¹ ENT Department, Ekiti State University Teaching Hospital, Ado Ekiti, Nigeria;

² ENT Department, Federal Teaching Hospital Ido-Ekiti/Afe-Babalola University Ado-Ekiti (ABUAD), Nigeria;

³ ENT Department, Lagos state Teaching Hospital, Ikeja, Nigeria;

⁴ ENT Department, Federal Teaching Hospital, Gombe, Nigeria;

⁵ Department of community Health, Federal Teaching Hospital Ido-Ekiti, Nigeria

Corresponding Author: Dr. Olajide Toye Gabriel, Department of Ear, Nose & Throat, Federal Teaching Hospital, Ido Ekiti, Ekiti State, Nigeria /Afe-Babalola University Ado-Ekiti (ABUAD), Nigeria. Tel: +238034656993; E-mail: toyeolajide@yahoo.co.uk.

Running title: Adegbiji et al: Communication disorders among children in a developing country, Nigeria

	ABSTRACT
	BACKGROUND
	METHODS
	RESULTS
	DISCUSSION
	FUNDING
	CONFLICTS OF INTEREST
	REFERENCES

	ABSTRACT

Background: Communication disorders in children are an invisible disability posing challenges to otorhinolaryngologist in developing countries. The aim of this study was to determine the prevalence, sociodemographic features, aetiology, types of communication disorders among under 18 years children attending our facility.
Methods: This was a prospective study conducted in ear, nose and throat department in a Nigerian university teaching hospital, from June 2014 to May 2019. Data were obtained by using pretested interviewers assisted questionnaires from consented patients and analyzed using SPSS version 20.0.
Results: Prevalence of communication disorder was 16.1%. Male was 68.2% with male to female ratio of 2.1:1. Communication disorder is commoner in first child 58.1% and detected by mother in 70.5% cases. Major cause was due to infection in 68.2%. Large percentage of communication disorder were language disorder in 60.8% and speech disorders which constitute 39.2% with associated varying degrees of hearing impairment in 78.8% of them. Sensorineural hearing impairment was noted in 69.6% cases. Language disorders were delayed speech & language, mutism and specific language impairment in 22.6%, 16.6% and 14.7% respectively. Major speech disorder was articulation problem in 15.7%. Main sources of referral were 52.5% from paediatrician while 30.9% was from general practitioners.
Conclusions: There was high prevalence of communication disorder which was associated with high prevalence of hearing impairment. The major causes were infection with inadequate obstetrics management.

	BACKGROUND

   Communication is defined as the process used to exchange information with others which includes the ability to receive, comprehend, produce and express messages (1). It involves interchange of thoughts, opinions, or information by speech, writing, or signs from a sender to a receiver via some media towards a mutually accepted goal or direction (2). Communication also occurs through a variety of modalities, including nonlinguistic, verbal, and paralinguistic processes (1).

   Language is a communication involving syllables or words that can be combined to yield phrases and sentences expressed commonly as oral and aural (speech and hearing) or as manual and visual (reading and writing) (1).

   Speech is a verbal language communication that involves oral production and articulation of words from specific motor behaviors which requires precise neuromuscular coordination of respiration, phonation, and resonance with articulation systems into sounds, as well as voice quality, intonation, and rate (1).

   Communication disorder (hearing, swallowing, speech and language) is a form of disorder that affects somebody’s ability to communicate which ranges from simple sound substitution to inability to understand (3).

   Communication disorder is one of the most prevalent symptoms in young children with developmental delays (4). It is usually identified around 2–3 years of age (5). In high socio economic countries, the prevalence of both speech–language disorders range from 0.5% to 7% (decrease with age) and hearing loss range from 0.05% to 0.23% (lower than that found in low socio economic countries) (6-8). Meisels and Fenichel reported that communication disorders occur in 8% of all young children (9).

   Communication disorder, impact a child’s social and emotional skills, cognitive skills and the acquisition and mastery of academic skills in school (10).

   The disorders may be congenital, developmental or acquired in children. They may also arouse from hearing impairment, brain damage, organic and non-organic causes (11).

   The literature and the statistical information on the magnitude of communication disorders among Nigeria children and other developing countries are scarce (12). This study was aimed to determine the prevalence, sociodemographic features, aetiology, types of communication disorders seen among under 18 – year old children attending our facility.

	METHODS

   This was a prospective research design. The study was conducted in ear, nose and throat department in a Nigerian university teaching hospital, over a period of 5 years (June 2014 to May 2019).

   All children with diagnosis of communication disorder were enrolled into the study. Informed consent was obtained and pretested interviewers assisted questionnaires were administered.

   Apart from the demographic characteristics of the parents, detailed pre natal, natal and post natal history was taken. History of low birth weight, neonatal jaundice, birth asphyxia, preterm delivery, febrile illness was obtained (6). Relevant history as relates to congenital malformation of the head and neck, toxic infective processes, convulsions, developmental milestones, recurrent catarrh, noise exposure and past hospital admission was obtained.

   General, systemic, ear, nose and throat examination were carried out including mandatory oto microscopy was carried out on all patients with findings also documented.

   Audiological and other relevant tests were carried out to arrive at definitive diagnosis. Some of the tests administered were tympanometry, otoaucostic emission, free field audiometry, pure tone audiometry and brainstem audiometry where indicated.

   Individuals with speech and language complaints were evaluated to arrive at a definitive diagnosis. Parents of children with hearing impairment, voice, fluency, articulation and language disorders were counseled regarding the nature of the disorder, causes and treatment (6).

   The data collected were collated and analyzed using SPSS version 20.0 software. Descriptive statistics was done by frequency table, percentage, bar chart and pie chart to express the data.

   Ethical clearance for this research was sought for and obtained from the ethical committee of our center.

	RESULTS

   A total of 1,352 children under 18 years were seen out of which 217 (16.1%) had communication disorder. All the studied age group were affected with peak prevalence of 121 (55.8%) at (0-5) years (Figure 1).

   There were 148 (68.2%) males and 69 (31.8%) females given a male to female ratio of 2.1:1. There were 196 (90.3%) Christian while 21 (9.7%) practices Islam. Majority 132 (60.8%) are urban dwellers as compare to 85 (39.2%) who are rural dwellers. Educational levels of the parents were 96 (44.2%) secondary followed by 60 (27.6%) primary and 38 (17.5%) post-secondary. The parents occupation were civil servant and housewife in 111 (51.2%) and 52 (24.0%) respectively. Twenty eight (12.9%) parents smoke cigarettes while 127 (58.5%) indulge in alcohol consumption. Communication disorder is commoner in first child than other children in 126 (58.1%) and 91 41.9%) respectively. Mother in 153 (70.5%) detected communication disorder than father in 64 (29.5%) as illustrated in Table 1.

   Infections are responsible for major causes of communication disorders in 148 (68.2%) of patients. Major causes of communication disorder in this study were febrile illness/convulsion 44 (20.3%), otitis media 34 (15.7%), ototoxicity 21 (9.7%), measles 19 (8.8%), cerebral palsy 16 (7.3%) and adenotonsillar diseases 16 (7.3%). Other causes were meningitis, neonatal jaundice, low birth weight, birth asphyxia and trauma in 14 (6.5%) 13 (6.0%) 12 (5.5%) 10 (4.6%) and 9 (4.1%) respectively showed in Table 2.

   In this study, commonest types of communication disorder was language disorder in 132 (60.8%) of the patients others were 85 (39.2%) speech disorder and 11 (5.1%) swallowing disorder. One (0.5%) of the patient had visual disorder. Communication was associated with varying degrees of hearing impairment in 171 (78.8%) as in Figure 2.

   Sensorineural hearing impairment in 151 (69.6%) was the commonest types of hearing impairment followed by 56 (25.8%) conductive hearing impairment and 10 (4.6%) mixed hearing impairment. The encountered degrees of hearing impairment in this study included mild moderate, moderate-severe, severe and profound in 64 (29.5%), 31 (14.3%), 19 (8.8%), 23 (10.6%) and 31 (14.3%) respectively.

   Main type of language disorder were delayed speech and language, mutism and specific language impairment in 49 (22.6%), 36 (16.6%) and 32 (14.7%) respectively. Others were 9 (4.1%) mental motor retardation and 6 (2.8%) aphasia showed in Table 3.

   Patterns of speech disorder among the patients were 34 (15.7%) articulation disorder, 21 (9.7%) voice disorder, 13 (6.0%) hypernasality, 12 (5.5%) hyponasality and 5 (2.3%) fluency disorder as demonstrated in Figure 3. Sources of patients referral were 114 (52.5%) from paediatrician, 67 (30.9%) from general practitioners, 22 (10.1%) Obstetrician/gynaecologist and 14 (6.5%) self-reporting.

   Commonest disability among the patients with communication disorder was 81 (37.3%) behavioural disability. Other disabilities were social well-being, cognition, poor academic achievement and limit vocational choices in 72 (33.2%), 54 (24.9%), 49 (22.6%) and 43 (19.8%) respectively.

View larger version : [in a new window] Figure 1. Age group distribution among patients.

 

View larger version : [in a new window] Figure 2. Distribution of communication disorder among patients.

 

View larger version : [in a new window] Figure 3. Types of speech disorder among patients.

	DISCUSSION

   Communication disorder is one of the most common childhood disabilities worldwide with limited relevant researches in low-income countries, such as Nigeria (13). The prevalence of communication disorder in this study was 16.1% this falls within the ranges of prevalence (10.0%-25.5%) from other African countries (14). This agrees with high prevalence of communication disorders in developing countries and Africa (15).

   All the studied age group had different form of communication disorder. Commonest age of presentation for assessment was around preschool age group 3 and 4 years. Some were in nursery school with poor communication. There is poor social interaction with peers and teachers. The delayed in presentation was due to inexperience and watch to catch up with time by the parents (10, 11). Few other cases are delayed in seeking specialist intervention until when the child reaches 6 years of age or more. This may have adverse effects on learning, behavior, social skills (16).

   On the sociodemographic features, majority of the parents bring their children for communication assessment and it was noted that male gender were more affected. This could be due to hormonal issues and slower neurological maturity in males (17). Poor social, vocal stimulation and interaction with other siblings is very poor in first child with poor parental obstetrics skills and child rearing contribute high prevalence of communication disorder among first child. Communication disorder is dominant among patients living in urban setting than rural setting (18, 19). Health care facilities with screening program are easily accessible among urban dwellers. Educated parents are well informed with good jobs and financially capable of caring for their wards. High prevalence of communication disorder is common in children of educated and civil servant with early presentation. Mothers detect communication disorder in children more than father. Father are engaged by various activities in searching and caring for family needs while mothers have more close contact with the children.

   Hearing impairment and communication disorder was secondary to different aetiology. The commonest causes is infective or complications from its treatment. Major predisposing factors are unregulated access to ototoxic drugs, unlawful traditional/ native medical practices, high prevalence of local concussion hawkers, poor access to health care facilities due to inadequate professionals, high practice of tradition birth attendance, lack of awareness about the preventive measures and poor hygiene activities in low income countries like ours [6, 20, 21]. Common infection includes neonatal febrile illness/convulsion disorders, otitis media and measles. Other infections may be from viral, bacterial and parasitic lesion. These are usually wrongly treated as malaria with local concussion leading to neurological damage and hearing impairment. Poor obstetrics management leading to preterm delivery, low birth weight, birth asphyxia, cerebral palsy and neonatal jaundice are major causes of neurological damage and communication disorder. Poor medical history is a major reason for unknown aetiology in this study.

   Communication disorder is associated with hearing impairment and swallowing disorder in our findings. These may be a co-morbid problem. Prevalence of hearing impairment was higher among patients with language disorder and speech disorder this may be due to study of paediatric groups (22, 23). Visual disorder was noticed in one of the patient whose both parents were blind (24). She was brought to the clinic on failure to verbal communicate at age 5 years. Main communication disorders in our findings were speech disorder and language disorder.

   Bad obstetrics history, poor management of infection are major causes of sensorineural hearing impairment with great effects on both language and speech devepoment in this study less possibility of noise exposure (25, 26). Upper airway infection with otitis media was responsible for conductive hearing impairment which affects speech acquisition (27). Patients with severe and profound degrees of hearing impairment in this study mainly had language disorders. Patients with mild and moderate degrees of hearing impairment had mainly speech disorder.

   Neurological damage of sense organ, neural and motor components in different degrees affect language acquiring and other developmental milestone as in this research. There was a higher prevalence in younger male children as documented in other study (28). Delayed speech and language were mainly due to mild, moderate and moderate severe hearing impairment. Deaf mutism and mental motor retardation are secondary to severe neurological disorder. Aphasia in this study was from head trauma.

   Fluency disorder (stuttering or stammering) affect mainly male also uncommon speech disorder in this study (29). Commonest speech disorder is articulation disorder usually among first child with normal hearing. Voice disorder is common among children with voice abuse from singing, shouting, excessive noise and upper respiratory infection. In our findings hypernasality and hyponasality disorders were due to pharyngeal and sinonasal diseases respectively from adenoid, tonsils and sinonasal diseases.

   There are various sources of patients with communication disorder for otorhinolaryngology, head and neck consultation in this study. Our major source was from paediatricians which are first contact by parents whose children with any medical disorder followed by family/general practitioners as a result of their closeness to the family. From parents (mothers) contacts and discussion which usually involves health issues usually leading to few cases of self-reporting in this research.

   Communication disorder with associated hearing impairment greatly affected children behaviour, emotional, socialization and education in this research. Because communication skills remain pivot to social, emotional and psychological development in children even minor impairments can have great negative effect on patients (30). These problems if not identified, assessed and treated early may lead to frustrations that can lead to destruction to themselves and others members of the community. The limitation of the study is that it is hospital-based and the data cannot represent the entire population.

   Communication disorders have high prevalence in this study with associated high prevalence of hearing impairment. The major causes were both infection and inadequate obstetrics management. Early detection by screening of risk children and prompt treatment intervention to prevent avoidable disability in future is recommended.

	FUNDING

   There was no financial support. It is a self-sponsored research study.

	CONFLICTS OF INTEREST

   The authors declare that no conflicting interests exist.

	REFERENCES

1. New York State. The Official Website of New York State. Available at: https://www.health.ny.gov/community/infants_children/early_intervention/disorders/ch2_bkgr.htm.
2. National Institute of Deafness and Other Communication Disorder. What are Voice, Speech and Language? Bethesda, MD USA; 2009.
3. Developmental and Communication Disorders in Children with Intellectual Disability: The Place Early Intervention for Effective Inclusion Udeme Samuel Jacob1 Angela Nneka Olisaemeka1 Isioma Sitamalife Edozie. Journal of Education and Practice. 2015; 6: 36.
4. American Speech-Language-Hearing Association. Preferred practice patterns for the profession of speech-language pathology. 2006.
5. Wetherby A, Prizant B. Toward earlier identification of communication and language problems of infants and young children. J Speech Lang Hear Res. 1996:110-113.
6. Konadath S, Chatni S, Lakshmi MS, Saini JK. Prevalence of communication disorders in a group of islands in India. Clinical epidemiology and global health. 2017; 5: 79–86.
7. Dockrell J, Ricketts J, Lindsay G. Understanding Speech, Language and Communication Needs: Profiles of Need and Provision (2012). 2012.
8. Stevens G, Flaxman S, Brunskill E, Mascarenhas M, et al. Global and regional hearing impairment prevalence: an analysis of 42 studies in 29 countries. Eur. J. Public Health. 2013; 23 (1): 146–152.
9. Meisels J, Fenichel E. New visions for the developmental assessment of infants and young children Washington, DC: Zero to Three. Washington: National Center for Infants, Toddlers, & Families. 2004; p289–312.
10. Garg S, Chadha S, Malhotra S, Agarwal A. Deafness: Burden, Prevention and Control in India. 2009.
11. Paul S. The diagnostic approach to symptoms and signs in pediatrics: principal causes of verbal communication difficulty. Lippincott Williams & Wilkins. 2006.
12. Aboul-Oyoun A. Epidemiological study of communicative disorders in Upper Egypt. Unpublished doctoral dissertation, Faculty of Medicine. Ain Shams university, Cairo, Egypt; 2000.
13. Nwanze H. Father say it differently; A case report using father–child interaction for language stimulation. Journal of Emerging Trends in Educational Research and Policy Studies. 2013; 4 (1): 8-12.
14. Jochmann A. Speech and language treatment in East Africa. The ASHA Leader. 2006; 11 (2): 8-9.
15. United Nations. Mainstreaming disability in the development agenda (E/CN.5/2008/6). Retrieved from http://www.un.org/disabilities/documents/reports/e-c. 2008.
16. Rossetti LM. Communication intervention: birth to three (3rd ed.), Singular, Thomson Learning, Canada. 2001.
17. Martin B. Speech and communication. Philadelphia: The Normal Child, Elsevier co. 2006; p83–102.
18. Sallam YA. Prevalence of subtypes of specific language impairment. Unpublished doctoral dissertation, Faculty of Medicine. Ain Shams university, Cairo, Egypt. 2011.
19. Smith B. ADHD among preschooler: Identifying and treating attention deficit hyperactivity disorders in very young children requires a different approach. Am Psychol Assoc. Monitor Psychol. 2011; 42 (7): 50.
20. Bhat R, Babu SK. Health insurance and third party administrators: issues and challenges. Econ Polit Weekly. 2004; p3149–3159.
21. Dev SM, Mooij J. Social sector expenditures in the 1990s: analysis of central and state budgets. Econ Polit Weekly. 2002; p853–866.
22. Konadath S, Suma C, Jayaram G, Sandeep M, et al. Prevalence of communication disorders in a rural population of India. J. Hear Sci. 2013; p41–49.
23. Sinha SK, Shivaswamy J, Barman A, Seth D, et al. Prevalence of communication disorders in a rural population at taluq level of Gujarat, India. Clinical epidemiology and global health. 2017; 5: 73–78.
24. Mosca R, Kritzinger A, van der Linde J. Language and communication development in preschool children with visual impairment: A systematic review. S. Afr. J. Commun Disord. 2015; 62 (1): 119.
25. Lin FR, Niparko JK, Ferrucci L. Hearing loss prevalence in the United States. Arch Intern Med. 2011; 171 (20): 1851–1853.
26. Zytoon MA. Occupational noise exposure of fishermen aboard small and medium-scale fishing vessels. Int. J. Ind. Ergonom. 2013; 43 (6): 487–494.
27. Béria JU, Raymann BCW, Gigante LP, et al. Hearing impairment and socioeconomic factors: a population-based survey of an urban locality in southern Brazil. Rev. Panamer Salud Públ. 2007; 21 (6): 381–387.
28. Binu A, Sunil R, Baburaj S, Mohandas M. Sociodemographic profile of speech and language delay up to six years of age in Indian children. Int J Med Res Health Sci. 2014; 3 (1): 98–103.
29. Dockrell J, Ricketts J, Lindsay G. Understanding Speech, Language and Communication Needs: Profiles of Need and Provision. 2012.
30. Heba Gad-Allah, Samar Abd-Elraouf, Tamer Abou-Elsaad, Mahassen Abd-Elwahed. Identification of communication disorders among Egyptian Arabic-speaking nursery schools’ children. Egyptian Journal of Ear, Nose, Throat and Allied Sciences. 2012; 13: 83-90.

The exquisite patterns on the luxury replica watches dial, the date display window at replica watches six o'clock, and the black sculpted Arabic numerals demonstrate the replica rolex exquisite craftsmanship of rolex watches uk the fine watchmaking style.