I’m often asked by concerned parents if they should stick to one language or if they can speak a multi-languages with their children. They’re concerned if the second language will cause their child to have a language delay. I’d like to note that the content of this post is a combination of my own personal opinions through my years of experience as a speech and language pathologist as well as the research I’ve done. With that in mind, every child is very different and will respond differently although there are some universal “rules” just as are allergies and allergens!

According to Sara Johnson (the author of Oral-Motor Exercises for Speech Clarity, Assessment and Treatment of the Jaw- Putting it all Together: Sensory, Feeding and Speech, the Drooling Program, Activities for Kids, Assessment and Treatment of the Jaw and other educational materials) every child is born with the ability to produce EVERY sound in every language by the age of 3 years old. Their system is equipped to learn and produce all sounds regardless of the language, therefore, in my opinion and experience it only makes sense that children will not be “confused” by multi-languages they hear and are spoken to. At times it may be difficult as a parent to know who to “trust” as many in the medical establishment are still teaching that bilingualism may cause a language delay. However,  children aren’t exactly having to “learn” twice as many words, and they don’t have to think about which language bucket to put each word into. Rather bilingual children are picking up each language as “packages of sounds” they are hearing around themselves. For those more fortunate who have a housekeeper (who often speaks a different language than the child’s “mother’s tongue”), you’ll notice how easily your child/children “code switch” between the different languages. Drawing from a personal experience, my cousin needed to let their housekeeper know where an item was in the house, he called his grandmother and spoke in English and easily translated everything to the housekeeper in Spanish. He was 2.5 years old at the time! This observation is further supported by Kendall King and Lyn Fogle from Georgetown University in their note: ”…research indicates that the ability to switch back and forth between languages, sometimes called code-switching, is  a sign of mastery of two linguistic systems, not a sign of language  confusion, and that children as young as 2 are able to code-switch in socially appropriate ways (Lanza, 1992).” From my experience it’s best to assign a language to each adult and not to interchange the languages. For instance, dad may only speak English to the children, mom only French, housekeeper only Spanish. Children can easily navigate through each language especially with consistency.

According to the Science of Learning Blog: “babies growing up in a bilingual environment are better able to attend to perceptual cues such as a change in voice tone or facial expression, in both languages and can apply this ability to distinguish things in the world as well.” In the case of children who are language delayed, you can still apply the same rule. Keep in mind that they are delayed, and therefore will be delayed in all languages and will learn all of them at the same paste should you keep everything CONSISTENT. According to Center for Applied Linguistics, 2006, “Although many parents believe that bilingualism results in language delay, research suggests that monolingual and bilingual children meet major language developmental milestones at similar times.”

What is Childhood apraxia of speech (CAS)?

CAS is a motor speech disorder presenting itself as difficulty saying sounds, syllables, and words; not due to muscle weakness or paralysis. Apraxia comes from the root word “praxis” which means planed movement. It’s the brain’s problem in planning to move the body parts (lips, jaw, tongue) needed for speech. CAS is sometimes called verbal apraxia, developmental apraxia of speech, or verbal dyspraxia. CAS doesn’t effect their cognition as the child knows exactly what the child wants to say, but his/her brain has difficulty coordinating the muscle movements necessary to say those words. Children with CAS may present with delayed language development, other expressive language problems, difficulties with fine motor movement, hupersensitive/hyposensititve in their mouths,

General signs to look for in a very young child:

1. Does not coo or babble as an infant
2. First words are late, and they may be missing sounds
3. Only a few different consonant and vowel sounds
4. Problems combining sounds; may show long pauses between sounds
5. Simplifies words by replacing difficult sounds with easier ones or by deleting difficult sounds (although all children do this, the child with apraxia of speech does so more often)
6. May have problems eating

General signs to look for in a very young child:

1. Makes inconsistent sound errors that are not the result of immaturity
2. Can understand language much better than he or she can talk
3. Has difficulty imitating speech, but imitated speech is more clear than spontaneous speech
4. May appear to be groping when attempting to produce sounds or to coordinate the lips, tongue, and the jaw for purposeful movement
5. Has more difficulty saying longer words or phrases clearly than shorter ones
6. Appears to have more difficulty when he or she is anxious
7. Is hard to understand, especially for an unfamiliar listener
8. Sounds choppy, monotonous, or stresses the wrong syllable or word

Treatment options for CAS

Research has shown frequent therapy (3-5 times per week) is more effective for children with CAS. Treatment targets improving the planning, sequencing, and coordination of muscle movements for speech production. It’s crucial that the child gets feedback from a number of senses such as tactile, visual, and auditory that will help him/her readily repeat syllables, words, sentences, and longer utterances to improve muscle coordination and sequencing for speech. For children with cognitive capacity to understand picture stimuli, it’s very helpful to develop their core vocabulary with the use of pictures and books. Some of the specialized treatment methods are PROMPT, Oral-motor work, Kauffman’s apraxia of speech amongst other methods.

Some helpful links:

Apraxia-Kids

ASHA

Donna Lederman

NIDCD

Web-Med

Speech refers to the spoken form of language; it’s the sounds that make up language.  It is the verbal expression of language that includes articulation (pronunciation).  Speech sounds are made of phonemes (the smallest units of sound that have meaning).  A phoneme is a mental representation of a sound that has predictable variants that are called allophone.

What is language?

Language refers to the entire system of expressing and receiving information in the code/rules that make up a specific language via speaking, reading, writing, and/or gesturing.

A child may present with delay or disorder in speech, language or both.  For example a child may not have any difficulty pronouncing his/her words correctly, however may be unable to put more than two words together.  In retrospect, he/she may use words and/or phrases to express ideas, but may be difficult to understand by his/her environment.  Another child may both be difficult to understand and have difficulty following directions.

What are speech and language disorders?

Any problems or disruption in communication and related areas such as oral motor function, cognition, swallowing and/or social pragmatics is considered a disorder in speech, language or both.  These delays/disorders may range from simple sound substitutions to the inability to understand or express oneself, or use the oral-motor mechanism for functional speech and feeding.  Some causes of speech and language disorders may include hearing loss, neurological disorders, brain injury, mental retardation, drug/alcohol abuse, physical impairments (i.e. cleft lip/palate), vocal abuse/misuse, weakness of the oral-motor musculature, and maturation.

What are speech disorders?

Speech disorders include the following problems according to the American Speech-Language-Hearing Association (ASHA):

Articulation/Phonological disorders à Difficulty forming and combining sounds when speaking such as sound omission (ha for hat), sound distortion (sirt for shirt), sound substitution (wabbit for rabbit), addition of sounds (cuhlock for clock).  It is difficulties in producing sounds in syllables or saying words incorrectly to the point that other people can’t understand what’s being said.

Apraxia of speech à A speech sound disorder that affects the ability to initiate speech; to sequence and say sounds, syllables or words consistently; and/or to use appropriate syllable stress in speech.  The problem is not due to muscle weakness or paralysis, but rather the brain’s ability to plan movement of the body parts needed for speech (lips, tongue, jaw).

Fluency/Stuttering à An interruption in the flow or normal rhythm of speech, difficulties maintaining appropriate rate of speech.  It is characterized by hesitations, repetitions (st-st-stuttering), or prolongations (ssssstuttering) of sound, syllables, words, or phrases.  Most often, stuttering begins in children ages 2-6 years who are developing language skills.  It may go away by itself or may last a lifetime.

Resonance/Voice disorders à A problem characterized by poor voice quality (harsh, hoarse, breathy, nasal), inapropriate pitch (too high, too low, never changing, interrupted by breaks), or inappropriate loudness (too loud, too soft) and may accompany pain or discomfort for the child when speaking.

Resonance disorders à A problem with hypernasality where the child sounds very nasal in spontaneous speech across all speech sounds other than /m/, /n/, /ing/.  This problem is often mistaken as a voice disorder, however, it is rather a problem with the velopharyngeal mechanism.

Dysarthria à A combination of speech sound, fluency, and/or voice problems stemming from weakness, paralysis, or lack of coordination among the body parts used for speech.  Neurological causes may include stroke, cerebral palsy, Parkinson’s disease, multiple sclerosis, and amyotrophic lateral sclerosis (ALS or Lou Gehrig’s disease).

What are language disorders?

Language disorders are difficulties in receiving, processing, formulating, and/or sending messages).  It is an impairment in the ability to understand and/or use words in context, both verbally and nonverbally. Language disorders may be due to any of the following:

Word meaning à Reduced vocabulary size or trouble finding words.

Word endings-incorrect grammar à not using correct plurals, possessives, or tense.

Word order à Using incorrect grammar.

Word use à Not taking turns or staying on topic during conversations, not being able to describe an event in sequence, using slang expressions in formal speaking situations, or making demands rather than asking questions.

Listening à Understanding and remembering and following directions.

Asking and answering WH-questions.

Reasoning and problems solving.

What is typical speech and language development?

It is crucial to discuss your child’s speech and language as well as other development concerns with his/her pediatrician from an early stage at every routine to differentiate immature development vs. their ability to communicate due to a problem.  Below is a guideline of developmental norms:

Receptive Language Development – learning to listen and understand language:

Birth

• They are aware of environmental sounds.
• Are very attentive to sounds close to them and startle/cry if there is an unexpected noise.

0 – 3 months

• They turn to the adult/caregiver when they are speaking.
• They smile and recognize the caregiver/parent’s voice.
• May stop their activity and attend to unfamiliar sounds.
• They often respond to comforting tones regardless of the familiarity of the voice.

4 – 6 months

• They often respond to the word “no”.
• They are responsive to changes in your tone of voice (i.e. angry, happy, sleepy).
• They begin to enjoy rhythm and music and look for the source of sounds.

7 – 12 months

• They listen when they’re spoken to.
• They turn to look at your face when called by name.
• They discover and engage in games.
• They recognize the names of familiar objects.
• They begin to respond to requests.

1 – 2 years

• They point to pictures in a book when the objects are named.
• They point to a few body parts when asked.
• They can follow simple-single commands.
• They understand simple questions.
• They like listening to simple stories and enjoy songs and rhymes.

2 – 3 years

• They understand two stage commands.
• They understand contrasting concepts or meanings.
• They notice sounds like the telephone or doorbell ringing.
• They may point to or become excited, get you to answer, or attempt to answer themselves.

3 – 4 years

• They understand simple “who,” “what,” and “where”.
• They can hear you when you call from another room.

4 – 5 years

• They enjoy stories and can answer simple questions about them.
• They hear and understand nearly everything that is said to them.

Expressive Language Development – learning to speak and use language.

Birth

• They communicate via different sounds to let others know they are experiencing pleasure, discomfort or pain.

0 – 3 months

• They smile at people when they come into view.
• They “coo and goo” when content.
• Their cries “differentiate” depending on the situation.

4 – 6 months

• They gurgle sounds or “vocal play” while playing with adults or themselves.
• Their babbling intensifies and it will sound like they are “talking.”
• The “speech-like” babbling includes many sounds including the bilabial (two lip) sounds “p”, “b”, “m.”
• By using sounds or gestures, they express their needs and wants.
• They can make very “urgent” noises to prompt you into action.

7 – 12 months

• The sound of their babbling changes and they acquire more consonants as well as long and short vowels.
• They use speech or other sounds to get attention.
• Their first words should have appeared (i.e. mama, doggie, night-night, bye-bye)

1 – 2 years

• They accumulate more words as each month passes.
• They ask 2-word questions (i.e. where ball?, what’s that?, more chippies?, what that?).
• They combine two words in other ways to make “stage one sentence types” (i.e. birdie go, no doggie, more push).
• Words are produced more clearly as more initial consonants are used in words.

2 – 3 years

• Their vocabulary expands and can name most things in their environment.
• They usually use one, two or three word utterances which family members can usually understand.
• They ask for or draw attention to what they want by naming it, using one of its attributes or by commenting.

3 – 4 years

• Their sentences become longer as they combine four or more words.
• They talk about things that have happened away from home, and are interested in talking about pre-school, friends, outings, and interesting experiences.
• They usually present with fluent and/or clear speech where other people/strangers can understand them.

4 – 5 years

• They speak clearly and fluently in an easy-to-listen-to voice.
• They use long and detailed sentences (i.e. we went to the zoo but we had to come home early because mommy wasn’t feeling well).
• They use “adult-like” grammar to tell long and involved stories and maintain topics.
• Most sounds are pronounced correctly, with some lisping present on sounds “r”, “v” and “th”.
• They communicate easily with familiar adults and with other children.

When would I use the services of a speech-language pathologist?

The Speech-language pathologist thrives to meet the needs of each child in developing their competence in communication skills.  A communication disability may interfere with one or all of the following elements of the educational process: academic achievement, frustration in speaking situations, social interactions, task completion, or intelligibility.  The program provides speech & language services to children in Infant Toddler Programs (birth to three), in PreSchool Programs (three & four-year-olds), Regular & in Special Education Programs (Kindergarten-12^th Grade).  You might use the services of a speech-language pathologist if…

• You have difficulty understanding what the child is trying to say;
• You think the child is speaking differently from children of the same age;
• The child has difficulty telling you what he or she wants; or
• The child has difficulty understanding what people are saying.

What is a speech-language pathologist (SLP)?

An SLP is a licensed health care professional who diagnose, evaluate, and treats children & adults who have difficulty speaking (speech & language), listening, fluency (stuttering), pragmatics (social skills; turn-taking), voice, swallowing, differences in dialects or accents, reading, and/or writing. SLPs are educated to work with people who use more than one language. They are skilled at distinguishing communication disorders from communication differences that may result from being multilingual. SLPs also work with people who want to improve the effectiveness of their daily or professional communication or modify their accent.  Speech-language therapy is the treatment for most kids with speech and/or language disorders/delays.  Remember that a speech disorder refers to a problem with sound production, whereas a language disorder refers to a difficulty understanding or putting words together to communicate ideas.

I guess the point I’m trying to make is that I had language ALL around me.  Today I see kids talking MUCH less and PLAYING much more.  By playing I mean using technology.  Yes, my 4-year-old clients knows how to use the computer and smoothly “surf” the net, much better than even me.  I often find myself asking them to “show me” how to operate something on the computer, DS, itouch, etc.  It never seems to amaze me when they comes and asks me if I’ve heard of the new toy in the market!!!  I’m ashamed at times when I can’t do a simple math computation without the use of a calculator where in my childhood my brain calculated everything much more accurately and quicker than my hand reaching for a calculator.  I’ve noticed even a “regression” in my own brain’s ability to solve, reason, analyze and much more today than when I was younger!  I find myself thinking, well I don’t need to “know” this, I can just find the answer when I need it by a touch of a button.

Although, kids have many more resources and are growing technologically, they’re spending much less time “TALKING” to one-another and learning from their surrounding.  Most of the new language they learn, I believe come from TV shows, computer instructions, and/or games that have characters talking.  Even road trip mini conversations have now been replaced by cartoons in the car to keep children “engaged”!!!

Kids learn when they are taught.  When talking to your children and their just learning language you can help build it by adding on to their sentences.  When your chid points and says “car go,” you can respond by saying “yes, that’s right, RED CAR IS GOING,” or “I SEE THE CAR GO.”  Kids learn best by imitation and repetition.  I remember my teacher always mentioning to us “repetition is the hallmark of education.”  It is true! We learn best by repeating something over and over, until it becomes second nature.  When playing blocks with your child, teach them propositions by saying: “put red block on top,” “give me the yellow block that’s behind the blue one,” “put red block in the box,” “the green block is under the red block,” “take all the blocks out of the box” and so on.  You can work on colors, propositions, following directions and your spending time with your kids all at the same time.  You can even work on sizes by having different size blocks: “give me the small green block.”

You can work on propositions, sizes, colors, sounds and names when playing with farm toys and farm animals: “the big brown cow is next to the pony, they’re eating and playing on the grass, the doggie is playing with her puppies in the basket,” etc.  Notice, you’re modeling correct grammar using present tenses, possessives and also working on what “baby animals” are called.

If your child likes to play with cars, you can do the same type of activities where you’re working on colors, sizes, propositions, and also speed.

The key is finding what your child likes and interests them enough to want to participate in the game.  Once you’ve gotten their attention with their favorite toy, they’re all yours and ready to learn!!!

He actually smiled upon seeing me and reached his hand to grab mine.  He walked with ease to the therapy room without mom and cooperated pleasantly throughout the session.  For the first time he produced the sounds /p/ and /k/ during play and actually used them with intent.  I had to use all my might to hold myself back from crying and he reached for my hand and walked me to the bookcase to read a book.

It’s because of these days I find the strength and the love to continue waking up every morning and driving to work with absolute excitement and love for what I do.

I found that along with Talk-Tools, Myofunctional Therapy has helped so much in helping him finally improve! He’s so motivated now that he actually comes in and remarks about how much better his /sh/ sounds are. Using Myofunctional Therapy has helped him build strength in his tongue muscles and find more control to help approximate the sounds more precisely.

Most of us don’t realize how early communication begins. Communication skills develop immediately after birth, whether it’s through vocalization or non-verbal expressions! Newborns cry to indicate hunger, discomfort, having the need to be changed, comfort, pleasure and so forth. We as caregivers and/or parents promote communication by looking in their eyes, cooing with them, asking questions, answering to their cries and smiles. In fact we begin communicating to “unborn” children even when they’re in the womb. Needless to say it’s very crucial to ensure our children are able to communicate their needs appropriately and understand the world around them. My personal belief is: Our words are the breath that vibrate through the body and gives life to our intentions. This vibration is the binding force among individuals.

Below are some ways you can help promote speech and language development:

Social Language is one of the first areas of communication composed of 2 parts:

1) EYE CONTACT! In some cultures it is considered impolite for a youngster to look at his/her elder in the eyes when speaking with them, however, it is crucial to not that through direct eye contact we learn a great deal about our environment and social language! When communicating with your child, look into his/her face eyes as often as possible. By doing this you’re not only teaching your child “attention” and “engagement”, but as also facial affect, correct articulation and language intonation patterns (ie. question, answer, exclamation).

2) TURN TAKING! Engage in a back and forth conversation with your child such as pausing after making statements or asking questions to give them a moment to verbalize. This skill can also be accomplished during play by using objects and toys during pretend play.

Expressive Language is the verbalization part of language:

1) GIVE YOUR CHILD SPACE! When communicating with your child, allow them time to “think” their thoughts through and formulate a sentence. Don’t rush to finish off their sentences or talk over them. Encourage them to “verbalize” their needs rather than point or make “eh” sounds to show you what they want. If your child points to an object encourage verbalization by modeling, ie. “oh you want the ball! Say ‘give me the ball please’.”

2) GIVE CHOICES! Give your child choices and then let them express their choice by pointing, vocalizing, or attempting words, ie. “do you want the apple or the banana?” By doing this your also building confidence in your child because they feel in control even though YOU are the one giving them choices!

Receptive Language is the “comprehension/understanding” of what’s being spoken:

1) FOLLOWING COMMANDS/INSTRUCTIONS! Simple instructions such as “give me a kiss” or “get the ball” and slowly build to make it 2-part requests; ie. go to your room and get the ball.  You can slowly build on these requests and make them more complicated by adding time references such as “after you go to your room get the ball, then come in the kitchen and finish your lunch” and etc.

2) READ BOOKS! I LOVE reading books to kids. Reading books works on many different elements of language such as attention span, memory, auditory processing development, vocabulary, language, and being able to make inferences amongst many other. Start by reading very simple books with one or two pictures on each page and discuss what you see, ie. what color is her dress, is this a boy or a girl, what is she/he doing, where is she standing, where do you think she/he will do next, etc. Ask simple questions that can be answered verbally or by pointing to the correct picture. Model the correct answer if your child doesn’t respond within 10-15 seconds and ask the question again.

Vocabulary Development:

1) REINFORCEMENT, DEMONSTRATION AND LABELING! Model the correct word in response to your child’s attempt of incorrect production of a word or a phrase, ie. should he/she say “nana” for “banana” respond by saying “yes you’re right, it’s a BANANA, BANANA can you try? say BANANA. Do it with a smile and in an encouraging tone. Praise them for trying pleasantly and encourage correct production by modeling, but never be pushy!

2) EXPLORE AND LABEL! As you’re driving label what you see, in the house there are many opportunities of labeling and teaching new vocabulary, ie. “you’re sitting on the couch, look mommy is sitting on the floor/chair.”

Articulation is the production of sounds:

1) BE OBSERVANT AND INVOLVED IN YOUR CHILD’S PRODUCTIONS! Be aware of how your child’s environment understands his/her speech. It’s “cute” when you’re child uses “baby language”, however, it hinders their development socially not to mention their self esteem when they’re not being understood and are constantly asked to repeat themselves. Don’t be over worried if your “TODDLER” doesn’t produce /or mispronounces all the sounds (in English) because many sounds are later developing sounds. However, be mindful of their progress and consult a speech and language pathologist if your child is NOT clear at least 30% of the times by their environment by the age of 3! For your convenience a chart of sound acquisition is posted on this blog your can refer to!

2) ARTICULATE YOUR EVERY WORD! Make sure you speak in a slow and articulate manner when speaking with your child. Don’t “speed talk”, and remember to look at them in the eyes when speaking with them to ensure they’re looking at your mouth and face to learn sound “placement”.

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Snoring, mouth breathing, or apnea early in life may predict later behavioral and emotional problems, researchers found.

Signs of sleep-disordered breathing in children, ages 6 to 69 months, predicted a 60% higher risk of behavioral problems, such as hyperactivity, at age 7, Karen Bonuck, PhD, of Albert Einstein College of Medicine in New York City, and colleagues reported.

The children with the worst symptoms that persisted the longest were most likely to develop hyperactivity, conduct, and social problems in the longitudinal study in the April issue of Pediatrics.

But even the kids whose symptoms resolved after peaking at around 18 months faced a 40% to 50% elevated risk of behavioral problems at age 7 compared with those who never had symptoms.

Sleep-disordered breathing also correlated with anxiety and depression across all the symptomatic groups, with 32% to 65% elevated odds at age 7 (all P<0.01 orP<0.05).

These “findings suggest that sleep-disordered breathing symptoms may require attention as early as the first year of life,” the researchers wrote.

That may mean monitoring and treatment such as surgery for the enlarged tonsils and adenoids that typically lead to abnormal breathing during sleep in children, Bonuck explained to MedPage Today.

“There’s no reason for parents to be alarmed,” she said. “Our evidence appears to provide the strongest evidence to date that [sleep disorders] do play a causal role and therefore reducing these symptoms particularly early in life is likely to have some benefit in reducing future problems.”

For clinicians, simply asking, “How is your child sleeping?” isn’t enough, Bonuck argued.

They “need to ask more and better questions about children’s sleep when parents take children in for well visits,” she told MedPage Today, noting that one recent study found that about half of parents see snoring as a sign that their child is sleeping well.

The findings came as little surprise to the pediatricians contacted by ABC News in collaboration with MedPage Today.

Stephen Lauer, MD, PhD, of the University of Kansas Medical Center in Kansas City, said he sees problems related to sleep-disordered breathing every day in clinic.

“It used to be that I would ask if I child snored if I saw large tonsils,” he noted. “It has now become a standard part of the well-child check. And when there are issues of behavioral problems, school performance, and especially attention deficit hyperactivity disorder concerns, the first question I ask has to do with sleep and snoring.”

Sleep problems are quite common in such cases, but treatment helps, agreed Rajiv Naik, MD, a pediatrician with the Gundersen Lutheran Health System in La Crosse, Wis.

“Many children have been cured of their behavioral problems with appropriate treatment of their sleep disturbance,” he wrote in an e-mail.

Longitudinal observational data supports that conclusion, but only multicenter, randomized controlled trials, like the ongoing National Institutes of Health–funded Childhood Adenotonsillectomy study, can prove the cause-and-effect relationships, Bonuck’s group noted.

Their study included more than 9,000 children in the Avon Longitudinal Study of Parents and Children, a birth cohort study of children in a region of southwest U.K.

Based on parent reports of children’s snoring, mouth breathing, and witnessed apnea for ages 6 to 69 months, the children were broken into five “clusters” for presence and duration of sleep-disordered breathing. Early clusters were defined as:

• Cluster 1: Symptoms peaked at 6 months and then abated
• Cluster 2: Symptoms peaked at 18 months and then abated
• Cluster 3: Symptoms peaked at 30 months and then persisted (“worst case”)
• Cluster 4: Symptoms emerged at 42 months and then persisted (“late symptom”)
• Cluster 5: “Normals” who were asymptomatic throughout

Five comparable later clusters demonstrated similar patterns to the early clusters, except in a “late symptom” cluster where snoring and mouth breathing peaked together at lower levels at 57 months with no marked apnea. Also, the peak at 6 month apnea levels was nearly double those of the early clusters.

Compared with the 45% of kids with no symptoms, all the other groups showed significantly elevated risk of being in the worst 10% for behavioral screening score on the Strengths and Difficulties Questionnaire (all P<0.01 or P<0.05).

The 8% of “worst case” kids (cluster 3) had 49% elevated risk of being in the top 10% for total behavioral problem score at age 4 and up to two-fold excess risk at age 7.

Hyperactivity was the outcome most consistently associated with symptomatic sleep-disordered breathing across the groups.

Significant odds ratios for hyperactivity at age 4 ranged from 1.19 for the 20% in cluster 1, whose symptoms abated after peaking at 6 months, to 1.56 for the “worst case” group (cluster 3).

For hyperactivity at age 7, the odds ranged from 1.48 for cluster 1 to 1.88 for the 20% of kids with symptoms in cluster 2.

Conduct problems, such as aggressiveness and rule breaking, showed associations similar to those with emotional problems.

Being in the top 10% for problems getting along with other kids was 33% to 48% more likely for the worst case group at age 4 and 7 but wasn’t consistently elevated in the other groups.

These risks appeared to be independent of 15 potential confounding factors, such as socioeconomics, exposures during gestation, breastfeeding, birth weight, and gender.

But the results are likely conservative, the researchers suggested.

They noted limitations from using parental reports of sleep-disordered breathing rather than objective testing and difficulty of distinguishing observed apnea form central apnea in infancy.

This article was developed in collaboration with ABC News. 

Below is a chart reflecting speech sound acquisition. The upper range indicates when 90% of children have learned that sound. For example,90% of children have acquired the “n” sound by the time they are 4 years old; 90% of children have learned “s” sound by the time they are 7 years old.

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