behs343 project scenario 6

of 17The Examination of a Child Not Speaking as Expected by the Parent

The Examination of a Child Not Speaking as Expected by the Parent

Lot in Life Research Paper

Professor: Dr. Crystal Neal

Student: Modupe Olayinka Sarratt

Assignment Due Date: 3/10/2013

The Process of Parenting

Course: BEHS343 Section6382

Scenario 6 Intern Examination for Speech and language Delay in two years old girl

Revised: February 23, 2013


Abstract

To examine a child for language issues require the guardian or parent(s) to schedule an

appointment even though is just a concern or worry about a child not thriving as expected based

on beliefs. Many parents believe speaking occurs as a child grows, especially when a child starts

walking, but usually that is not the case. Research for language development indicates that is the

process, through parenting, begins between the ages of two and five. According to Jane Brooks,

parenting is “how parents help children make sense of the world around them and develop sense

of self to learn to express them” (Brooks, 2011 p. 234). Therefore, speech disorders are difficult

to diagnose at two years because that is when a child is beginning to connect and transfer

gestures, signals or expressions into words. At two years old, children are able to transfer a few

simple words from gestures to language such as, “bye, mommy or daddy”. According to

research for children development, “children progress from having about 50 words at nineteen

months to 10,000 words at age six” depending on the parenting style (Brooks, 2011 p. 235). The

process to diagnosing speech delays start with consultation, observation, and neurophysiological

exams to rule out hearing impairment.


Content

Introduction 4

Encounter 5

Consultation 6

Initial visit 7

Subsequent visit 8

Physical exam 9

Assessment Chart 10

Test 11

Finding 12

Recommendation 14

Plan 14

Reference 16


Introduction

Language is the expectation that every parent places on his or her children for addressing

society and culture. Therefore, worrying about a child not speaking is a concern because

speaking is imitation of what is heard, ‘we speak what we heard’ (Sarratt, 2013), but speaking

and language are two different things despite the connection. To be able to speak a language

depends on the parenting style, choices for words, culture, and the environment. In some culture,

making a distinct sound such as crackle is an act of speaking. Speaking is vocal while language

is dialect. The commonalities for dialect in most societies are by creating words to represent

actions or to mean something. How children comprehend the words depend on the parent and the

environment. By age six, it is possible that a child is able to have a vocabulary of enough words

to speak complete sentences or able to comprehend enough words to talk effectively. For a child

to be able to convey language or a dialect to speak depends on how old the child is, instead of

how well the language is taught. Although language and speech are similar, there is a difference.

Speaking is vocalizing something, such as mumbling or babbling, while language is what the

parent and society teaches.

In order to examine a child, who is not speaking, requires discussions with the parent to

clarify the difference between languages, speaking, and hearing. The medical procedure to

examine language is the examination for neurophysiological development, the ability of child to

be able to speak, learn, and relate to others. The medical procedure for speech is to test a child

for ability to vocalize, which is not necessary if no visible birth defects, such as cleft lip. The

medical procedure for hearing is to test a child for the ability to listen and respond to sounds. In


addition, the medical procedures require testing a child for emotional development, the ability to

associate and connect.

Encounter

On December 03, 2012, a meeting was held with a mother to discuss her concerns about

her two year old daughter who did not express the same speech skills, compared to other children

of the same age. Modupe Sarratt, the intern examiner explained to the mother that speaking is

associated with hearing, according to academic journal article written by Amy R. Lederberg,

Brenda Schick, and Patricia E Spencer (2013). The article suggests that, “Language development

has long been recognized as the most important area affected by hearing loss. Although the

relation between the degree of hearing loss and an individual's access to spoken language is

complex, hearing loss is often categorized as mild, moderate, moderately-severe, severe, severe-

profound, or profound. Children with milder losses typically achieve access to speech when

fitted with hearing aids; however, any degree of loss raises the risk of language delays”

(Lederberg et al 2013).

A research for language development suggests that children understand words more than

they can use them. “At age two, children have a vocabulary of about three hundred words. By

age two, toddlers have also made the leap to putting two words together to form a sentence”,

according to Jane Brooks in the process of parenting (Brooks, 2011 p. 213). The acts of

speaking begin when babies develop in the womb. Sucking and crying after birth is a way of

speaking using emotional reactions in different atmosphere to indicate ‘I am here’, ‘I not

comfortable in this environment’, ‘can you help me’, making the parent feel the need to cuddling

and protect the baby. Babies speak or vocalize naturally with signals and expressions such as,


crying, sucking, smiling, cooing, and laughing, but the parents have to teach the children how to

connect speaking to language. Therefore, how children develop languages depends on the

parenting style and word choices. For example, if a child learns from the parent that making

noises or sounds is way to speak, the child would grow using just sounds as their language. If

word use is slumber, slow, not active, or incoherent, then children imitate or use those patterns as

a way of speech. During child development, parents help children to associate signals with words

that a child develops as a language. Currently, there is no specific test for speech for two year

olds, except hearing tests to eliminate deafness. Children develop language from parents

speaking them; parents choice of words and style to teach language is very crucial because that is

how a child learns to speak.

As intern explained to the mother, the medical protocol for examining her daughter

includes scheduled initial visit for consultation to gathering information, subsequent visits for

examination, possible referring the child for testing, and follow-ups to discuss the findings. As a

professional intern, understanding the family history and being able to evaluate the child for

speech delay requires clarifying the differences between languages and speaking, analyzing and

discussing finding for language development and the causes for speech delay, while observing

the child’s behavior and perception to provide recommendations.

Consultation

On December 04, 2012, a mother comes in concerned that her two years and three

months old daughter has not begun speaking and it seems as if the daughter does not interact as

much with other children on social occasions. Explained to the mother the factors for speech and

language development of two years old depends on the process of cell development of the


muscle and the nervous system, as well as the environment. At two, a child words increases

from babbling to joining of words to associating objects and actions with words. For example,

‘mommy go, bye mommy, doggie eat’ etc. In addition, a child developing the ability to

understand an adult may not be clear at two, but is being built into child development.

Moreover, at two years of age, a child may not be able to speak a particular language. A

suggestion to the parent, when speaking to the daughter, look directly at her, so that the daughter

can connect the facial expressions into the meaning of words that are used. Use actions to help

the child associate particular words with objects and events. Inform parents that to help a child

develop language is by constantly exposing a child to sound of voices, particularly words that

require verbal response. For example, associate yourself as ‘mommy’ and ask your daughter to

call for mommy. Schedule follows up in a week to examine for neurophysiological development.

Initial visit

December 11, 2013, examined daughter for neurophysiological development by

observing the daughter interacting with other children at receptionist area, designed for children

to play with toys, play with other children, listen and respond to instructions as depicted in the

image by Talking Point.Org for children communication.


(Bing Images)

Impression:

Appearance and grooming- child is well dress, no rash or injury

Skin tone: normal

Muscle tone: interacting with other, picking up and playing with objects:

within normal limit for second year.

Facial expression for interaction- normal-no muscle weakness

Movement, daughter line up according for group action and name calling

in the audio sound of a talking toy.

Neurologic physiology structure and function within normal for age

Assessment for motor skills with a reflex test was conducted. A reflex test is a simple physical

test with a light knee tap with hammer to test for the function of the nervous system, eliminating

neuromuscular deficit such as, spinal bifida. The results for the daughter are normal.

Examination of head, neck, and spine indicates no abnormalities or bruising.

Schedule follow up in 2 weeks to address the issues

Subsequent visit

On December 25, 2012, the daughter was examined for emotional development skills.

Explained to the parent that the emotional development of a child requires a child being able to

associate, connect, and interact with other family member, which requires immediate family


members to initiate conversation in the level for a child to converse. In addition, at age two,

children understand that people’s feelings lead to actions for conversing or talking, in her case,

for speaking. Explain that communication for two years old usually uses simple words and

gestures, and sometimes they are able to echo what they hear or mix a few words with babbling.

The mother is twenty-seven years old, single, and works full-time at local grocery store. The

mother and her daughter reside in two bedroom apartment, the father comes and goes, and

occasionally stays for few days via arrangement, grandmother is fifty years of age with medical

history of a mild stroke two years ago, and helps to care for the daughter while mother work

while the mother works. Mother had a normal delivery at nine months, and no history of birth

defects. The daughter is two years old and three months on December 27, 2012 and utters few

words such as, ‘bye mommy, happy, bottle hot, grandma and daddy’. The daughter responds to

simple commands such as, “pick up the bottle” and “come here”. However, she does not respond

to commands in long statements such, saying ‘I love my daddy and mommy’ and daughter

follows gestures to say ‘goodbye! The child prefers to play with toy, sit in her grandmother’s lap,

and watch TV in the presence of other children or peers, instead of interacting with them.

Daughter is not taken any current medication

Vaccination is up to date according to mother

Vital Signs: Height: 34 inches, Average, within normal limit for 2 years old, Weight: 29 lbs.,

Average, within normal limit for 2 years old, Respiration: 22 per minutes, normal for 2 years old

Temperature: Afebrile, normal temperature, Blood Pressure: not perform Pulse: 100 and regular

Allergies: No known of any drug allergy or environmental

Physical Examination


Physical examination is essential for evaluating general wellbeing, including the

appearance for well-developed, well-nourished for two years olds. Evaluation of the head and

neck for normal growth, clear throat, normal tonsil, quality teeth, and the neck with no carotid

bruits; all of these evaluations seems normal. Vision is within normal limits for two year olds, as

she was able to follow and recognize objects from a distance. Hearing evaluation indicates a

slightly abnormal reaction to quiet speech with whispering, the child steering indicates lack of

clarity. The lungs are normal, no wheeze, no crackling or bubbling sound heard during

evaluation. Abdomen sound is also within normal for bowel movement, no masses or tenderness

felt with gentle pressure for palpation exam. Extremities observations were normal with no

cyanosis and the peripheral pulses were intact. Schedule follows up in 2 week to discuss child

emotional development.

Assessment chart for emotional development

Are you worried because your daughter seems late in starting to talk

Mother: Yes

Is there a concern that your daughter cry without a reason or do you think that your daughter

cries unnecessarily? Mother response: no, not really

How would you describe your daughter when she express anger, do you think when she is

angry, there is a reason for her to be angry? Mother response: I think when she angry she has a

reason, but sometimes I wish she tells me what is wrong.

Note: crying and tantrum are children ways for expressing conflict. According to Jane Brooks,

“anger represent 23 percent for emotional development and parent-child interactions account for

71 percent, and parents usual response is not to comfort but to give the child a practical,

problem-solving response” (Brooks, 2010 p 237).


Does your daughter seem to be developing normally in other ways such as, understanding and

responding with physical skills to command? for example, picking up a toy if she is ask or do

you have to repeat what you said or increase you voice for her to respond.

Mother response: no, not all the time

Mother: Sometimes, I have to repeat myself for her to respond, the sometimes for when I wonder

if she hears me.

Clarification: Do you think something may be going on during the sometimes when you feel

like she did not hear you, what is sometimes to you?

Mother: sometimes is like when she is acting clumsy or maybe not feeling good or sometimes

when she is focusing on something.

Note: eliminate the possibility for hearing defect by referring for hearing test.

Is she able to join two words together, for example, Bye mommy or mommy go.

Mother: Yes

Clarification: Is she able to say the words clearly

Mother: Yes

Noted: It is a common knowledge that “hesitation in speaking is normal for children” because is

a stage that most young children go thru due to the excitement of new discovery such as, new

word for growing brain to develop knowledge. Because of the brain, working faster to expand

knowledge of new words and things affect the children to hesitate about talking that were

normal for social development. For social development, some children developed self-seeking

word of their own or imitates activities of their favorite word such as “No” for social response.

(Sarratt, 2013)


Test

The test perform to rule out hearing impairment was patient referral to an audiologist, a

specialist for hearing tests and neurologic evaluations performed in the office to rule out sensory

and motor defects. There is no test for speech at second year because there is no history of birth

defects, such as cleft lip, an upper lip congenitally divided into two parts that have been only

partially reunited by surgery. In addition, there is no problem with vocalization because speech

is a selective process taught by the parent. According to an abstract of academic journal by Lori

B. Astheimer and Lisa D. Sanders In Developmental Cognitive Neuroscience 2(1):120-128

indicated that “directing attention to word onsets may be important for speech processing in

young children who would otherwise be overwhelmed by the rapidly changing acoustic signals

that constitute speech.” Technically, neurological function for speech processing in the children

is between “3- to 5-year-old” (Lori & Lisa (2011). Schedule follows up in 2 week to review the

result for hearing test.

Finding

The findings for daughter examination suggested that language development for speaking

were normal and there was no reason for daughter not speaking. The hearing test result for the

daughter was normal. There was no neurological impairment for speech delay, daughter was able

to speak more than 50 words, able to links words to action such as, “bye mom when mom is

asked to leave the room, observation of daughter playing and interacting with peer and adult

were normal for two years old. According to Jane Brooks, the indication for physical and

neurophysiological development were normal between ages two and five for these reason, “

children grow from about 34 inches and 29 pounds at age two to 42 inches and 42-45 pounds by

age five ‘children’s brains are active primed for learning 5.5 words per day, or having about 50


words by two.’” Moreover, at “three-year-old, children brain develop twice as many synapse for

connection among the brain cells and is twice more active to increases children neurotransmitter

to processing information for cognition and social functioning” (Brooks, 2011 p. 235). In

addition, research by Longobardi, Rossi-Arnaud and Spataro indicated, “both verbal and non-

verbal variables predicted the level of language development at 23 months ‘early individual

differences in the use of words and gestures were associated with later differences in linguistic

abilities’” (Longobardi, Et. al 2011).

Further information provided to parent include brief explanation for “intellectual

development” of children depend on what children observe others doing in actions with words

for interaction would increase a child ability for “verbal skills” and children develop the

“motivation when parents are warm, encouraging, and open in conversation with their children,”

stated in the process of parenting by Jane Brooks. (Brooks, 2011 p. 235)

Explained to the mother, there is no reason for her daughter not speaking; my advice is

for the mother to interact more with her daughter with clear pronunciation of expression or

words, and to include family member to speak clearly to the child. Indicated that research for

children development by Mayo Clinic said, “Every child grows and develops at his or her own

pace” (MFMER 1998-2013). Her daughter tends to follow a fairly predictable path, the

predictable path for language skills as follow: a child is able to “speaks about 50 words, answers

simple question, links two words together, uses some adjectives (big, happy), and able to speaks

clearly enough for parents to understand some of the words” (MFMER 1998-2013). However,

parent could help to improve a child speech developmental by develop a pattern by which to

speak to the child for her to respond in his or her own term. Otherwise, a child would speak

when he or she is ready. Possible cause is lack of stimulation otherwise; the child is developing


normally for two years old. Lack of stimulation to interact usually is because the parent(s) is not

communicating enough to get the child attention and case like hers is common among working

couple and single parent. Occasional raise of voice or repeat to get daughter attention is because

the daughter is used to mom tone that sometimes sound like monotone for her to just looks at

mom instead of action, for example is as if the parent is talking to the wind. Advice mother, there

is no obvious medical reason for daughter not speaking.

Recommendation

Patient guidance was referral to community outreach service for parenthood and child

development at local public health located in Annapolis. Recommend mother to seek psychiatric

counseling for dealing with the pressure of being a single mother. Provide a booklet on how to

help children develop language, and admonish to read medical journal on child development

especially on the topic for speech and language and to get involve more with interaction for

daughter and mom talk for conversation.

Plan

The plan was an intervention to provided support to the mother and the child by

contacting two local community agencies to obtain information for language development and

for parenting skills. Visit to Annapolis Outreach Clinic on February 15, 2013 inquiry about

language development, personal communication with the nurse and the visiting physician

inferred “there is no specific test for language at age two beside neurological examination with

hearing test to rule out deafness” (Sarratt, 2013). The visit to Anne Arundel County Department

of Health on February 05, 2013 for parenting assistant referenced parent and child to attend a 14-

session program designed to strengthening the families. Conferring with the director of the


program, the program provides training to parent on how to help a child develop social skills and

life skills that structured with family activities and games. Many people from the Arundel

County Department of Health contributed to the input of strengthening the families programs to

help provide stability for struggle family. The cost for 14-session depends on the assessment of a

child needs and the parent ability to pay. (Sarratt 2013) The families program encourages the

parent to talk with the children about what they see and to ask the children for what they like or

dislike. According to Anne Arundel County Department of Health (2013), the benefits of

program to the parent and the child were as follow:

• Improve family communication,

• Provide effective discipline,

• Set constructive limitations,

• Use attention and rewards to improve their children’s behavior, and

• Understand the negative impact of substance abuse on family relationships.

What children gain through Strengthening Families, the Strengthening Families Program

helps children to:

• Develop better communication and social skills,

• Understand their feelings, Solve problems,

• Resist peer pressure,

• Learn the consequences of substance abuse, and

• Comply with family rules.

One parent experience suggested that having a ritual to practice talking or speaking

would encourage a child to develop language for speaking. Children are inventive at age two

from what children heard or learned. Once a child mastered the words for expression, he or she


will speak; the child could surprise the parent with long sentence. For some children, speaking

depends on when the child feel should could put the word together that would make a logical

sense. Therefore, some children may delay speaking until he or she feels confidence that what he

or she is saying make sense to the parent or the people around them.

References

ASHA. (1997-2013). American Speech-Language-Hearing Association

http://www.asha.org/public/speech/development/schoolsFAQ.htm

Bing Images. (2013). Talking Point.Org, the first stop for information on children’s

communication http://www.talkingpoint.org.uk/EY-worker.aspx

Brooks, J. (2011). The process of parenting (8th ed.). NY: McGraw-Hill.

Informal Interview. (2013, February 15). Annapolis Outreach Clinic 92 Washington Street,

Annapolis, Maryland

Informal Interview. (2013, February 05). Anne Arundel County Department of Health,

Informal Behavioral Health Building 122 North Langley Rd, Suite A, Glen Burnie,

Maryland

Lederberg, A. R., Schick, B., & Spencer, P. E. (2013). Language and literacy development of

deaf and hard-of-hearing children: Successes and challenges. Developmental Psychology,

49(1), 15-30. doi:10.1037/a0029558

Longobardi, E., Rossi-Arnaud, C., & Spataro, P. (2011) A longitudinal examination of

early communicative development: Evidence from a parent-report questionnaire.

http://www.talkingpoint.org.uk/EY-worker.aspx

http://www.asha.org/public/speech/development/schoolsFAQ.htm


British Journal Of Developmental Psychology, 29(3), 572-592.

doi:10.1348/026151010X523473

Lori B. A., & Lisa D., S. (2011) Elsevier Ltd, Temporally selective attention supports speech

processing in 3- to 5-year-old children. Developmental Cognitive Neuroscience, 2120-

128. doi:10.1016/j.dcn.2011.03.002.

MFMER, (1998-2013). Mayo Foundation for Medical Education and Research

Sarratt, M. (2013 February 05 & 15) Personal Communication