Speech delay

tallaght01

Hi guys. Just had a question for the docs, especially the GPs (or any other paediaticians that use this forum).

Inspired by this thread:

http://www.boards.ie/vbulletin/showthread.php?t=2055417599

in the parenting forum, I'm wondering about peoples' approach to speech delay.

My take on the issue is that a kiddy with a speech delay should be seen by a GP first. The GP should examine the child for physical causes of the delay. They should also be checked for signs of ADHD and autism (due to high co-morbidity).

If the GP feels the kiddy has isolated speech delay, then refer to speech+language therapist. If the GP feels it could be more complex than that, the a referral to paeds is made.

The paediatrician then co-ordinates the physical assessment, genetics, hearing tests, speech therapy etc.

But some person on the thread, who doesn't say what she works at, but claims to be in the game, is advising parents that a physical assessment is not required for speech delay, as long as it's isolated. I don't know how she knows it's "isolated" without other investigations, but there ya go.

I personally think that's some of the dodgiest advice I've ever seen given on boards.

I know most speech delay sorts itself out, but it doesn't mean we shouldn't look for it!

But I was wondering of that's what she's seeing on her day to day practice. She seems to have a low opinon of GPs.

So, just wondering how you guys handle it in Ireland.

RobFowl

I see you've made a friend on that forum Tallaght

For what its worth the approach you've outlined would be my preferred one. It also fits in with best practice reviews such as
http://www.bmj.com/cgi/content/full/328/7434/272?etoc
raemie21 doesn't seem to feel GP's have any role to play but O Busari et al (link above) state "This process of detection and treatment should be multidisciplinary, involving the parents, school teacher, paediatrician, paediatric neurologist, ear, nose, and throat specialist, child psychiatrist, child psychologist, linguist, and speech pathologist. Specific language and cognitive deficits in a child should be taken into account when providing treatment and should focus on the interrelation among voice, speech, language, and cognition.5 The aetiology, pattern, and severity of the language should determine the choice of therapy in terms of intensity (extent of investigations), scope (professionals involved in the management), and form (type of treatment offered). The goal of treatment should include minimising disability and maximising the child's potential"

sunnyjim

I'm actually shocked by that thread. Even the last 2 posts.

ZYX

One of the problems for GPs is finding a good speech therapist. There are a lot of crap ones out there in private sector and public referrals can take 6-12 months.
A number of years ago I saw a child who had seen a private speech therapist. Now this child was very disruptive and had been unable to do a hearing test because he was so disruptive. Speech therapist told parents child had "global cognitive impairment" probably due to autism. Parents as you can imagine were devestated. First time I saw them was when they were looking for a referral re Autism. I examined child who had barn door hearing loss. Referred to ENT. Gromets inserted, child could hear and therefore no longer disruptive, speech followed soon after. Had they come to me first they would have saved a huge amount of distress.

metrovelvet

sunnyjim wrote: »

I'm actually shocked by that thread. Even the last 2 posts.

I posted the penultimate post on that thread, not to dismiss what tallaght01 was saying but because my pediatrician didnt seem to follow the protocol he described and it has made me a bit nervous, that's all.

Prime Mover

When someone pulls out the "medical model of service delivery" line it's usually a good sign you have a CAM zealot or someone with a grudge against doctors for some reason... all rational argument will be ignored.

tallaght01

metrovelvet wrote: »

I posted the penultimate post on that thread, not to dismiss what tallaght01 was saying but because my pediatrician didnt seem to follow the protocol he described and it has made me a bit nervous, that's all.

I would imagine (I hope anyway :P )your paediatrician DID have a listen to your kid's heart, and do a physical examination at his/her 18 month check, though. No?

I can't believe that people who work in healthcare and see kids with developmental delay actually believe a medical examination isn't essential for speech delay!!!!

I've also seen horrible gluey ears that have been ignored. Usually because the parents have seen a private speech therapist. All the public ones that I've worked with liase very closely with us, thankfully.

Lol @ medical-model-of-care nazis. It's so true. For me it's a poor prognostic indicator when assessing how easy the user of that phrase is going to be to work with :P:pac:

Saintly

Interesting thread and I couldn't agree with you more Tallaght01. Except for that part where you told raemie21, 'you have the same chip on your shoulder about doctors that lots of allied health professionals have'.

Am I the only allied health person who works in a hospital where people, for the most part, get along?!! Obviously there are bad days - but most of the disagreements I witness in hospitals generally relate to someone having a bad day/on a power trip and/or making a reasonable point in an unreasonable way - I've pretty much seen every profession throw up examples of that kind of behaviour, including my own. I've had a few positive experiences of remote hospital work in Oz too. I don't have gripes with any individual profession and despite the occasional frustrations of working with lots of people all coming from different training backgrounds/perspectives really enjoy MDT work - we have excellent relationships with our excellent docs - a really nice respectful working environment.

See? One Allied Health worker in the docs corner at least!

tallaght01

Hi saintly. Thanks for your input.

I have an excellent relationship with the allied health professionals were I work, almost exclusively. That's been the case in almost every hospital that I've worked in.
I work with one radiographer who's lazy, but it's nothing to do with her being a radiographer. I work with one or 2 nurses who are lazy. Again, they would have been lazy in whatever profession.
One of the docs I worked with yesterday drives me nuts with his laziness.

But there's hundreds of staff at our hospital. We have amazing speech therapists, physios and pharmacists. I would have a dreadful job without them.

But any doctor will tell you that there will always be people with a chip on their shoulder. EVERY doc gets it.

Raemie is a classic example. I was pointing out that you need a doc to do a medical exam to ruke out organic pathology. She immediately regarded that as some kind of arrogant, elitist protectionism. But, just like I can't perform a speech/physio/psychology assessment, they can't perform a medical assessment.

But, I agree with you. Every friday when I'm not working, I go out with the physios, pharmacists and nurses from work. Speech pathology never come for some reasons. BUt we're all good mates.

What profession are you on, saintly?

ZorbaTehZ

That thread should have been locked after post 13 and left at that. How does this not fall into the category of potentially dangerous threads? [that this forum(med+bio) needs to be so careful about...] crazy.

DrIndy

making loads of new friends tallaght! ;-)

Saintly

Medical social worker. Generally, docs are grand in my book - I'm in ED work right now - and on a daily basis, get referrals from docs for pts (many presenting with relatively minor complaints) for bereavement counselling/trauma counselling/stress management etc - our guys seem to ask the right questions and establish a good degree of trust with a pt.

Being the token bleeding heart liberal on the team, obviously there are times when I disagree with our docs i.e. have resort to playing the violin in the ED/promise to clear other beds while telling the sad story of just why our 80 year old Mrs X shouldn't be sent home alone with no services with her nasty fracture. On busy days, with a full waiting room, I'm pretty much an embodiment of bedblockers everywhere in a doctor's eyes (I live with one who regularly informs me about the shortcomings of my profession!) - but in almost all cases, docs will listen and reverse their decision, if they feel it's warranted. Even if they don't I accept that ultimately it's their decision/responsibility - just as they don't interfere with our statutory responsibilities in hospital in child protection cases/pm procedures/domestic violence work.

Saintly.

Fionnanc

Second ZYX. MAKE SURE THE KID AIN"T DEAF 1st. Especially the ones that have had multiple URTI/middle ear infections.
Liked the other thread. Great argument. Perhaps you may refer a kid to Raemie that can't speak due to an acute asthma attack to see if you get a diagnosis of something developmental with added anxiety features.

As a note, sometimes even with nasty fractures it is better to send the person home without services if you can get the family to call in daily to do the cooking/shopping/help with dressing etc.
Commonly elderly ladies with Colles fractures can be manipulated, set and casted with local anaestheti/+/- sedation and sent home with family members to take responsibility, even if this means calling them at 3 am, and the patient moving in with the adult family for a while. Especially when you have a C-diff/vomiting bug on the inpatient wards/casualty corridor.

I am constantly amazed at the elderly being dropped off in A+E by family, who then promptly disappear and turn off their mobiles, claim they cant look after a relative(even when not working) etc. As you are well aware, when admitted, the subvention forms are always delayed leaving the patient in the acute ward. Rant over.

Will always admit on social worker's advice though. Usually have a better idea than me what families can cope with.

Wibbs

tallaght01 wrote: »

My take on the issue is that a kiddy with a speech delay should be seen by a GP first. The GP should examine the child for physical causes of the delay.

FWIW as an outsider I agree completely and if had a child in that situation I would go to a GP as a first principle. Beyond their obvious and extensive training and expertise the clue is in the G part. They are far better placed to take an all over position and cross off the list of possible pathologies. Things that could easily be missed by a specialist. Of course, it's not their area of expertise, just as you said you're no speech therapist. At that point then handing on to a specialist whichever specialist that happens to be.

It sounds like simple logic to me. If I find my car is not keeping it's electrical charge, I don't go straight to an alternator specialist and tell them to rebuild the alternator. Yea they may be experts at alternators, but I would go to my mechanic first. By lifting up the bonnet and having a poke around he could find it's a simple case of a loose earth strap and I wouldn't have wasted time and money on an alternator rebuild and still be at square one. I also agree it sounds like chipontheshoulderitis(maybe others can enlighten on the medical term;)).

Fionnanc wrote:

I am constantly amazed at the elderly being dropped off in A+E by family, who then promptly disappear and turn off their mobiles, claim they cant look after a relative(even when not working) etc. As you are well aware, when admitted, the subvention forms are always delayed leaving the patient in the acute ward. Rant over.

I've seen that up close and it saddened and angered me in equal measure. I had a relative who happened to be in hospital over the christmas period many moons ago. On christmas day I noticed a lot of elderly patients that seemed fine taking up beds. Of course looking fine and being fine is a big diff and what the hell would I know, but I was chatting to one of the doctors and mentioned this in passing.

She told me that it was very common, but especially at that time of the year, for people to leave elderly relatives in hospital. People who could be at home with some usually simple medical back up. A couple of them she said were effectively healthy and just needed medication as the acute issue that brought them to hospital had passed. Like you said, these relatives disappear off the face of the earth and didn't even visit these people, mothers, fathers, grandmothers, grandfathers on xmas day. One of the nurses piped in with one experience where the son and daughter of one woman the previous year actually said that they didn't want the extra hassle of having their mother around to "ruin" christmas day. They even started to bicker about which one wasn't going to take her. Unreal.

This particular doctor was visibly upset by this. She wasn't even supposed to be there, but had come in anyway just to say hello for a few hours and check up on patients on her own time(and catch up on paperwork. That raised a smile from her:)). One of the nurses was the same. I was rarely or as honestly shocked(or equally heartened by some peoples genuine humanity). Now as this was over 10 years ago, I thought that things may have changed, but apparently not, or at least it's still a known issue. Unreal is the only word for it.

metrovelvet

tallaght01 wrote: »

I would imagine (I hope anyway :P )your paediatrician DID have a listen to your kid's heart, and do a physical examination at his/her 18 month check, though. No?

Yes, well as much as she could, son didnt make it easy for her!:pac:

She also ordered a hearing test, I guess to test for tones.

raemie21

tallaght01 wrote: »

I can't believe that people who work in healthcare and see kids with developmental delay actually believe a medical examination isn't essential for speech delay!!!!

.....
Lol @ medical-model-of-care nazis. It's so true. For me it's a poor prognostic indicator when assessing how easy the user of that phrase is going to be to work with :P:pac:

Tallaght, I'm sure you mean very well but you do have a very poor understanding of speech and language difficulties.

A medical exam is not and will never be essential for a child with speech/language delay. Add as many exclamation marks as you want, you'd be laughed out the door of any child developmental clinic here if you came in with that kind of attitude.

• Based on figures from last July, there are over 4,300 children waiting for speech and language assessment in Dublin alone.
• Given the recent recruitment freeze, add on another 200 or 300 to that.
• Add on another few thousand who are already in the system, be it attending for intervention one-to-one or groups, on review and school programmes..
• Add on another couple of thousand for Galway, Cork, Limerick, Waterford.....and the rest of the country.

Ooh, I'd say we'll have well over 10,000 children by now...
Not to mention other 1000 or so with undetected LI who are not yet in the system.

You want them all to start banging on the doors of GPs and Paediatricians for assessments tomorrow???
Stop, you're cracking me up.....:rolleyes:

Of course, there are some children who will need to attend for medical assessment but in terms of the overall number presenting with communication difficulties, it's small. Christ the health system would collapse altogether if we started sending every kid with a lisp off for a heart exam...

Moreover, you seem to be continously missing the point that I took issue with the fact that you said it was "a bad idea" to go for a S&L assessment first.....I don't care if parents want to seek a GP's opinion, I don't think it's necessary although it is often a natural first port of call...However, for you to advise parents only to go to GP first is very poor indeed.

Oh and I'm a medical-model-of-care nazi? Cheers, I actually take that as a compliment..

DrIndy

I'm keeping a very close eye on this thread folks.

It will remain civil.

raemie21

RobFowl wrote: »

I see you've made a friend on that forum Tallaght

For what its worth the approach you've outlined would be my preferred one. It also fits in with best practice reviews such as
http://www.bmj.com/cgi/content/full/328/7434/272?etoc
raemie21 doesn't seem to feel GP's have any role to play but O Busari et al (link above) state "This process of detection and treatment should be multidisciplinary, involving the parents, school teacher, paediatrician, paediatric neurologist, ear, nose, and throat specialist, child psychiatrist, child psychologist, linguist, and speech pathologist. Specific language and cognitive deficits in a child should be taken into account when providing treatment and should focus on the interrelation among voice, speech, language, and cognition.5 The aetiology, pattern, and severity of the language should determine the choice of therapy in terms of intensity (extent of investigations), scope (professionals involved in the management), and form (type of treatment offered). The goal of treatment should include minimising disability and maximising the child's potential"

Never said that GPs haven't a role to play.

My point was that it's not necessary to attend a GP since HSE speech and language and psychology services in the community operate an open referral policy. And my other point was that it's not a 'bad idea' to go to S&L therapist as first professional contact...

That article you referenced has one case study and rather ironically, the child showed significant improvements after S&L intervention without a need for specific neurological assessment...

Oh sure, there are lots of 'ideal' clinical assessment & intervention pathways out there but mainly restricted to the literature rather than real-life practice...

It's difficult for children with S&L difficulties to even get a cognitive assessment at present, never mind a psychiatric, ENT, paediatric and neurological assessment...

And no matter what Tallaght says, I assure you that my colleagues in Paediatrics and Neurology welcome any previous assessment/reports available to them - so to advocate a delay in seeking a S&L assessment for a child presenting primarily with an S&L difficulty is really just stupid.

tallaght01

Children with speech and language delay require a medical examination.

Speech delay is the most common manifestation of global developmental delay. It's also commonly associated with other pathology (eg glue ear).

I don't know what you do, Raemie, but thankfully any doctor will realise the importance of the clinical examination. The kid doesn't need anything fancy. Just a physical checkup. They don't need "heart tests".

The american academy of family physicians published the following in relatiion to assessing a child with speech delay:

[/quote]A precise measurement of the child's height, weight and head circumference is necessary. A review of the appropriate parameter on the growth chart also can help in early identification of some types of speech delay. Any dysmorphic features or abnormal physical findings should be noted. A complete neurologic examination should be performed and should include vision and hearing evaluations............
[/quote]

The child should be examined by the GP as he refers them to the speech therapist.

Most GPs do this, so I'm not that concerned that you think they shouldn't be doing it. Doctors can't get weighed down by numbers. Raw figures are meaningless anyway. Regardless of how many kids are waiting to see their speech therapists, there are enough GPs to cope. They must be getting referred to by someone.

It would be negligent for a GP not to examine the child.

The speech therapist makes a better assessment when they know that either A) There's no medical pathology likely or There's a specific athology present (for example when I refer a kid to a speech therapist with progressive bulbar palsy, they'll concentrate more on his swallow than his speech etc).

There is no delay in referral by seeing a GP. In fact, the GP can streamline the process, by triaging. If the GP is worried, he should be able to get a quicker appointment. That's why it's a bad idea not to go to the GP first.

I don't know what else to say...... speech delay is often associated with other medical problems. The speech therapist functions better when they have some medical info.

I have no idea why that's such a difficult concept. But if it is, then that's fine. The GPs do a good job with this kind of thing, so I'm happy that the kids get sorted properly. That's certainly been my experience.

RobFowl

raemie21 wrote: »

You want them all to start banging on the doors of GPs and Paediatricians for assessments tomorrow???

Most Irish GP's offer same day appointments so you wouldn,t have to wait until tomorrow !

ZYX

raemie21 wrote: »

Add on another couple of thousand for Galway, Cork, Limerick, Waterford.....and the rest of the country.
Ooh, I'd say we'll have well over 10,000 children by now...
Not to mention other 1000 or so with undetected LI who are not yet in the system.

You want them all to start banging on the doors of GPs and Paediatricians for assessments tomorrow???
Stop, you're cracking me up.....:rolleyes:

I think you are missing the point here. You are saying there are 10,000 children either attending or waiting review by speech therapists. Do all of these need to be seen by a speech therapist. If not, surely having them seen by a doctor first to out rule things like tongue tie, glue ear etc makes sense. There are about 3,000 GPs in Ireland. That works out at 3 per GP. Not only could they all easily be assessed by a GP by tomorrow, they could be seen before lunch time today. If only a few hundred did not need referral to you then that is a few hundred appointments saved for children who actually need it. This would greatly speed things up not slow them down.

littlebug

I find the most shocking thing about this (and the other) thread is that the mother of an 18 month old with 3 words has been told he has a speech delay.

I think there's a further link in all of this that no one has even mentioned and that's the phn who is often the gatekeeper to the speech therapist. I personally know of one case where the delay from a parent originally ringing phn with concerns, to the phn actually doing anything about it and referring her tp ST was nearly 6 months... add many more months since the referral was made and they haven't had an appointment yet due to the waiting lists mentioned above. Nearly a year on and the child still hasn't seen a ST. I think that's shocking tbh.... precious development time being wasted. If she had gone the GP route would it have been any quicker?

metrovelvet

littlebug wrote: »

I find the most shocking thing about this (and the other) thread is that the mother of an 18 month old with 3 words has been told he has a speech delay.

?

I find it a little alarming myself and this was a second opinion!

raemie21

Ah Tallaght re-read the original thread again....

The original point we disagreed on was the advice you gave to the OP that it wasn't a good idea to go to the SLT.

Now I have the highest of respect for GPs and indeed often regret not doing the GP scheme myself but in terms of child development, I wouldn't be so confident about their ability to screen for delays. It is well documented that over 50% of developmental delay is not picked up until a child starts school and indeed GP screening measures are often lacking in specificity and sensitivity. There was a good article in the BMJ of British Journal of GP a few years ago looking at the pathway of kids with SLI. For most kids, there was a two year delay between original GP appointment and the time they got to see an SLT. The reason was a number of (unnecessary) referrals to Paediatrics/Neurology/Psych and an overall lack of coherence.

Oh sure, a GP is often a good place to start and can check for ear infections, oro-facial exam etc. but for every poor SLT that you mention, there are an equal number of GPs that will give false reassurance to parents too.

Anyway, the discussion we had about the need for a medical assessment was referring to Paeds & Neurology. My annoyance and comments about the medical model were in response to your very strange claim that all was well 'as long as the kid ends up with you.' Given your current work in A&E, I find it very odd that you would advocate this approach. Inappropriate referrals are one of the single biggest reasons why the health system is not working. In A&E, a lot patients would be better served by an out-of-hours GP service. From a psychiatric point of view, I do not need a kid to sit on the waiting list for 6-8months with 'low mood, emotional/behavioural diffs' when it turns out that he has Developmental Co-ordination Disorder and secondary emotional diff due to demands/capacity. His needs would have been far better served with NEPS and Community OT & SLT. And the worst thing about all this, is that after sitting on our waiting list for 8months, he is discharged and has to start the referral process all over again and wait longer for services that his GP should have referred him to in the first instance. Yes, of course there will always be kids that will need extra caution and be referred 'just in case' but in general? No. And before you jump on me again, that's not just one case I'm thinking of, I would estimate we get probably as many appropriate as inappropriate referrals overall.

You came out with another gem then, saying that a GP letter saying a child has poor speech is as much use as a full S&L assessment. To be honest, that's by far the worst statement on that thread and God, I don't know exactly how much experince you had in the area or what way your consultants worked, but that is an absolutely shocking thing to say. An OT, a Psychological and an SLT assessment are crucial to differential diagnosis of ANY developmental delay and to determine overall management. How can you claim that a GP saying a kid is slow to talk is as much use as an S&L assessment evaluating speech sound errors, voice, comprehension, expression and pragmatic/social communication skills?! Indeed it is your dismissal of the value of allied health involvement that is the most 'dangerous' of both of us. Even as Metrovelvet's experience tells us, most Paediatric assessments will consist of a short physical examination but will mainly rely on case history from parents and previous involvement with other professionals. Of course reports are well valued and crucial to their hypothesis.

I don't have much else to say on the matter. While I'm amused and rather flattered that you started a thread in my honour, it has certainly been quite an eye-opener for me to see the lack of public awareness and the very narrow-minded view that people have about different health professionals.

You can be as patronising as you like but to be honest, I've seen literally hundreds of children with speech and language difficulties in the past few years. At present, this is mainly from a psychiatric/neurodevelopmental perspective and would include assessments with my colleagues in psychiatry, psychology, speech & language, occupational therapy, social work, nursing and play therapy. I'm very comfortable and confident with what I've said ono these threads. And I assure you that we all socialise successfully, even the SLTs come out for drinks with me on a Thursday evening :rolleyes:

As a final note, may I point out that you're using the terms 'speech' and 'language' interchangeably but they refer to two entirely different concepts of communication. So perhaps that's adding to your confusion.

eth0_

I think you're the one who's being patronising to Tallaght01 tbh. Don't forget he is/was a paediatrician!

The first reaction of most parents with a child who is not developing properly in terms of speech and language is obviously going to be their GP. I doubt anyone realises they can just book an appointment with a SLT w/o GP referral.

The first thing that should be checked is obviously the physical - signs of deafness etc.
Why would I bother sending a kid to a SLT for months if in the end it could turn out he/she has partial hearing?!

sillymoo

raemie21 wrote: »

I don't have anything sensible to say on the matter.

Fixed that for ya

tallaght01

The thread was started to see if there had been a change in the way Irish GPs deal with speech delay.

There doesn't seem to have been.

I'll repeat myself. I said it was a bad idea to go straight tot he speechie. It's not the right move because the speechie will prefer if they have an idea of what the medical situation is. It will also allow them to make a better assessment.

I said a full medical examination that happens to not have found anything is as much use to my in an initial consultation as a SALT assessment. I then refer the kid to SALT once I know there isn't a glue ear or something like that.

You talk about "screening". Developmental screening by GPs is being advocated by no-one here. Now you're the one mixing up terms.

You misunderstood my point about the referral "ending up with me". What I actually said was "at least those kids ends up with a paediatrician", as opposed to me in A+E lol.

I don't know where neurology comes in here. The kid needs a full neurological examination, but the GP/paediatrician can do this.

I'm not sure what your point is.

I told the OP to bring her kid to a GP first, before the speechie. Then the GP can make the appropriate referral as required.

I think that's sensible, the GPs here say that's how they do it. You may think they're crappy at picking up developmental delay, but they're better at it than people who don't do physical examinations.

Do you still think kids with speech or language delay don't need a medical examination? Do you really believe that? Surely, if you're a psychiatrist, you must have seen a million cases of "delerium" in hospitals that have an underlying medical cause, for example???

tallaght01

sillymoo wrote: »

Fixed that for ya

Careful u (wagging finger).

Do you young troublemakers not have some studying to do?

On a related not (being too lazy to start a new thread) good luck to everyone doing exams, there must be quite a few of you.

Actually I should put that in that off topic thread thingey....

Dizzyblonde

I've been lurking and reading this thread, and I want to add my opinion as a mother. One of my daughters had a speech problem when she was very young and I brought her to my GP (it would never have even dawned on me to do otherwise). Our GP checked her and told me it would most likely right itself by the time she was 5 - which it did. This saved the unnecessary waste of a speech therapist's time when other children needed it more and also reassured me that there was nothing else going on that I should worry about.
In my opinion, if a child has an undiagnosed condition and is on a waiting list to see speech therapist, then that is wasted time in which the child could be having tests/treatment for the underlying cause.
As a mother I would advise any parent to see their GP first.

raemie21

Well the GP is essentially doing a developmental screen as they're deciding whether the kid needs more detailed assessment and which service to refer to if necessary. I'm not sure how literal you're going to take it..?

Yeah it's useful for an SLT that glue ear is outruled for example, but my concerns centre around whether this referral to the SLT is made in the first instance. The OP in the other thread, her daughter was bilingual which of all things, is very often misunderstood and misadvised re management. And as far as I remember, the GP had already seen the kid one or two months previously?

I still can't understand the poor value you seem to have placed on allied health reports. A GP can outrule basic medical causes, but level of cognitive ability, motor and self care skills/sensory needs and speech and language abilities were certainly very (and more) desirable when I worked in Paeds.

It's ok, I assumed you were referring to your previous position when you spoke about kids 'ending up' with Paeds but the notion that they all should go for a Paeds assessment is rather bizarre. That's like me saying that any child with an episode of aggressive behaviour or an expression of low self-esteem should attend a child psych..

As I've mentioned earlier, the difference between speech and language is being grossly overlooked....

The issue of the need for medical assessment depends on a definition of same. The age of the child, previous assessments and presenting difficulty are just some of the factors to take into account. The figures I'd outlined above are also worth considering. And again, there seems to have been a misunderstanding....I was referring more to a need for a full Paeds/Neur/Psych assessment as that what it seemed you were talking about.

Apart from the literature, we can only both base our opinions on clinical experience. I'm absolutely not anti-GP but over the years, certainly received more referrals from Clinical & Educational Psychologists, SLTs and OTs. I would say that allied health professionals are well placed to spot 'warning signs' or markers re developmental delay (ok not heart rate or other medical signs :rolleyes:) but perhaps I've been very fortunate with those I liaised and worked with..

raemie21

Dizzyblonde wrote: »

I've been lurking and reading this thread, and I want to add my opinion as a mother. One of my daughters had a speech problem when she was very young and I brought her to my GP (it would never have even dawned on me to do otherwise). Our GP checked her and told me it would most likely right itself by the time she was 5 - which it did. This saved the unnecessary waste of a speech therapist's time when other children needed it more and also reassured me that there was nothing else going on that I should worry about.
In my opinion, if a child has an undiagnosed condition and is on a waiting list to see speech therapist, then that is wasted time in which the child could be having tests/treatment for the underlying cause.
As a mother I would advise any parent to see their GP first.

Yeah, there's a lot of research being done currently on 'late talkers' and outcomes. As you've mentioned, big drain on SLT resources in the community but for every child who does catch up spontaneously, another child will not. There are certain prognostic indicators to take into account and children who are more at risk are certainly prioritised. Kudos to the GP for getting it right although he could have easily got it wrong (sorry to be awkward but it's very true). Mind you, if he based his decision on particular criteria, he should contact Psychology/Linguistics/Medical Departments around the world, he might end up a rich man....

There are more children with isolated speech and language difficulties and as Tallaght and I have discussed at length, there may not always be any cause. That's my main point on this thread. I've seen a lot of kids, say even at the ages of 9-10 and they have such poor communication skills and I can't understand how they weren't picked up earlier...

tallaght01

I think the reason that SALTs prefer a medical examination before they see the patient is so they can have an idea what they're looking for. Thge more specialisedc you get, the more you like to have an idea what you're looking for.

Just as I, in paediatrics, don't want a GP referring a kid with a "he might be sick" tag, our SALTs prefer us to give an idea about our concerns.

For example, if there's xcranial never abnormalities, they might do more advanced swallow testing, depending on what's affected. If there's poor tone and I've referred to gastro for a possible fundoplication, then a detailed swallow assessment (usually radiological) is pretty much essential. The need to focus on cognition and speech/language skills in themselves are more important if I suspect cerebral palsy and am awaiting an MRI, say.

Clinicians in overstretched services need to be able to give our colleagues an idea of what they're looking for.

I don't place a reduced value on a SALt assessment. I just think they should come after the medical assessment, so that we can rule out medical cases that don't need referral, and to give the SALT an idea of what they might be dealing with (aswell as giving an idea of the urgency).

The GPs can refer to paeds, and they usually do if they suspect there's an underlying problem. Many GPs will manage speech delay in the community in isolation, and I'm happy with this. GPs are very good at referring what needs to be referred. Some GPs refer what they think is isolated speech delay, and I happily see those cases too, although there's a hell of a waiting list.

I just think everything needs to happen in it's own time. Bilingual families produce kids with speech delay too, so the "bilingualness" of the situation shouldn't preclude us from assessing that child medically.

Her GP saw the kids a few weeks earlier, but the child was only 18 months old I think, which wouldn't have concerned me in particular I have to say. I was more trying to get the point across that in general the GP should be the first port of call. I suspect an 18 monther from a bilingual family who hadn't got great speech wouldn't have gotten a referral from their GP. That's the kind of thing GPs are good at keeping in the community, thank god!

metrovelvet

Could being exposed to different accents in the same language affect things? I know an Irish woman in the US who points to this as the reason behind her 17 mos old not speaking but I dont know... I was speaking at 1 and had parents with accents.

tallaght- everytime I read your posts I get more and more nervous ...its like reading one of those college psychology textbooks and seeing symptoms and causes all over the place.

raemie21

tallaght01 wrote: »

Clinicians in overstretched services need to be able to give our colleagues an idea of what they're looking for.

I don't place a reduced value on a SALt assessment. I just think they should come after the medical assessment, so that we can rule out medical cases that don't need referral, and to give the SALT an idea of what they might be dealing with (aswell as giving an idea of the urgency).

Agreed, although it can work the other way too in some cases.
The OP's daughter was nearly three I thought? That's why I was a little apprehensive...Maybe it's a matter of parents being more specific when they visit GPs and outlining their concerns exactly rather than GPs informally assessing themselves.

Prevalence of specific language impairment in increasing and not being diagnosed; given the high co-morbidity between language and emotional/behaviour, we see a lot of kids who should have been in the service years earlier, and that's even allowing for time on waiting list... I actually couldn't find any studies comparing isolated S&L vs delayed S&L in the context of a medical condition/general developmental delay but I'd assume it's higher for the first and certainly they're more at risk for not being identified.

I guess the value I would place on a medical assessment would depend on its purpose....ruling out tongue tie, palatal elevation, dysmorphic features, soft neurological signs, hearing vs appropriate referral onwards.

Slightly off topic but since you mentioned, is it just me or is the idea of SLT practice including swallowing management odd? Met a friend of a friend the other day, an SLT in adult neurology and apparently 90% of her caseload is videofluoroscopy and advice re food constitution...God, think if I trained for four years in communication development and disorder, and ended up with that, I'd crack up. But each to their own I guess.

DrIndy

Still watching the thread.

Raemi21 - can you find a link to the BMJ article on referral pathways for most appropriate assessment? I would be interested in reading it.

raemie21

metrovelvet wrote: »

Could being exposed to different accents in the same language affect things? I know an Irish woman in the US who points to this as the reason behind her 17 mos old not speaking but I dont know... I was speaking at 1 and had parents with accents.

tallaght- everytime I read your posts I get more and more nervous ...its like reading one of those college psychology textbooks and seeing symptoms and causes all over the place.

No, I'm quite sure that accents don't affect language development!
It's essentially the same words with basic sound structure albeit with slightly different intonation and maybe different stress on some syllables.

Bilingualism is a huge advantage for children. Research has shown that comprehension tends to develop age-appropriately in both languages but expressively, kids are often delayed. This tends to resolve spontaneously over time though. Bilingualism is a big cognitive and linguistic plus for kids. I'm a bit cloudy on details but I remember a few studies back in the mid 1990s with pre-school and school age children..in one, they agve the kids a word e.g. 'brick' and asked them to list as many functions as they could in a given time. The bilingual kids were much more able to think 'outside the box' and the theory was that bilingualism allows a person to develop a more flexible way of thinking and a wider concept of words and their meaning. Similarly, in another study, they asked kids to repeat sentences but replace certain words e.g. replace 'I' with 'macaroni' (clearly a US study). Again, the bilingual kids outperformed the monolingual kids, being much more fluent and completing the task in quicker times.

Apologies for the the terms uses on the thread, I'd thought about that alright. I think we were really getting into the nitty-gritty and all possible scenario mode, hence the medical overload. Your child had actually seen a Paed recently and she was happy with him I thought? Made a referral to SLT. The wait can be a bit sh1t but try not to worry too much.

raemie21

DrIndy wrote: »

Still watching the thread.

Raemi21 - can you find a link to the BMJ article on referral pathways for most appropriate assessment? I would be interested in reading it.

Yeah course, might take me a while to track.
It was a retrospective study for about 40kids who had specific language impairment and ended up attending specialised language units.

RobFowl

raemie21 wrote: »

It was a retrospective study for about 40kids who had specific language impairment and ended up attending specialised language units.

Am a regitered BMJ subsriber and was able to do a search. Could not find any articles matching Raemie21's exact criteria . the only one close was an editorial

James Law and Gina Conti-Ramsden
Treating children with speech and language impairmentsBMJOct 2000;321:908 - 909; doi:10.1136/bmj.321.7266.908


TBH a retrospective study of 40 children would be considered a very poor quality trial.
It has come to the stage in this thread to "put up or shut up".
Raemie21 has very strong opinions. If he/she want's them to be taken seriously it is time to present evidence in terms of references to back them up.

raemie21

As requested and for general interest:

Parent concerns & professional responses: the case of specific language impairment. British Journal of General Practice (2005) 55 p.710-714

Developmental surveillance of infants and young children in paediatric primary care. Current Opinion in Pediatrics (2003) 15 p.624-629.

An examination of the pattern of preschool referrals to speech and language therapy. Child Language Teaching & Therapy (2000) 16 p.59-71

Age 13 - Language and reading outcomes in late talking toddlers. Journal of Speech, Language and Hearing Research (2005) 48 p.459-472.

Speech language impairment - How to identify the most common and least diagnosed disability of childhood. Medscape Journal of Medicine (2008) 10 p.136

ICAN publication www.ican.org.uk The Cost to the Nation of Children’s Poor Communication Skills. (?2006)

Language Outcomes of 7 year old children with and without a history of late language emergence. Journal of Speech, Language and Hearing Research (2008) 51 p.394-408

If you're unable to access them, let me know and I can send them individually.

tallaght01

that's a lot of papers.

Which one is the randomised study showing that kids with speech delay don't need a medical assessment?

RobFowl

The BMJ one quoted is not there !!! Still waiting

RobFowl

I've had a look at quite a few of those now. They are very interesting. Generally they seem to advocate population based screening rather than opportunistic screening. Opportunistic screening (as was the case with the original poster on the parenting forum) seems to misdiagnose, over refer and cause excessive parental anxiety.
The consensus as far as I see is the screening should occur in primary care but use more structured screening tools and questionnaires.
I have not seen any advice in those articles I've seen so far which advises bypassing the GP or avoiding a medical assesment.

DrIndy

Is there any benefit to joint screening (SLT and GP)?

Cannot GP's screen developmental delay as normal and SLT's screen speech delay and treat as needed provided they always refer new patients for medical assessment too to ensure that other areas of development are assesed?

Cannot SLT's also be heavily involved (even primary assessor) in initial screening (thus saving potentially 6 months before even SLT referral) but have and automatic direct referral route to Paediatrics for new patients seen?

I think these are important questions and thoughts are welcome. If one of these approaches were to be used - what safety nets should be implemented to ensure safe practise?

Lets continue this debate with fresh eyes and fresh views - it has been at time passionate and the only thing that actually shows is people are very interested in their speciality and expressing that.

New opinions are very welcome to this forum as long as there is a scientific basis demonstrated as it was.

tallaght01

Problem is that there's probably not enough SALTs to provide for routine screening.

Not sure if there's a good evidence base that examines outcomes from population screening for speech delay.

Would be interesting to see, though.