Practical steps in the rehabilitation of children with speech and language impairment in Nigeria

Niger J Paed 2015; 42 (4): 293 – 298

PERSPECTIVE

Nwosu N

Practical steps in the rehabilitation

of children with speech and

language impairment in Nigeria

DOI:http://dx.doi.org/10.4314/njp.v42i4.2

Accepted: 25th June 2015

Abstract : Background: Medical

parents on ways to facilitate their

and allied health professionals and

child’s communication develop-

Nwosu N

(

)

educators are often the first point

ment.

New York City – Department of

of contact for parents who are

Method: Review of studies that

Education

7702 37 Ave.,

concerned with their child’s com-

have investigated methods of treat-

Jackson Heights, NY 11372

munication

abilities.

Because

ing speech and language impair-

USA

there are few speech-language

ments was performed.

Email: ncoffoha@gmail.com

pathologists in Nigeria, it be-

Results: The practical steps and

comes imperative for medical and

suggestions presented have been

educational professionals to pro-

proven to be effective at facilitat-

vide practical steps and sugges-

ing children’s speech and language

tions to parents to help facilitate

development.

their child’s speech and language

Conclusion: Medical and allied

development.

health professionals and educators

Objective: To provide an over-

should avail the parents with ap-

view of speech and language de-

propriate and effective information

velopment and impairment and

that would enable them to address

ultimately empower professionals

their child’s speech and language

with the practical steps to guide

impairment.

Introduction

phology (i.e., structure of words and meaning of parts of

words), syntax (i.e., rules governing the way words are

When Nigerian parents are concerned with their child’s

combined and organized to form clauses, phrases and

communication abilities, they often seek assistance from

sentences), semantics (i.e., words related to their refer-

doctors and teachers because there are few speech-

ents and meanings) and pragmatics (i.e., rules of social

language). Children are stimulated to communicate

language pathologists practicing in Nigeria. Medical

professionals (e.g., peadiatricians, otolaryngologists,

when motivated, cued and prompted.

psychiatrists, neurologists), allied health professionals

(e.g., audiologists, physical therapists) and educators

Speech and language development

(e.g., teachers, schools administrators) often times are in

a positon to advise and provide suggestions to parents

Infants start learning in utero. The fetuses can hear ex-

regarding their child’s communication abilities. There

ternal sounds before birth. Their brain and sensory sys-

are several practical steps and strategies that will be dis-

tems begin topreparefor the speech and language system

cussed in this paper that medical and educational profes-

in their environment. Newborns can make fine discrimi-

sionals can suggest to parents to help facilitate their

nations among the speech sounds they hear and prefer

child’s speech and language development.

the sounds of the language they have been exposed to.

Children soon acquire the phonemic (i.e., sound), pho-

What is speech and language?

nological, morphological, semantic, syntactic, and prag-

matic components of their native language.

Speech and language skills are needed when communi-

cating and exchanging information. Speech is a system

Cognitive, biological and social changes during infancy

that relates meaning with sounds. It consists of articula-

impact communication development. Children experi-

tion (i.e., the physical production of sounds), voice (i.e.,

ence several milestones as they develop speech and lan-

the quality, loudness and resonance of sounds), and flu-

guage skills. At two months of age children begin coo-

ency (i.e., the smooth and rhythmic flow of sounds and

ing and have intentional communication. At six months

words). Language is a socially shared code for repre-

their teeth erupt, their mandibles grow downward, their

senting concepts through the use of arbitrary symbols

tongue and pharynx elongate resulting in production of

and rule-governed combinations of those symbols.

3(p7)

consonant-vowel combinations (e.g., /da/). At twelve

Language involves knowing its phonology (i.e., rule

months, there is more dissociation of gross motor move-

governed distribution and sequence of sounds), mor-

ments, greater dissociation of oral and pharyngeal struc-

294

tures resulting in more varieties of sound productions.

impairment was documented in 65%, speech disorders

Children universally have their first words at approxi-

in 30%, rhinolalia (a nasal quality in speech) in 2%, and

stuttering in 2% of the children. Aremu, et al investi-

mately twelve months of age. Also at twelve months, the

diaphragm becomes more dome-shaped resulting in

gated children and adults who were referred for speech

greater air intake and production of reduplicated and

and language therapy at the University of Ilorin Teach-

variegated babbling. At eighteen months, children are

ing Hospital in North Central Nigeria. More than half

able to jargon, produce most vowels, and produce many

(58%) of the patients had a diagnosis of deaf-mutism

consonants. They are able to use 5 to 10 single words

(the inability to speak), 21% had delayed speech devel-

and comprehend about 50 words. By twenty four

opment, 4% slurred speech pathology, 13% impaired

months, fastmapping occurs and vocabulary expands to

speech, 3% stammering/stuttering and 1% with aphasia.

Nwokah

50 words with the production of two-word combina-

studied disfluent bilingual Igbo/English in

tions. These speech and language milestones continue

Anambra State Nigeria and reported that 9.2% of Nigeri-

ans were individuals who stutter.Research

8-13

throughout childhood.

on Nigeri-

ans with impaired speech and language abilities report

Signs of speech and language impairment

individuals presenting with articulation disorders, flu-

ency disorder (i.e., stuttering), and autism spectrum dis-

Children with speech and language delays and disorders

order.

have difficulties understanding what is said to them and

have difficulties expressing their thoughts. A speech and

The role of speech-language pathologists

language disorder refers to an impairment in a person’s

articulation of speech sounds, fluency, voice, compre-

According to the American Speech-Language-Hearing

Association the role of speech-language pathologists

hension and use of spoken, written or other symbol sys-

tems. According to the American Speech-Language-

include but are not limited to utilizing evidence-based

Hearing Association , signs of speech and language im-

approaches to intervention, counseling, collaboration

pairment include:

with family members and other professionals, and iden-



Problems understanding what others say

tification of individuals at risk for or presenting with



Difficulties following directions and recalling infor-

cognitive-communication disorders. Speech-language

mation

pathologists are trained to follow specific diagnostic



Problems saying words and expressing thoughts

procedures needed for differential diagnosis that con-



Difficulties producing sounds that are clear and

sider the impact of cultural, ethnic, regional, linguistic,

intelligible

dialectical differences and socioeconomic factors that

may impact speech and language learning and use.

15-



Troubles playing and interacting



Problems reading and writing

Speech-language pathologists service individuals with

articulation and phonological

delays/disorders, voice

Risk indicators

disorders, fluency disorders, language delays/disorders,

social pragmatic disorder, hearing loss, memory loss,

A range of environmental, biological, genetic, and peri-

language learning disabilities, alternative-augmentative

natal conditions may be associated with adverse devel-

communication needs, and reading and writing difficul-

opmental outcomes that result in speech and language

ties.

impairments. Advances in medical technology make it

possible for high risk children to survive. Risk indicators

Speech-language pathologists are also trained to provide

for learning disabilities, speech disorders and language

services to individuals with dysphagia, feeding and/or

impairments in children include low Apgar score, low

swallowing disorder. Feeding involves the manipulation

birth weight, preterm birth, chronic otitis media, family

of food in the mouth before swallow. Swallowing is the

history of speech and language disorders, exposure to

movement of the bolus from the oral preparatory stage

environmental toxins, stroke, brain injuries, cancer (e.g.,

to the oral stage, then from the pharyngeal stage to the

laryngeal, oral), limited language exposure, and pov-

esophageal stage, then finally to the stomach. Dysphagia

erty. These risk indicators may result in children with

can result in aspiration, airway obstruction, malnutrition,

delayed cognitive skills, limited attention, hearing loss,

dehydration, constipation, and phagophobia, fear of

neurological disorders, intellectual disabilities, and

swallowing. Speech-language pathologists are trained to

physical impairments such as cleft palate, that nega-

assess for dysphagia and provide management tech-

tively impact speech and language development.

niques.

Speech and language impairment in Nigeria

Parents should seek the services of speech-language

pathologist when they are concerned about their child’s

Studies

8-10

that have investigated the prevalence of

communication abilities. Admittedly, there is a national

speech and language impairment in Nigeria reveal that 8

shortage of speech-language pathologists in Nigeria,

-30% of individuals with communication concerns in

however, it is hoped that the Nigerian educational sector

Nigeria present with speech impairments. Some funet

and the regulatory bodies should assist in training more

al’s study at Lagos University Teaching Hospital with

speech-language pathologists so as to cater to the needs

children between ages six months and fifteen years with

of Nigerians. Medical and educational professionals

communication disorders in Nigeria revealed hearing

should refer parents to speech-language pathologists to

295

assess and treat children with communication disorders.

Therapeutic methods

Speech and language assessment methods

Therapeutic methods used to treat children with speech

and language difficulties are vast, diverse and individu-

Norm-referenced and criterion referenced testing are

alistic. It involves use of prompts, cues and counseling.

two types of traditional standardized assessment meas-

During therapy, speech and language skills are facili-

ures used to assess the performance of children’s speech

tated using the prompt hierarchy (i.e., general, verbal,

and language abilities. Norm-referenced tests compare

visual and tactile prompts) with scaffolding towards

the child’s performance to that of other children. Crite-

independence. There are several approaches in a thera-

peutic program. The therapist-directed approach aims

rion referenced tests compare the child’s performance on

specific skill, grammatical structure, or linguistic con-

at controlling the environment so that the intervention is

cepts to independently predetermined criteria. The ad-

effective at changing behavior. Such therapist-directed

vantages of most standardized tests is that they are well

approaches include drills and modeling. The child-

constructed so asto meaningfully compare children us-

directed approach, for obstinate and unassertive commu-

ing clear administration and scoring criteria, validity,

nicators, focuses on the therapist reacting to the child’s

reliability and standardization measuring central tenden-

behaviors and providing linguistic mapping. Examples

cies and variability.

of child-directed approach include expansions (i.e., ex-

pansion of child’s utterances with detail), recasting (i.e.,

There are many standardized tests that assess speech

expansion of child’s utterance into a different type of

skills including the Goldman Fristoe Test of Articulation

sentence) and parallel talk (i.e. productions about child’s

– Third Edition, the Khan-Lewis Phonological Analysis

actions). Hybrid approaches such as focused stimulation

– Second Edition, the Structured Photographic Articula-

facilitate language by exposing the child to multiple

tion Test – Second Edition, the Weiss Comprehensive

repetition of a specific linguistic target within a commu-

nicative context.

Articulation Test, the Stuttering Prediction Instrument,

the Stuttering Severity Instrument – Fourth Edition, and

the Test of Oral & Limb Apraxia. Some of the standard-

In addition to oral communication, speech-language

ized tests that assess language abilities include the Pre-

pathologists are involved in providing individuals with

school Language Scale-5, the Clinical Evaluation of

various means of communication such as sign language,

Language Fundamentals – Fifth Edition, the Peabody

picture cards, assistive technology and communication

Picture Vocabulary Test – Fourth Edition, the Oral and

devices. For individuals with feeding and swallowing

Written Language Scales – Second Edition, the Test of

concerns, speech-language pathologists provide manage-

Language Development – Primary/Intermediate Fourth

ment techniques as it related to positioning, food presen-

Edition, the Test of Problem Solving- Third Edition, the

tation, diet consistency, oral/pharyngeal/laryngeal exer-

Boston Diagnostic Aphasia Battery, the Scales for Cog-

cises, swallowing maneuvers, and intraoral prosthetic

nitive Assessment of TBI, the Western Aphasia Battery

devices for swallowing.

– Revised, and the Test of Language Competence – Ex-

panded Edition. Dysphagia is examined by performing a

Parent can avail themselves of the services of the few

clinical evaluation of swallowing function, a fiberoptic

speech and language associations and programs in Nige-

endoscopic evaluation and ultrasound imaging.

ria. The Speech Pathology and Audiology Association

of Nigeria accredits training programs and ensures ethi-

Speech and language pathologists are often confronted

cal standards in the practice of speech pathology and

with concerns about using standardized assessment tests

audiology. The Stuttering Association of Nigeria aims at

with children from culturally and linguistically diverse

educating people about stuttering and provides a support

backgrounds. Tests and other evaluation materials

network for individuals who stutter. The University of

should not be culturally and racially biased. Standard-

Ibadan has an audiology and speech pathology program

ized tests present with a number of biases including

under their department of special education. Parents and

situation bias, linguistic bias, format bias, value bias and

medical and educational professionals should seek out

sampling bias. Lack of appropriate assessment materials

clinics and centers within their locality that service chil-

for children from diverse and multicultural backgrounds

dren with speech and language impairments.

can result in over identification, under identification or

misidentification of children as having speech and lan-

Suggestions for parents

guage impairment. Accurate assessment of spoken and

written language skills in children from culturally and

Medical and educational professions should advise par-

linguistically diverse backgrounds should not depend

ents about certain measures to facilitate children’s

solely on the use of standardized norm-referenced test

speech and language development. Parents should be

procedures. Alternative assessment measures are non-

advised to provide appropriate oral and dental care by

traditional assessment measures that should be used to

visiting oral care specialists such as dentists and oto-

determine a child’s performance abilities. Alternative

laryngologists. Parents should be instructed to have their

assessment measures include review of records, observa-

child’s hearing assessed by audiologists to rule out hear-

tions, ethnographic interviews, informal assessments,

ing loss. They should be encouraged to facilitate their

and use of processing-dependent and dynamic assess-

child’s language by doing the following:

ment measures.

296

Talking to their child using short sentences during

Singing, reciting poems and rhyming with their

daily activities and modeling appropriate sentences

child: There are numerous books and nursery rhymes

for their child to imitate: Parents should provide many

that have repetitive words and phrase that offer opportu-

nities to learn sounds and words. Brandtet al reported

opportunities for their child to hear and say sounds cor-

rectly. They should talk about what they are doing and

that music is essential to learning oral language.

what their child is doing. Parents should talk during

Playing outdoor games, puzzles, card game and other

daily activities; while taking their child’s bath, dressing

gamesthat require turn taking with their child: Board

their child, making meals, feeding their child, and on

games such as ayo and checkers and hand clapping

outings with their child (e.g., markets, shops). As their

games are great ways to facilitate speech and language

at home. Gibbons et al’s study on social skills games

child gets older, parents should use longer sentences to

communicate with their child. Girolamettoet al used

that require turn taking in children with autism revealed

focused stimulation, repetition and modeling on children

improvement in pragmatic and expressive language

with receptive and expressive language delays. Results

skills.

revealed an increase in the children’s vocabulary and

utterance length. Additionally, Buschmannet al’s study

Encouraging your child to greet and engage in con-

of children with expressive language delays revealed

versation: Children learn from peers and should be en-

couraged to socialize. Mashburn et al’s study of peer

that parent training on child-directed speech and model-

ing resulted in an increase in vocabulary, sentence pro-

expressive language on the development of receptive

duction, morphology and syntax.

and expressive language skills indicate that language

achievements are positively related to their peer’s ex-

Expanding on what the child says: For example, when

pressive language abilities.

their child says “rice”, parents can ask “Do you want

Giving full attention to their child when their child is

rice?” and model “I want rice”. Robertson & Weis-

speaking: Parents should be advised to provide a relaxed

mer’s study of 2-year old children with receptive and

slow environment so that their child does not feel pres-

expressive language delays revealed expansion, recast-

sured to talk and respond. Parents should not speak fast

ing, parallel talk, and child-directed speech strategies

or rush the child to speak. It is important for parents to

were effective at increasing the number of single words

reduce conversational and lifestyle pressures to improve

speech fluency.

and word combinations produced by children.

Labeling and naming objects, actions and people:

Speaking to their child in a language the parent is

fluent in: According to Roseberry-McKibbin parents

Parents should name family members, foods, animals,

body parts, clothing items, toys, vehicles, and actions.

should speak to their children in the language that is

most comfortable for them. Yip & Matthews’ study of

As parents label objects, they should talk about objects’

functions (e.g. “People wear glasses to see.”). Parents

a Cantonese-English learning child found evidence of

can also look through albums and name family members

transfer from Cantonese to English as the child learned

and places in pictures. Moller et al’s study of children

English. Providing a good language model allows chil-

with expressive language delays revealed that modeling,

dren to incorporate the appropriate structures learned

labeling and repetition increased the children's language

from their primary language of exposure into their sec-

output as it relates to syntax and semantics.

ondary language.

ASHA

33,34

Reading interesting enjoyable story books aloud to

provides useful suggestions and strategies for

their child: Parents should be encouraged to reread the

parents to use with children who present with communi-

cation difficulties. The Stuttering Foundation gives

books to promote retention of language and develop-

ment of phonological awareness (i.e., ability to identify

several pieces of advice for parents when stuttering is a

and manipulate sounds and words). Kim et al’s study

concern. Ideally, the strategies should be implemented

on six-year- old children’s linguistic awareness skills

with the guidance of a speech-language pathologist,

revealed that phonological awareness, orthographic

however these practical steps can be applied until one is

awareness (i.e., ability to form letter patterns), and mor-

accessible.

phological awareness training were predictors of word

reading skills.

Encouraging their child to retell stories and daily

Conclusion

events: Parent should ask questions to assist their child

in retelling stories. Older children should not only retell

In most developed countries, speech and language disor-

stories orally, but also in writing. Morrow investigated

ders are treated by speech-language pathologists, how-

children’s story dictation to determine if oral language

ever, in Nigeria lack of adequate awareness, coupled

improved in children who were asked to frequently retell

with the few speech-language pathologists that practice,

stories. Results of the study indicated that frequent prac-

mitigate against easy access to speech and language ser-

tice and guidance in story retelling had a positive effect

vices. Medical and educational stakeholders should fash-

on improving dictation of original stories and oral lan-

ion a pathway for the recruitment and training of speech-

guage complexity.

language pathologists.

297

References

Ayo-Aderele S. Nigeria has only

13. Nwanze H. Spoken language in

24. Moller D, Probst P, Hess M. Im-

300 speech pathologists, audiolo-

Nigerian children with features of

plementation and evaluation of a

gists –

autism. Brit J Human Soc Sci.

parent training for language de-

Ademokoya. Punch [Internet].

2013;8(2):1-6.

layed children. [German]. Praxis

2013 June 5 [cited 2014, Sept 12].

14. American Speech-Language-

der Kinderpsychologie und Kin-

Available from: http://

Hearing Association. Roles of

derpsychiatrie.2008;57(3):197-

www.punchng.com/health/nigeria-

speech-language pathologists in

215.

has-only-300-speech-pathologists-

the identification, diagnosis, and

25. Kim YS, Apel K, Otaiba, SA. The

audiologists-ademokoya/

treatment of individuals with cog-

relation of linguistic awareness

Bernthal JE, Bankson NW, Flip-

nitive-communication disorders:

and vocabulary to word reading

sen, P Jr. Articulation and phono-

position statement [Internet]. 2005

and spelling for first-grade stu-

logical Disorders. 7th ed. Boston:

[cited 2015 Apr 12]. Available

dents participating in response to

Pearson Education; 2013.

from: www.asha.org/policy.

intervention. Lang Speech Hear

Owens, R. Language development:

15. Battle DE. Middle Eastern and

Serv. 2013;44:337-347.

an instruction. 6th ed. New York:

Arab American cultures. In: Battle

26. Morrow LM. Effects of structural

Allyn and Bacon; 2005.

DE. Communication disorders in

guidance in story retelling on chil-

Gleason, JB, Ratner, NB. The

multicultural populations. 3rd ed.

dren’s dictation of original stories.

Development of language. 8th ed.

Boston: Butterworth-Heinemann;

27. A, Gebrian M, Slevc LR. Music

Boston: Pearson/Allyn & Bacon;

2002. p.113-134.

and early language acquisition.

2012. American Speech-Language

16. Battle DE. Communication disor-

Front Psychology. 2012;3 :327.

-Hearing Association. Definitions

ders in multicultural and interna-

28. Gibbons M., Labbe R, Fahey K,

of communication disorders and

tional populations. 4th ed. St.

Beal H, Fahey K, Mahan L, Hall

variations [Internet]. 1993 [cited

Louis: Mosby; 2012.

NE. Social skills development in

2015 Jan 20]. Available from:

17. Laing SP, Kamhi A. Alternative

young children with autism: a pilot

www.asha.org/policy

assessment of language and liter-

study. Paper presentation at: ASHA

American Speech-Language-

acy in culturally and linguistically

Convention Presentation; 2011 Nov 15

Hearing Association. Early detec-

diverse populations . Lang Speech

-17; San Diego , California .

tion of speech, language, and

Hear Ser. 2003;34:44-55.

29. Mashburn AJ, Justice LM, Downer

hearing disorders [Internet]. 2015

18. Langdon HW, Cheng LR. Collabo-

JT, Pianta RC. Peer effects on

[cited 2015 Mar 15]. Available

rating with interpreters and transla-

children’s language achievement

from http://www.asha.org/public/

tors: a guide for communication

during pre-kindergarten. Child

Early-Detection-of-Speech-

disorders professionals. Eau

Dev. 2009;80:686-702.

Language-and-Hearing-Disorders/

Claire, WI: Thinking Publications;

30. Guitar B, Conture EG. The child

who stutters: to the pediatrician. 5

National Joint Committee on

2002.

Learning Disabilities. Learning

19. Paul R. Language disorders for

ed. Stuttering Found. 2013 [cited

disabilities and young children:

infancy through adolescence: lis-

2015 Feb 20]. Available from:

identification and intervention

tening, speaking, reading, writing,

http://www.stutteringhelp.org/

[Internet]. 2015 [cited 2015, May

and communicating. 3rd ed. St.

sites/default/files/PedBook.pdf

1]. Available from: http://

Louis: Mosby; 2011.

31. Roseberry-McKibbin C. Serving

www.ldonline.org/article/11511/

20. Ellis Weismer S, Robertson SB.

children from the culture of pov-

Somefun OA, Lesi FE, Danfulani

Focused stimulation approach to

erty: practical strategies for speech

MA, Olusanya BO. Communica-

language intervention. In:

-language pathologists. The ASHA

tion disorders in Nigerian children.

McCauley R, Fey M. Treatment in

Leader. 2001 Nov 6;6:4-16.

Int J Pediatr Otorhi. 2006;70

language disorders in children:

32. Yip V, Matthews S. Syntactic

(4):697-702.

conventional and controversial

transfer in a Cantonese-English

Aremu SK, Afolabi OA, Alabi BS,

approaches. Baltimore: Brookes

bilingual child. Bilingualism: Lang

Elemunkan IO. Epidemiological

Publishing Co.; 2006.p.175-202.

Cognition.2000;3:193-208.

profile of speech and language

21. Girolametto L, Pearce PS, Weitz-

33. American Speech-Language-

disorder in North Central Nigeria.

man E. Interactive focused stimu-

Hearing Association. Activities to

Int J Biomed Sci. 2001;7(4):268-

lation for toddlers with expressive

encourage speech and language

272.

vocabulary delays. J Speech Hear

development [Internet]. 2015

10. Nwokah EE. The imbalance of

Res.1996;39(6):1274-1283.

[cited 2015 Mar 13]. Available

stuttering behavior in bilingual

22. Buschmann A, Jooss B, Rupp A,

from: http://www.asha.org/public/

speakers. J Fluency Disord.

Feldhusen F, Pietz J, Philippi H.

speech/development/Parent-Stim-

1988;13:357 – 373.

Parent based language intervention

Activities.htm

11. Bakare MO, Ebigbo PO, Ubochi

for 2- year-old children with spe-

34. American Speech-Language-

V. Prevalence of autism spectrum

cific expressive language delay: a

Hearing Association. Suggestions

disorder among Nigerian children

randomized controlled trial. Arch-

for parents [Internet]. 2015 [cited

with intellectual disability: a stop-

Dis Child. 2001;94:110 – 116.

2015 Mar 12]. Available from:

gap assessment. J Health Care

23. Robertson SB, Weismer SE. Ef-

http://www.asha.org/public/

Poor U. 2012;23(2):513-8 .

fects of treatment on linguistic and

speech/development/suggestions/

12. Lagunju IA, Bella-Awusah TT,

social skills in toddlers with de-

35. The Stuttering Foundation. 7 tips

Omigbodun OO. Autistic disorder

layed language development. J

for talking with your child

in Nigeria: profile and challenges

Speech Lang Hear . 1999;42:1234 –

[Internet]. 2015 [updated 2015,

to management. Epilepsy Behav.

1248. Available from: http://

Apr 21; cited 2015, Mar 16]. Available

2014 Oct;39:126-9.

jslhr.asha.org/cgi/reprint/

from: http://www.stutteringhelp.org/7-

42/5/1234

tips-talking-your-child