Braz. j. . vol.81 número4

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www.bjorl.org

Brazilian

Journal

of

OTORHINOLARYNGOLOGY

ORIGINAL

ARTICLE

Epidemiology

of

communication

disorders

in

childhood

phoniatric

clinical

practice

夽

,

夽夽

Marta

Gonc

¸alves

Gimenez

Baptista

a,b,∗

,

Beatriz

Cavalcanti

Albuquerque

Caiuby

Novaes

c,d

,

Mariana

Lopes

Favero

c,d

a_Program_of_Graduate_Studies_in_{Phonoaudiology,}_Pontifícia_Universidade_de_São_Paulo_(PUC-SP),_São_Paulo,_SP,_Brazil b_Clínica_{Interdisciplinar}_Prof._Dr._Mauro_Spinelli,_São_Paulo,_SP,_Brazil

c_Pontifícia_Universidade_Católica_de_São_Paulo_(PUC-SP),_São_Paulo,_SP,_Brazil d_Derdic,_Pontifícia_Universidade_Católica_de_São_Paulo_(PUC-SP),_São_Paulo,_SP,_Brazil

Received16January2014;accepted6January2015 Availableonline9June2015

KEYWORDS

Childlanguage;

Language development;

Speechdisorders;

Epidemiology

Abstract

Introduction:Languageacquisitionanddevelopmentrequireanunderstandingofphysicaland psychosocialaspectsduringdiagnosisandtreatment.Atthispoint,apartnershipbetween pho-niatricphysiciansandotherhealthprofessionalsisoftenadeterminantforfavorableprognosis.

Objective:Toidentifytheclinicalandepidemiologicalcharacteristicsofapediatricpopulation attendingaphoniatricclinicalpractice.

Methods:Study design: Cross-sectional cohort. Retrospective, epidemiologicalstudy of297 children,seeninphoniatricappointmentsbetween1976and2005.Outcome variableswere referralorigin,gender,age,meanage,diagnosis,andtreatmentapproach.

Results:66%weremaleand34%werefemale,withameanageof6.4years.Thelargestnumber ofreferralsfor phoniatrictreatmentscame fromspeech therapists(38%).Thepredominant complaintwas alteration inspeech (35%);thediagnostics inspeech,language, andfluency (49.5%)arenoteworthy.Consideringthetotalofthepatientsanalyzed,28.2%werereferredfor speechtherapyand11.8%forpsychotherapy.

Conclusion:The studiedpopulationis predominantlymale,thediagnosis pointstoahigher incidenceincasesofimpairmentinspeech,language,andfluency;themostcommontreatment wasspeechtherapy.

夽

Pleasecitethisarticleas:BaptistaMGG,CaiubyNovaesBCA,FaveroML.Epidemiologyofcommunicationdisordersinchildhoodphoniatric clinicalpractice.BrazJOtorhinolaryngol.2015;81:368---73.

夽夽_Institution:_Pontifícia_Universidade_de_São_Paulo_(PUC-SP),_São_Paulo,_SP,_Brazil.

∗_{Corresponding}_author.

E-mail:martagimenezbap@uol.com(M.G.G.Baptista).

http://dx.doi.org/10.1016/j.bjorl.2015.01.006

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PALAVRAS-CHAVE

Linguageminfantil;

Desenvolvimentoda

linguagem;

Distúrbiosdafala;

Epidemiologia

Epidemiologiadosdistúrbiosdecomunicac¸ãonainfânciaemclínicafoniátrica

Resumo

Introduc¸ão: Aquisic¸ão e desenvolvimento da linguagem demandam cuidados exigindo com-preensão dos aspectos orgânicos e psíquicos no diagnóstico e tratamento. Assim, parceria entre foniatra e outros profissionais é, muitas vezes, determinante de um prognóstico favorável.

Objetivo: Caracterizarclínicaeepidemiologicamenteosdistúrbiosdecomunicac¸ãoemcrianc¸as napráticaclínica.

Método: Coortetransversalhistórica.Estudoepidemiológicoretrospectivode297prontuários de crianc¸as atendidas em consulta foniátrica no período entre 1976 a 2005. Variáveis: origem do encaminhamento, gênero, média da idade, diagnóstico e conduta para trata-mento.

Resultados: 66%foramdogêneromasculinoe34%dofemininocommédiadeidadede6,4anos. Maiornúmerodeencaminhamentosfoirealizadoporfonoaudiólogos(38%).Aqueixa predomi-nanteeradealterac¸õesnafala35%eressaltam-seosdiagnósticosnaáreadafala,linguageme fluência(49,5%).Dototaldestacaram-seosencaminhamentospara:28,2%fonoterapiae11,8% psicoterapia.

Conclusão:A populac¸ão atendida foi predominantemente masculina, o diagnóstico aponta maiorincidênciaemquadrosdecomprometimentonafala,linguagemefluênciaeotratamento maisindicadofoifonoterapia.

Introduction

For the establishment of proper diagnosis and

appropri-ate treatment, children with language disorders require

the services of a coordinated medical and phoniatric

team capable of considering that organic, psychological,

and social factors can be part of the genesis of this

problem.1

Evenincaseswherethereisanobviousfunctional

abnor-malityofanorganorsystem,e.g.,incasesofhearingloss,

cleftpalate,andencephalopathy,itiscriticaltounderstand

that the problems that arise in patients with

communi-cation difficulties are complexand sometimes difficult to

understand. Affected children and their families, when

seeking help for communication difficulties look for

clini-calresponsesthatappreciatethebiopsychicfoundationsof

theirlanguagedisorder.2

Theotorhinolaryngologistinvolvedinphoniatricsplaysa

keyroleinthiscomplexprocessofhumancommunication,

notonly at the timeof diagnosis, but alsoduring his/her

communicationwiththeteamhelpingtoformulatethebest

conduct and the most appropriate intervention for each

patient.3

Similarly,duetothelargenumberofpotentialdiagnoses

forachildwithalanguagedisorder---forexample,specific

languageimpairment,languagedelay,andarticulation

dis-orders,webelieve thatepidemiologicalstudiesareuseful

tohelpinselectingthecompositionoftheteamnecessary

to care for these children. In this sense, the aim of this

studywastoepidemiologicallycharacterizethepracticeand

thereferralsmadetoaphoniatricclinicforcommunication

disordersoccurringinchildhood

Methods

ThestudydesignwasapprovedbytheEthicsCommitteeof

PontifíciaUniversidadeCatólicadeSãoPaulo,accordingto

Declarationno.06919712.6.0000.5482.

A retrospective study of a historical cross-sectional

cohortwas conducted. Froma total of 843 patients with

complaints of a disorder of communication submitted to

phoniatricassessment andtreatment inaprivateclinic in

the city of São Paulo between June of 1976 and January

of2005half,wereanalyzed(thoseregisteredwithaneven

number).Fromthesemedicalrecords,onlychildrenofboth

gendersofbetweenages1yearand11yearsand11months

wereincluded,totaling422records.

Exclusioncriteria:incompleteorillegiblerecords

Duringthephoniatricconsultation,onesemi-openinterview

tookplace, where datawere collectedon thecomplaint,

previoushistoryofthecomplaint,familyhistory,schooling,

familyroutine,feedinghabits,neuropsychomotor

develop-ment,andsocialandfamilyrelationships.

In addition to an otorhinolaryngological examination,

the phoniatrist used games and symbolic play, drawing,

and writing (depending on the child’s age) to investigate

aspectsrelated to global and oral motor functions,

audi-tory and visual perceptual functions, static and dynamic

balance,and spatial orientation at body and graphic

lev-els.Theexaminationsprovidedbythechild’sparentsduring

the consultation were also considered, and the physician

orderedotherappropriateteststocomplementthedatafor

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0%

P≤0.01 Pho

noaudiologist Physi

cian School

Acquainta nce

Not i nformed

Psycho logist

Psyc hopedagogi

st

Insti

tution _Dentist Nurse Teac

her

Spontaneously attended the clinic 38.0%

19.9%

10.4%

8.4% _7.7% 5.4%

3.7% 3.4%

1.3% 0.7% 0.3% 0.3% 35%

30%

25%

15%

10%

5% 20%

Figure1 Distributionofreferrals acceptedby phoniatrists, accordingtothesourcesoforigin.

Fortheanalysis,thefollowingvariableswereused:

gen-der,meanage,referralsource,familycomplaint,diagnosis,

andconduct.

The statistical analysis wasperformed usingan ANOVA

parametrictest(quantitativeandcontinuousdata)andthe

equalityoftwoproportionsnonparametrictest(qualitative

data).Asignificancelevelofp=0.05(5%)witha95%

confi-denceintervalwasestablished.4

Results

Of422medicalrecords,22wereexcludedfor

incomplete-nessand103forbeingoutsidethestipulatedage.Thus,297

medicalrecordswereevaluated.Ofthissample,most

chil-drenweremale(n=196;66%)comparedtofemales(n=101;

34%;p<0.001)andthemeanagewas6.3±0.3years.Mostof

thepatientscamefromthecityofSãoPaulo,i.e.,65.32%of

cases(p<0.01%).Mostreferralstophoniatricconsultation

were made by speech therapists, 38% (Fig.1). The main

familycomplaintwasachangeinspeech(p≤0.01;Fig.2),

and the most frequent diagnosis was established in the

speech/language/fluencyarea(49.5%;p≤0.01;Fig.3).

Inthe analysis of the gender and diagnostic variables,

nostatisticallysignificantdifferenceswerefoundbetween

thetwogenderswithrespectto‘‘hearing,’’‘‘neurological

picture,’’and‘‘voice’’diagnoses(andalsoin‘‘no

diagno-sis’’cases).Astatisticallysignificantdifferencewasfoundin

thosediagnosesrelatedtospeech/language/fluencyareas,

with a prevalence of 63.9% in boys and 36.1% in girls

(p<0.001)(Table1).

Thephoniatricdiagnosiswasanalyzedconsideringthree

age groups, distributed as follows: 0---5 years, >5 and

≤10 years, and >10 years. In the first two age groups,

speech/language/fluency was the most common

diagno-sis. However, in the group of children over 10 years of

age, the most frequent diagnosis was established in the

reading/writing/learning area, with 33.3%, but therewas

no statistical differencevs. the diagnoses established for

speech/language/fluencyandemotionaldisturbance(30.3%

and15.2%,respectively;Table2).

Thephoniatristreturned46.7%ofthesepatientstothe

professionalsresponsibleforthepatient’sreferral:28.2%for

speechtherapy,11.8%forpsychotherapy,and3%for

educa-tionalpsychology,asshowninFig.4.Theremainingpatients

(10.3%)weretoreturntothephoniatristformonitoring.

Discussion

Phoniatrics is an areaof otorhinolaryngologywhich treats

humancommunicationdisorders,focusingonvoice,speech,

language,hearing,andswallowingfunctions.1_As_a_function

of the complexity of the process of human

communica-tion and of the enormous range of possible diagnoses, it

0%

P≤0.01 5% 10% 15% 20% 25% 30% 35% 35.0%

19.5% 16.8%

5.7%

3.7% _3.0% _3.0%

1.3% 1.3% 1.0% 1.0% 1.0% 0.7% 0.7% 0.7% 40%

Alterations in speech Learning

Delayed speech/language Speech fluency

Voic e

Behavior

Alterations in speech + learning

Alterations in speech + orofacial motricity Global development

Alterations in speech + global development Learning + behavior

Questioning about the theoretical approach used in speech therapy Alterations in speech + behavior

Hearing

Orofacial motricity

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0%

P≤0.01

*Speech/Language/fluency

**O. M.

Reading/writing/learnin g

***Emotional disorde r

Hearing Voice

Neurological presentatio n

No diagnosis

Otorhinolaryngological presentation

10% 20% 30% 40% 50% 60%

49.5%

15.5%

13.1%

10.4%

7.4%

3.0%

1.0% _0.7% _0.3%

Figure3 Diagnosisdistributionaccordingtomaindisordersfound.*Speech/language/fluency---languagedeviations,language deviationsdelay,speechdisorders,specificlanguagedisorder,dyspraxia, anddisfluency.** Articulationdisorders,alterationsin chewing,swallowing,andrespiration,sigmatism,malocclusion,andtonedeficitofOFA(O.M.=oralmotricity).***Inhibition,clinical picturesofpsychosis,autism,psychicimbalance,anddepression.

Table1 Distributionofdiagnosticsbygender.

Disturbances(byarea) Female Male p-Value

n % n %

Hearing 10 45.5% 12 54.5% 0.546

Emotional 10 32.3% 21 67.7% 0.005

Speech/language/fluency 53 36.1% 94 63.9% <0.001

Reading/writing/learning 8 22.2% 28 77.8% <0.001

Oralmotricity 15 33.3% 31 66.7% 0.002

Neurologicalpicture 1 50.0% 1 50.0% 1.000

Otorhinolaryngological 0 0% 3 100% 0.014

Voice 3 33.3% 6 66.7% 0.157

Withoutadiagnosisa ₁ _100% ₀ _0% _0.157

a _Medical_record_without_a_diagnosis.

Table2 Distributionofmaindiagnosesbyagegroup.

Disturbances(byarea) ≤5years >5and≤10years >10years

n % n % n %

Hearing 5 4.8% 14 9.8% 3 8.8%

Emotional 10 9.5% 16 11.2% 5 14.7%

Speech/language/fluency 73 69.5% 66 46.1% 10 29.4%

Reading/writing/learning 0 0.0% 23 16.1% 12 35.3%

Oralmotricity 17 16.2% 24 16.8% 4 11.8%

is believed thatthesuccess of thetreatment for

commu-nication disorders in childhoodis intimately linked to an

interdisciplinarystrategyandtoaneffective interlocution

amongtheteammembers.

The analysis of the population representedby the 297

successfullyevaluatedmedicalrecordsreflectsthefindings

in the literature. A significant majority of families

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0.0%

Phonoaudiologist Psychologist Psychopedagogist Return to referring professional Monitoring continuation

with phoniatrist 5.0%

10.0% 15.0% 20.0% 25.0% 30.0% 35.0% 40.0% 45.0% 50.0%

28.2%

11.8%

10.3%

3.0%

46.7%

Figure4 Distributionofphoniatristconduct.

appointmentwithacomplaintofspeechdisorder(Fig.2).5

However,whenanalyzing thephoniatric diagnosis(divided

into broad areas, as a result of statistical adjustments),

itcan be notedthat malegender representsa significant

majorityofalterationsbothinthespeech/language/fluency

area, the most frequent diagnosis group (Fig. 3) that

includeslanguagedeviations,delaysinlanguageacquisition,

speech disorders, specific language disturbance,

dysprax-ias, anddysfluency, aswell asin the reading and writing

alterations, oral motricity problems, emotional disorders,

andotorhinolaryngologicaldisorders(Table1).Thiscouldbe

explainedbyhormonalissuesinboysandtheirslower

neuro-logicalmaturity,and,accordingtosomestudies,alsobythe

socialdemandsthatareincurredinthesechildren,when,by

culturalimposition,theyarecalledupontospeakcorrectly.

Thereareseveralexplanationsforthemalepredominance

intheliterature,butthereisnodefinitiveconsensus.6---8

Theageofchildrenatthetimeofthephoniatric

assess-mentwasaround6years,withameanageof6.4±0.4years,

which may coincide with their entrance into elementary

school.Inthiscontext,thechildisinsertedintothesocial

group,interactingwithpeers andteachers;thus, thereis

agreater demand for communication, and thismay

high-lighttheexistingdifferencesinthegroup,9,10_stimulating_the

child’sreferralandthesearchforaphoniatricevaluation.

However,inmanycases---anddependingontheseverity

of this delay --- seeking specialized care and/or a

phoni-atricdiagnosisonly whenthechildreaches 6yearsofage

mayhavenegativedevelopmentalconsequencessincegood

communicationisessential forphysical andmental

devel-opmentWhile 60%of children withlanguagedelay at the

age of 2 years achieve language development similar to

thatoftheirnormalpeersin12monthswithouttreatment,

thepersistenceoftheirsymptomsbringsadverseeffectson

learning,behavior,socialskills,andmentalhealthin

adult-hood;therefore,theyshouldnotbeoverlooked.11

Itmustalsobeconsideredthatattheageof6,thechild

beginstolearnhowtoreadandwrite,bothnecessary for

developingliteracy. Achild whohasnotconsolidated oral

languagemayhavelowerchancesofadvancinginthe

writ-tenlanguageatthesamepaceofotherchildren,considering

thatpartoforalskillsareusedinthewritingprocess.12

Table2documentshowspeechandlanguagedelayscan

belong-lastingthroughout childhood;thisis themost

fre-quent diagnosis under 5 years of age and between 5 and

10 years of age, and is almost as common as the

read-ing/writing/learningalterationsinchildrenover10years.

We believe that an interdisciplinary approach in the

phoniatricscliniciscriticaltoagoodprognosisfor

commu-nicationdisorders. Fig.4 presentsa goodexample of the

interdisciplinarynatureand,especially,ofthecomposition

of theteam, sincemost ofthe patients returnedtotheir

originalcareprovidersattheconclusionoftheirphoniatric

assessment,toproceedwiththetreatment.

In the formation of this team, a partnership between

thephoniatristandthespeechtherapist isoffundamental

importance, whether in the treatment of clinically

com-plexcases, in longitudinal follow-uppursuing adiagnosis,

or interpreting specific data stemming fromthe language

assessment.

Thespeechtherapiststandsoutastheprofessionalwho

often directs patients to phoniatric evaluation (Fig. 1);

furthermore, he/she is the professionalwho receives the

greatestnumberofindicationsofpatientsbasedonthe

pho-niatrist’s clinical conduct (Fig.4). Itmust be emphasized

that well-coordinated work between these specialties

---phonoaudiologyandphoniatrics---cancontributetogreater

efficacyinthetreatment ofchildrenwithspeechand

lan-guagedisorders.13,14

Theimportanceofthepsychologistasamemberofthe

interdisciplinaryteamfortreatingcommunicationdisorders

isworthmentioning. Inthisseries,11.8%ofpatientswere

referredbythespeechspecialistforapsychological

evalu-ation(Fig.4).Consideringthatpsychologicaldisordersand

sufferingaredirectlyrelatedtolanguageproblems,15---17_and

are frequently the primary cause of the delay, an

inter-vention that considers the child’s psychic and language

(6)

Conclusion

Thepopulationstudiedcomprisedpredominantlymales,and

thediagnosispointstoahigheroccurrenceofproblemsin

thespeech,languageandfluencyarea.Themostcommonly

recommendedtreatmentwasspeechtherapy.

Funding

This study was supported by CAPES (Coordenac¸ão de

Aperfeic¸oamentodePessoaldeNívelSuperior).

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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