Journal of Communication Disorders 38 (2005) 349358

Changes in speech and language development of a young child after decannulation

Robert Kraemer a,*, Elena Plante a, Glenn E. Green b
Department of Speech and Hearing Sciences University of Arizona Tucson, 7022 E. Baker St., 85710 Tucson, AZ, USA b Departments of Surgery, Pediatrics and Speech and Hearing Sciences University of Arizona Tucson, Tucson, AZ, USA Received 9 September 2004; received in revised form 30 December 2004; accepted 28 January 2005
a

Abstract This report reviews the speech and language development of a child who, as result of complete subglottic stenosis, was aphonic from birth until 2 years and 11 months of age at which time laryngotracheal reconstruction provided normal respiration. The boy had congenital subglottic stenosis requiring neonatal tracheostomy. The congenital subglottic stenosis progressed to complete subglottic stenosis during the neonatal period. The childs speech and language development was monitored for a 24-week period following airway reconstruction. Learning outcomes: The reader will learn about and be able to describe: (1) the speech and language development of a child who was aphonic from birth until 35 months of age, (2) the effects of surgical repair of a tracheotomy on the childs speech and language development, (3) the likely importance of babbling in speech and language development. # 2005 Elsevier Inc. All rights reserved.

1. Introduction Infants born with an obstructed or underdeveloped airway often require tracheotomy. Tracheotomy is a procedure that creates an opening below the level of the larynx. The opening, or stoma, allows a breathing tube, or cannula, to be inserted into the airway enabling respiration. If the airway happens to be completely obstructed above the
* Corresponding author. Tel.: +1 520 886 7289; fax: +1 520 621 9901. E-mail address: rjk@email.arizona.edu (R. Kraemer). 0021-9924/$ see front matter # 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.jcomdis.2005.01.002

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tracheotomy, vocal fold vibration and normal speech production, are not possible. Successful surgical reconstruction of the larynx and trachea accompanied with removal of the cannula (decannulation) allows natural breathing to occur. Subsequently, vocal fold functioning will begin. Normal vocal fold functioning subsequent to surgical repair may or may not result in immediate age-appropriate vocalization, babbling, or early speech (Oller, 2000, p. 118). Furthermore, vocalizations may be delayed by as much as several weeks or months postdecannulation (Oller, 2000, p. 118). Such a delay was evidenced by the child in Locke and Pearsons (1990) study. The child produced only a few words at 2 months postdecannulation, and a tenth of the canonical syllables expected for a child her age of 1 year and 10 months. Furthermore, there are several studies of children aphonic well into their rst year of life that reported the presence of age-appropriate speech a short time postdecannulation (Bowman, Shanks, & Manion, 1972; Hill & Singer, 1990; Rosingh & Peek, 1999; Simon, Fowler, & Handler, 1983). For example, the child whom Bowman et al. (1972) followed was aphonic until 22 months of age, but began to produce words 3 months post-decannulation. Therefore, a childs age at decannulation may determine whether or not the child will have both speech and language delays (Kaslon & Stein, 1985; Simon et al., 1983). A group of children studied by Simon et al. (1983) illustrated this relationship. Children decannulated between birth and 3 months of age demonstrated verbal language commensurate with their intellectual ability. Thus, absence of vocal practice during the rst 3 months of life appears to have minimal negative effects on speech and language development. In contrast, children decannulated from 12 to 47 months of age had both speech and language difculties. The presence of age-appropriate vocalizations in children de-decannulated prior to 3 months of age suggests that infant vocalizations during this period are not vital to later developing speech and language skills. Furthermore, it has also been suggested that practicing speech gestures through babbling is not a prerequisite for the development of normal speech and language (Lenneberg, 1967, p. 140). Children decannulated during the second year of life sometimes produce words shortly after decannulation, without the benet of prior vocal practice (Bowman et al., 1972; Hill & Singer, 1990; Rosingh & Peek, 1999; Simon et al., 1983). Therefore, is practice a necessary component for the development of ageappropriate speech and language? Children who lacked the opportunity to practice the vocal movements of speech but have been listening to speech and language for months or years may be able to develop normal speech and language within a relatively short period of time without the vocal practice that babbling is thought to provide. It should be noted, however, that acquisition of age-appropriate speech and language may be inuenced by the childs age at cannulation, the duration of cannulation, i.e. age at decannulation, the presence of sensory decits, neuro-motor impairments or developmental disabilities such as mental retardation (Hill & Singer, 1990). Although studies of the speech and language acquisition of tracheotomized infants and toddlers provide insight into aspects of speech and language development, concerns about data interpretation remain. Studies examining the speech and language development of tracheotomized children often include children who had additional impairments (Hill & Singer, 1990; Simon et al., 1983); were aphonic for varying periods of time (347 months)

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(Hill & Singer, 1990; Simon et al., 1983); may or may not have babbled prior to their tracheotomy (Hill & Singer, 1990; Simon et al., 1983); or possessed other means of communication (Adamson & Dunbar, 1991; Hill & Singer, 1990; Simon et al., 1983). Although the children involved in these studies presented with a variety of factors that could affect their speech, language, and health status, most of these children were able to acquire age-appropriate speech and language, with or without remediation. Children decannulated prior to 1 year of age may have a better chance of acquiring ageappropriate speech and language than those decannulated in their second year of life. This may be explained, in part, in that children decannulated prior to 1 year of life have gained use of their vocal mechanisms prior to verbalization. Children who are aphonic into their second year of life and who have acquired age-appropriate speech and language in the absence of vocal practice during the rst year warrants further study. Such information has clinical relevance for the treatment of such children. In addition, observation of early expressive speech and language acquisition later than normal may also inform theoretical views of this process. This case study presents data on the speech and language acquisition of a child who was cannulated shortly after birth and remained cannulated until he was 2 years and 11 months of age.

2. Method 2.1. Participant This is a case study of a 2-year, 11-month-old male child who, due to both a subglottic stenosis of the trachea and laryngeal webbing, underwent tracheotomy with cannula placement shortly after birth. The child, along with his twin sister, was born 3 weeks prematurely.1 Other than premature birth and cannulation, his early health history and development were unremarkable. The child used manual sign, which consisted of simple single-word signs to communicate while the cannula was in place. Surgical repair of the childs trachea was completed when he was 2 years, 11 months of age. The procedure of laryngotracheal reconstruction consisted of creating a split along the anterior inferior border of the thyroid cartilage, the cricoid cartilage, and the trachea to the level of the stoma. A section of the childs rib cartilage was then used to widen the split. Initially, an oral endotracheal tube was placed until partial healing had occurred and the tube was removed. An audiological evaluation was performed 6 weeks post-decannulation. At the time of testing the child had just completed 2 weeks of antibiotic medication for an ear infection. He was nasally congested and he expressed ear discomfort via ear pulling. Acoustic immittance testing indicated normal ear canal volume bilaterally with normal pressure and compliance in the left ear and substantial negative pressure and reduced compliance in the right. These results are compatible with the presence of uid in the right ear. Conditioned play audiometry was used to test hearing sensitivity. Results indicated normal hearing sensitivity in the left ear
1 The subjects twin sister also presented a slight stenosis of the trachea, but because her condition was not lifethreatening she was not cannulated.

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and normal to borderline normal hearing sensitivity in the right. Speech Reception Thresholds (SRT) were 15 dB HL in the left and 25 dB HL in the right ear. 2.2. Procedures Tracking of the childs speech and language development began shortly after his release from the hospital following the second surgical procedure. The researcher (a certied speech-language pathologist) elicited speech during play activities. The child was seen at home twice weekly for 8 consecutive weeks, then once weekly for 4 consecutive weeks and twice monthly for the remaining 8 weeks. Video and audio recordings were made of these sessions and used to analyze the childs use of speech and language. Standardized tests were administered to assess the childs speech and language status at various times during the study. The childs articulation skills were assessed via the GoldmanFristoe Test of Articulation (GFTA) (Goldman & Fristoe, 1986) which was administered 3 weeks and 12 weeks post-decannulation. The childs single-word lexicon was assessed with the Peabody Picture Vocabulary TestIII (PPVT-III) (Dunn & Dunn, 1981) which was administered 3 weeks and 24 weeks post-decannulation. The childs vocabulary was assessed via the MacArthur Communicative Development Inventory: Words and Sentences (MCDI:WS) (Fenson et al., 1993) at both 3-week post-decannulation and again at 24 weeks post-decannulation. Finally, a language sample was obtained 25 weeks post-decannulation when the child was 3 years, 5 months old.

3. Results The majority of the childs vocalizations at 2 weeks post-decannulation consisted of vegetative sounds, such as crying, burping, sneezing, and laughing. His parents reported that the child seemed startled by his own crying and laughing immediately after his decannulation. They also reported that he was crying, burping, hiccupping, coughing and laughing within 1 week of his reconstruction. Vocalizations during the latter part of this 2week period were characteristic of Oller, Eilers, Neal, and Schwartzs (1999) expansion stage of vocal development. Performance on the GFTA at 3 weeks post-decannulation revealed that the childs sound inventory included only a few phonemes. The results of the GFTA are presented in Table 1. The childs phonological processes evidenced at 3, 12, and 24 weeks post-decannulation are presented in Table 2. These ndings reveal that the childs sound system expanded rapidly during this period. Administration of the PPVT-III resulted in a standard score of 91 at 3 weeks postdecannulation. Likewise, parents completion of the MCDI:WS at this time revealed that the child produced, via manual signs accompanied by vocalizations, 294 words. The MCDI:WS was used as a criterion-referenced tool to asses the childs vocabulary development.2 Both MCDI:WS and PPVT-III at 3 weeks indicated that the child understood more than he expressed manually or verbally. His age-appropriate receptive
2

No age-reference is provided because the subject was beyond normative range of this test at this time.

R. Kraemer et al. / Journal of Communication Disorders 38 (2005) 349358 Table 1 Subjects GFTA phonetic inventory post-decannulation Consonants 3 weeks 12 weeks 24 weeks b, p, d, k, g, m, n, w b, p, d, t, k, g, m, n, w h, f, v, s, z, l, r b, p, d, t, k, g, m, n, w h, f, v, s, z, l, r Vowels a, I, u, ei, au, e, , a, I, u, ei, au, e, , , a, I, u, ei, au, e, , ,

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, ,

Table 2 Subjects phonological processes post-decannulation (GFTA and speech sample data) 3 weeks Initial consonant deletion Medial consonant deletion Final consonant deletion Backing Stopping Gliding Voicing Devoicing Rounding Syllable reduction Cluster reduction 12 weeks Initial consonant deletion Final consonant deletion Backing Stopping Gliding Voicing Cluster reduction 24 weeks Final consonant deletion Cluster reduction

skills were consistent with his neurological status. PPVT-III standard scores and MCDI:WS percentiles at both the 3-week and 24-week administrations are presented in Table 3. Vocalizations 4 weeks post-decannulation were characteristic of Oller et al.s (1999) canonical babbling stage of vocal development together with utterances consisting largely of single words. During the rst 8 weeks post-decannulation, the child was able to imitate sounds /f/, /s/, and /l/ on a naming task, none of which were observed previously during structured play activities. He also evidenced front tongue positioning as well as some slight lingual groping during these productions. During this 8-week period, the child not only increased his phonemic inventory, but his expressive ability as well. He produced two- and
Table 3 PPVT and MCDI Test scores post-decannulation PPVT-IIIstandard score 3 weeks post-decannulation 91 MCDI raw score (percentile) 294 2 0 517 7 18 (15)Vocabulary (10)Irregular words (5)Sentence complexity (45)Vocabulary (20)Irregular words (30)Sentence complexity

24 weeks post-decannulation

103

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three-word utterances during both structured and unstructured play. Although he did not produce all of the age-appropriate phonemes expected of 3-year olds at 12 weeks postdecannulation, he was able to imitate them when modeled by the researcher. Table 4 presents a month-by-month synopsis of his speech and language development. At 16 weeks post-decannulation, the childs utterance length had increased to ve-word utterances. Although utterance length had increased, such morphosyntactical errors as article omission, overgeneralization of past-tense forms, and inconsistent use of appropriate plural markers were present in mist of his verbalizations. Although the child frequently omitted articles, he often marked the omitted article with a schwa. Results of the PPVT-III at 24 weeks post-decannulation yielded a standard score of 103 and those of the MCDI:WS at this time placed his verbal production of 517 words at the 45th percentile (Table 3). These ndings on the MCDI:WS were supported by the analysis of the language sample that was also collected at 24 weeks post-decannulation. The childs mean length of utterance in morphemes (MLU) was 2.56, which is characteristic of Stage III of Browns Stages of Language Development (Brown, 1973) and fell within the predicted age range presented by Miller (1981). This language sample was analyzed using Systematic Analysis of Language Transcriptsversion 5.0 (SALT) computer software (Miller & Chapman, 1995).
Table 4 Month-by-month speech and language development First month Speech: Voice quality: breathy and hoarse. Heavy mouth breathing. Poor breath support. Vocal play: predominantly bilabial [bou dou, bae dae, bae dae bu]. Other vocalizations noted: Raspberries, yeah, uh-oh. Vowel distortion noted as well as lengthened vowel duration. Tongue thrusting and groping noted. Fourth week: inconsistent speech production continued to be noted. Language: Single-word phrases noted. Began labeling toys and objects: i.e. Pooh, Piglet, Tigger, and Monkey. Categorization noted: i.e. farm animals vs. zoo animals; cars vs. trucks. Began questioning: why? Verbal Negation: no! Action: play. Third week: productions of his name were noted. Fourth week: two word sentences were noted. Second month Speech: Vocal play noted: variegated (di ada da, ni ni ni na). Improved lingual movement for /l/ noted. Language: Two word utterances appeared.

R. Kraemer et al. / Journal of Communication Disorders 38 (2005) 349358 Table 4 (Continued) Third month Speech: Producing animal sounds. Language: Increased spontaneous speech: i.e. greetings, negation, and requestives. Continued use of vocal play, such as babbling. Consistent two and three word utterances noted. Presence of marking noted via schwa within utterances longer than three words. Fourth month Speech: Lingual movement stabilized for productions of /l/ and /s/. Language: Began using three to ve word utterances more consistently. Fifth month Speech: Consistent production of blends: pl, kr, gr, and gl noted. Consistent use of fricatives and affricatesslight lisp noted. Language: Increase use of spontaneous speech during unstructured play. Sixth month Speech: Song production: Twinkle, Twinkle Little Starproduced babbling for unknown wordsmelody of the song remained intact. Consistent target productions of /s/ and /z/. Consistent production of affricates. Appropriate vowel production. Improved intelligibility of connected speech noted. Language: Consistent questioning noted. Commented about his likes and dislikes. Consistent production of object attributes noted. Decrease use of marking noted. Reduction of babbling noted.

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4. Discussion Oller et al. (1999) suggested that typically developing infants progress through stages of vocal development in order to arrive at what is recognized as speech. Although the child was unable to produce vocalizations during his rst 35 months of life he did so after a second laryngotracheal reconstruction. The childs vocalizations often co-occurred with babbling. This childs, speech and language development progressed through the normal

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sequence of stages that characterize the development of younger children, but at a more rapid rate. Locke (1994) hypothesized that normal language development involves four critically timed phases of linguistic capacity and that each phase of speech and language development is supported by distinct neural substrates. Locke (1994, p. 609) stated that the rst two phases are primarily affective and social as the infant orients to and learns about the physical appearance of the face and voice . . . and begins to interpret and respond in kind to affective messages that are conveyed. He hypothesized that neural processing during the rst two phases is carried out by right hemisphere mechanisms, which are developmentally more mature than the left at this age. During the third phase, usually occurring between 20 and 30 months of age, analytical and computational functioning begins. Analytical and computational functioning are necessary for the development of phonology, morphology, and syntax. Locke links the appearance of these functions to left hemisphere mechanisms that have become active at this age. Finally, processing during the fourth phase involves the integration of the neural mechanisms in both hemispheres thereby enabling extensive lexical learning (Locke, 1994, p. 609). The child in this study began to vocalize at 31 months of age and to verbalize linguistic (lexical) information at 4 weeks post decannulation (at 35 months of age). Viewed from Lockes account of language development, the childs rapid progress to single word production at 36 months of age suggests that he was integrating processing mechanisms attributed to both right and left hemispheres. However, his vocal behaviors, which Locke attributes to earlier stages of brain maturation, also occurred at an age that corresponded to Lockes phase four. Thus, this case suggests that the early vocal behaviors, which usually precede speech in normal children, are not simply a consequence of their maturational stage. Indeed, occurrence of canonical babbling at age three is more consistent with the view that children use babbling and vocal practice for rening their speech skills. It should be noted that the child was exposed to a language rich environment, both before and after decannulation, which is compatible with his normal receptive skills at decannulation. Post-decannulation, his parents used such daily activities as playtime, dinner, bath time, and bedtime as opportunities to engage the child in verbal communication. The childs verbal communication also may have been aided by having a talkative twin sister, who provided a consistent, same-age communication model. Study of this child afforded an opportunity to examine the late onset of speech and language acquisition in a child who was unable to produce babbling during infancy because of an unfortunate physical impediment. The presence of babbling in this child is consistent with earlier studies of children who did not babble upon decannulation (Bowman et al., 1972; Lenneberg, 1967). Therefore, the fact that some children do and others do not babble post-decannulation suggests that babbling is not a prerequisite for subsequent language development. Whether or not babbling occurs, normal speech and language development has been observed in children who are neurologically intact. Tracheotomized children who possess normal cognitive ability and acquire ageappropriate speech and language post-decannulation such as the child in this study, provide insight on the nature of language development. This case also suggests that early precommunication behaviors may not necessarily reect the stage of brain maturation.

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This child, who produced babbling behaviors during his post-decannulation speech and language development, was at the age that Locke suggests the left hemisphere has taken over linguistic processing. However, this child babbled at an age when his motor, cognitive, and receptive abilities far surpassed those that typically occur concurrently with babbling. This suggests that the phases of linguistic acquisition suggested by Locke are not guided by a childs age or brain maturation but are, instead, a reection of the childs stage of speech and language production.

Appendix A. Continuing education Speech and language development of a young child post-decannulation Questions 1. Tracheostomy is a surgical procedure that: a. opens an airway below the level of the larynx. b. opens an airway above the level of the trachea. c. opens an airway below the level of the trachea. d. opens an airway at the level of the larynx. e. none of these. 2. A cannula enables: a. adequate inspiration of oxygen. b. normal speech production to occur during tracheotomy. c. normal speech production to occur after tracheotomy. d. adequate exchange of oxygen. e. none of these. 3. The presence of age-appropriate vocalizations post-decannulation in children tracheostomized prior to 3 months of age suggests that: a. later developing speech and language cannot be obtained in these children. b. babbling will not occur. c. later developing speech and language depends upon infant vocalizations. d. later developing speech and language does not depend upon infant vocalizations e. none of these. 4. Locke suggested that neural processing during the rst two phases of neural development is carried out by mechanisms in: a. the midbrain. b. the right hemisphere. c. both hemispheres simultaneously. d. the left hemisphere. e. none of these. 5. According to Lockes phases of development, the subjects rapid progress to single word production at 36 months of age was due to: a. the integration of the mechanisms attributed to both right and left hemispheric processing. b. mechanisms attributed to right hemisphere processing.

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c. mechanisms attributed to left hemisphere processing. d. The subjects ability to speak. e. none of these.

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