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An Assessment of Risk Factors of Delayed Speech
and Language in Children: A Cross-Sectional
Study
Anish Kumar , Maryam Zubair , Azouba Gulraiz , Sruti Kalla , Saif Khan , Srushti Patel , Maria F.
Fleming , Princess T. Oghomitse-Omene , Parth Patel , Muhammad Saqlain S. Qavi
1. Internal Medicine, Ghulam Muhammad Mahar Medical College Hospital, Sukkur, PAK 2. Clinical Research,
University of Tripoli, Tripoli, USA 3. Medicine, California Institute of Behavioral Neurosciences and Psychology,
Fairfield, USA 4. Internal Medicine, Maharajah's Institute of Medical Sciences, Vizianagaram, IND 5. Hospital
Medicine, North Manchester Hospital, Manchester, GBR 6. Pediatrics, Gujarat Medical Education and Research Society
Medical College, Gandhinagar, IND 7. Medicine, Forum of Artificial Intelligence in Medicine, Miami, USA 8. Medicine,
Universidad Central de Venezuela, Caracas, VEN 9. Pediatrics and Neonatology, Delta State University Teaching
Hospital, Abraka, NGA 10. Pediatrics and Child Health, Covenant Community Care, Detroit, USA 11. General Practice,
Shri M. P. Shah Medical College, Jamnagar, IND 12. Internal Medicine, Akhtar Saeed Medical and Dental College,
Lahore, PAK
Corresponding author: Muhammad Saqlain S. Qavi, saqlainqavi002@gmail.com
Abstract
Introduction
Communication is the exchange of information through speaking, writing, and other mediums. Speech is
the expression of thoughts in spoken words. Language is the principal method that humans use for relaying
information; consisting of words conveyed by speech, writing, or gestures. Language is the conceptual
processing of communication. Problems in communication or oral motor function are called speech and
language disorders. Developmental delay is diagnosed when a child does not attain normal developmental
milestones at the expected age. Speech and/or language disorders are amongst the most common
developmental difficulties in childhood. Such difficulties are termed 'primary' if they have no known
etiology, and 'secondary' if they are caused by another condition such as hearing and neurological
impairment, and developmental, behavioral, or emotional difficulties.
Objectives
The objective of our study was to observe the risk factors for speech and language delay in the children
presenting to the speech therapy clinic of a tertiary care hospital in a large urban center.
Methodology
A cross-sectional study was conducted on 150 children presenting at the speech therapy clinic of Lahore
General Hospital from July to August 2021. A well-designed questionnaire was used to collect data about the
sociodemographic profile, and biological, developmental, and environmental risk factors of speech and
language delay in children. SPSS, version 25 (IBM Corp., Armonk, NY) was used to enter and analyze the
data.
Results
Parents or caretakers of a total of 98 male and 52 female children took part in this study aged 2-11 years.
The average age of speech and language delay among the children was 5.65 years, 66.7% of which went to
normal school while 31.3% went to special school; 66.7% were from urban areas. Around 60% had middle ear
infections, and 34.7% were found to have oropharyngeal anomalies. A history of intrapartum complications
was found in 68.4% of children; 46.7% of children had a history of use of a pacifier and 38% had a history of
thumb sucking. Nearly 39% of children belonged to a multilingual family environment and 66.7% had a
family history of screen viewing for more than two hours.
Conclusion
The major risk factors contributing to speech and language delay in children are family history of speech and
language delay, prolonged sucking habits, male gender, oropharyngeal anomalies, hearing problems, and
middle ear infections. Measures should be taken to educate people regarding risk factors, courses, and
management of speech and language delay in children.
Categories: Family/General Practice, Otolaryngology, Pediatrics
Keywords: uk - united kingdom, gdm- gestational diabetes mellitus, iq - intelligence quotient pdd- pervasive
developmental disorders, opd- outpatient department, ent - ear nose and throat, lbw- low birth weight, spss-
1 2 3 4 5 6
7, 8 9, 10 11 12
Open Access Original
Article DOI: 10.7759/cureus.29623
How to cite this article
Kumar A, Zubair M, Gulraiz A, et al. (September 26, 2022) An Assessment of Risk Factors of Delayed Speech and Language in Children: A Cross-
Sectional Study. Cureus 14(9): e29623. DOI 10.7759/cureus.29623
statistical package for the social sciences, or- odd's ratio, who- world health organization
Introduction
Speech is the most important form of conveying information and it can only be made possible through
language. Language essentially embodies the words relayed via verbal or non-verbal ways. Disorders of
speech and language could be defined as affliction in oro-motor function and dysfunction or lack of
communication. Delayed speech and language can be identified when a patient does not achieve what is
expected at an appropriate age [1].
Of the children going to primary schools, nearly 5% have a detected delay in speech and language. The
global prevalence of these disorders in this age group varies between 3%-20% [2]. However, the percentage
of speech and language disorders in school-going children is lower than the global average [3]. This could be
one of the most significant hindrances to developmental difficulty in any child, which can be termed as
primary if no possible etiology could be diagnosed. However, if a diagnosis is established, it can be referred
to as a secondary cause. These causes can be classified as hearing difficulty, behavioral or emotional
problems, and/or neurological causes [4].
As per the U.S. Preventive Services Task Force, the causative factors for these disorders consist of family
history, premature birth, intrauterine growth retardation (IUGR) male gender, and parents of low
socioeconomic background [5]. Nearly 4/5th of school-going children suffer from at least one episode
of otitis media in their school life that can lead to delayed speech and language. Suckling in children
has previously been linked to speech and language disorders. Excessive sucking of pacifiers,
dummies, thumbs, and/or bottles can cause a decreased sense of the oral cavity and could also lead to oro-
motor dysfunction. Family history of speech and language disorders has a strong association with a delay in
speech and language [6]. Nearly half of the children with such disorders have a positive family history; the
type of disorder, however, can vary [7].
All children must be screened for speech, language, and hearing difficulties. A delay in diagnosis and
management can lead to a permanent loss in cognitive development leading to low intelligent quotient (IQ),
difficulty in communication, and illiteracy [7]. There is a vast majority of evidence in the support of speech
therapy in the setting of these disorders. Idiopathic etiologies have a better prognosis. An assessment of risk
factors could lead to devising strategies in achieving the prevention of these disorders.
Materials And Methods
This was a cross-sectional study. The study was conducted in the speech therapy clinic at a tertiary care
public hospital in a large urban center in Pakistan. The hospital is 1196 bedded teaching hospital and has 31
departments. There is only one speech therapy clinic on the second floor of the outpatient department
(OPD) building. On average, the speech therapy clinic receives 2-3 patients per day. The study population
included all children with speech and language delays who presented to the speech therapy clinic of Lahore
General Hospital. The data were collected from July 2021 to August 2021. The approval (00/67/20) was
obtained from the IRB of Lahore General Hospital before data collection.
The sample size was estimated using the World Health Organization (WHO) sample size software by using
the formula of estimating population production with specified relative precision. With a confidence level of
95% and an anticipated population proportion of 73% with a relative precision of 10%, the minimum sample
size was 150. The sampling technique used was nonprobability convenient sampling because of limited
resources and a shortage of time. All children who presented to the speech therapy clinic of Lahore General
Hospital were included. However, children diagnosed with autism spectrum disorder were excluded
alongside those whose attendants refused after informed consent was provided.
Data were collected using a well-structured questionnaire after obtaining informed consent. The
questionnaire consisted of four main parts. Sociodemographic profile, biological factors, family-based risk
factors, and environmental factors. Data were collected with the help of face-to-face interviews with
attendants of patients (children) coming to the speech therapy clinic of the Lahore General Hospital. A
predesigned structured questionnaire was used. Data were collected by a group of eight doctors and
students, and the questionnaire was translated into the local language for convenience. The questionnaires
were checked for completeness every day.
SPSS software, version 25 (IBM Corp., Armonk, NY) was used for the entry, analysis, and computation of the
data. For quantitative variables, the mean, median, and standard deviation were calculated. For qualitative
variables, frequency distribution tables and percentages were generated. Data are presented using frequency
tables, charts, and graphs. Descriptive analysis was used for sociodemographic and categorical data. The
variables associated with speech and language delay were analyzed using bivariate analysis. A p-value of less
than 0.05 and a confidence interval of 95% were considered statistically significant.
Results
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A cross-sectional study was conducted in July and August 2021 on children presenting to the speech therapy
clinic of Lahore General Hospital. Data were collected from attendants of 150 children using a well-
structured questionnaire by a nonprobability convenience sampling technique. From the sociodemographic
profile of the patients, the following results were obtained. Table 1 describes the demographic profiling of
the participants.
2022 Kumar et al. Cureus 14(9): e29623. DOI 10.7759/cureus.29623 3 of 10
Variables Categories Frequency (N) Percentage (%)
Gender
Male 98 65.3
Female 52 34.7
Paternal education
Illiterate 26 17.3
Primary/Middle school 50 33.3
High school 46 30.7
Graduate and higher 28 18.7
Maternal education
Illiterate 34 22.7
Primary/Middle school 70 46.7
High school 10 6.7
Graduate and higher 36 24.0
Father's occupation
Unemployed 13 8.7
Employed 137 91.3
Nature of occupation
Job 75 50.0
Businessman 75 50.0
Mother's occupation
Housewife 104 69.3
Working 46 30.7
Place of residence
Rural 50 33.3
Urban 100 66.7
Socio-economic status
Upper 11 7.3
Middle 91 60.7
Lower 48 32.0
Type of school child goes to
Normal 103 68.7
Special 47 31.3
No of siblings
One 15 10.0
Two 51 34.0
Three 32 21.3
Four 32 21.3
Five 9 6.0
Six 7 4.7
Seven 1 7
Eight 3 2.0
Child's birth order
First 67 44.7
Second 45 30.0
Third 21 14.0
Greater 17 17.3
TABLE 1: Descriptive analysis of demographic factors
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The respondents were group matched for age. The mean age of the respondents was 5.65 years, and the
standard deviation was ±2.66 years. Almost half (68) of the total 150 patients had a significant injury, illness,
or hospitalization. Of the total sample, 114 also had hearing problems. Table 2 describes the frequency of
probable causes for speech and language disorders.
Variables Categories Frequency (N) Percentage (%)
Any significant injury, illness, or hospitalization
Yes 68 45.3
No 82 54.7
Any seizure disorder
Yes 58 38.7
No 92 61.3
Any hearing problem
Yes 114 76
No 36 24.0
Ever had a middle ear infection
Yes 89 59.3
No 61 40.7
Any other illness related to ear, nose, and throat (ENT)
Yes 74 49.3
No 76 50.7
Consanguinity of parents
Yes 63 42.0
No 87 58.0
Any oropharyngeal deformity
Yes 52 34.7
No 98 65.3
Age of father at child's birth
Greater than 40 years 62 41.3
Less than 40 years 88 58.7
Age of mother at child's birth
Greater than 40 years 64 42.7
Less than 40 years 86 57.3
TABLE 2: Frequency of biological factors
We found that 40.0% and 34.7% of the mothers had a history of hypertensive disorder during pregnancy and
gestational diabetes, respectively. A history of anemia during pregnancy was present in 34.0% of the
mothers. A history of fetal distress was found in 22 of the patients. The children with a history of neonatal
seizures, prematurity, and low birth weight were 27.3%, 28.0%, and 33.3%, respectively.
Breastfeeding history was present in 78 children, while 72 children were bottle feeders. A history of thumb
sucking was positive in 38.0% of all children. A history of pacifier use was found in 46.7% of the children
(Table 3).
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Variables Categories Frequency (N) Percentage (%)
Feeding history
Breastfeeding 78 52.0
Bottle-fed 92 48.0
History of thumb sucking
Yes 57 38.0
No 93 62.0
History of use of pacifiers
Yes 70 46.7
No 80 53.3
TABLE 3: Frequency table of feeding/developmental risk factors
Most of the children belonged to the joint family system (64.0%), while the rest were from the nuclear family
(36%). No family members greater than four were present in 35.3% of the total cases. A family history of
speech and language disorder was found to be positive in 98 of the total presented cases. A total of 38.7% of
the children lived in a multilingual family environment (Table 4).
Variables Categories Frequency (N) Percentage (%)
Type of family Joint 96 64.0
Nuclear 54 36.0
No. of family members
Greater than four 53 35.3
Equal to or less than 4 97 64.7
Family history of speech and language disorder
Present 98 65.3
Absent 52 34.7
Mother-child separation
Yes 61 40.7
No 89 59.3
Father’s absence from home
Yes 48 32.0
No 102 68.0
Multilingual family environment
Yes 58 38.7
No 92 61.3
TABLE 4: Frequency table of family-based risk factors for speech and language delay
A history of recent trauma or stress was detected in 28 children alongside other findings (Table 5).
Variables Categories Frequency (N) Percentage (%)
History of recent trauma or stress
Yes 28 18.7
No 122 81.3
Screen Viewing (television, mobile, or laptop)
Greater than two hours 100 66.7
Equal to or less than two hours 50 33.3
TABLE 5: Frequency table of environmental factors for speech and language delay
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Various risk factors were compared with each other to determine which were significant. A chi-square test
was applied. The associations analyzed are provided below in Tables 6-9.
Family history of speech and language disorder Chi-square P-value
Present (n) Absent (n)
Gender of child 0.073
Male 69 29
Female 29 23
TABLE 6: Association between gender of child and family history of speech disorder
History of hypertensive disorder pregnancy Chi-square P-value
Yes n (%) No n (%)
Any oropharyngeal deformity 0.141
Yes 25 (41.7 27 (30.0)
No 35 (58.3) 63 (70.0)
TABLE 7: Association between a history of maternal hypertension and oropharyngeal deformity
Any hearing problem Chi-square
Yes (n) No (n) P-value
Screen viewing 0.043
Greater than two hours 71 43
Equal to or less than two hours 29 7
TABLE 8: Association between screen time and family history of speech disorder
Consanguinity of parents Chi-square
Yes n (%) No n (%) P-value
Family history of speech and language disorder 0.182
Present 45 (45.9) 18 (34.6)
Absent 53 (54.1) 34 (65.4)
TABLE 9: Association between consanguinity of parents and family history of speech disorder
Results indicate there are risk factors for developing a speech and language disorder with being a male, being
born as the first child, being born in a joint family and parents who are illiterate, and those who have a
family history of disorders. A positive association has been established, as shown in the tables above (Tables
6-9).
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Discussion
When a child's speech is incomprehensible or does not achieve what is required at a specific age, it can be
referred to as a speech and language delay. Major risk factors can be divided into antenatal, neonatal, or
developmental. Maternal participation that is widely concerned with developing communication in children
includes motivating the child to speak, imparting elaborative remarks, storytelling, and involving the child
in reading [7]. The literacy of fathers and mothers also affects the development and speech of a child.
Among the parents who came with their children with delayed speech and language, 22.7% of mothers were
illiterate, 46.7% had primary education, 6.7% had higher secondary education, and 24% were graduates.
Mondal et al. also indicated that maternal illiteracy is a risk factor for speech and language delay [8].
Psychological disorders in parents, breastfeeding, the interaction of siblings, and the size of the family have
a significant impact on the development of speech and language [7]. Our study showed that the average age
of children with speech and language delay was 5.5 years, ranging from 2-11 years of age. Out of 150
respondents, 98 (65.3%) were male, and 52 (35.7%) were female, indicating that males are at a higher risk for
developing speech and language delays. Similar results were shown in a study by Mondal et al. where 33% of
male children and 19% of female children presented with speech and language delay [8].
Barry et al. found that all parents of affected children had a family history of language or speech disorders.
Around 24% also had a first-degree relative with the disorder [9]. Our study showed that approximately
65.3% of children had a previous family history of speech and language delay, indicating that family history
is a major risk factor for speech and language delay, similar is the case with maternal hypertension during
pregnancy [8,10]. Yasin et al. observed that 23% of the patients presenting with speech disorders or delays
also have a psychiatric diagnosis and it is important to evaluate these patients with a multidisciplinary team
and refer them to the mental health clinic for the screening of psychological disorders [11].
A positive association between language delay and frequency of screen time was observed. Children who
developed delayed speech and language began watching television (TV) at the age of 7 ± 5 months vs. 12 ±
5 months in normal children and consumed increased time watching TV i.e. 3 ± 1.90 h/day vs. 1.85 ± 1.18
h/day in normal children. Children who began watching TV at <12 months of age and watched TV for more
than two hours a day were nearly at a six times higher risk of developing delayed language and speech [12].
Tan et al. concluded that a supportive environment at home with absolute breastfeeding and a
harmonious family environment in the initial years of development considerably helped in attaining
language skills [13]. Multivariate analysis revealed that exclusive breastfeeding for <6 months, delayed gross
motor milestones, >2 hours/day of screen time, and deficient social exchange are significant risk factors for
delayed speech in children [14]. According to the National Committee on Vital and Health Statistics at the
Department of Health and Human Services, Washington, nine factors were constantly recognized as having a
distinctive impact on delayed language and speech. Risk factors included male sex, the presence of hearing
disorders, and impulsive behavior. While protective factors included having a more persistent nature, being
socially active, and good maternal health. Lastly, the factors that could be either risky or protective
comprised having an elder sibling, parental LOTE (languages other than English), and a supportive learning
environment at home [15].
Our results showed that 44.7% of the children who presented with a delay in speech and language were first
born, 30% were second born, and the remaining children were of greater order, which indicates that the
prevalence of speech and language delay is higher in first-born children of the family, which is due to the
lack of experience of parents regarding the child’s development. However, the study by Mondal et al. shows
that higher prevalence is found in those of the third or greater order [11]. This study shows that children
with prolonged sucking habits are more prone to speech and language delays. Fox et al. stated that sucking
habits were a significant factor in speech and language delay [10].
Most of the children with speech and language delays were living in the joint family system (64%), whereas
the remaining 36% were living in the nuclear family system, which shows that the prevalence of speech and
language delays is high among children living with joint/large families. Many studies favor this factor as a
risk factor for speech and language delay, except the study by Fox et al. in the UK which observed that
unilingual families pose a higher risk of speech and language delay [8,10].
Of the children included in our study, 27% had a history of neonatal seizures, 72% had a preterm birth, and
33.3% had a low birth weight. Similar results were shown in another study in which 31% of children with
speech and language delay were born with low birth weight and 14% were born preterm [16]. In our study,
59.3% had a history of middle ear infection, 34.7% were found to have oropharyngeal disorders, and 76% had
associated hearing problems. Similar findings were observed in studies conducted in various settings
[2,8,10]
Chonchaiya et al. suggested that speech and language therapy is effective for children with phonological or
vocabulary difficulties. No remarkable difference was observed between clinician-administered therapy and
that implemented by trained parents [16]. Speech and language delay causes impairment of intelligence of
2022 Kumar et al. Cureus 14(9): e29623. DOI 10.7759/cureus.29623 8 of 10
the child and development of mental capabilities; therefore, timely diagnosis is necessary to prevent the
long-term effects of delay. Children who are exposed to any risk factor for speech and language delay should
be monitored and taken to the speech therapy clinic for a checkup. However, any underlying cause of the
delay should be screened and treated first.
Limitations
This was a hospital-based cross-sectional study, and only patients arriving at one hospital were included.
Since the study addresses some personal and sensitive behavior, there is a possibility of falsified reporting
among attendants of children, especially given the face-to-face interview modality of data collection. Other
limitations include potentially uncontrolled confounding effects and reporting bias due to the self-reported
nature of the data collection method.
Conclusions
From the study, it was found that factors that contributed the most to the speech and language delay in
children were male gender, long-term sucking habits, illiteracy of the mother, preterm birth, low birth
weight, oropharyngeal deformity, hearing problems, intrapartum or postpartum complications and previous
family history of speech and language delay. The less significant factors were low socioeconomic status,
order of the child, occupation of father and mother, socioeconomic status, and no family members.
Parents should be educated regarding the effects of speech and language delay on their children and how to
avoid preventable risk factors. Special care should be given to females during pregnancy and the postpartum
period. Children should be monitored carefully for delay of milestones, especially regarding speech, and care
should be sought if a delay is observed. Speech therapy is recommended in any case of speech and language
delay for proper diagnosis and treatment.
Additional Information
Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Lahore General Hospital
issued approval 00/67/20. Animal subjects: All authors have confirmed that this study did not involve
animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all
authors declare the following: Payment/services info: All authors have declared that no financial support
was received from any organization for the submitted work. Financial relationships: All authors have
declared that they have no financial relationships at present or within the previous three years with any
organizations that might have an interest in the submitted work. Other relationships: All authors have
declared that there are no other relationships or activities that could appear to have influenced the
submitted work.
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