Thursday, July 14, 2011

Late Talkers: No Risk for Adolescent Psychosocial Problems

From Medscape Medical News

Deborah Brauser

July 13, 2011 — Toddlers who are "late talkers" (but without other developmental delays) are not at increased risk for behavioral and/or emotional problems in adolescence, according to findings from Australian researchers.
Although the large cohort study found that 2-year-olds with lower scores on language development tests also had poorer psychosocial scores than their counterparts with better language skills, these problems did not follow them 3 to 15 years later.
"We suggest that [the psychosocial] problems identified at age 2 years are due to the difficulties of not being able to communicate, such as frustration," lead author Andrew J.O. Whitehouse, PhD, associate professor at the Telethon Institute for Child Health Research at the University of Western Australia in Perth, told Medscape Medical News.
"When late-talking children 'catch-up' to normal language milestones, which happens for the majority of children, psychosocial problems are no longer apparent. However, we have good evidence that if language problems persist to the school-aged years, then these children are at increased risk of psychiatric difficulties," added Dr. Whitehouse.
He noted that although "it is important to be mindful" of the 2-year mark as a crucial opportunity to gauge the progress of a child's language development, it should be viewed as a guideline and not as a strict cut-off for impairment.
"Rather, toddlers not reaching these milestones need to be exposed to the most language-rich environment possible and monitored closely."
The study was published online July 4 in Pediatrics.

Nonenduring Impairments
The investigators evaluated data from the Western Australian Pregnancy Cohort Study (also known as the Raine Study) on 1245 children with language milestones deemed "normal" at the age of 2 years (healthy controls) and 142 late talkers (scoring at or below the fifteenth percentile for their sex on the parent-reported Language Development Survey [LDS], which examines expressive vocabulary).
The participants also underwent assessments with the Child Behavior Checklist (CBCL) at the age of 2, 5, 8, 10, 14, and 17 years.
Results showed that the late talkers had poorer behavior scores in total (P = .03), internalizing (P < .01), and externalizing difficulties (P = .04), and "higher risk for clinically significant internalizing and externalizing problems," compared with the healthy control subjects.
However, after adjustment for confounders, no significant association with psychosocial problems for the late talkers was found at any of the follow-up time points.
"The main findings are that late talkers have increased levels of behavioral and emotional problems at age 2 years. But these problems are not enduring," said Dr. Whitehouse.
The investigators write that the results "may provide support for a wait-and-see approach in public health systems with finite resources" for those who are otherwise typically developing.
However, a limitation cited was that a comprehensive measure of receptive language ability was not included in the original Raine Study.
"The next big research goal is to find a way to identify, as early as possible, which children will have life-long language difficulties. These are the ones who will be at risk for psychosocial difficulties as well. The earlier we intervene, the better the outcome for these children," said Dr. Whitehouse.
AAP: Full Assessments Recommended
"Overall, I think this is a good study, with a really large community-based sample that they were able to track over a long time," Michelle Macias, MD, professor in the division of developmental-behavioral pediatrics at the Medical University of South Carolina in Charleston, told Medscape Medical News.
"It's reassuring to know that kids who talk late may not have long-lasting behavioral and emotional problems. However, the investigators, as they mention, were not able to do full assessments, so we don't know what the pattern of language delay really was, just which kids didn't have as many words," she added.
Dr. Macias, who is also chair of the American Academy of Pediatrics (AAP) section on developmental and behavioral pediatrics, noted that it is also important to examine understanding of language, including appropriate nonverbal communication, such as smiling, pointing, and even babbling.
Still, family practitioners want to know: Are they talking? And if not, what should we do about it? The Academy policy is that if there is any delay, you should assess all aspects of their development," she explained.
"In other words, when a child comes in for their 2-year-old well visit and they don't have that many words, the policy is that you need to use a formal, standardized development screen no matter what."
Dr. Macias also voiced concerns that the study stated the participating children were otherwise typically developing, but did not explain how that was determined, and that the CBCL, like the LDS, is based on parent report.
"That's a pretty good tool to use but, again, it was one measure and the kids were not screened to see exactly what their behavior problems were. And what happened later to the late talkers? Were they put into speech therapy? Were some interventions provided for the parent for the behavior?"
"Perhaps it's that if the kids are treated early, then they get better. But that wasn't really discussed," noted Dr. Macias.
Still, she said, she does not want to detract from the long-term findings.
"Overall, I think it's great to have something so reassuring. My only concern is that I hope people don't now think: 'Good, late talkers are going to ultimately be fine so further assessments are not needed'."

"Instead, we recommend screening for other areas of development in these kids, including checking their hearing, a screen for autism, and a full language assessment with a speech language pathologist. You actually don't want to do too much 'watching and waiting' if they truly have a language delay," concluded Dr. Macias.
The study was funded by the National Health and Medical Research Council, the Raine Medical Research Foundation, the Telethon Institute for Child's Health Research, and the Women's and Infants Research Foundation. The study authors and Dr. Macias have disclosed no relevant financial relationships.
Pediatrics. Published online July 4, 2011. Abstract

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