5 | 15% | 6% | Nil |
| 1.6–2.5 | 48.6% | 33.34% | 13.8% |
| 2.6–3.5 | 74.02% | 59.9% | 43.4% |
| 3.6–5 | 89.9% | 82.3% | 67% |
| 5–10 | 100% | 98.6% | 22% |
| 10.1–15 | 100% | 100% |
Fig. 1.
Age of suspicion, identification, and intervention for children with communication disorders
The family members who suspected their child to be having communication disorders are mostly mothers having the highest percent of suspicion rate (71.1%), then fathers (15.3%), grandparents (7.7%), and the relatives and neighbors who pointed out or suspected presence of communication difficulty in children (5.9%), as depicted in Fig. 2.
Fig. 2.
Identification of presence of speech and language problem by family members
On analyzing the risk factors associated with communication disorders, it was found that parents of total 631 (30.32%) children had consanguineous marriage and the highest percentage were seen in children with hearing impairment (67%). The information regarding other risk factors associated with the communication disorders were obtained in three stages which revealed that 27.6% subjects had affected prenatal history, 42% had natal history and 30.4% had postnatal history, as depicted in Table 2. Around 2% of natal and 5.2% of post-natal history were unspecified or of unknown origin.
Table 2.
Distribution of risk factors associated with the development of communication disorders
| Prenatal (24%) | Natal (48%) | Postnatal (28%) | |||
|---|---|---|---|---|---|
| Maternal infections | 24.04% | Pre mature delivery | 46.7%) | High fever | 58% |
| Toxin exposures and self-medication | 11% | Delayed birth cry | 32.3% | Ototoxicity and othertoxin exposure | 12.6% |
| Bleeding | 4.6% | Hypoxia | 27.8% | Infections | 37.06% |
| Accidents | 2.34% | Low birth weight (< 1500gm) | 17.66% | Seizure | 32% |
| Poor health | 3.6% | Breech delivery | 1.62% | Acquired trauma | 2.64% |
| Unsuccessful attempts of abortion | 0.28% | Neonatal jaundice | 54% | Admitted to NICU | 36.67% |
| Neonatal seizure | 33.4% | Ear Discharge/ache | 4.4% | ||
| Cranio-facial anomalies | 2.4% | Pathological jaundice | 34% | ||
| Syndrome | 1.03% | ||||
| Other unspecified | 2% | Other unspecified | 5.2% | ||
After the detailed audiological evaluation, speech-language evaluation, psychological evaluation and consultation of occupational therapy and physiotherapy, the data of children with different communication disorders were classified to find the percent of different disorder and it was found that 892 of the children had hearing impairment, 510 children were diagnosed with autism spectrum disorder, 430 children were diagnosed with developmental delay, 133 children had intellectual disability, 98 children had late language emergence, and 18 children had cerebral palsy, as depicted in Table 3.
Table 3.
Distribution of communication disorders based on different disorders, age and sex
| Communication disorders | Total no. of participants |
Mean age (± SD) | Male | Female |
|---|---|---|---|---|
| Hearing Impairment | 892 |
6.9 years (± 1.28) |
64.3% | 35.7% |
| Developmental delay | 430 |
2.3 years (± 0.88) |
56.6% | 43.4% |
| Autism Spectrum disorders | 510 |
2.9 years (± 2.23) |
72.3% | 27.7% |
| Intellectual disability | 133 |
7.89 years (± 1.34) |
49.9% | 52% |
| Cerebral palsy | 18 |
6.7 years (± 0.78) |
50.1% | 49% |
| Late language emergence | 98 |
2.1 years (± 0.33) |
52% | 48% |
A study on Prevalence and causes of communication disorder in Northern Karnataka suggested that Hearing Impairment was found to be the most prevalent in both children (30.81%) and adults (32.1%). Further, specific language impairment (8.04%), Delayed Speech and Language secondary to Cerebral palsy (7.21%) and delayed speech and language secondary to Intellectual Disability (6.15%) were also a few of the communication disorders seen [13].
Discussion
This survey was conducted to see the age of suspicion and identification of communication disorders in children from different rural and urban areas of West Bengal and other concomitant factors. The study was conducted on children within the age range of 0.7 to 15 years. It was found that the suspicion rate increased with increasing age with a saturation in percent after 5 years while with increasing age, it was found that the concern regarding the child’s inability to express needs or difficulty in communication increased as depicted in Table 1 and Fig. 1. Mothers were found to have a high suspicion rate having a concern that something is wrong with development of their children as shown in Fig. 2. The occurrence of disability has been higher in males as in India, 2.21% of the total population, among which 7.5% exhibits speech disability, with higher prevalence of disability among males (2.4%) than females (1.9%) [25]. From the 14-item questionnaire, the detailed information including the risk factors associated with communication disorder was obtained which revealed that among the 30.32% children who had consanguineous marriage and the highest percent were seen in children with hearing impairment (67%), then the children having developmental delay (20%) and cerebral palsy (12%). The prenatal factors included maternal infections (34.04%), toxin exposures and self- medication (11%) and bleeding (4.6%). Natal factors included premature delivery in 46.7% subjects, delayed birth cry (32.3%), hypoxia (27.8%), low birth weight (<1500 gm) in 17.66% subjects, breech delivery (1.62%), neonatal jaundice (56%) and neonatal seizure (33.4%), syndrome (1.03%) and Cranio-facial anomalies (2.4%). Postnatal factors included high fever (58%), ototoxicity and other toxin exposure (12.6%), infections (37.06%) and seizure (35%). Incidence of consanguineous marriage has been reported to be one of the highest seen risk factors (20.78%) associated with most of the communication disorders along with other relevant factor also some of the contributing factors for causing a communication disorder [9].
Consultation of a medical professional, primarily an ENT specialist was availed by 2.8 years (SD: ± 1.89) of age and sizably, 32% of the doctors during the first visit assured the parents not to worry as the child would learn language with age and only 43.4% were referred for rehabilitation. Among them, 57.8% of parents opted for consultation with rehabilitation clinics on first referral while 43% consulted second doctors and pediatrician before approaching multidisciplinary rehabilitation clinics and the identification of communication disorders occurred at 4.5 years (SD: ± 2.64) and 59.9% among them were male while 40.1% of them are female. In a study done on children with hearing impairment suggested the average age at which identification of hearing impaired was done by an audiologist for the first time was 9.3 years yet 95% of parents did not perceive delay in the initiation of aural rehabilitation [21]. Among the children identified to have communication disorder, about 62.8% of children had family history of hearing or speech problems. JCIH (2019) recommended High Risk Register factors were found to be present in 68.9% of identified children (Principles and Guidelines for Early Hearing Detection and Intervention Programs 2019).
Audiological evaluation findings showed around 42.86% of the total participants had hearing impairment in which majority (91%) of the children indicated bilateral severe to profound degree of sensorineural hearing loss, a few (8.9%) of the children had hearing loss of moderately severe degree. Among the total population, a majority of 84% of children had an A-type tympanogram, 12.6% of the children had a history of ear-discharge and 5% of the children had a B-type of tympanogram suggestive of presence of middle ear pathology. Middle ear pathology is one of the common ear conditions in children in India, especially in children with cleft lip and palate [11]. Although it does not cause severe impact in speech and language development in children, middle ear infections can cause fluctuating hearing loss and can make the speech perception and processing harder [22].
Speech and language evaluation was done, which showed most children had significant delay in receptive expressive language skills. Children with hearing loss (42.8%) showed remarkable delay in verbal receptive and expressive language skills only while other developmental skills were found to be age appropriate with adequate non-verbal communication skills. Children with autism spectrum disorder (24.5%) showed an atypical pattern of development with a markable history of regression in acquired speech and language skills at 18 to 20 months and poor social and emotional skills. The children diagnosed within the autism spectrum encompassed individuals with unspecified natal factors (2%) and post-natal factors (5.2%). These children exhibited a unique profile, characterized by a regression in speech and language skills, yet without any discernible or documented origin for this regression. This subset of cases underscores the intricacy and variability within the spectrum of autism, urging further research and exploration into the underlying factors contributing to these distinctive patterns of development. Similarly, according to the World Health Organization [26], autism, also referred to as autism spectrum disorder, encompasses a diverse group of conditions closely tied to brain development. Approximately 1 in every 100 children is affected by autism. While characteristics of autism may become noticeable in early childhood, diagnoses are frequently delayed until later stages of development. It's crucial to recognize that the abilities and needs of individuals on the autism spectrum exhibit significant variation and can evolve over time.
As many as 20.66% of children who were diagnosed with developmental delay showed significant delay in all developmental milestones, 7% amongst them showed gross delay in all developmental milestones. Children with intellectual disability (6.4%) also showed significant delay in developmental milestones and limited communication skills with the receptive language age of these children were found to be between 5.0 and 5.11 years in ALD (mean-5.67 ± 1.28) and expressive language age between 3.0 and 3.11 years (mean-3.92 ± 2.44). Around 4.7% of the total subjects who were diagnosed with late language emergence showed delay in expressive language skills only. Children who were diagnosed with cerebral palsy (0.86%) showed delayed motor milestones and receptive skills, expressive skills, and cognitive skills while social and emotional skills were found to be good.
The study indeed exhibited certain limitations that could be addressed in future extensions of the research. It is essential to note that the study was geographically confined, conducted within a specific region, and featured a relatively modest sample size. Consequently, the generalizability of the findings to a broader population may be constrained. Furthermore, although diligent efforts were made to validate the questionnaire, it is noteworthy that the translation of the questionnaire into different languages was not formally validated. This was primarily due to the questionnaire's utilization by clinicians who conducted interviews with caregivers in their respective regional languages, facilitating effective communication but potentially introducing linguistic variations.
Conclusion
The landscape of early identification has undergone significant transformation, driven by advancements in technology, the implementation of screening programs, and heightened awareness among the general population. Despite these advancements, there remains a notable delay in the identification of children with disabilities. It is essential to recognize that the occurrence of disability in children can be influenced by multifactorial elements, encompassing family history and various prenatal, natal, and perinatal risk factors.
However, the primary cause behind the delay in identification is a complex interplay of factors, including a lack of awareness, a dearth of proper guidance, and a prevalent inclination toward adopting a "wait-and-watch" approach. This delay in identification can have far-reaching consequences, hindering timely interventions that are critical for the optimal development and well-being of affected children. As we move forward, addressing these underlying factors becomes imperative, not only to enhance the early identification of disabilities but also to ensure that children receive the support and interventions they need promptly.
Acknowledgements
The authors would like to express their sincere gratitude to the Assistant Director of AYJNISHD, R.C., Kolkata, for their invaluable support and guidance throughout the research process. Their expertise and insights greatly contributed to the successful completion of this study. The authors would also like to extend their appreciation to the respected members of the Department of Speech and Hearing for their assistance and collaboration. Their input and cooperation were instrumental in conducting the study and analyzing the data. The authors are grateful for their valuable contributions and commitment to advancing the field of speech and language intervention for children with autism.
Funding
This research study was conducted without receiving any external funding. The authors would like to clarify that there were no financial contributions or grants provided for this research.
Data Availability
All the data relating to the study from the data collection to the entire study period is enclosed with the authors and can be shared with email on request.
Declarations
Conflict of interest
The authors have declared that this study was a non-funded project and no conflict of interests existed at the time of research.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
All the data relating to the study from the data collection to the entire study period is enclosed with the authors and can be shared with email on request.