European Journal of Cardiovascular Medicine

About 15%  of the world’s population has some form of disability. It is estimated that at least 2% of all children born each year have a disabling condition. Many of these children have speech and or language delay and disorders that may have a significant effect on personal, social, cognitive, academic or vocational life ¹

Language develops in an orderly sequential manner and it is the most common form of communication. Speech and language development is considered to be a useful indicator of a child’s overall development and cognitive ability. Several types of speech and language delay and disorders have been described. Speech and language problems can exist together or separately. In general a child is considered to have a speech delay if the child’s speech is significantly below the norm for children of the same age. The delayed child’s language skills are acquired in a normal sequence, but at a rate slower than normal². In speech or language disorders, the child's speech or language ability is qualitatively different from the normal development. Language disorder could be receptive (understanding) or expressive (speaking).

Preschool children with speech and language delay may be at increased risk for learning  disabilities once they reach school age³. Speech and language delayed children have shown more behavioural problems and impaired psychosocial adjustment. Early identification of speech and language delay can help in the prevention of persistent impairments. Early  intervention during preschool period has a greater positive impact on child than later services provided.

Development assessment should be considered a two step process comprising screening and diagnosis. Screening is for picking up children in need of detailed assessment and diagnosis is for precisely defining the problems. Screening is an important component of early identification and family education which is particularly relevant for young children. Screen positive children require detailed evaluation to confirm the suspected delay or disorder. The Denver Developmental screening test (DDST), The Bayley Scales for infant development (BSIDS), The early language milestone scale, Receptive Expressive Emergent Language Scale (REELS), Baroda Development screening test (BDST), Trivandrum development screening chart (TDSC)⁴  are few  screening tools under use.

Language Evaluation Scale Trivandrum (LEST)⁵ a validated Indian tool against Receptive Expressive Emergent Language Scale (REELS)⁶ was developed by Child development centre (CDC) Thiruvananthapuram for screening of language skills of young children. LEST is divided into LEST 0-3 years and extended LEST (3-6 ) years. Language Evaluation Scale Trivandrum ( LEST) 0-3 years has total 33 items of receptive language and expressive language skills. LEST is a culturally appropriate, simple, less time consuming screening tool that can be easily used by community health workers and health professionals.

The present  study was planned to detect the prevalence of speech and language delay among 0-3 years old children attending paediatric outpatient department (OPD) using Language Evaluation Scale Trivandrum (LEST 0-3).

AIM

To assess the prevalence of speech and language delay among 0-3 year old children using Language Evaluation Scale Trivandrum ( LEST 0-3).

OBJECTIVE

To study the risk factors for speech and language delay.

This cross sectional descriptive study was conducted among 400, 0-3 years old children attending the Paediatrics OPD of a tertiary care hospital.Children with hearing loss, autism and global developmental delay were excluded. Children were recruited in the study after obtaining permission from parents. Each child was given LEST (0-3) and test questionnaire. The performance of LEST was finally interpreted as normal if all items were done for the completed age. Questionable if one item was not done and delay if 2 or more items were not done. LEST screening report was discussed with parents once screening was completed. If the child failed the screening process further evaluation was recommended. Data collected was analysed statistically using Chi- Square test for goodness of fit of ratios and test of independence of attributes.

Out of  400 children studied 53% were boys and 43% were girls

Table 1: Age distribution of study population

30% of study population were below 12 months, 35% were between 13-24 months and 25-36 months each

Table 2: Speech and language delay in study group using Language Evaluation Screening Test (LEST)

The percentage of children with speech and language delay was 13.5% among study group. 3% of children had questionable delay.

Graph  1

Table 3: Speech and Language delay in different age group

The prevalence of language delay in age groups <12 months, 13-24 months, 25-36 months were 6.7%, 17.1% and 15.7% respectively. 7.2% of 13-24 months and 1.4 % of 25-36 months children had questionable delay.

Table 4: Gender related variation in speech and language

The male female ratio of children with language delay was 59:41.The percentage of males having delay were found to be more compared with that of females (15% males with 11.7% females) even though the difference was not statistically significant

Table 5: Sociodemographic factors with speech and language delay

Low maternal or paternal education was not associated with language delay in present study. 66.7% of Language delayed children were from rural area.55.5% of language delayed children belonged to extended or large family where 44.5% belonged to nuclear family.

Table 6: Birth order and  language delay

Language delay was found to be more prevalent in second born child (16.7%) compared to first born child (12.5%).

Table 7: Gestational age of  language delayed children

 35% of preterm babies had speech and language delay, 11.4% of term babies had delay

Table 8: Birth weight and language delay

100% babies with birth weight < 1000 grams and 44.4% babies with birth weight between 1001-2000 grams had language delay.

Table 9: Perinatal complications and language delay

29.6% language delayed children had antenatal and natal problems. 37% had post natal problems. Hypertensive  disorders of pregnancy, gestational diabetes mellitus, maternal hypothyroidism, intrauterine growth retardation, oligohydramnios, perinatal depression, neonatal seizure and neonatal sepsis were the perinatal complications encountered in present study

Table 10: Home Screening questionnaire (HSQ) and language delay

Home Screening questionnaire (HSQ) with 30 well designed questions about home environment and language environment was used. HSQ has been validated against the gold standard  Home Observation for the Measurement of Environment Inventory⁷. HSQ score < 19 was taken as negative home environment and score > 20 was taken as positive home environment. Most of the children with speech and language delay had negative home environment (81.5%) which was statistically significant (p <0.001)

Screen time among language delayed children

Screen time for this study was included watching television, mobiles, tablets, or other devices and playing video games. 66.7% of speech and language delayed children were found to have screen time more than 2 hours a day

                                 Graph 2

The high prevalence of speech and language delay or disorders make it a major public health challenge. Assessment of children for speech and language delay and defects can involve various approaches, although there are no uniformly acknowledged screening tests for use in primary care settings. Language Evaluation Scale Trivandrum is a validated Indian tool with an acceptable sensitivity (66.7%), specificity (94.8%), positive predictive value, negative predictive value (98.7%) and likelihood ratios for 2 items delay⁵. LEST 0-3 years was used in present study to detect the prevalence of speech and language delay

The prevalence of language delay in this study was 13.5%. This  was comparable with the study done by Abraham et al⁸  upto to six years old children where the prevalence was 13.7%. In this study 3% of children had questionable delay with one item delay. In the study done by Kavitha et al al,⁹ 6.6% of language delay was observed among 0-12 months children using LEST which was comparable to the present study where it was 6.7%. The language delay was 17.1% among 13-24 months and 15.7% for 25-36 months. In a study by Campbell et al¹⁰ the speech & language delay was 15.6% among 3 years old children.Prevalence of 27% speech and language delay was documented among 0-3 years by Mondal et al.^11\

Prevalence of  speech and language delay in various studies

In the study, there was a male preponderance with a male female ratio of 59:41 of language delayed children. Male sex was a major risk factor for language delay in most of the studies¹⁰ Prematurity¹⁴  and  low birth weight¹⁵  has been associated with language delay. 35% of preterm babies had language delay in present study. 100 % babies with birth weight <1000 grams and 44.4% babies with birth weight between 1001-2000 grams had language delay.Perinatal complications were found to be  associated with language delay. 55.5% language delayed children belonged to extended or large family. No association could be made with parental education and language delay.No significant association was seen with lower socioeconomic class in this study. According to the U.S. Preventive Services Task Force, the risk factors for speech and language delay consist of family history, premature birth, intrauterine growth retardation, male gender, and parents of low socioeconomic background.¹⁶

Most of the children with speech and language delay had negative home environment including negative home language environment (81.5%) with Home screening questionnaire score < 19 which was statistically significant (p <0.001). Language develops through an interaction between nature (innate ability to communicate)  and nurture (environment). A child’s early home environment has  profound effect on his well being. A stimulating language rich environment is a significant factor for language development of children. Research has linked negative home environment during children’s first 3 years with poorer language development, impaired cognition and later behavioural problems. A focused environmental intervention to enhance the language learning environment in home would be beneficial for children with speech and language delay. Quality of home environment predicted 9-month phonemic discrimination ability (a foundational skill of language development)¹⁷ According to Tan et al, 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 ¹⁸

In the study Speech & language delay was 66.7%  among children who have screen time more than 2 hours a day. Children who use smart media devices may be less likely to engage in activities that encourage speech development, such as talking to their parents and siblings which results in language delay.¹⁹ Children who have been watching TV before 12 months of age and watched TV for more than two hours a day were nearly at six times higher risk of developing delayed language and speech.²⁰ World Health Organization (WHO) states that children below 2 years of age should not be exposed to screen time, children between the ages of 2 and 4 years should not exceed one hour screen time per day.

Early identification of speech and language delay among preschool children results in early intervention and improved outcome. LEST is a validated, simple screening tool that can be used for speech and language assessment. This study using LEST 0-3 showed that speech and language delay is prevalent among 0-3 years old children. Prevalence of 13.5% language delay and 3 % questionable delay shows the importance of early screening among these children.

Among the study group, Prematurity, Low birth weight, perinatal complications and male gender were found to be associated with speech and language delay. Majority of language delayed children were from rural area and from larger families. Parental education and socioeconomic status were not found to be associated with delay. Negative home environment has profound impact on speech and language development of children. 81.5% of speech and language delayed children had negative home environment. Language rich stimulating and nurturing environment is essential for proper language development of children. Screen time more than 2 hours per day was an important risk factor for speech and language delay in this study. Screen time should be restricted to minimum to improve speech and language skills of young children

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