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Speech and language problems

Medicine > Neurosciences

Differential Diagnosis Schema 🧠

Developmental Disorders

  • Developmental language disorder (DLD): Delayed speech and language development without any identifiable cause, affecting expressive and/or receptive language.
  • Autism spectrum disorder (ASD): Impaired social communication and repetitive behaviours; may include delayed language development or atypical language use.
  • Global developmental delay: Delayed speech and language as part of overall delayed development in multiple domains.
  • Intellectual disability: Speech and language delays associated with below-average cognitive function and adaptive behaviours.
  • Specific learning disorder: Difficulties with language skills, such as dyslexia, which may affect reading, writing, and speech.

Neurological Disorders

  • Aphasia: Acquired language disorder due to brain injury (e.g., stroke), characterized by impaired language production, comprehension, or both.
  • Dysarthria: Motor speech disorder resulting from neurological injury, leading to slurred or slow speech that is difficult to understand.
  • Apraxia of speech: Motor planning disorder where the patient has difficulty with the coordination of the muscle movements necessary to produce speech.
  • Cerebral palsy: Neurological disorder caused by non-progressive brain injury, affecting motor function and often associated with speech and language difficulties.
  • Neurodegenerative diseases: Conditions like Parkinson’s disease, multiple sclerosis, or amyotrophic lateral sclerosis (ALS) may lead to speech difficulties.

Psychiatric Disorders

  • Selective mutism: Anxiety disorder in which a child who is normally capable of speech is unable to speak in certain social situations.
  • Schizophrenia: May present with disorganized speech, including incoherence or poverty of speech.
  • Depression: Can lead to reduced speech output, monotone speech, or slowed speech as part of psychomotor retardation.

Hearing Impairment

  • Conductive hearing loss: Commonly due to otitis media with effusion (glue ear) in children, leading to delayed speech and language development.
  • Sensorineural hearing loss: Caused by damage to the inner ear or auditory nerve, leading to difficulties in speech development and articulation.
  • Auditory processing disorder: Difficulty in processing auditory information despite normal hearing, leading to difficulties in understanding and producing speech.

Key Points in History 🥼

Developmental Milestones

  • Speech milestones: Delays in babbling, first words, or sentences may indicate developmental language disorder or hearing impairment.
  • Gross and fine motor skills: Delays in other developmental milestones may suggest global developmental delay or cerebral palsy.
  • Social interaction: Poor social engagement and communication may indicate autism spectrum disorder or selective mutism.

Speech Characteristics

  • Speech clarity: Assess for articulation errors, slurred speech, or stuttering, which may indicate dysarthria or apraxia of speech.
  • Fluency and coherence: Incoherent or disorganized speech may suggest psychiatric conditions such as schizophrenia.
  • Language comprehension: Difficulties in understanding language may indicate receptive language disorder or hearing impairment.
  • Vocal quality: Hoarseness or monotone voice can be associated with neurological disorders or depression.
  • Onset: Sudden onset of speech difficulties may suggest neurological events like stroke or traumatic brain injury.

Background

  • Past Medical History: Previous neurological events (e.g., stroke), head injury, or history of recurrent ear infections.
  • Drug History: Medications that may impact cognitive function or speech, such as antipsychotics or anticonvulsants.
  • Family History: Family history of speech and language disorders, autism, or hearing impairment.
  • Social History: Environmental factors, such as exposure to multiple languages, social deprivation, or trauma.

Possible Investigations 🌡️

Hearing Assessment

  • Pure tone audiometry: Assesses the degree and type of hearing loss, particularly in older children and adults.
  • Otoacoustic emissions (OAE): Screening test for cochlear (outer hair cell) function, used in neonates and young children.
  • Auditory brainstem response (ABR): Measures the hearing nerve’s response to sounds, used to diagnose hearing loss in infants or those who cannot complete a traditional hearing test.

Speech and Language Evaluation

  • Formal speech assessment: Conducted by a speech and language therapist to evaluate articulation, fluency, receptive and expressive language abilities.
  • Language development scales: Tools like the Reynell Developmental Language Scales, used to assess language abilities in children.
  • Pragmatic language assessment: Evaluates the use of language in social contexts, important in diagnosing autism spectrum disorder.

Neuroimaging

  • MRI brain: Indicated if there is a suspicion of neurological causes such as stroke, brain tumors, or cerebral palsy.
  • CT head: Used in acute settings to assess for traumatic brain injury or other structural abnormalities.
  • Functional MRI: May be considered in research settings to assess brain regions involved in language processing.

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Neurosciences