Keywords
dysphasia - risk factor identification - multimedia exposure
Introduction
Developmental dysphasia (developmental dysphasia) is a specific disorder in neurological development that causes children to have limited communication, either expressive (verbal communication through speaking and speaking) or receptive (comprehension of comprehensive information conveyed by others) or both.[1] In contrast to the term general dysphasia, developmental dysphasia includes neurological aspects and developments that occur at the age of the learning phase and talking to children.[2] The term dysphasia is also different from aphasia, in which sufferers of aphasia experience more severe speaking and language disorders.[1] The general characteristics of people with developmental dysphasia are better receptive speech ability than expressive speech ability; the patient’s ability to carry out spontaneous monologue talks is better than the commend dialogue talks; not fluent in story-telling; and limitations in syntactic abilities in language.
Developmental dysphasia is included in language disorder. This disease will cause delay in a child's ability to learn to communicate and speak (speech delay). Language disorders can also cause a person to suffer from speech disorder in the long term.[3] There have been many studies related to cases of disruption in communication with children from other countries. In a study conducted in Australia, 13% of elementary school-aged children were diagnosed with speech disorders. In this study, it was also concluded that the prevalence of speech disorders was higher than behavioral, mental, and hearing disorders.[4] Data in the last 25 years in Amsterdam indicate that developmental dysphasia can occur in children aged 8 months to 12 years.[1]
Until now, research on the prevalence of developmental dysphasia in Indonesia has never been conducted. In theory, genetic factors and environmental factors play a role in causing developmental dysphasia. In some cases, dysphasia is caused by a mutation in the GRN gene that is derived from the dominant autosomal chromosome. This gene mutation is also associated with behavior disorders.[5] In some cases, dysphasia is caused by a mutation in the GRN gene that is derived from the dominant autosomal chromosome. This gene mutation is also associated with behavior disorders.5 Other cases of dysphasia are associated with epilepsy which starts at an early age and that involve GRIN2A gene mutations.[6] Gender also influences the prevalence of speaking and speaking disorders. The male sex has a higher risk of 2:1 in studies that use a uniform distribution of population between male and female sexes.[7] Besides genetic and sex factors, environmental factors such as exposure of children to technology (TV, gadgets) can also cause communication delays and disintegrate concentration of children that can lead to developmental dysphasia.
Cases of developmental dysphasia will have an impact on communication disorders as adults, for example, stuttering, where it is caused by trauma, stroke, or injury to the brain. Apart from being caused by those reasons, stuttering can also be caused by conditions of limited communication skills that occur during the development of children. Stuttering is included in terms of speech disorders where the ability to speak is not fluent accompanied by an excessive repetition of sounds, words, and phrases, and a break when speaking.[8] In a study conducted from 2008 to 2011, at least 3 million Americans experience stuttering, with the most frequency found in young children aged 2 to 6 years.[9]
In theory, many factors play a role in causing developmental dysphasia in children. However, until now, there have been no studies that explain the factors that influence the developmental dysphasia in children. The impact of this disease in the long term has a significant influence on the academic ability and communication in children. Therefore, identification and analysis of factors that influence this disease are very important so that in the future preventive measures could be taken.
Methods
This study used an analytical survey method with a cross-sectional approach carried out in Dewi Sri Karawang Hospital and in the Karawang community. The research subjects were parents of pediatric patients diagnosed with dysphasia and parents of nondysphasia children in the Karawang region who had met the inclusion and exclusion criteria. This study comprised two groups: control group and case group. The control group consisted of 22 children, whereas the case group consisted of 30 children.
In the case group, inclusion criterion was children aged 12 to 72 months who experienced delays in speaking according to the criteria for delayed talking by Allen and Rappin: (1) children at the age of 10 months who cannot babble, (2) children at the age of 18 months who cannot speak words other than daddy/mama and cannot point out what he/she desired, (3) children at the age of 24 months who have not been able to compose sentences consisting of two words/speech cannot be understood/the child does not understand other people, and/or children examined by the Early Language Milestone Scale Score scale (ELMS-2) experiencing slow talk, (4) children with delayed speech without functional organ disorders (including congenital abnormalities), (5) having data in the form of medical records or health cards, and (6) parents consenting that their children become research samples.
Children also underwent screening stimulation of growth in toddlers and preschoolers based on guidelines from the Ministry of Health, Directorate General of Community Health Development, Republic of Indonesia. These guidelines are intended to inform the patient about their cognitive status level, but it is not used for the diagnostic purpose. The cognitive status data are required for understanding whether there is a connection between the cognitive status and developmental dysphasia occurrence in the patient. However, the hospital did not make it an obligation for children to undergo an intelligence quotient (IQ) test. Instead, the hospital did screen each of the patients as per the guidelines from the ministry to get information about their cognitive status. The screening stimulation process involved several criteria, namely coarse motion ability, smooth motion ability, speaking and language skills, and socialization and independence capabilities. These criteria are distinguished by age: 0 to 3 months, 3 to 6months, 6 to 9 months, 9 to 12 months, 12 to 15 months, 15 to 18 months, 18 to 24 months, 24 to 36 months, 36 to 48 months, 48 to 60 months, and 60 to 72 months. The presence or absence of cognitive problems in patients is detected by determining the age-level ability of the patient; if the level of ability is in accordance with his age, then the patient has normal cognitive status.[10] In our case, all of the patients had normal cognitive status.
The exclusion criteria included children with delays in speaking and who had a neurological examination/hard sign and dysmorphology, children with delayed speaking and suffering from hearing loss. In the control group, inclusion criteria were nondevelopmental dysphasia children aged 12 to 72 months and residence of Karawang.
Data collection was conducted by questioning the parent of both groups to identify risk factors for child development dysphasia, such as family history, gender, febrile seizures, exposure to TV/gadget, and mother's employment status. The obtained data were analyzed using multivariate statistical regression: enter-method with a 95% confidence level to see the correlation between risk factors and child development dysphasia.
Result
This study involved 30 children with developmental dysphasia in Dewi Sri Hospital; negative controls accounted for 22 children. The research subjects consisted of 28 (54%) males and 24 (46%) females. The average age of the study subjects was 45.57 months ± 16.75 months (range: 1–6 years). The study was conducted by interviewing and filling out questionnaires aimed at the parents of patients to determine the condition of children with dysphasia. The results of the study show that there are several risk factors that have a significant effect on childhood developmental dysphasia, such as multimedia exposure, heat convulsions, and genetics.
-
Multimedia exposure (TV, gadgets, mobile phones) is one of the environmental factors that influence children's developmental dysphasia. We ask the respondent about how long their children were exposed to the multimedia. We classified the exposure into two types: (1) children with multimedia exposure of less than 1 hour and (2) children with multimedia exposure of more than 1 hour. In this study, criteria for less than 1 hour per day were used for low exposure and for more than 1 hour per day were used for high exposure following the recommendations of the American Academy of Pediatrics (AAP), in which for children aged 2 to 5 years, the maximum limit of exposure to multimedia is 1 hour. From the results of this study, most children in the case group were exposed to more than 1-hour multimedia exposure (24 children), whereas in the control group, 11 children were exposed to less than 1 hour to multimedia. The results of multivariate analysis also showed that multimedia exposure influenced the incidence of developmental dysphasia (p = 0.010).
-
Febrile seizures: these occurred in 50% of the case group and 13.63% in the control group and influenced the occurrence of dysphasia in children (p = 0.042).
-
Genetic factors: these can significantly influence the incidence of child development dysphasia, with a p-value of 0.008.
Some risk factors that do not affect child development dysphasia are as follows:
-
The employment status of mothers: in the case group, 53.3% (16 people) mothers did not work and 46.7% (14 people) mother worked. In the control group, mothers who did not work were lesser in number than those who worked ([Table 1]). The results of multivariate analysis also showed that maternal working status did not affect the incidence of developmental dysphasia (p = 0.549).
-
Based on gender, the case group showed that male sex suffered more from developmental dysphasia than women, but the results of multivariate analysis showed that gender variables did not have a significant effect (p= 0.745) on the incidence of dysphasia development in a child ([Table 2]).
Table 1
Respondent characteristics
|
Demographics
|
Case group (30)
|
Control group (22)
|
|
N
|
%
|
N
|
%
|
|
Age (years)
|
|
|
|
|
|
1–3
|
12
|
40.00
|
3
|
13.64
|
|
4–5
|
9
|
30.00
|
16
|
72.73
|
|
≥ 6
|
9
|
30.00
|
3
|
13.64
|
|
Gender
|
|
0.00
|
|
0.00
|
|
Men
|
20
|
66.67
|
14
|
63.64
|
|
Women
|
10
|
33.33
|
8
|
36.36
|
|
Febrile seizure
|
|
0.00
|
|
0.00
|
|
Yes
|
15
|
50.00
|
3
|
13.64
|
|
No
|
15
|
50.00
|
19
|
86.36
|
|
Multimedia exposure
|
|
0.00
|
|
0.00
|
|
High (>1 h a day)
|
24
|
80.00
|
7
|
31.82
|
|
Low (< 1 h a day)
|
6
|
20.00
|
11
|
50.00
|
|
Genetic family history
|
|
0.00
|
|
0.00
|
|
Yes
|
14
|
46.67
|
1
|
4.55
|
|
No
|
16
|
53.33
|
21
|
95.45
|
|
Mother's level of education
|
|
0.00
|
|
0.00
|
|
Elementary school
|
1
|
3.33
|
2
|
9.09
|
|
Junior high school
|
1
|
3.33
|
4
|
18.18
|
|
High school
|
20
|
66.67
|
9
|
40.91
|
|
College
|
8
|
26.67
|
7
|
31.82
|
|
Income
|
|
0.00
|
|
0.00
|
|
> 3 million IDR
|
23
|
76.67
|
5
|
22.73
|
|
< 3 million IDR
|
7
|
23.33
|
17
|
77.27
|
|
Mother's employment status
|
|
0.00
|
|
0.00
|
|
Yes
|
14
|
46.67
|
12
|
54.55
|
|
No
|
16
|
53.33
|
10
|
45.45
|
Table 2
SPSS result
|
Variable
|
p-Value
|
|
Febrile seizure
|
0.042[a]
|
|
Multimedia
|
0.010[a]
|
|
Genetic family history
|
0.008[a]
|
|
Mother's employment status
|
0.549
|
|
Gender
|
0.745
|
a Significant (p< 0.05).
Discussion
Children must be exposed to language at the earliest possible age so that they can master the language. Preschool age is the recommended age.[4] Language disorders that occur in preschool children will have an impact on the ability to write and understand academic subjects.[7] Speech and language disorders that are not properly treated will have an impact on communication skills and verbal, behavioral, psychosocial, and academic adaptation.[11] Based on the results of this study, the risk factors that influence the occurrence of child dysphasia are multimedia exposure, febrile seizure, and genetic heredity.
Multimedia Exposure
The result shows that multimedia can affect the incidence of developmental dysphasia. This result is consistent with that in the research by Nurmalasari, in which a higher intensity of gadget exposure influences the delay in children's speech.[12] Multimedia exposure (TV, gadgets, mobile phones) is one of the environmental factors that influence children developmental dysphasia. Research conducted by Chonchaiya and Pruksananonda, Duch et al, and Lin et al showed that there is a relationship between excessive multimedia exposure (screen) in children under 6 years of age and delayed speech.[13]
[14]
[15] In addition, Lin et al's research shows that television exposure correlates with higher speech development delay in children aged 15 to 35 months. Duch et al showed that infants and toddlers who watch television excessively as much as 2 hours per day or more have a 5.5 times greater risk of getting a small score on communication section of the Ages and Stages Questionnaire (ASQ-3).[14] The same results are shown by research conducted by Chonchaiya and Pruksananonda who pointed out that children who watch television for more than 2 hours per day have six times greater risk of experiencing delays in speaking.[13]
Febrile Seizure
Febrile seizures occur in children who experience learning difficulties[16] but have not been studied for their effects on developmental dysphasia. This is different from the research conducted by Hidajati in which the seizure factor did not significantly influence the incidence of dysphasia in children. Based on the data collected from 30 children with developmental dysphasia, 50% experienced seizures and 50% did not experience it. While in control case only 13.6% of children experienced a febrile seizure.
Genetic Family History
Hidajati’s research[17] showed that “genetic factors were a significant factor of childhood dysphasia.” This research also found that genetic factors have significant influence on the incidence of child developmental dysphasia (p = 0.008). Research conducted by Tallal et al showed that most cases of specific language impairment have a history of language impairments (LI) in their families. The study also showed a significant correlation between family members who had LI and the family descendants who had LI. When more family members have LI, then the proportion of descendants who will have LI also increases.[18] Another study conducted by Loo and Young also shows that genetic factors influence the incidence of speech disorders.[19] The study conducted a genetic examination of 9-year-old boys who had speech disorders and learning difficulties. The results of the study were the discovery of DNA duplication on chromosome 7. The chromosome 7 region of 7q22.1 to 7q31 in various studies was associated with a delayed speech in autism as well as in various other diseases related to the speech component (language). Furthermore, research conducted by Cukier shows abnormal chromosomes that strengthen the involvement of 7q22-31 chromosome.[20] Consistent with previous studies, this study also shows an association between heredity (genetic) and the development of developmental dysphasia in children. This might be based on the presence of abnormal chromosome 7 regions 7q22-31. Further research is required to find out whether developmental dysphasia in children in Karawang is also related to chromosome 7 or not.
Mother's Employment Status
Mother's Employment Status
The low intensity of mother–child interaction can also affect the linguistic abilities of children[21]; therefore, it is assumed that the status of the mother's employment plays an indirect role in the development of children's speech skills. The working status of the mother is related to the amount of time parents spend talking to their children. A working mother will have less time to talk with children. The amount of time parents speak to their children is related to the development of children's vocabulary and language. Kuhl et al's research on learning perceptions of speech shows that interactions between humans greatly influence the development of a child's language. Kuhl also revealed that the best learning for babies is through direct interaction and not from television. The advantages of screen time can affect the development of children's speech because parents spend less time interacting with their children.[23] However, in this study, the result shows that the mother employment status did not become a significant factor in the occurrence of children developmental dysphasia in Karawang.
Gender
In this study, gender is not related to the incidence of children developmental dysphasia. Gender has become a unique factor to be investigated in the event of delays in speaking. Many studies show that there are more men who experience delays in speaking compared to women. But, after reviewing it, the sex differences reported in several studies are the result of a bias, which is more likely to study men in clinical research.[22]
Conclusion
Febrile seizures, excessive multimedia exposure (> 1 hour per day), and identified hereditary factors are significant risk factors for children developmental dysphasia in Karawang, with an age range from 1 to 6 years (p = 0.042, 0.10, and 0.08). Meanwhile, gender and mother's employment status did not affect the occurrence of child dysphasia (p = 0.549 and 0.745).
