Clinical Practice Guideline: Interventions for Developmental Language Delay and Disorders.

BACKGROUND: It is estimated that 9.9% of children have developmental language disorders (DLD), 7.6% in the form of circumscribed DLD without any serious accompanying impairment and 2.3% with comorbidities that have a bearing on language, such as hearing disorders. Developmental language disorders are among the more commonly treated childhood disorders; if they persist, they often adversely affect educational attainment and social standing later in life. Developmental language delay during the third year of life is an important risk factor for developmental language disorders. METHODS: This interdisciplinary clinical practice guideline reflects current knowledge on evidence-based interventions for developmental language delay and disorders. A systematic literature review was conducted on the efficacy of various interventions against developmental language disorders. RESULTS: The recommendations in this guideline include: for expressive developmental language delay, structured parental training (Hedges' g = 0.38-0.82); in case of a receptive component or other risk factors, language therapy (Cohen's d = -0.20-0.90); for phonological pronunciation disturbances, phonological or integrated treatment methods (Cohen's d = 0.89-1.04); for phonetic disturbances (in the absence of a developmental language disorder), a traditional motor approach; for lexical-semantic and morphologic-syntactical disturbances, combinations of implicit and explicit methods (input enrichment, modeling techniques, elicitation methods, creation of production opportunities, metalanguage, visualizations; Cohen's d = 0.89-1.04). Further recommendations include interventions for pragmatic-communicative developmental language disorders, as well as for developmental language disorders in bi-/multilingual children and in children with impaired hearing, intellectual disability, autism-spectrum disorders, selective mutism, and syndromes and multiple disabilities that have a bearing on language. Inpatient language rehabilitation is also recommended in certain situations. CONCLUSION: Early parent- and child-centered interventions combined with pedagogical language promotion, and the use of evidence-based treatment components, dose frequencies and forms, and settings, can help improve the efficacy of interventions for developmental language delay and disorders.

[Participation of Patients in the Development of Clinical Guidelines: A Selective Country Comparison in a Narrative Review]. / Die Beteiligung von Patient*innen an der Entwicklung von Leitlinien in der Klinischen Medizin. Ein selektiver Ländervergleich in narrativer Übersicht.

AIM: A clinical practice guideline aims to optimize patient care by recommending diagnostic or treatment pathways, based on the best available research and practical experience. Therefore, the needs and preferences of patients and their families should be incorporated. The aim of this study was to examine regulations and standards of patient involvement in guideline development, using a selective comparison of countries. METHOD: Information was extracted from publicly available websites and guidelines development manuals for the United Kingdom (UK), the United States, Canada, and Australia. They were compared and discussed in a narrative review. RESULTS: In the UK, at least two people from among patients or the public must be involved in all guideline development committees and during all stages of the development process. The US National Academy of Medicine recommends active participation in guideline development groups by patients with disease-specific experience and patient representatives from the public. The Canadian Task Force on Preventive Health Care wants patient preferences to be involved, especially in the development of final guideline recommendations and usability testing. In Australia, guidelines receive the approval or seal of approval of the National Health and Medical Research Council if at least one patient representative can be shown to have been a member of the committee and to have been involved in the entire process of guideline development. CONCLUSION: The selective country comparison shows that patient involvement in guideline development and the binding nature of the rules vary considerably, and that there are no uniform standards for involvement. Many issues of involvement are unresolved, and special sensitivity will be needed to bring together the life and experiences of patients/laypersons and the medical system on an equal footing.

[Early detection of primary developmental language disorders-increasing relevance due to changes in diagnostic criteria?] / Früherkennung primärer Sprachentwicklungsstörungen ­ zunehmende Relevanz durch Änderung der Diagnosekriterien?

Language development disorders (in German: Sprachentwicklungsstörungen, SES) are the most common developmental disorders in childhood. In contrast to "secondary SES," "primary SES" (prevalence about 7%) are not (co-)caused by other developmental disorders or diseases. In the German modification of the International Statistical Classification of Diseases and Related Health Problems (ICD-10-GM-22), primary SES are referred to as "circumscribed developmental disorders of speech and language" (in German: USES; international previously known as Specific Language Impairment SLI), with an intelligence quotient (IQ) < 85 as an exclusion criterion, among other criteria. In ICD-11, primary SES are listed as "developmental language disorders" (DLD).German-speaking speech and language therapists would now like to replace the term "USES" with "DLD" using the diagnostic criteria proposed by the international CATALISE consortium (Criteria and Terminology Applied to Language Impairments Synthesizing the Evidence), in an effort to redefine the disorder. However, according to this conceptualization, only children with an intellectual disability (IQ < 70) would be excluded from the diagnosis. This change in the diagnostic criteria would most likely result in an increase in prevalence of DLDs. This makes the issue of early detection more important than ever. This discussion paper explains that the public health relevance of primary SES is growing and that systematic early detection examinations will play an even more important role. With early diagnosis and treatment, risks in the areas of mental health, behaviour and skill development can be mitigated.Currently, diagnosis (and therapy) are usually carried out relatively late. The way out could lie in the application of neurobiological parameters. However, this requires further studies that examine child cohorts for early indicators in a prospective longitudinal design. The formation of an early detection index from several indicators should also be considered.

[Therapy of Language Disorders in Childhood: A Guideline is long overdue]. / Therapie von Sprachentwicklungsstörungen: Eine Leitlinie ist längst überfällig.

In speech and language therapy of developmental language disorders, it is still largely unclear how evidence from individual therapeutic expertise integrates into clinical-practical procedure. Therefore, development of a therapy guideline addressing language disorders in childhood, especially for kindergarten- and preschool children, is long overdue for two reasons and poses a particular challenge: (1) Language disorders that are not associated with a comorbidity are given varying terms; (2) all language disorders are an interface between medical, psychological, educational, linguistic and language therapeutic disciplines. The German Society for Phoniatrics and Pedaudiology has registered now an evidence-based (S3) national "Interdisciplinary Guideline for the Therapy of Language Disorders in Childhood" (in the Association of the Scientific Medical Societies AWMF; register no. 049-015). That should close the gap between language-therapeutic practice and research, and thus to provide the best evidence-based therapy recommendation respectively therapy decision in a specific therapy case.

[Development of Auditory Processing and Perception Skills with and without APD in Primary School Age]. / Entwicklung auditiver Verarbeitungs- und Wahrnehmungsleistungen mit und ohne AVWS im Grundschulalter.

BACKGROUND: We examined two student age groups (1st and 4th class) in a control-group comparison whether the maturation processes of the central hearing system in typically developing children are also present in children with Central Auditory Processing Disorders (CAPD) at primary-school age. MATERIALS AND METHODS: The analyses included results of a behavioral test battery from 82 first graders (40 with CAPD; 42 healthy controls) and 65 fourth graders (35 with CAPD; 30 healthy controls). An ANOVA with the total value of the following 7 standardized examinations, and subsequently a MANOVA with the detailed test results were carried out: Speech (words) in Noise Recognition (Göttinger Sprachaudiometrie II); Dichotic Word Pair Understanding (Uttenweiler-Test); Heidelberger Phoneme Discrimination Subtests: Phoneme Discrimination, Phoneme Identification, Phoneme Analysis; the Subtest Auditory Sequential Memory for Digits of the Illinois Test of Psycholinguistic Abilities (German version); Mottier's Nonword Repetition Test. RESULTS: The ANOVA showed significant main effects of "class" (1st versus 4th; p < 0.001, η²â€Š= 0.418) and "group" (CAPD versus healthy controls; p < 0.001; η²â€Š= 0.690), but no interaction effects between both. The result of the MANOVA was similar. Main effects, but only for two tests (phoneme identification; phoneme analysis) as well as the interaction of "class" and "group" were statistically significant, with statistically small effect sizes of 3 and 6 %. DISCUSSION: Based on this cross-sectional study, the difference between the two study groups appears to be independent of the school class level. CONCLUSION: At primary-school age, there is evidence of maturation of the central hearing system for both children with CAPD and healthy children.

[Test Diagnosis of Processing Disorders (APD) in Primary School - a factor analytical study]. / Testdiagnostik von AVWS im Grundschulalter ­ eine faktorenanalytische Untersuchung.

OBJECTIVE: Our eclectic test battery for diagnosing Auditory Processing Disorders (APD) was applied in some pre-studies. Now, its underlying content structure should be examined by a factor analytic study. MATERIAL AND METHODS: Test results from 143 children with APD with an average age of 8.3 (SD 1.1) yrs. went into several Exploratory Factor Analyses (EFA; principal component analysis). Considering the underlying correlations of the test variables, and in consideration of the results of discriminant analysis pre-studies, an EFA with 12 (of a total of 16) diagnostic test variables seemed appropriate. RESULTS: The Kaiser-Meyer-Olkin-measure of sampling adequacy was moderate middling to good (0.739). The determination of the optimal number of factors was based on the Kaiser criterion (eigenvalue > 1) and spoke in favour of four factors accounting for a cumulative variance of 63.7 %. A Scree-Test confirmed the four-component-solution. The component matrix showed that the loadings of the unrotated factors was mostly large on the first factor and therefore hardly to interpret. To obtain a better representation of the components, a Promax rotation was conducted. A clearly interpretable pattern of the rotated loadings resulted, forming these four components: phonematic processing; verbal-auditory memory; fundamental hearing processing, and a processing component of low redundance speech. CONCLUSION: Based on these findings, a preliminary model of the central auditory processes of our APD-test battery was drafted as well as a contribution to construct validity made.

Emotion Recognition in Kindergarten Children.

BACKGROUND/AIMS: Recognition and understanding of emotions are essential skills in nonverbal communication and in everyday social functioning. These are already evident in infancy. We aimed to compare how young children recognize facial emotional expressions from static faces versus vocal emotional expressions from speech prosody. METHODS: Participants were 313 kindergarten children (162 girls, mean age = 51.01, SD 9.65 months; range 36-72). The design consisted of a visual and an auditory block (with 45 randomized trials each). Children were seated in front of a 14-inch laptop monitor and received visual stimuli (photos of faces) or auditory stimuli (spoken sentences) via loudspeakers. RESULTS: Recognizing emotions from looking at static faces was found to be easier compared to interpreting emotions transmitted by speech prosody alone. The ability to interpret emotions from both faces and speech prosody increased with age. It was easier to identify a "happy" emotion from a facial expression than an "angry" or "sad" one, whereas a "sad" emotion could be more easily recognized from speech prosody alone than facial imagery alone. Girls were significantly better than boys in identifying "sad" facial expressions. CONCLUSION: The results of the study are discussed in terms of educational implications for nonverbal communication.

Clinical Expertise Is Core to an Evidence-Based Approach to Auditory Processing Disorder: A Reply to Neijenhuis et al. 2019.

The opinion article "An Evidence-based Perspective on Misconceptions Regarding Pediatric Auditory Processing Disorder" by Neijenhuis et al. (1) presents a distorted view of the evidence-based approach used in medicine. The authors focus on the amorphous non-diagnostic entity "listening difficulties" not auditory processing disorder (APD) and create confusion that could jeopardize clinical services to individuals with APD. In our perspective article, we rebut Neijenhuis et al. (1), and more importantly, we present a rationale for evidence-based practice founded on the premise that research on APD is only clinically applicable when conducted on clinical populations diagnosed with APD.

[Prediction of modality-specific working memory performance in kindergarten age]. / Vorhersage von modalitätsspezifischen Arbeitsgedächtnisleistungen im Kindergartenalter.

OBJECTIVE: Working memory (WM) as a central cognitive construct is a fundamental prerequisite for learning and provides a marker of developmental disorders. It has received considerable attention in recent years. Here, multivariate regression analyses using generalized linear models were conducted to determine predictor variables for phonological and visuospatial WM. MATERIAL AND METHODS: The phonological WM was investigated by repetition of non-words (subtest PGN of the German SETK 3-5) and number recall (K-ABC-subtest), the visuospatial WM by the imitation of a sequence hand movements (K-ABC-subtest hand movements). The estimation of intelligence was operationalized by the performance in the K-ABC-scale "Simultaneous Processing". SAMPLE: Kindergarten kids (N = 169; 49 % boys; 51 % girls), mostly with migration background and German as second language (mean age: 45.9; SD 6.2; min 36, max 61 months). They visited the kindergarten at the time of testing for 9.9 (SD 6.9) months, on average and had an average intelligence. Independent variables were chronological age, gender, kindergarten attendance until the test examination, intelligence, migration background. RESULTS: Both phonological and visuospatial working WM performance were on average not reduced. Chronological age and simultaneous processing were found to be significant predictors for the performance in all WM tests. CONCLUSION: In the age from 36 to 61 months both working memory systems can be described as a congenital, maturity-dependent and rather gender non-specific mechanism.

[APD in First Graders. Which tests discriminate between normal and impaired children?] / Diagnostik von AVWS bei Erstklässlern: Welche Tests trennen auffällige von unauffälligen Kindern?

OBJECTIVE: In a controlled group comparison it was shown for 2nd, 3th and 4th graders that children with auditory processing disorders (APD) could be distinguished from those without (Non-APD) by three to four diagnostic tools. The hit rate was 93.6 % resp. 97.5 % 1, 2. The current study investigated whether such a separation is also possible in first graders. MATERIAL AND METHODS: Performance of 77 first graders in two clinically and diagnostically confirmed groups (n = 40 with APD, mean age: 6.93, SD 0.53 yrs; n = 37 Non APD, mean age: 6.90, SD 0.52 yrs) in 8 auditory processing tests of an eclectic test battery were compared (Dichotic Words Test; Phoneme Discrimination and Phoneme Identification; Word-Understanding in Background Noise; Binaural Summation Word Test; Sound Blending; Auditory Sequential Memory of Digits; Nonword Repetition). RESULTS: A differentiation of each clinical group with a multivariate statistical tool (discriminant analysis) functioned successfully. Children with APD were significantly distinguished from unimpaired children with an accuracy of 94.8 % (cross-validated in 92.2 %) via four test variables: (1) Auditory Sequential Memory of digits; (2) Phoneme Discrimination; (3) Nonword Repetition; (4) Word Understanding in Background Noise. CONCLUSIONS: The quality of the diagnostic a-priori-grouping using a multivariate statistics (discriminant analysis) could be confirmed for first graders too.

[Auditory Processing Disorder: Is The Diagnosis Already Possible In First Graders?] / Auditive Verarbeitungs- und Wahrnehmungsstörung: Ist die Diagnose schon bei Erstklässlern möglich?

OBJECTIVE: Significant differences in performance on an eclectic German test battery for Auditory Processing Disorders (APD) was found in the most diagnostic tools between children with APD and controls in the 2nd, 3rd and 4th school year of primary education. Aim of the present study was to examine whether it is also the case for first graders. MATERIAL AND METHODS: The performance in the behavioral test battery (including 14 specific auditory tests) was compared in two subject groups (aged 6-8 yrs): 41 first graders with APD of a clinical database, 37 typically developing first graders without APD (controls). RESULTS: Significant mean group differences were detected in the performance on 12 of 14 tests, because children with APD showed lower scores (excepted from two PaTsy-subtests: sound frequencies; sound intensities). The significance concerning the monaural threshold values narrowly retained statistical significance with Bonferroni correction. The controls mastered the PaTsy-subtests only in 86-89 % of all cases, children with APD in 73-83 %. The test scores of both boys and girls with APD were lower than those of their peers without APD. CONCLUSIONS: First graders with versus without APD could be significantly distinguished. Generally, there was seen a trend that in first graders the same performance was reduced as in elementary school pupils of higher grade level. For use in clinical diagnosis of APD, nonverbal auditory tests for the investigated specific age segment appears debatable.

A European Perspective on Auditory Processing Disorder-Current Knowledge and Future Research Focus.

Current notions of "hearing impairment," as reflected in clinical audiological practice, do not acknowledge the needs of individuals who have normal hearing pure tone sensitivity but who experience auditory processing difficulties in everyday life that are indexed by reduced performance in other more sophisticated audiometric tests such as speech audiometry in noise or complex non-speech sound perception. This disorder, defined as "Auditory Processing Disorder" (APD) or "Central Auditory Processing Disorder" is classified in the current tenth version of the International Classification of diseases as H93.25 and in the forthcoming beta eleventh version. APDs may have detrimental effects on the affected individual, with low esteem, anxiety, and depression, and symptoms may remain into adulthood. These disorders may interfere with learning per se and with communication, social, emotional, and academic-work aspects of life. The objective of the present paper is to define a baseline European APD consensus formulated by experienced clinicians and researchers in this specific field of human auditory science. A secondary aim is to identify issues that future research needs to address in order to further clarify the nature of APD and thus assist in optimum diagnosis and evidence-based management. This European consensus presents the main symptoms, conditions, and specific medical history elements that should lead to auditory processing evaluation. Consensus on definition of the disorder, optimum diagnostic pathway, and appropriate management are highlighted alongside a perspective on future research focus.

[Indicators for Speech Comprehension in Migrant Children. A comparison of Extreme Groups]. / Indikatoren für Sprachverständnis bei Kindern mit Migrationshintergrund. Ein Extremgruppenvergleich.

Objective Children with migrant background learning German as second language are frequently considered having problems in speech comprehension and speaking; nevertheless, it is very difficult to objectify that for young children. For this purpose risk-factors should be determined empirically. Material and Methods The study comprised 126 children from a developmental longitudinal study in 7 day-care centers in Frankfurt/M and Darmstadt. The sample was sorted into two extreme groups by their achievement in oral German language comprehension: criterion T-score ≥46=age appropriate (N=61) vs. T-score ≤32=poor (N=65). The study used an assumed best-subtests variable-selection (intelligence; grammatical based comprehension; verbal conceptualization; recognition of semantic and grammatical inconsistencies) to examine risk-factors for the quality of development in German as second language. Results Intelligence was average in both groups, however, significantly different (T-score=54.1; SD 6.7 vs. T-score=42.2; SD 8.8; p<0,001). Risk-factors for a separation between rather convenient and less convenient conditions for the development of German as second language could be identified by applying discriminant analyses (in order of descending magnitude): intelligence; recognition of verbal inconsistencies; mother's level of education; grammatical based comprehension. Regarding the group affiliation, 88% of the children with poor and 84% of those with age appropriate oral comprehension could be correctly classified within the selected samples. Conclusions The results provide an acceptable standard to distinguish migrant children with an age appropriate oral comprehension in German as the second language from such with a poorer one.

Common Misconceptions Regarding Pediatric Auditory Processing Disorder.

Pediatric hearing evaluation based on pure tone audiometry does not always reflect how a child hears in everyday life. This practice is inappropriate when evaluating the difficulties children experiencing auditory processing disorder (APD) in school or on the playground. Despite the marked increase in research on pediatric APD, there remains limited access to proper evaluation worldwide. This perspective article presents five common misconceptions of APD that contribute to inappropriate or limited management in children experiencing these deficits. The misconceptions discussed are (1) the disorder cannot be diagnosed due to the lack of a gold standard diagnostic test; (2) making generalizations based on profiles of children suspected of APD and not diagnosed with the disorder; (3) it is best to discard an APD diagnosis when another disorder is present; (4) arguing that the known link between auditory perception and higher cognition function precludes the validity of APD as a clinical entity; and (5) APD is not a clinical entity. These five misconceptions are described and rebutted using published data as well as critical thinking on current available knowledge on APD.

[Assessment of Social-Communicative Behaviour Problems and Expression of Emotions in Three- to Six-Year Old Children in Nursery School and Kindergarten]. / Beurteilung von sozial-kommunikativem Problemverhalten und Emotionsausdruck Drei- bis Sechsjähriger in einer Kindertageseinrichtung.

Developmental support and promotion of children with behavioural disorders received little attention in nursery school and kindergarten in the last years. Parents expect that their children exhibiting psychosocial deficits or problems in social-communicative competence will also get support by the said educational institutions. This requires a preliminary, but reliable and economic monitoring, estimation and evaluation of selected behaviour patterns. Therefore, we developed and validated a scale to rate social-communicative behaviour problems and expression of emotions. Factor analysis suggested two factors which corresponded to the intended measurement object and the defined taxonomy of behavioural problems (scale 1: mainly internalized behaviour; scale 2: externalized behaviour). Both internal consistency and split-half reliability proved to be good. High convergent criterion validity was found for scale 1 and still substantial, although lower, for scale 2. The rating is simple and can be performed within ten and scored within five minutes. The result is a reliable indicator for a step-by-step approach to recommend an expanded specific psycho-diagnostics, so that therapeutic interventions as well as prevention programmes for vulnerable children and appropriate social training programmes can start timely.

Pediatric health-related quality of life: a structural equation modeling approach.

OBJECTIVES: One of the most referenced theoretical frameworks to measure Health Related Quality of Life (HRQoL) is the Wilson and Cleary framework. With some adaptions this framework has been validated in the adult population, but has not been tested in pediatric populations. Our goal was to empirically investigate it in children. METHODS: The contributory factors to Health Related Quality of Life that we included were symptom status (presence of chronic disease or hospitalizations), functional status (developmental status), developmental aspects of the individual (social-emotional) behavior, and characteristics of the social environment (socioeconomic status and area of education). Structural equation modeling was used to assess the measurement structure of the model in 214 German children (3-5 years old) participating in a follow-up study that investigates pediatric health outcomes. RESULTS: Model fit was χ2 = 5.5; df = 6; p = 0.48; SRMR  = 0.01. The variance explained of Health Related Quality of Life was 15%. Health Related Quality of Life was affected by the area education (i.e. where kindergartens were located) and development status. Developmental status was affected by the area of education, socioeconomic status and individual behavior. Symptoms did not affect the model. CONCLUSIONS: The goodness of fit and the overall variance explained were good. However, the results between children' and adults' tests differed and denote a conceptual gap between adult and children measures. Indeed, there is a lot of variety in pediatric Health Related Quality of Life measures, which represents a lack of a common definition of pediatric Health Related Quality of Life. We recommend that researchers invest time in the development of pediatric Health Related Quality of Life theory and theory based evaluations.

Health related quality of life of immigrant children: towards a new pattern in Germany?

BACKGROUND: To study Health related quality of life (HRQoL) of a sample of kindergarten children with migration background. METHODS: Five kindergartens in Frankfurt/Main and Darmstadt (Germany) participated. HRQoL was measured with the Kiddy-KINDL (KK) in 3 to 5 year old children. We examined the associations of HRQoL with socio-demographic variables, positive development and resilience, socio-emotional and motor development. Linear regression models were applied to examine differences in HRQoL between migrant and native-born German children. RESULTS: The response rate was 90.5% (N = 283). The children had predominantly migrant background (81.35%). Perceived health was slightly higher in migrants (69.85, SD 17.00) compared to native-born German children (68.33, SD 17.31, p > 0.05), even though migrant children were characterized by a lower socio-economic status (p < 0.01). CONCLUSIONS: Results suggest that HRQoL at early ages in our study exhibits a different pattern than reported previously in studies among older individuals. We attribute the discrepancy partly to a possible changing pattern of migration in Europe with more migrants capable to migrate with healthy profiles, and to the age of our population. Our findings underscore the need to study the life course trajectory of HRQoL among young immigrants and replication in representative samples.

[Music-based intervention in children]. / Musikbasierte Intervention bei Kindern.

Music-based interventions with children are an effective method in health and sickness treatment and in education systems. The engagement with music enables positive transfer effects on extra-musical developmental domains. Music therapy was applied primarily as a practically-oriented scientific discipline both within the framework of a multi-modal therapy approach as one treatment component and focused specifically on children with emotional disorders within a somatic therapy concept and in rehabilitation. The following narrative overview will present music therapy's working basis, treatment goals, and select outcome research in children from 2005-2010. There currently exists a substantial lack, even within empirical research, in relation to the application of music therapy to children. This is an opportunity to initiate a broad range of study for the future. Current challenges and opportunities in scientific, music-based intervention in the paediatric population lie in the concretization of differential indications (both in intervention approach and duration), replicable comparative therapy (alternated treatment-design), the application of a music-therapeutic placebo requirement, as well as in the verification and analysis of specific music therapeutic mechanisms.