Speech and language delay in children: Prevalence and risk factors

Abstract

Context:
Intelligible speech and language is a useful marker for the child's overall development and intellect. Timely identification of delay by primary care physicians can allow early intervention and reduce disability. Data from India on this subject is limited.

Aims:
To study the prevalence and risk factors of speech-language delay among children aged 1-12 years.

Settings and design:
A cross sectional study was conducted at the Pediatric outpatient department of a teaching hospital.

Materials and methods:
Eighty four children (42 children with delayed speech and 42 controls) aged 1-12 years were included. The guardians of these children were requested to answer a questionnaire. History of the child's morbidity pattern and the risk factors for speech delay were recorded. The child's developmental milestones were assessed.

Statistical analysis used:
Data entry was analyzed using SPSS software, version 16. Standard statistical tests were used. A p value of less than 0.05 was taken as statistically significant.

Results:
Speech and Language delay was found in 42 out of 1658 children who attended the OPD. The risk factors found to be significant were seizure disorder (P=< 0.001)), birth asphyxia (P=0.019), oro-pharyngeal deformity (P=0.012), multilingual family environment (P=< 0.001), family history (P=0.013), low paternal education (P=0.008), low maternal education (P=< 0.001), consanguinity (P=< 0.001) and inadequate stimulation (P=< 0.001).

Conclusions:
The prevalence of speech and language delay was 2.53%. and the medical risk factors were birth asphyxia, seizure disorder and oro-pharyngeal deformity. The familial causes were low parental education, consanguinity, positive family history, multilingual environment and inadequate stimulation.

Full text

© 2019 Journal of Family Medicine and Primary Care | Published by Wolters Kluwer - Medknow 1642
Background
Developmental delay is diagnosed when a child does not
attain normal developmental milestones at the expected age.[1]
Speech is the sound produced, while language is a measure of
comprehension.[2] The acquisition of intelligible speech and
language is a useful marker for the child’s overall development
and intellect.[3] Speech delay is dened as when the child’s
conversational speech sample is either more incoherent than
would be expected for age or is marked by speech sound error
patterns not appropriate for age.[4,5]
Evidence implies that untreated speech and language delay can
persist in 40%–60% of the children and these children are at
a higher risk of social, emotional, behavioral, and cognitive
problems in adulthood.[6,7] Prevalence of speech delay has
been difcult to estimate because traditionally there is a belief
that speech delay may run in families and it is not a cause of
alarm. Often a “wait‑and‑watch” policy leads to late diagnosis
and intervention for speech delay. Primary care clinicians and
family physicians are the rst point of contact for children with
speech and language delay. It thus becomes their responsibility
to identify obvious speech and language delay and address
parental concerns.
Hearing loss is a well‑documented etiology of speech delay.[8,9]
However, the causes of speech–language delay are compound
and represent an intricate relationship between the biological
Speech and language delay in children: Prevalence and
risk factors
Trisha Sunderajan1, Sujata V. Kanhere1
1Department of Pediatrics, K.J. Somaiya Medical College, Hospital and Research Centre, Mumbai, Maharashtra, India
Abs tr Ac t
Context: Intelligible speech and language is a useful marker for the child’s overall development and intellect. Timely identification
of delay by primary care physicians can allow early intervention and reduce disability. Data from India on this subject is limited.
Aims: To study the prevalence and risk factors of speech‑language delay among children aged 1‑12 years. Settings and Design: A
cross sectional study was conducted at the Pediatric outpatient department of a teaching hospital. Materials and Methods: Eighty
four children (42 children with delayed speech and 42 controls) aged 1‑12 years were included. The guardians of these children were
requested to answer a questionnaire. History of the child’s morbidity pattern and the risk factors for speech delay were recorded. The
child’s developmental milestones were assessed. Statistical Analysis Used: Data entry was analyzed using SPSS software, version 16.
Standard statistical tests were used. A p value of less than 0.05 was taken as statistically significant. Results: Speech and Language
delay was found in 42 out of 1658 children who attended the OPD. The risk factors found to be significant were seizure disorder
(P=<0.001)), birth asphyxia (P=0.019), oro‑pharyngeal deformity (P=0.012), multilingual family environment (P=<0.001), family
history (P=0.013), low paternal education (P=0.008), low maternal education (P=<0.001), consanguinity (P=<0.001) and inadequate
stimulation (P=<0.001). Conclusions: The prevalence of speech and language delay was 2.53%. and the medical risk factors were
birth asphyxia, seizure disorder and oro‑pharyngeal deformity. The familial causes were low parental education, consanguinity,
positive family history, multilingual environment and inadequate stimulation.
Keywords: Prevalence, risk factors, speech and language delay
Original Article
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DOI:
10.4103/jfmpc.jfmpc_162_19
Address for correspondence: Dr. Sujata V. Kanhere,
K.J. Somaiya Medical College, Hospital and Research Centre,
Eastern Express Highway, Sion, Mumbai,
Maharashtra ‑ 400 022, India.
E‑mail: sujatak@somaiya.edu
How to cite this article: Sunderajan T, Kanhere SV. Speech and language
delay in children: Prevalence and risk factors. J Family Med Prim Care
2019;8:1642-6.
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Sunderajan and Kanhere: Speech and language delay: Prevalence and risk ractors
Journal of Family Medicine and Primary Care 1643 Volume 8 : Issue 5 : May 2019
development and social environment in which the child learns
to speak.[9]
Data on this subject from India are sparse compared with the
West.[10] Thus, a cross‑sectional study assessing the prevalence and
factors affecting speech and language delay in children between
1 and 12 years was undertaken.
Materials and Methods
This cross‑sectional study was conducted at the pediatric
outpatient department (OPD) of a tertiary care teaching hospital
during the month of January 2018 after obtaining approval from
the Institutional ethics committee. Written informed consent was
obtained from the guardians prior to enrolment of the children.
Every consecutive child (age 1–12 years) who was brought by
caregivers for suspected delayed speech or who was referred
specically for speech delay or who was found to have delayed
speech on DQ/IQ testing and every child undergoing speech
therapy was included. Children whose caregivers did not give
consent for participation in the study were excluded. A total of
42 children formed the study group and 42 children without
speech‑language delay were enrolled as the control group after
obtaining consent from their guardians.
The caregivers of all these children were requested to answer
a predesigned, pretested, and validated questionnaire. The
questionnaire consisted of questions related to demographic data,
birth history, history of the morbidity pattern of the child (any
illness for which the child was treated either on an OPD basis or
hospitalized), along with the high‑risk factors for speech delay.
The child’s growth was assessed using anthropometry (weight,
height, head circumference), and developmental milestones
were examined at the time of contact and recorded in a data
collection sheet.
Statistical analysis
Data entry was done using Microsoft Excel 2007 and was
analyzed using Statistical Package for Social Sciences (SPSS)
software, version 16. Descriptive analysis was presented as mean,
standard deviation, and frequency. Statistical tests of signicance
used were unpaired t‑test, Chi‑square test, and Fisher’s exact test.
A P value of less than 0.05 was taken as statistically signicant.
Results
A total of 1658 children belonging to the age group 1–12 years
attended the pediatric OPD during the study period [Figure 1]. In
all, 42 children (2.53%) were found to have speech and language
delay. Of these children, one child had autistic features, one
child had cerebral palsy, and another child had hearing loss as
a comorbidity.
The study group and controls were compared for baseline
characteristics, and there was no statistically signicant difference
between the two groups in terms of age, gender, religion, and
socioeconomic status [Table 1].
Seven medical risk factors for speech–language delay were
compared in both the groups [Table 2]. There was a statistically
significant difference between the two groups for three
factors – seizure disorder, birth asphyxia, and physical (oro‑
pharyngeal) deformity, suggesting an association between these
risk factors and speech–language delay.
Eleven family–based risk factors were also studied between the
two groups [Table 3]. Multilingual family environment, positive
Table 1: Comparison of baseline characteristics between
study and control groups
Characteristic Study group
(
n
=42)
Control
group (
n
=42)
P
Age (years) 65.9+36.08 62.74+34.3 0.675***
Gender
M
F
25 (59.5%)
17 (40.5%)
22 (52.4%)
20 (47.6%)
0.510*
Religion
Hindu
Muslim
27 (64.3%)
15 (35.7%)
26 (61.9%)
16 (38.1%)
0.821*
Low socioeconomic status 29 (69%) 22 (52.4%) 0.118*
*Chi‑square test; **Unpaired
t
‑test; ***= Fisher's exact test, P value <0.05 is statistically signicant
Table 2: Comparison of medical risk factors for
speech‑language delay between study and control groups
Factor Study group
(
n
=42)
Control
group (
n
=42)
P
Hearing loss 1 (2.4%) 0 1.000***
Persistent otitis media 2 (4.8%) 0 0.494***
Seizure disorder 11 (26.2%) 0 <0.001*
Birth asphyxia 11 (26.2%) 3 (7.1%) 0.019*
Low birth weight 10 (23.8%) 5 (11.9%) 0.15*
Preterm birth 5 (11.9%) 2 (4.8%) 0.433***
Physical
(oro‑pharyngeal)
7 (16.7%) 0 0.012***
*Chi‑square test; **Unpaired
t
‑test; ***Fisher’s exact test. Bold: P value <0.05 is statistically signicant
Total attendance
of Pediatric OPD
n = 2399
Children aged
1-12 years
n = 1658
Children aged
<1 yr or > 12 yrs
n = 741
Children with
speech-language
delay (Cases)
n = 42
Children without
speech-language
delay (controls)
n = 42
Figure 1: Flowchart showing children with speech delay attending
the pediatric OPD
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Sunderajan and Kanhere: Speech and language delay: Prevalence and risk ractors
Journal of Family Medicine and Primary Care 1644 Volume 8 : Issue 5 : May 2019
family history of speech–language delay, consanguinity, low
paternal education, and low maternal education were found to be
associated with speech–language delay. There was a statistically
signicant difference between the two groups for these ve
factors.
Environmental factors such as trauma, chronic noise exposure,
television viewing >2 h, and inadequate stimulation were
studied [Table 4]. Of these, only inadequate stimulation was
found to be statistically signicantly different in the study group.
Figure 2 summarizes the eight statistically signicant risk factors
associated with speech‑language delay.
Discussion
In our study, speech–language delay was found in 2.53% of the
children attending pediatric OPD. These results are similar to
the prevalence reported from developed countries which ranges
from 2% to 8%.[3,11] Other studies have shown a higher incidence
of speech–language delay in males[12] and attributed it to the
slower maturation of the central nervous system among boys
and also by the inuence of testosterone which stops cell death
and makes proper connections difcult.[12] However, our study
found no gender difference.
A number of medical factors related to language delay were
assessed – hearing loss, persistent otitis media, seizure disorder,
birth asphyxia, low birth weight, preterm birth, and physical
(oro‑pharyngeal) deformity. Birth asphyxia, seizure disorder, and
physical (oro‑pharyngeal) deformity were found to be statistically
signicant risk factors. The association between birth asphyxia
and language delay has been well documented by other studies.[13]
The effect of epilepsy on speech–language has been reported by
Mehta B et al.[14] The hypoxic insult to the brain during a seizure
could prove detrimental in various areas of development and
can manifest as speech and language delay. The association of
oral and pharyngeal abnormalities with speech–language delay
has been reported.[15] Hearing loss has been implicated in delayed
language acquisition by other studies.[8,9] However, it was not
found to be a signicant risk factor as only one child had hearing
impairment in our study.
The nonmedical risk factors were divided into two
groups – family‑based risk factors and environmental risk
factors. The family‑based risk factors studied were as follows:
multilingual family environment, high birth order, consanguinity,
family history of speech–language disorders, large family size,
family discord, low paternal education, low maternal education,
maternal occupation, mother–child separation, and absence
of father. Our study found multilingual family environment,
consanguinity, a positive family history of speech–language
disorder, low paternal education, and low maternal education
to be signicant factors associated with speech–language delay.
A multilingual home environment, commonly seen in India, could
confuse the child during the early stages of learning a language.
We found consanguinity to be a statistically signicant risk
factor. Other studies have documented the association between
Table 3: Comparison of family‑based risk factors for speech‑language delay between study and control groups
Factor Study group (
n
=42) Control group (
n
=42)
P
Multilingual family environment 31 (73.8%) 3 (7.11%) <0.001*
Family history of speech disorder 10 (23.8%) 2 (4.8%) 0.013*
Large family size 19 (45.2%) 23 (54.8%) 0.383*
Family discord 9 (21.4%) 6 (14.3%) 0.383*
Low paternal education (<10th std) 30 (71.4%) 18 (42.9%) 0.008*
Low maternal education (<10th std) 34 (81%) 12 (28.6%) <0.001*
Mother‑child separation 3 (7.1%) 0 0.241***
Absence of father 4 (9.5%) 0 0.116***
Maternal occupation 5 (11.9%) 3 (7.11%) 0.713***
Consanguinity 25 (59.5%) 8 (19%) <0.001*
High birth order 13 (31%) 7 (16.7%) 0.124
*Chi‑square test; **Unpaired
t
‑test; ***Fisher’s exact test. Bold: P value < 0.05 is statistically signicant
Table 4: Comparison of environmental risk factors for
speech-language delay
Factor Study group
(
n
=42)
Control
group (
n
=42)
P
Trauma 1 (2.4%) 0 1.000***
Chronic noise exposure >65 db 9 (21.4%) 6 (14.3%) 0.393*
Television viewing >2 h 16 (38.1%) 15 (35.7%) 0.821*
Inadequate stimulation 26 (61.9%) 0 <0.001*
*Chi‑square test; **Unpaired
t
‑test; ***Fisher’s exact test. Bold: P value < 0.05 is statistically signicant
Figure 2: Signicant risk factors associated with speech–language delay
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Sunderajan and Kanhere: Speech and language delay: Prevalence and risk ractors
Journal of Family Medicine and Primary Care 1645 Volume 8 : Issue 5 : May 2019
consanguinity as an important risk factor for hearing loss leading
to speech delay.[16] Interestingly, in our study consanguinity was
found to be a signicant risk factor for speech–language delay
even in the absence of hearing loss.
A positive family history of speech‑reading disorders (stuttering,
unclear speech, late speaking, poor vocabulary, dyslexia) with the
affected member being a rst‑degree relative has been known
to be associated with speech and language delay.[10,17] Parents
with better education not only engage their children more
but also use more complex words that in turn stimulate and
enhance the language skills of their children.[3] A large family
size being a signicant factor in speech delay was documented
by Karbasi et al.[18] In our study, large family size was found in
both the groups, and hence family size was not found to be
signicant.
The environmental factors analyzed were as follows:
trauma, chronic noise exposure >65 db, television
viewing for more than 2 h, low socioeconomic status, and
inadequate stimulation. We found inadequate stimulation
to be statistically significant which is in agreement with
other studies.[19] Although there is a considerable amount
of literature demonstrating higher birth order and low
socioeconomic status as a risk factor for communication
problems,[10,20] our study failed to do so.
Strengths of the study
The strengths of the study are that we have studied a large
number of risk factors not routinely examined by Indian
authors. The results of this study can help family physicians
and primary care clinicians identify risk factors to facilitate
timely detection and provide early intervention for speech and
language delay.
Limitations of the study
The limitations of this study are that our study population was
small and strictly hospital‑based which could cause some amount
of sample bias. Second, only a cross‑sectional assessment was
made to diagnose speech–language delay in children.
Future directions
Large multicentric follow‑up studies should be done for a better
understanding of the factors influencing speech–language
development.
Conclusion
The prevalence of speech and language delay was 2.53% and
the risk factors associated with it were both biological and
environmental. The medical risk factors were birth asphyxia,
seizure disorder, and oro‑pharyngeal deformity. The familial and
environmental causes were low paternal education, low maternal
education, consanguinity, positive family history, multilingual
environment, and inadequate stimulation.
Acknowledgement
The authors would like to thank Dr. Satish Mali, Assistant
Professor, Department of Community Medicine, K. J. Somaiya
Medical College and Research Centre for statistical guidance.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conicts of interest.
References
1. Meschino S. A child with developmental delay: An approach
to etiology. Paediatr Child Health 2003;8:16‑9.
2. Saeed HT, Abdulaziz B, AL‑Daboon SJ. Prevalence and risk
factors of primary speech and language delay in children
less than seven years of age. J Community Med Health Educ
2018;8:608.
3. Sidhu M, Malhi P, Jerath J. Early language development in
Indian children: A population‑based pilot study.Ann Indian
Acad Neurol 2013;16:371‑5.
4. Shriberg LD. Four new speech and prosody‑voice
measures for genetics research and other studies in
developmental phonological disorders. J Speech Hear
Res 1993;36:105‑40.
5. Shriberg LD, Austin D, Lewis BA, McSweeny JL, Wilson DL.
The speech disorders classification system (SDCS):
Extensions and life span reference data. J Speech Lang Hear
Res1997;40:723‑40.
6. Law J, Rush R, Schoon I, Parsons S. Modeling developmental
language difficulties from school entry into adulthood:
Literacy mental health and employment outcomes. J Speech
Lang Hear Res 2009;52:1401‑16.
7. Morgans A, Ttofari Eecen K, Pezic A, Brommeyer K,
Mei C, Eadie P, et al. Who to refer for speech therapy at
4 years of age versus who to watch and wait? J Pediatr
2017;185:200‑4.e1.
8. Wooles N, Swann J, Hoskison E. Speech and language delay in
children: A case to learn from. Br J Gen Pract 2018;68:47‑8.
9. Shriberg LD, Kent RD, Kraals’ HB, McSweeny JL, Nadler CJ,
Brown RL. A diagnostic marker for speech delay associated
with otitis media with effusion: Backing of obstruents. Clin
Linguist Phon 2003;17:529‑47.
10. Mondal N, Bhat B, Plakkal N, Thulasingam M, Ajayan P,
Rudhan R. Prevalence and risk factors of speech and
language delay in children less than three years of age.
J Compr Ped 2016;7:e33173.
11. Wren Y, Miller L, Peter JT, Emond A, Ralston S. Prevalence
and predictors of persistent speech sound disorder at eight
years old: Findings from a population cohort study. J Speech
Lang Hear Res 2016;59:647‑73.
12. Silva GM, Couto MI, Molini‑Avejonas DR. Risk factors
identification in children with speech disorders: Pilot study.
Codas 2013;25:456‑62.
13. Stanton‑Chapman TL, Chapman DA, Bainbridge NL,
Scott KG. Identification of early risk factors for language
impairment. Res Dev Disabil 2002;23:390‑405.
14. Mehta B, Chawla VK, Parakh M, Parakh P, Bhandari B,
Gurjar AS. EEG abnormalities in children with speech and
[Downloaded free from http://www.jfmpc.com on Friday, June 12, 2020, IP: 98.14.229.38]

Sunderajan and Kanhere: Speech and language delay: Prevalence and risk ractors
Journal of Family Medicine and Primary Care 1646 Volume 8 : Issue 5 : May 2019
language impairment. J Clin Diagn Res 2015;9:CC04‑7.
15. Lyons DC. Relationship of oral and pharyngeal abnormalities
to speech. Arch Otolaryngol 1932;15:734‑8.
16. Reddy VVM, Bindu HL, Reddy PP, Rani UP. Role of
consanguinity in congenital neurosensory deafness. Int J
Human Genet 2006;6:357‑8.
17. Hayiou‑Thomas ME, Carroll JM, Leavett R, Hulme C,
Snowling MJ. When does speech sound disorder matter for
literacy? The role of disordered speech errors, co‑occurring
language impairment and family risk of dyslexia. J Child
Psychol Psychiatry 2016;58:197‑205.
18. Karbasi SA, Fallah R, Golenstan M. The prevalence of
speech disorder in primary school students in Yazd‑Iran.
2011;49:33‑7.
19. Leung AK, Kao CP. Evaluation and management of the child
with speech delay. J Am Board Fam Med 1999;59:3121‑8.
20. Chaimay B, Thinkhamrop P, Thinkhamrop J. Risk
factors associated with language development problems
in childhood – A literature review. J Med Assoc Thai
2006;89:1080‑6.
[Downloaded free from http://www.jfmpc.com on Friday, June 12, 2020, IP: 98.14.229.38]