Specific speech and language development disorders in children: clinical guidelines

List of Abbreviations

BPEI — benign epileptiform discharges of infancy

SRD – speech-language delay

ICD-10 – International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) — a version of the ICD classifier developed in 1989 and adopted by the WHO in 1990.

GSD - general speech development.

PMCC – psychological, medical and pedagogical commission.

ASD – autism spectrum disorder

DLD – developmental language disorder, disorders in which normal speech development is impaired in the early stages of speech ontogenesis.

ADHD – attention deficit hyperactivity disorder.

«FH+» family - presence of specific speech development disorders in close relatives of the child

«FH-» family a family in which relatives have no history of speech development disorders.

LKS - Landau-Kleffner syndrome

SMA - sensory-motor alalia

PP CNS – perinatal lesion of the central nervous system.

tMCT - transcranial micropolarization

TMS – transcranial magnetic stimulation

PN - phonetic disorders

FPD - phonetico-phonemic underdevelopment

EEG – electroencephalography

SLI - Specific language impairment - specific speech development disorder.

Terms and Definitions

Affricates — consonant sounds consisting of a plosive and a fricative component: Ts, Ch.

Vibrants - trilled, rolling consonants in which the air stream causes the active organ to vibrate (or trill): R, Zh.

Gammacism - distorted pronunciation of the sounds G and G¢.

DLD specific risk group – a cohort of children whose parents (caregivers) report disorders in the development of speech and communication skills: absence of speech, delay in the stages of its formation, pronounced impairment of sound pronunciation to the degree of speech unintelligibility, whose psycho-speech development assessment according to the results of medical screening interview indicates a high probability of having DLD.

Voicing defects – speech defects in the pronunciation of voiced consonants leading to their replacement with paired voiceless sounds

Softening defects – speech defects in the pronunciation of soft consonants leading to their replacement with paired hard sounds

Iotacism - distorted pronunciation of the sound Y.

Kappacism - distorted pronunciation of the sounds K and K¢.

Lambdacism - distorted pronunciation of the sounds L and L¢.

Paraphasias - replacement of correct sounds, letters, syllables, words with others that do not comply with the norms and rules of the language

Rhinolalia -- disorders of voice timbre and sound pronunciation caused by anatomical and physiological defects of the speech apparatus

Rotacism - distorted pronunciation of the sounds R and R¢.

Sigmatism – distorted pronunciation of sibilants (S, S¢, Z, Z¢, Ts) and hushing sounds (Sh, Zh, Ch, Shch)

Mixings - specific articulation disorders in the form of mutual replacement of a newly acquired sound with a former substitute

Sonorants – consonants in the formation of which voice prevails over noise. Sonorant consonants include the sounds M, N, L, R. The consonant sound Y also belongs to this group.

Substitutions - specific articulation disorders in the form of replacing a sound with another correctly pronounced sound similar in the manner of production, and/or place of articulation, and/or active articulating organ, and/or hardness/softness feature

Phonetico-phonemic underdevelopment – impairment in the pronunciation of a single sound, a group of sounds, or several groups of sounds, as well as underdevelopment of phonemic processes (phonemic hearing, phonemic perception).

Phonetic disorders – impairment in the pronunciation of a single sound, a group of sounds, or several groups of sounds.

Chitism - distorted pronunciation of the sounds Kh and Kh¢.

Elisions – specific articulation disorders in the form of omissions of a sound/sounds

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Among the numerous disorders accompanied by limitations in speech functioning, the condition under consideration, specific speech-language disorder (SLD), occupies a wide niche with a prevalence of 5–8% in the pediatric population [122, 123]. SLD falls within the scope of several medical disciplines (psychiatry, neurology, pediatrics). The purpose of these clinical guidelines is to achieve a national medical consensus regarding this pathology.

The conditions from the SLD group considered in these clinical guidelines (specific speech articulation disorder or dyslalia, expressive language disorder or developmental dysphasia of expressive type, receptive language disorder or developmental dysphasia of receptive type) are characterized by primary speech development disorders. In these cases, the child has age-appropriate intelligence, normal hearing, and normal conditions for acquiring speech; the developmental delay manifests without a preceding period of normal development [80]. In accordance with the ICD-10 classification, these disorders are classified under subcategories F.80.0, F 80.1, F 80.2, as well as G 96.8. These speech disorders are understood as disorders in which normal speech development is impaired from the early stages and is not a consequence of traumatic brain injury, neuroinfection, epilepsy, neurodegenerative diseases, autism, mental retardation, intellectual disability, hearing loss, and other CNS diseases [1, 28, 124].

Children with a specific speech articulation disorder experience difficulties only with the pronunciation of individual speech sounds (F 80.0). The term dyslalia is also used to denote this disorder.

Children with expressive or receptive language disorders (F 80.1; F 80.2) experience difficulties in understanding speech and/or pronouncing words and sentences.

The attitude of the scientific and professional community towards making a diagnosis for speech disorders varies widely. The cautious position of a number of authors is largely due to concerns about stigmatization, as well as the risk of shifting the focus of attention when analyzing speech disorders to the medical aspects of the problem while underestimating the role of individual developmental characteristics, society, family, and education. The opposite opinion is based on the fact that the use of generally accepted nosological units and verified diagnostic criteria is necessary to identify the category of patients who need comprehensive medical and pedagogical care and legally secures their right to create special educational conditions, specialized treatment and rehabilitation. Along with this, standardized approaches to the diagnosis of speech disorders make it possible to ensure more correct and comparable morbidity accounting across various indicators and, consequently, improve the quality and reliability of scientific research [91].

In domestic psychiatric literature, the division of speech disorders into partial speech development delays and general forms of speech underdevelopment (alalia) has become established [18, 43]. In Russian guidelines on child and adolescent psychiatry published over the last ten years, speech delays are considered within the framework of describing mental development disorders (borderline intellectual deficiency) [18], [60]. The authors of the National Guideline on Psychiatry draw attention to the contradiction between the term «alalia» and SLD [61].

In modern Russian medical scientific and practical literature, the term developmental dysphasia is frequently encountered [22, 53], which is actively used in pediatric neurological practice. Diagnosis and treatment of these speech disorders are presented in the federal guideline on pediatric neurology [70]. At the same time, this group of conditions is in practice coded under ICD-10 subcategory G 96.8 Other specified disorders of central nervous system.

Foreign sources contain numerous definitions that meet the criteria for SLD:

- infantile speech [129],

- delayed speech [126],

- language disorder [138];

- communication impairment [127]

- developmental language impairment [117];

- developmental language disorder (Laasonen M. et al., 2018) [120].

The authors of a multinational, multidisciplinary Delphi study on the diagnostic criteria for developmental language disorder (DLD) highlight the problem of confusing heterogeneous concepts such as language, speech, and communication in the naming of speech disorders, believing that the separation of these concepts is of practical importance [89]. Language function in this context includes the comprehension and production of words and sentences for the purpose of exchanging thoughts and information, which can occur in oral, written, and signed modalities. Speech is the ability to correctly produce the sounds used for verbal communication. Communication is a broad concept encompassing various verbal and non-verbal ways of transmitting information. Language is a system of signs and a set of rules for their use to construct utterances. Speech is the form in which these rules are implemented through the generation of utterances in acoustic form [44].

Participants in the CATALISE consensus study [89] consider it incorrect to use the term "delay" to denote speech disorders, as it implies a lag in speech development parameters by a certain number of standard deviations and a gradual leveling out of developmental rates to normative values as the central nervous system matures. DLD, like other neurodevelopmental disorders, implies the persistence of residual manifestations not only within childhood, but also at later stages of ontogenesis, as evidenced by follow-up studies [97, 116].

Without diminishing the importance of early detection of speech and other mental development disorders [143], some researchers draw attention to the fact that children with a slow rate of speech development ("late talkers") with a limited expressive vocabulary between 18 and 24 months often recover their speech functions within normal limits without correctional intervention, thereby emphasizing that a developmental speech delay does not always correlate with DLD [139]. According to Ch. Njokiktien, a diagnosis of speech delay can be made up to two and a half years of age [53].

At the same time, many authors emphasize the importance of early screening for speech and other mental parameters, establishing "red flags" for each age stage that should serve as warning signals for parents, physicians, and educators, determining the need for an in-depth examination of the child by specialized professionals [90, 111].

Most researchers agree that the use of the term "specific" in formulating a diagnosis of DLD emphasizes the primary (idiopathic) nature of speech disorders, contrasting them with secondary speech disorders arising within the structure of other neuropsychiatric disorders, as well as those resulting from auditory sensory deficits [91]. At the same time, this group of disorders has a polymorphic etiology, in which biological factors play a significant role [6, 49, 26, 134, 135].

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

There is no consensus on the etiology (causes) and pathogenesis (brain mechanisms) of DLD. Currently, DLD, like other neurodevelopmental disorders, is viewed as a pathology with a polymorphic etiology. Among the main etiological factors, hereditary, cerebral-organic, and social-environmental factors can be distinguished [26, 79, 84, 87, 135]. Due to the polymorphism of etiological-pathogenetic factors and the clinical features of speech disorders, there are currently no reliable routine laboratory and instrumental methods that would allow diagnosing DLD with high reliability [91].

Etiology

Heredity

The hereditary nature of DLD is indicated by the results of family history studies. The incidence of children with DLD in families with a positive family history of DLD is about 20%-30%, whereas in the general population, DLD is significantly lower, observed in 40%-60% of cases in a close relative ("FH+ families"). The risk of developing DLD in children from FH+ families increases to 28%, which is 4 times higher than in children from families where relatives had no history of speech development disorders ("FH- families") [96]. From 50% to 70% of children with DLD have at least one close family member with a similar disorder [153]. Male monozygotic twins demonstrate a higher risk of developing speech disorders (70%) compared to dizygotic twins (46%) [92].

Data from studies attempting to identify chromosomal regions harboring genes responsible for speech disorders in children have been published: FOXP2, CNTNAP2, ATP2C2, CMIP [133]. For instance, a locus on chromosome 16 is presumably associated with poor performance on a non-word repetition test, whereas a locus on chromosome 19 is associated with poor performance on expressive speech tests [88, 106].

Among earlier works, Annette's right-shift theory is of interest, according to which the prerequisite for deviations from the usual left-hemispheric lateralization pattern for speech and concomitant hand preference is the absence of the "right-shift" gene, or the RS gene [98].

Cerebral-organic factors

Residual-organic cerebral disorders are risk factors for DLD [1, 109, 154]. Anamnestic indications of antenatal, perinatal, and early postnatal risk factors in children with DLD occur, according to several authors, in 75-85% of cases. These are represented by the following complications: pregnancy toxicoses, threatened miscarriages due to Rhesus incompatibility, maternal somatic diseases in the stage of decompensation, prematurity, infections, hypoxic-ischemic encephalopathy, and central nervous system trauma in the perinatal period [44, 76]. Follow-up studies of premature children revealed delayed speech development in this category of patients, and learning difficulties, reading and writing problems, attention deficit, and behavioral control issues in school age [30]. In children born with severe asphyxia, the appearance of babbling and first words is delayed by 3-6 months [64]. In a meta-analysis presented in the scientific literature, an Apgar score below 5 is considered a reliable risk factor for the development of DLD [142].

Social and environmental factors

Social and educational deprivation, sensory deprivation, upbringing in a family with low communicative speech input, insufficient contact and play with peers, and upbringing in bilingual families can have a negative impact on speech development [89]. The highest sensitivity to deprivation effects is observed in the age range that is the sensitive period for the development of speech abilities [14].

Various somatic diseases of the child can serve as precipitating exogenous factors for cognitive developmental delay, complicating the course of the disorder and hindering its correction. Thus, there is evidence of the negative impact of hypothyroidism [37, 82] and obstructive sleep apnea syndrome (OSAS) [8, 46] on the development of cognitive (including speech) skills. Taking these factors into account is necessary for the correct verification of DLD during diagnostic procedures and the formulation of a comprehensive treatment program.

Pathogenesis

During a standard neurological examination and the use of traditional laboratory methods (electroencephalography, neuroimaging), at least half of the children with speech disorders do not show any abnormalities, which, however, does not provide grounds to deny their neurobiological nature. In the process of ontogenesis, starting from birth, the system of brain structures responsible for functions associated with oral speech undergoes dynamic changes, among which axon retraction and synaptic connection formation, the establishment of left-hemisphere dominance by 4-5 years of age, and the formation of adequate interhemispheric connections via the corpus callosum can be noted. Various prenatal development disorders (e.g., cell migration processes, physiological embryonic cell death) and brain structure damage in the pre- and postnatal periods can negatively affect neurodevelopment [53].

The results of instrumental diagnostic methods provide useful material for further research. Data from electroencephalographic studies cited in scientific literature have recorded manifestations of morphofunctional immaturity of the brain's bioelectrical activity in children with SRSD, which, however, cannot be considered a specific phenomenon [44, 76]. Acoustic evoked potential studies revealed an atypical electrophysiological response to auditory stimuli in patients [19]. An MRI study with optimized voxel-based morphometric assessment in children with SRSD showed a smaller gray matter volume compared to the control group in the right postcentral parietal gyrus, as well as an increase in cerebrospinal fluid volumes [108]. Functional MRI data revealed atypical lateralization and functioning of the main language areas of the brain in patients with SRSD [99].

1.3 Epidemiology of the Disease or Condition

The incidence of SRSD in children ranges from 4 to 8% [23, 61, 76, 83, 153]. In preschool children, this figure is slightly higher at 5-10% [93]. SRSD is more commonly observed in boys, with literature data showing a male predominance ranging from 1.3:1 to 5.9:1 [44, 149, 152].

The prevalence of the least complex and relatively easily remediable variants of SRSD—dyslalias (specific speech articulation disorder)—shows an upward trend from 8–17% in the 1950s to 52.5% by the end of the 20th century [72].

The variability of terms used to define speech disorders, the low rate of seeking medical help for speech disorders, or the use of speech diagnosis nomenclature in cases where speech pathology is secondary and part of other diseases and conditions, hinder an adequate assessment of morbidity.

Currently, epidemiological analysis of SRSD is difficult due to the lack of statistical data on the prevalence of speech disorders in children in the Russian Federation.

1.4 Features of Coding the Disease or Condition

In ICD-10, SRSD are included in categories F80 - F89. Common features of disorders in this category are:

a) onset obligatorily in infancy or childhood;

b) impairment or delay in the development of functions closely related to the biological maturation of the central nervous system;

c) a continuous course without remissions or relapses characteristic of many mental disorders.

F80 Specific developmental disorders of speech and language

These are disorders in which normal speech acquisition is disturbed from the early stages. The conditions cannot be explained by neurological or speech mechanism pathology, sensory impairments, intellectual disability, or environmental factors. The child may be more able to communicate or comprehend in certain well-known situations compared to others, but speech ability is always impaired.

Formally, category F80.x includes several diagnostic categories that describe secondary speech disorders and must be considered for differential diagnosis. As noted above, the therapeutic strategy for secondary speech disorders must be determined by the course of the underlying disease. In these clinical guidelines, these categories are not discussed in detail and are included to remind clinicians of the need for differential diagnosis. Such diagnostic categories include:

F80.3 Acquired aphasia with epilepsy (Landau-Kleffner syndrome) - a disorder in which a child with previously normal speech development loses both receptive and expressive language skills while general intelligence remains intact; the onset of the disorder is accompanied by paroxysmal EEG abnormalities (almost always in the temporal lobe regions, usually bilateral, but often with more widespread disturbances) and, in most cases, epileptic seizures. The etiology of the condition is unknown, but clinical data suggest an inflammatory encephalitic process. Given these circumstances, speech disorders in this syndrome are secondary, and the therapeutic strategy should include measures targeting primary epileptic encephalopathy

F80.81 Speech and language developmental delays due to social deprivation

This group is represented by speech disorders and delayed formation of higher mental functions caused by social deprivation or educational neglect. The clinical picture manifests as a limited vocabulary, underdeveloped phrasal speech, etc. The therapeutic strategy should include measures to eliminate social deprivation

F80.82 Speech and language developmental delays combined with intellectual developmental delay and specific learning disorders

This diagnostic category is used to characterize speech disorders in children with intellectual disability or school skill disorders. In such cases, a second code from categories F70.xx - F79.xx or F81.x must be used.

General recommendations:

When speech delay is part of a general intellectual or general developmental lag, the condition should not be coded as F80.-. Intellectual disability coding F70 - F79 must be used.

In cases where speech disorders are more severe than non-verbal skill delays and significantly determine social functioning disorders, the specific developmental disorder of speech should be coded in addition to the intellectual disability category (F70-F79).

Secondary speech disorders due to hearing impairment should be excluded from F80 - F89 if the severity of hearing loss adequately explains the speech delay, but included if partial hearing loss is merely a complicating factor rather than a direct cause. Nevertheless, a strictly defined distinction is impossible. A similar principle applies to neurological pathology and anatomical defects. Thus, articulation pathology caused by a cleft palate, or dysarthria due to cerebral palsy, must be excluded from this section. On the other hand, the presence of mild neurological symptoms that could not cause a speech delay is not a ground for exclusion.

Diagnostic categories including primary speech disorders of common origin (actual SRSD, grouped together according to type of course, prognosis, and unity of therapeutic tactics):

F80.0 Specific speech articulation disorder

Includes:

- developmental physiological disorder;

- articulation developmental disorder;

- functional articulation disorder;

- lalling (baby talk);

- dyslalia;

- phonological development disorder.

Excludes:

- aphasia NOS (R47.0);

- dysarthria (R47.1);

- apraxia (R48.2);

- articulation disorders combined with expressive language disorder (F80.1);

- articulation disorders combined with receptive language disorder (F80.2);

- cleft palate and other anatomical anomalies of oral structures involved in speech function (Q35 - Q38);

- articulation disorder due to hearing loss (H90 - H91);

- articulation disorder due to intellectual disability (F70 - F79).

F80.1 Expressive language disorder

Includes:

- motor alalia;

- speech developmental delays of the general speech underdevelopment (GSU) level I – IV type;

- developmental expressive dysphasia;

- developmental expressive aphasia.

Excludes:

- developmental dysphasia, receptive type (F80.2);

- developmental aphasia, receptive type (F80.2);

- pervasive developmental disorders (F84.-);

- pervasive developmental disorders (F84.-);

- acquired aphasia with epilepsy (Landau-Kleffner syndrome) (F80.3x);

- elective mutism (F94.0);

- intellectual disability (F70 - F79);

- organically based expressive speech disorders in adults (F06.82x with a second code R47.0); - dysphasia and aphasia NOS (R47.0).

F80.2 Receptive language disorder

Includes:

- developmental receptive dysphasia;

- developmental receptive aphasia;

- word deafness;

- verbal auditory agnosia;

- sensory agnosia;

- sensory alalia;

- congenital auditory imperception;

- developmental Wernicke's aphasia;

Excludes:

- acquired aphasia with epilepsy (Landau-Kleffner syndrome) (F80.3x);

- autism (F84.0x, F84.1x);

- elective mutism (F94.0);

- intellectual disability (F70 - F79);

- speech delay due to deafness (H90 - H91);

- expressive dysphasia and aphasia (F80.1);

- organically based expressive speech disorders in adults (F06.82x with the second code R47.0);

- organically based receptive speech disorders in adults

F80.88 Other disorders of speech or language development

Includes:

- baby talk;

- babbling speech.

1.5 Classification of the disease or condition

Throughout the history of its study, speech function disorders have been in the focus of attention of various specialists (psychiatrists, neurologists, psychologists, speech-language pathologists, linguists) [4, 20, 36, 45, 48, 57, 72, 73]. The consideration of individual types of deviations in speech functioning from normative variants from various scientific and practical perspectives has led to the emergence of diverse classification approaches and specific terms firmly established in the practice of individual specialists, which creates difficulties when attempting to form a common conceptual framework.

Based on practical and applied considerations, it seems appropriate to distinguish between primary speech disorders arising from direct damage (including deviations from normative developmental variants) to the brain regions responsible for speech functioning, and secondary speech disorders that occur due to the primary impairment of other organs and systems (primarily hearing loss, as well as primary intellectual developmental disorder, conditions of social and pedagogical neglect, other mental and neurodevelopmental disorders (ASD, etc.), epilepsy, traumatic brain injuries, neuroinfections, acute cerebrovascular accidents, neurodegenerative conditions). The separation of speech disorders from these perspectives is crucial due to differences in prognostic assessment and the selection of first-line therapeutic strategies.

While in the case of "primary" speech disorders, an optimistic prognostic outcome depends on the earliest possible intervention and adequate therapy (see the chapter on "treatment"), in the case of "secondary" disorders, the success of overcoming speech functioning limitations depends on the prognosis of the underlying disease. Obviously, in cases of secondary speech disorders caused by diseases that entail irreversible damage or developmental aberrations of certain brain parts leading to a complex of stable mental deficits, achieving a normative level of speech functioning is an unlikely outcome, and treatment strategies are determined by the primary condition.

When describing types of speech disorders to characterize the degree of totality of damage (insufficient development) of various aspects of speech (comprehension, production, articulation, lexico-grammatical structuring), the terms "systemic" and "partial" are used.

To understand the place of DSD (developmental speech and language disorders) among other types of speech disorders, as well as the relationship of classifications used in psycho-pedagogical and speech therapy practices (clinical-pedagogical classification [73], psycho-pedagogical classification [45]) with medical systematization reflected in ICD-10, schematic diagrams are provided below, in which classification units (terms) corresponding to the pathology under consideration (DSD) are highlighted in bold (Figure 1 and Figure 2)

Figure 1

The place of DSD in the clinical-pedagogical classification

Figure 2

The place of DSD in the psycho-pedagogical classification

1.6 Clinical presentation of the disease or condition

Specific speech articulation disorder (F80.0) is a partial primary speech disorder, the clinical picture of which is limited to impaired articulation (sound production), does not affect the lexico-grammatical aspect of speech, with normal hearing and preserved innervation of the speech apparatus. In neurological practice, it is used under the term "dyslalia". In medical speech-language pathologist reports, it is designated by the terms "dyslalia", "phonetic disorder", "phonetic-phonemic underdevelopment".

Based on the mechanisms of occurrence, two variants of specific speech articulation disorder are distinguished:

- mechanical – arising due to defects in the structure of the articulation apparatus: bite anomalies (distal, mesial, open, deep, edge-to-edge), dental arch anomalies, structural features of the hard and soft palate, lips, tongue, frenulum of the tongue.

- functional – arising due to biological and social causes.

Symptoms of dyslalia may be part of the clinical picture of expressive language disorder (F80.1) and receptive language disorder (F80.2) and in this case are not coded separately.

If dyslalia is not eliminated in a timely manner, there is a high risk of developing specific reading disorder (F81.0) (dyslexia) and specific spelling/writing disorder (F81.1) (dysgraphia).

Main symptoms: isolated monomorphic or polymorphic qualitative sound production disorder (elisions, substitutions, mixes, distorted pronunciation of a sound/sounds (sigmatism, rotacism, lambdacism, kappacism, gammacism, chitism, iotacism, voicing and softening defects, etc.)

Diagnostic criteria:

• presence of specific qualitative sound production disorders

• absence of signs of impairment in the lexico-grammatical aspect of speech

• absence of signs of intellectual decline

• absence of signs of other mental and neurological diseases that may be accompanied by speech disorders.

Differential diagnosis of specific articulation disorder should be carried out:

• with age-related features of sound production

• with dysarthria

• with accent and dialect

Expressive language disorder (F80.1), developmental expressive dysphasia – a systemic primary speech disorder accompanied by signs of underdevelopment of all structural components of the language system (phonetic-phonemic, lexico-grammatical, semantic) due to a dysfunction of the speech-motor analyzer.

In medical speech-language pathologist reports, it is designated by the terms "general speech underdevelopment", "systemic speech disorder", "speech development delay", "motor alalia".

Receptive language disorder (F80.2), developmental receptive dysphasia – a systemic primary speech disorder accompanied by signs of underdevelopment of all structural components of the language system (phonetic-phonemic, lexico-grammatical, semantic) due to a dysfunction of the speech-auditory analyzer with preserved physical hearing.

In medical speech-language pathologist reports, it is designated by the terms "general speech underdevelopment", "systemic speech disorder", "speech development delay", "sensory alalia".

The clinical picture of expressive and receptive language disorders is similar. Both forms of speech disorders are characterized by a discrepancy between the level of conversational speech development and the age norm and mental age.

At the same time, expressive language disorders are based on the underdevelopment of linguistic operations in the process of speech utterance production while semantic and sensorimotor operations are relatively primarily preserved, which complicates the acquisition of the system of linguistic signs and the use of speech as a full-fledged means of communication.

The basis of receptive language disorders is the insufficiency of the central (cerebral) part of the speech-auditory analyzer, leading to the underdevelopment of semantic and sensorimotor operations, as a result of which the process of speech utterance production is impaired. Clinically, this manifests as symptoms of impaired phonemic hearing and speech perception, which can range from almost complete incomprehension of speech to difficulties in understanding complex grammatical structures.

Main symptoms:

• absence or late onset of speech

• various sound production disorders, syllable structure disorders

• verbal and literal paraphasias

• insufficiency of passive and active vocabulary

• decreased phonemic hearing and perception (in receptive language disorder)

• impaired use and comprehension of grammatical categories

• difficulties in word formation

Additional symptoms:

• motor clumsiness, impaired fine (manual) motor skills (manual dyspraxia), movement dyscoordination

• hyper- or hypoactivity

• delay in the formation of higher mental functions (memory, thinking, perception, attention)

• transitory, unstable emotional and behavioral disorders (anxiety, sensitivity, emotional instability), often fitting into the astheno-emotional symptom complex (increased fatigue, exhaustion of mental and physical activity, drowsiness, decreased concentration, irritability, headache).

• Avoidance of speech, pathohistorical reactions, and communicative self-limitations caused by the child's reaction to not being understood by others

The severity of expressive and receptive language disorders can vary from severe to mild and is determined based on the correspondence of the child's actual speech status to the levels of speech development described in speech therapy science [45, 72] (Appendix A3.1).

Diagnostic criteria for expressive and receptive language disorders:

• mismatch between the level of speech development and the age norm (Appendix A3.2) and the level of cognitive functioning

• absence of signs of intellectual decline

• absence of signs of hearing loss

Differential diagnosis of expressive and receptive language disorders should be performed:

• absence of signs of other mental and neurological diseases that may be accompanied by speech disorders.

• with hearing impairments

• with autism

• with intellectual disability.

• with aphasias

• with mutism

Special conditions associated with expressive/receptive language disorder (developmental dysphasia) and comorbid pathology

• Secondary mental retardation

Due to a persistent, pronounced speech defect, particularly in the receptive (impressive) component, impairments in thinking and an impoverishment of play and cognitive interests may develop, leading to secondary mental retardation against an initially unaltered mental background. At the stage of its origin and formation, this secondary mental retardation largely depends on the state of the primary speech disorder, but as the child grows older, it transforms into an independent, hard-to-correct condition that significantly worsens the overall outcome of the disease, up to the development of intellectual disability. The development of secondary mental retardation requires special therapeutic approaches; therefore, it is advisable to indicate this comorbid condition after the main diagnosis, for example: "Receptive language disorder (F80.2), secondary mental retardation." In the case of secondary mental retardation development, it is permissible to indicate this disorder without an ICD-10 code. In the case of established secondary mental retardation, this condition is recommended to be classified under diagnostic category F80.82 (see below)

In certain situations, difficulties may arise in the differential diagnosis between secondary mental retardation due to a speech disorder and primary mental retardation, which requires an in-depth assessment of verbal and non-verbal intelligence.

• Emotional and behavioral disorders

The clinical picture of all types of speech and language disorders is often accompanied by impairments in interpersonal relationships, emotional and behavioral disorders [38]. However, these impairments are not persistent or global in nature, do not significantly affect social adaptation, and manifest selectively in stressful situations, for example, during corrective sessions with a child who has established a stereotype of non-verbal communication [67].

The unintelligibility of the speech of a child with a speech and language disorder to others, including family members and peers, contributes to the formation of an avoidance strategy for communication situations and withdrawal into oneself. The inability to fully express one's thoughts can be a cause of a negative emotional background. The negative impact of speech and language disorders on the emotional sphere of preschoolers is reflected in the increased levels of anxiety, aggression, or, conversely, apathy observed in them, as well as a low degree of adaptation in society [69]. In such cases, there are no grounds for making an additional psychiatric diagnosis, since the speech pathology itself determines the concomitant behavioral and emotional disorders. However, these disorders must be taken into account in structuring the most effective therapeutic work; furthermore, in the future, they may be complicated by more persistent changes up to peculiarities in personality formation. In order to record this aspect, which is important for prognosis and treatment, it is permissible to indicate this comorbid condition after the main diagnosis, for example: "Receptive language disorder, pathohoracterological aggressive reactions." Consultation with a medical psychologist is mandatory for the diagnosis of these conditions.

• Neurodynamic, cerebrasthenic, and partial cognitive impairments

In patients with a history of cerebral-organic pathology, partial impairments of mental functions may be observed: neurodynamic impairments, a high level of nervous process fatigability, which do not significantly affect intelligence indices and do not fall under the criteria of a psychiatric diagnosis [67]. These conditions can be regarded as cerebrasthenic syndrome (in case of prevailing fatigability) or partial cognitive disorder (in case of prevailing neurodynamic slowing and attention fluctuations without manifestations of ADHD). It is permissible to indicate this comorbid condition after the main diagnosis (for example: "Receptive language disorder, partial cognitive disorder").

In cases of pronounced clinical symptoms, hyperactivity phenomena can be classified as a separate diagnosis (F90.x) as a concomitant comorbid disorder [38, 67, 102].

Differential diagnosis of speech and language disorders is mainly carried out with the following diseases and conditions:

- speech disorders included in the structure of global developmental intellectual disorders (global developmental delays, intellectual disability),

- ASD,

- speech disorders due to an auditory analyzer defect,

- speech disorders due to acquired somatic and neurological diseases, for example, acquired aphasia with epilepsy (Landau-Kleffner syndrome).

Global developmental delays and intellectual disability

Differential diagnosis, along with the assessment of the clinical picture, is based on the results of studying the child's development, including their intellectual sphere, using various psychometric methods and test-questionnaires validated in the Russian Federation (see the section on diagnostic methods). For children with severe speech impairments, performance scores on verbal subtests may be lower than normative values, and therefore the use of non-verbal intelligence assessment methods is preferred for this category of patients.

Autism spectrum disorder

In children with severe forms of speech and language disorders, especially when they affect receptive language, social interaction impairments may be observed that bring them closer to children with ASD: isolation from peers, echolaliac speech without understanding its meaning, and limited and stereotyped interests [38, 53].

In children with ASD, along with speech communication impairments characteristic of autism, symptoms characteristic of speech and language disorders may also be observed. This is especially noticeable in patients with so-called high-functioning autism (Asperger syndrome).

The diagnosis of autism is made based on symptoms identified in the clinical picture that meet the criteria from the relevant ICD-10 categories (84.0-.9.), as well as using various psychometric methods and test-questionnaires validated in the Russian Federation [62].

Speech communication impairments in patients with ASD vary widely from the absence of purposeful use of speech for communication, abundant use of speech clichés and echolalia, to isolated impairments affecting the semantic-pragmatic side of speech in children with high-functioning autism, which is manifested by the fact that with formally well-developed speech skills, speech does not carry sufficient communicative direction (there is a fascination with certain speech forms, play with sounds, words, rhyming). Unusual tempo, rhythm, and melody of speech are also characteristic of children with ASD.

Speech disorders due to an auditory analyzer defect

Hearing impairment as a potential factor in impaired development in early childhood is indicated by various domestic and foreign authors [7, 89].

Hearing impairments in early childhood (1–2 years) are non-specific and may manifest with the following signs:

- absence of babbling,

- lack of response to sounds/speech,

- minimal level (or absence) of a drive for social interaction.

The greatest difficulties may arise when differentiating speech and language disorders with a sensory component from speech impairments due to an auditory analyzer defect. The following clinical features may assist in diagnosis [7, 31, 50].

- children with hearing loss tend to have a fairly stable perception threshold below which speech perception becomes impossible, whereas in sensory impairments, a flickering inconstancy of auditory function is noted,

- increasing the volume of addressed speech improves comprehension in children with hearing loss, but leads to the opposite effect in children with sensory impairments, who usually perceive quiet, calm speech better

- speech perception in children with sensory impairments, unlike normally hearing children or children with hearing loss, depends on the presentation rate of auditory stimuli (intervals between them), the quality of sounds (pure tones, noise, or speech sounds), emotional tone, and finally, the situation the child is in: silence calms such children and makes them more receptive to sound, and their reaction to quiet noises may be better in a home environment,

- unlike children with hearing loss, children with sensory impairments often exhibit hyperacusis—an increased sensitivity to sounds that are indifferent to others (noise, rustling, creaking, etc.), while children perceive such sounds painfully, become agitated, and show a specific behavioral response to them, etc.

The diagnosis of hearing impairment is confirmed by an otorhinolaryngologist-audiologist, while additional instrumental diagnostic methods are used to determine the degree of hearing loss more precisely (see the section on diagnostics).

Speech disorders due to acquired somatic and neurological diseases, for example, acquired epileptiform aphasia (Landau-Kleffner syndrome) (F80.3)

Landau-Kleffner syndrome (LKS) is a syndrome of acquired epileptic aphasia and a rare form of childhood epileptic encephalopathy. In LKS, over the course of several weeks to months (in very rare cases, even days), against the background of continuous diffuse epileptiform activity during sleep, there is a progressive regression of speech functions and behavioral disturbances. The age of onset is typically between 3 and 7 years. The awake EEG typically shows high-amplitude sharp waves or sharp-slow wave complexes located predominantly in the posterior temporal or temporoparietal regions (benign childhood epilepsy spikes with centrotemporal foci [BCEST] / benign childhood epileptiform patterns [BCEP]). During sleep EEG (in NREM and REM sleep phases), epileptiform activity spreads diffusely, replacing physiological sleep patterns and occupying up to 100% of the recording. The difficulty in diagnosing LKS lies in the fact that 20–25% of patients do not experience epileptic seizures despite the gradual deterioration of speech. Epilepsy in LKS manifests as polymorphic seizures: focal motor (pharyngooral and hemifacial), atypical absence seizures, atonic, bilateral tonic-clonic seizures (BTCS), and myoclonic seizures [35, 53].

The temporal relationship between the onset of epileptic seizures and the loss of speech is variable (ranging from a few months to 2 years). In the most severe cases, children lose the ability to speak (or speech is limited to isolated sound complexes). With milder deficits, speech fluency suffers, and articulation disorders are observed. In a small number of cases, voice quality is impaired with the loss of normal modulations [38]. Almost all patients achieve spontaneous remission of seizures and epileptiform activity upon reaching puberty (even without taking antiepileptic drugs); however, speech impairments may be irreversible if continuous epileptiform activity during sleep is not timely suppressed [35].

For differential diagnosis, it is important to study the medical history (presence of developmental regression with the loss of speech skills), assess the clinical picture (epileptic seizures, speech defects, emotional and behavioral disorders, etc.), and compare it with encephalographic data, including the recording of brain bioelectric currents during sleep.

Other developmental disorders of speech and language (F80.8) – which include: F80.81 – speech development delay due to social deprivation (includes delay due to socio-pedagogical neglect and physiological speech development delay), as well as F80.82 – speech development delays combined with intellectual developmental disorder and specific scholastic skills disorders.

In medical speech-language pathologist reports, this is designated by the terms "speech development delay," "psycho-speech development delay," and "difficulties in mastering school skills due to speech development delay."

The clinical picture of speech development delay due to social deprivation is characterized by a limited vocabulary (both active and passive), agrammatisms in oral speech, mismatch between the level of phrasal speech development and the child's age and cognitive status, with clear signs of reduced or absent access to a developing speech environment.

The clinical picture of speech development delay combined with intellectual developmental disorder and specific scholastic skills disorders is not limited to speech symptoms alone, but is complemented by cognitive disorders manifested as impairments in abstract-logical thinking, low cognitive activity, insufficient learning capacity, and impairments in attention, memory, and mental performance.

Speech disorders of this category are accompanied by borderline deviations from normative intellectual development values that do not reach the degree of mental retardation.

Elective mutism (F94.0) – a disorder characteristic of childhood and adolescence, included in ICD-10 under "Disorders of social functioning with onset specific to childhood and adolescence." The condition is characterized by pronounced, emotionally conditioned selectivity of verbal contact, where the child demonstrates normal speech communication in certain situations (usually in the home environment) but is unable (refuses) to speak in others (usually with unfamiliar people, in kindergarten, at school). The disorder most frequently first manifests in early childhood, with a second peak of incidence occurring at the beginning of school education. The duration of the condition ranges from several months to 2 years. The prevalence in the entire population of children and youth is 0.02%. Girls are affected more often (1.9:1). A combination with social anxiety, withdrawal in communication, sensitivity, tendency toward resistance and passive protest, etc., is typical. To diagnose the disorder, the condition must meet the following criteria:

1) expressive and receptive speech within the normal range (within two standard deviations relative to the normative level for the given age based on test data);

2) consistent, objectified inability to speak in specific social situations where speech is expected (e.g., at school), while speech is possible in other situations;

3) duration of the disorder exceeding 4 weeks;

4) the inability to speak must be consistent over time, and the situations in which speech appears or is absent must be constant and predictable;

5) absence of pervasive developmental disorders (F84);

6) the disorder is not caused by the child's unfamiliarity with the language in which speech is expected [38, 42].

To assess the state of speech, prove the preservation of speech function and the possibility of its use for communication, and rule out other disorders, audio and video recording methods of the patient at moments when they use speech in communication can be used.

Aphasias (R47). Speech and language developmental disorders should be distinguished from aphasias, which represent a partial or complete loss of already formed speech resulting from central nervous system damage (stroke, traumatic brain injury, brain tumor, etc.) [3, 9, 47, 74, 75].

The criteria for diagnosing aphasia in childhood are as follows:

1) a period of normal speech development preceding the breakdown;

2) partial or complete breakdown of speech functions associated with a confirmed CNS disease;

3) the typical age for childhood aphasias is 3–7 years [3, 66].

2. Diagnostics, medical indications and contraindications for diagnostic methods

During the diagnosis of speech and language developmental disorders, it must be taken into account that a key feature of childhood is the continuous and uneven process of ontogenetic development of structures and functions, which determines the adaptation of the systems and functional capabilities of the child's body to environmental conditions.

Speech dysontogenesis underlying speech and language developmental disorders is part of general mental dysontogenesis, which can occur in the form of retardation (delay), asynchrony (a combination of accelerated development of certain functions, systems, or personality components and delayed development of others), or regression (reactivation of reaction and functioning forms normal for an earlier age, but archaic for the child's current age).

The identification of signs of dysontogenesis that serve as precursors to speech disorders and allow classifying a child as being at risk for developing speech and language developmental disorders should be carried out starting from the second half of the first year of life. Diagnostic measures related to this are outlined in Section 5 of these clinical guidelines.

Criteria for Establishing the Diagnosis/Condition

The diagnosis is established on the basis of:

1. anamnestic data,

2. mental status assessment,

3. physical examination,

4. neurological status assessment,

5. laboratory tests,

6. instrumental examinations,

7. medical and speech-language pathology assessment,

8. psychological/neuropsychological examination.

2.1 Complaints and Anamnesis

Anamnesis collection is carried out when parents apply to a medical organization with complaints of delayed speech development and other speech disorders, as well as during specialized diagnostics upon referral by other specialists.

It is important to clarify the following information: the course of pregnancy and childbirth, parameters of neurological and somatic health in the first year of life, early psycho-speech and motor development, family and pedagogical conditions (parenting tactics and adult-child communication, organization of the developmental environment, "screen time" and the child's use of digital devices, bilingualism in the family), previously used methods of diagnostics and treatment of the child, the dynamics of speech and cognitive-behavioral symptoms, the child's social adaptation, comorbid diseases, and hereditary anamnesis.

2.2 Physical Examination

Physical examination methods are not specific and significant for the diagnosis of developmental speech disorders (DSD), but they allow for the assessment of the patient's general condition and physiological parameters.

The examination includes:

• Assessment of the general condition.

• Assessment of constitution (body type): (excess or deficiency of body weight may indicate metabolic disorders, endocrine pathology, eating disorders).

• Assessment of the child's physical development conformity to passport age.

• Identification of dysmorphic stigmata, which may indicate the presence of a genetic disease.

• Examination of the skin: Presence of neurocutaneous syndromes (e.g., in tuberous sclerosis, neurofibromatosis). Maceration areas on the facial skin around the lip border, excoriations on finger cuticles, etc., may be a consequence of obsessive habits frequently seen in children (lip licking, onychophagia). Possible traces of self-harm.

• Examination of the somatic state by organs and systems.

If signs of a somatic disease are detected, patients should be referred to relevant specialists for an in-depth examination.

2.3 Laboratory Diagnostics

There are no specific indicators of instrumental and laboratory examination methods that could reveal pathognomonic markers for DSD. The use of laboratory and instrumental diagnostics may be justified by:

• The need for differential diagnosis when a secondary nature of speech disorders is suspected, in order to exclude another leading disease.

• Clinical indications in the presence of signs of comorbid diseases requiring the use of laboratory and instrumental diagnostic methods.

It should be especially emphasized that the value of neuroimaging studies for making a diagnosis is insufficient to recommend their routine performance in all children with suspected DSD. Indications for neuroimaging in DSD are clinical grounds to suspect the presence of other disorders for which neuroimaging is necessary (e.g., epilepsy, suspected tumor or other brain formations, degenerative or demyelinating disease of the central nervous system, developmental regression).

2.4 Instrumental Diagnostics

Comments: Routine EEG has very low clinical significance and can only be performed if no other options are available. The main objective of the examination is not to confirm the diagnosis of DSD (no clear relationship between EEG changes and DSD has been established), but to exclude other disorders (ephemera/epilepsy, epileptic encephalopathies) to choose the optimal therapeutic tactics.

2.5 Other Procedures

Level of Certainty of Evidence – 4

Comments: A medical and speech therapy examination is the basic and primary diagnostic method for DSD. It aims to examine the structure of the articulation apparatus, mobility of articulation organs, sound pronunciation, phonemic perception, passive and active vocabulary, grammatical structure of speech, and the level of phrasal speech formation.

When suspecting the risk of DSD formation due to social factors (F80.81), special attention is paid to the quantitative and qualitative characteristics of speech contacts (correctness of speech of others, bilingualism, completeness of speech communication with adults and peers, etc.).

During a standard examination, it is convenient to use the Speech Profile Map (Appendix G3)

For a standardized assessment of speech development in children aged 3 to 11 years, the KORABLIK test battery («Clinical Evaluation of Basic Linguistic Competencies») can be used, assessing speech skills at the phonological, lexical, morphosyntactic, and discursive language levels in two modalities (comprehension and production of oral speech). Task presentation, response recording, and response scoring protocols are unified and presented in a tablet application. Norms for all tests and ages are integrated into it, with automatic comparison [55, 85, 86, 115].

Level of Certainty of Evidence – 4

Comments: children with DSD have a higher risk of developing a comorbid psychiatric disorder than the general population. At each examination, it is advisable for psychiatrists to clarify the presence of symptoms not related to DSD manifestations, in particular, insufficient cognitive functioning level, irritability, disinhibition, hyperactivity, aggression, auto-aggression, mood disorders, increased anxiety, and other symptoms.

Level of Certainty of Evidence – 5

Comments: The neurologist's task is to identify comorbid neurological disorders and neurological diseases accompanied by secondary speech disorders. The neurologist's role is extremely important in the diagnosis and treatment of epilepsy, which may be accompanied by speech disorders. Recognition and, if necessary, treatment of these diseases and conditions contribute to the correct choice of the target of intervention (primary disorder), as well as improve the functioning and quality of life of the child and increase the effectiveness of correctional and developmental interventions.

Level of Certainty of Evidence – 4

Comments: Based on systemic and differential medical-psychological/neuropsychological diagnostics, differential diagnosis between DSD and other psychological development deviations (e.g., mental retardation, autism spectrum disorders, social and pedagogical neglect) can be performed, and data can be obtained for developing an individual program of correctional and developmental interventions. If necessary, an in-depth examination of an individual mental process using special tests is possible. The selection of tests is made by a specialist individually, based on the data of the conducted medical-psychological/neuropsychological examination.

Level of Certainty of Evidence – 2

Comments: Currently, M-CHAT-R/F is the most effective and well-studied level-one screening tool for assessing ASD risk in children aged 16–30 months.

Level of Certainty of Evidence – 5

Comment: To assess the degree of intellectual disability, the following can be used:

The Merrill-Palmer-Revised (MPR) Scale of Development is designed for an objective, standardized assessment of psychomotor development in children aged 1 month to 6.5 years.

The Griffiths Mental Development Scales (GMDS) are designed for an objective, standardized assessment of psychomotor development in children aged 1 month to 2 years.

The Leiter International Performance Scale, Third Edition (Leiter-3) is used to assess verbal and non-verbal intelligence in children starting from 3 years of age [140].

The Wechsler Preschool and Primary Scale of Intelligence, Fourth Edition (WPPSI-IV) is used to assess verbal intelligence in children starting from 5 years of age [2, 144].

Level of Certainty of Evidence – 5

Comments: Hearing impairments can either be comorbid disorders in developmental language disorder or lead to symptoms resembling speech pathology, which necessitates differential diagnosis in every child with marked delays in speech comprehension or lack of speech. A complete audiologic assessment is performed using objective methods: objective audiometry, auditory steady-state response (ASSR) testing, and short-latency auditory evoked potentials. Timely diagnosis of comorbid hearing impairments is essential to ensure the effectiveness of remedial and developmental interventions. Objective hearing diagnostics may be preceded by subjective auditory function tests (pure-tone and/or speech audiometry), although only objective diagnostics can guarantee reliable results.

In accordance with Appendix 1 to the «Procedure for Conducting Preventive Medical Examinations of Minors» approved by Order of the Russian Ministry of Health No. 514n dated August 10, 2017, the list of examinations during preventive medical examinations of minors includes newborn hearing screening, as well as screening for children aged 1, 2, and 3 months (if records of prior screening are absent) [58].

Level of Certainty of Evidence – 5

Comments: The presence of comorbid somatic disorders in a child with developmental language disorder (developmental dysphasia)—particularly allergic processes, nasal breathing difficulties, chronic somatic and endocrine pathology—reduces the effectiveness of habilitation and rehabilitation measures. For a significant portion of somatic disorders, effective therapies exist that can substantially improve the quality of life of children with developmental language disorder and enhance the effectiveness of remedial and developmental interventions.

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

According to the consensus among leading researchers and experts, supported also by the developers of these clinical guidelines, the most effective treatment method for developmental language disorder is speech therapy and psychological interventions [94, 107, 111, 117, 122, 123]. Specialized speech therapy and psychological training combined with family-pedagogical techniques and approaches serve as the baseline treatment method for developmental language disorder.

Pharmacotherapy and physical modality therapy should only be used as adjunctive treatment methods.

Comprehensive rehabilitation of children with developmental language disorder is the most effective approach, including specialized speech therapy and psychological interventions, as well as family-pedagogical work.

3.1. Therapeutic methods of speech-therapy and psychological intervention

The fundamental and non-alternatives-based treatment method for children with developmental language disorder (developmental dysphasia) that targets core symptoms is a comprehensive medical-psychological-speech therapy intervention, which is administered continuously throughout the entire treatment course [94, 107, 111, 117, 122, 123, 158]. Periodic (1–2 times a year) intensive speech therapy courses lasting 3–6 weeks show the highest efficacy. Parent training sessions must be included in the treatment course to ensure supportive speech activities between intensive therapy courses. Intensive therapy courses should include at least 3 sessions per week.

Level of Evidence – 1

Comments: Conducted in both individual and group formats to overcome speech function impairments. The content, organizational form, frequency, and duration of the procedures are determined by the medical speech therapist based on the results of the child's diagnostic evaluation.

The principles of speech therapy support for children with developmental language disorder are: maximum utilization of various analyzers, reliance on intact analyzers, visual support, conscious learning, step-by-step progression and consistency, consideration of the social function of speech, adherence to the patterns of speech ontogenesis, the earliest possible initiation of speech therapy and habilitation, and the sequential selection of methods based on the child's current developmental level and the achievement of therapeutic objectives.

For recommended principles and directions of speech therapy in developmental language disorder, see Appendix A3.5.

Level of Certainty of Evidence – 4

Comments: Logorhythmic sessions are conducted in a group format to overcome syllable structure impairments by using speech exercises combined with movement and music. The content, frequency, and duration of the procedures are determined by the medical speech therapist based on the child's diagnostic evaluation results. The primary objectives of logorhythmic sessions are to overcome disorders of speech rhythm (syllabic, verbal, syntagmatic), difficulties in restructuring the rhythm of speech movements and word sound-filling, and to develop the perception and ability to reproduce speech rhythms at the syllable, word, and syntagm levels; musical rhythm should be regarded as a tool for shaping rhythmic processes in motor skills and speech.

Level of Certainty of Evidence – 5

Comments: The content, organizational format (individual or group), frequency, and duration of the procedures are determined by the medical psychologist (neuropsychologist) based on the child's diagnostic evaluation results. The neuropsychological program includes methods aimed at stabilizing the emotional state, activating energy potential, cognitive function training, optimization and correction of subcortical-cortical and interhemispheric interactions, and the formation of operational support for verbal and non-verbal mental processes (Appendix A3.6). Specific psychotherapeutic/psychocorrective intervention targets the mental processes that form the psychological basis of speech: attention, perception, memory across various modalities, and thinking. The development of praxis is carried out in several directions: general and manual motor skills (movement coordination, reciprocal coordination, motor memory), facial muscle praxis, symbolic praxis, object actions, hand posture praxis, spatial, dynamic, and constructive praxis.

Level of Evidence – 1

Comments: the involvement of parents and/or caregivers increases the efficacy of habilitation measures. In the context of this work, the immediate family environment is viewed as an important participant in the therapeutic and rehabilitation process. Failure to follow this recommendation reduces the treatment efficacy and the favorability of the prognosis, which the physician must inform the parents about before initiating treatment.

3.2. Pharmacotherapy.

There is no convincing evidence in modern scientific literature regarding the efficacy of pharmacotherapy for speech and language developmental disorders. Nootropic agents (N06BX Other psychostimulants and nootropics) have traditionally been the main class of drugs considered in relation to the pharmacotherapy of speech and language developmental disorders in domestic medicine. Globally, researchers and clinicians lack a well-established consensus on the use of nootropic therapy for speech and language developmental disorders: nootropic agents (N06BX Other psychostimulants and nootropics) are traditionally used in the treatment of speech and language developmental disorders in Russia and some Eastern European countries, but are not used in Western European countries and North America. Publications on the efficacy of specific nootropics (N06BX Other psychostimulants and nootropics) or cerebroprotectors (N07XX Other nervous system drugs) are based on isolated domestic studies. We found no meta-analyses or systematic reviews of studies on the efficacy of these drug groups in the treatment of speech and language developmental disorders.

Often, specialists responsible for making patient treatment decisions are influenced by the general debate surrounding nootropic therapy, which extends beyond the treatment of speech and language developmental disorders and is filled with arguments of varying degrees of scientific validity, including those attributed to evidence-based medicine or unverified clinical experience. Therefore, the guideline developers consider it necessary to establish provisions grounded in scientific facts that can help specialists objectify their positions for making responsible decisions.

1. Nootropic drugs are classified as a distinct class of drugs in the international drug classification system—the Anatomical Therapeutic Chemical (ATC) Classification System adopted by WHO, as well as by the Russian Ministry of Health: ATC code - N06BX Other psychostimulants and nootropics.

2. In published efficacy and safety studies of nootropic therapy, the majority of which are foreign randomized double-blind placebo-controlled trials, various conditions are defined as therapeutic targets: post-stroke rehabilitation [103, 157], post-stroke survival [159], prevention of post-stroke disability [121], traumatic brain injury rehabilitation [95], postoperative and post-anesthetic cognitive dysfunctions [104, 113, 136], cognitive functions in coronary artery bypass grafting [150], mild cognitive impairment in adults [137, 155], prevention of cognitive decline in the elderly [101], dementias [105], parkinsonism [146], chronic fatigue syndrome [119], cognitive functions in healthy adults [118, 130, 148], developmental dyslexia in children [112, 151, 156], cognitive functions in children with Down syndrome [125], breath-holding spells in children [147], and other conditions. Specialists should independently review the results of these studies, the publications of which are publicly available. The listed conditions are etiopathogenetically and age-specifically heterogeneous, and the effects of various nootropic agents (N06BX Other psychostimulants and nootropics) studied in them have specific differences; therefore, it is recommended to form a position regarding the efficacy of each medicinal substance for each specific nosology rather than globally.

3. General research data on the efficacy of various medicinal substances with nootropic action in childhood speech disorders are presented below.

Only a few of the cited studies meet the high-confidence standard of double-blind placebo-controlled trials; studies with a small number of participants are quite widely represented. The conducted studies are based on the hypothesis of stimulating neuronal processes underlying cognitive, including speech, activity using drugs with nootropic activity. The limited quantity and quality of studies determine the grades B and C of recommendation strength for using nootropic agents (N06BX Other psychostimulants and nootropics) in the treatment of speech and language developmental disorders.

No studies demonstrating the inefficacy of nootropic agents (N06BX Other psychostimulants and nootropics) in the treatment of patients with speech and language developmental disorders were found in domestic and foreign literature.

Based on the designs of most studies, the results of individual works, and their own clinical experience, the working group experts draw attention to the fact that in speech and language developmental disorders, nootropic therapy can be used exclusively as an adjunct to basic treatment strategies based on speech therapy [100, 131]. The effect of isolated nootropic therapy on the development of speech function is questionable.

There are no indications for the preferred choice of nootropic agents (N06BX Other psychostimulants and nootropics) depending on the structure of the speech disorder and comorbid cognitive disorders in speech and language developmental disorders.

There are no indications regarding the possibility or impossibility of combining several nootropic drugs (N06BX Other psychostimulants and nootropics) during a single course of pharmacotherapy.

In each individual case, the appropriateness of prescribing nootropic therapy is determined by the physician, taking into account, among other things, its presumed and historical efficacy/safety in a specific patient.

If patients with speech and language developmental disorders have comorbid psychiatric and neurological disorders meeting ICD-10 criteria, they must be diagnosed as a comorbid condition to justify the prescription of appropriate medications stipulated by the guidelines for their treatment.

There are no indications of specific approaches to drug selection and administration routes for treating disorders comorbid with speech and language developmental disorders in peer-reviewed medical information sources.

Level of Certainty of Evidence – 4

Comments:

The drug is used off-label.

Dosing regimen: for children, the recommended single injection dose is 0.1-0.2 ml/kg of body weight.

Injections of the drug are performed in the morning. Courses last 10 days with an interval of 1.5-6 months.

Double courses are described (during the first 10 days of the first month and during the first 10 days of the second month).

Level of Evidence – 3

Comments: There are two oral forms of the drug: liquid and tablet forms with varying medicinal substance content. The most optimal forms should be chosen based on the child's age. A single dose for children is 0.25-0.5 g. The daily dose for children is 0.75-3 g. The treatment course is 1-4 months.

3.3. Treatment by hardware exposure to physical factors

Just like pharmacotherapy, hardware-based treatment methods are adjunctive and cannot be used as an isolated intervention for treating speech and language developmental disorders. The evidence base for the use of hardware methods in the treatment of speech and language developmental disorders is currently significantly limited. In this regard, a description of hardware intervention methods in the treatment of speech and language developmental disorders is provided in these clinical guidelines to justify the possibility of their use by specialists as methods that enhance the effect of primary (speech) therapy.

Transcranial magnetic stimulation (TMS) is a method of neurostimulation and neuromodulation of brain structures based on the electromagnetic induction of an electric field in a target area of the brain. Repetitive TMS (rTMS) can be used for therapeutic purposes. The US Food and Drug Administration (FDA) has approved TMS for the treatment of major depressive disorder, a specific type of headache associated with migraine, and obsessive-compulsive disorder (OCD). Studies on the efficacy of TMS for specific speech and language disorders (SSLD) have not been conducted abroad. Three Russian studies indicate the efficacy of rTMS in treating SSLD in children; the results of one of them are presented in a format that allows for the evaluation of the method's efficacy from the standpoint of evidence-based medicine [52]. The efficacy of the technology has been demonstrated in combination with speech therapy and neuropsychological treatment and rehabilitation procedures. The procedure is performed exclusively by a physician: a neurologist, psychiatrist, or other specialist. There are contraindications and conditions where the method is ineffective. The decision to prescribe TMS is made taking into account, among other factors, the distance the child's place of residence is from the treatment facility: regular long-distance travel for the child to the treatment site (in cases of remote residence) may be associated with a lack of therapeutic effect due to child fatigue.

The appropriateness of prescribing a course of TMS to children with SSLD is determined by the attending physician, who oversees the monitoring, prescription, and control of treatment. The use of these procedures should be considered for children no earlier than 3 years of age.

Transcranial direct current stimulation (tDCS) is based on the therapeutic application of a low-intensity direct (galvanic) electrical current (usually not exceeding 2 mA) to the brain. The mechanisms of action of this therapeutic method are not yet fully understood. It is hypothesized that anodic stimulation enhances glutamate synaptic transmission, suppresses gamma-aminobutyric acid transmission, and positively or negatively modulates dopamine, serotonin, and acetylcholine transmission in the cerebral cortex [160, 161]. These mechanisms of action suggest that the method holds promise for clinical trials in various psychiatric and neurological disorders, including in children [162, 163, 164, 165, 166]. Individual domestic publications present the experience of using tDCS for speech disorders in children over 3 years of age [56, 81]. However, the authors found no studies proving the efficacy and appropriateness of prescribing tDCS for SSLD. This highlights the need for high-quality, large-scale randomized clinical trials.

4. Medical Rehabilitation and Sanatorium-Resort Treatment

Sanatorium-resort treatment based on the use of natural and preformed natural resources is an auxiliary component of habilitation and rehabilitation programs for children diagnosed with SSLD. Environmental factor therapy helps improve the body's overall adaptive capacity and sanogenesis; however, the efficacy of rehabilitation methods within sanatorium-resort treatment currently lacks a sufficient evidence base. Therefore, sanatorium-resort treatment can only be considered as a way to enrich the environment for the child's recreation and physical development.

5. Prevention and Dispensary Observation

SSLD is a common developmental disorder among preschool and school-aged children, for which there are currently no specific preventive measures. At the same time, early detection of signs of speech disorders, their potential causes, and comorbid diseases and conditions is a prerequisite for organizing early, comprehensive care for the child to improve the prognosis. Screening methods serve this purpose, allowing for the identification of at-risk groups of children in need of in-depth evaluation and treatment by specialized professionals.

By Order of the Russian Ministry of Health No. 396n dated June 13, 2019, "On Amendments to the Procedure for Conducting Preventive Medical Examinations of Minors, Approved by Order of the Ministry of Health of the Russian Federation No. 514n dated August 10, 2017," additions were introduced regarding the screening of 2-year-old children via parent questionnaires during preventive medical examinations to identify at-risk groups for the development or presence of mental development disorders. The psychiatrist examines only those children who are included in the specified risk group [41].

To prevent secondary complications derived from the core symptoms of SSLD, it is advisable for all patients with this disorder to undergo the therapy and habilitation methods described in Section 3.2 of the clinical guidelines, an important component of which is speech therapy and neuropsychological rehabilitation built on the principles of comprehensiveness and continuity.

An important component of secondary and tertiary prevention is working with the parents and immediate social circle of a child with SSLD. This component requires counseling and psychoeducation for parents (legal representatives) regarding the disease, its clinical course, treatment, and habilitation, based on modern scientific data and evidence of efficacy, as well as providing psychological support to the family.

The district pediatrician plays a central role in identifying children with developmental disorders, including SSLD. A detailed medical history, physical examination and general check-up with assessment of neuropsychiatric (including speech and language) development using special screening and standardized tests, and necessary laboratory and instrumental examinations allow for the timely identification of existing problems in children. Children in whom genetic, neurological, or psychiatric disorders are identified are referred to specialized professionals (e.g., a medical speech-language pathologist, neurologist, psychiatrist, otorhinolaryngologist-audiologist, geneticist, maxillofacial surgeon, etc.) for examination and treatment of the underlying condition. A child under 11 months of age is examined by the district pediatrician 14 times (including 3 home neonate nursing visits), from 1 year to 2.5 years of age — 6 times, and from 3 years to 17 years of age — annually [10, 58].

To identify "specific SSLD risk groups," the district pediatrician can use the "Adapted Diagnostic Algorithm for the Early Detection of Mental Development Disorders" (Appendix A3.1). The specialist must be familiar with the norms of ontogenesis (Appendix A3.2).

Dispanserization (preventive clinical examination) of children in their first year of life by a neurologist is performed twice (at 1 month and 12 months) [40, 59]. During the appointment, the "Adapted Diagnostic Algorithm for the Early Detection of Mental Development Disorders" (Appendix A3.1) may also be used. The specialist must be familiar with the norms of ontogenesis (Appendix A3.2).

Preventive medical examinations of children by a psychiatrist are conducted at the following ages: 2, 4, 14, 15, 16, and 17 years. Psychiatric examination of the child is of key importance for diagnosing SSLD, performing differential diagnosis with other mental diseases and conditions, identifying comorbid mental disorders, and determining further patient management tactics, including prescribing additional examinations and defining the program of therapeutic and habilitative measures [17, 58, 63].

For a detailed diagnosis of the structure of the speech defect, a speech therapy evaluation by a medical speech-language pathologist is necessary using the Speech Profile Card protocol. The scoring system is intended for the quantitative recording of the current level of speech function development for subsequent dynamic comparison.

6. Organization of Medical Care

Comprehensive care for children with SSLD is provided within the framework of outpatient polyclinic and inpatient medical services, as well as special remedial programs for children with severe speech disorders in educational institutions. The management of patients with SSLD generally includes stages implemented at various levels, each characterized by organizational forms depending on the severity of the speech pathology and concomitant disorders, a list of involved specialists, and the diagnostic, remedial, and therapeutic measures they implement.

Levels of care for children with SSLD.

Level I: Outpatient polyclinic care.

Level II: inpatient care.

Level III: education system

Patient models and recommended volumes of medical and correctional care

M1 - Children with isolated mild, predominantly articulatory, speech disorders that do not correspond to age norms.

M2 - Children with mild to moderately mild manifestations of developmental speech disorders, without severe comorbid neuropsychiatric disorders.

M3 - Children with severe and moderately severe forms of developmental speech disorders, without severe comorbid neuropsychiatric disorders.

M4 - Children with developmental speech disorders of varying severity, having severe comorbid neuropsychiatric disorders.

M5 - Children with developmental speech disorders of varying severity, who had severe comorbid neuropsychiatric disorders, but have achieved qualitative state compensation/remission.

Matrix of recommended volumes of care

Notes:

+ mandatory recommendation

+- optional (conditional) recommendation

[1] Patients are referred to second-line specialists by first-line specialists.

Criteria for Evaluating the Quality of Medical Care

References

Appendix A1. Working Group Composition

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience of these clinical guidelines:

psychiatrists.

neurologists.

pediatricians.

psychotherapists.

medical psychologists.

medical speech therapists.

educational psychologists

The members of the working group declare no conflict of interest requiring disclosure.

Table 1. Scale for assessing levels of evidence (LE) for diagnostic methods (diagnostic interventions)

Table 2. Scale for assessing levels of evidence (LE) for prevention, treatment and rehabilitation methods (preventive, therapeutic, rehabilitation interventions)

Table 3. Scale for assessing grades of recommendation (GR) for prevention, diagnosis, treatment and rehabilitation methods (preventive, diagnostic, therapeutic, rehabilitation interventions)

Procedure for updating clinical guidelines. The mechanism for updating clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based data on the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to the previously approved clinical guidelines, but no more frequently than once every 6 months.

Appendix A3. Reference Materials

Appendix A3.1. Description of speech development levels according to R.E. Levina, T.B. Filicheva

Level I of speech development

General characteristics: absence of commonly used speech.

Phrasal speech: absent or represented by babbling elements that consistently reproduce the situation they denote with the involvement of clarifying gestures. Each element used in such a "phrase" can have a different meaning and cannot be understood outside a specific situation. Babbling formations, depending on the situation, can be regarded as single-word sentences.

Speech comprehension: absent or there is a limited understanding of the meanings of grammatical word modifications. If situation-orienting cues are excluded, children are unable to distinguish singular and plural noun forms, past tense verb forms, masculine and feminine gender forms, and do not understand the meanings of prepositions. When perceiving addressed speech, lexical meaning predominates over grammatical form.

Lexical reserve: active vocabulary consists of a limited set of indistinctly pronounced everyday words, sound imitations, and sound complexes. Differentiated designation of objects and actions is practically absent. Polysemy of used words is characteristic. The same complexes are used to designate objects, actions, and qualities. Names of actions are replaced by names of objects, and vice versa. Passive vocabulary is usually wider than active vocabulary.

Grammatical structure of speech: morphological elements are not used to convey grammatical relations; root words devoid of inflections (endings) predominate.

Phonetic and phonemic functions: sound pronunciation is absent or characterized by polymorphic disorders.

Coherent speech: absent. Pointing gestures and facial expressions are actively used in communication.

Level II of speech development

General characteristics: rudiments of commonly used speech.

Phrasal speech: represented only by simple sentences consisting of 2-3 (more rarely 4) words.

Speech comprehension: improves due to the discrimination of certain grammatical forms (unlike Level 1); children can focus on morphological elements, which acquire a meaning-differentiating significance for them. Discrimination of singular and plural forms of nouns and verbs (especially with stressed endings) and masculine and feminine gender forms of past tense verbs is noted. Difficulties remain in understanding the number and gender forms of adjectives.

Lexical reserve: significantly lags behind the age norm. There is a lack of knowledge of many words denoting body parts, animals and their offspring, clothing, furniture, and professions. There are limited opportunities for using the object vocabulary, the vocabulary of actions and attributes; children do not know the names of the color, shape, and size of an object, substituting words with semantically close ones.

Grammatical structure of speech: gross errors in the use of grammatical structures are recorded. There is a mixing of case forms, the use of nouns in the nominative case, and verbs in the infinitive or the 3rd person singular and plural present tense;

errors in the use of number and gender of verbs, when changing nouns by numbers; lack of agreement of adjectives with nouns, numerals with nouns.

Phonetic and phonemical functions: sound pronunciation is characterized by the presence of numerous specific sound distortions, substitutions, and mixings. The pronunciation of soft and hard sounds, sibilants, affricates, voiced and voiceless sounds is impaired. A dissociation appears between the ability to pronounce sounds correctly in an isolated position and their use in spontaneous speech.

Coherent speech: names of objects, actions, and individual attributes are designated differentially; use of pronouns is possible, and sometimes conjunctions, simple prepositions in elementary meanings. Answers to questions about a picture related to family and/or familiar events of surrounding life are accessible.

Level III of speech development

General characteristics: everyday phrasal speech with problems in lexical, grammatical, and phonetic structure.

Phrasal speech: expanded phrasal speech with elements of lexical-grammatical and phonetic-phonemic underdevelopment.

Speech comprehension: approaches the norm. Insufficient comprehension of changes in word meanings expressed by prefixes and suffixes is noted; difficulties are observed in distinguishing morphological elements expressing the meaning of number and gender, in understanding logico-grammatical structures expressing cause-and-effect, temporal, and spatial relations. They inaccurately understand the meaning of low-frequency words, the figurative meaning of proverbs and metaphors.

Lexical reserve: nouns and verbs predominate in the active vocabulary. There are insufficient words denoting qualities, attributes, states of objects and actions. The inability to use word-formation methods creates difficulties in using word variants; the selection of root words, the formation of new words using suffixes and prefixes, and the selection of synonyms and antonyms are not always accessible. They often replace the name of a part of an object with the name of the whole object, or the required word with a semantically similar one.

Grammatical structure of speech: agrammatisms are represented by errors in the agreement of numerals with nouns, adjectives with nouns in gender, number, and case. Significant difficulties arise when using both simple and complex prepositions.

Phonetic and phonemical functions: characteristic is the undifferentiated pronunciation of sounds (especially sibilants, affricates, vibrants, and sonorants), in which one sound simultaneously replaces two or more sounds of a given or close phonetic group. Unstable substitutions and phoneme mixings are noted: in isolation, the sound is pronounced normatively, but in words and sentences, it undergoes mutual substitutions.

Coherent speech: simple expanded sentences predominate, complex structures are used extremely sparingly. There are difficulties in planning one's utterances and selecting appropriate linguistic means.

Level IV of speech development

General characteristics: everyday phrasal speech with residual manifestations of lexical-grammatical and phonetic-phonemic underdevelopment.

Phrasal speech: expanded phrasal speech with individual elements of lexical-grammatical and phonetic-phonemic underdevelopment.

Speech comprehension: insufficient level of lexical language means at the level of words and phrases with figurative meaning.

Lexical reserve: with a sufficiently diverse object vocabulary, there are no words denoting certain animals and birds, people of various professions, and body parts. Generic and specific concepts are mixed in answers.

When designating actions and attributes of objects, standard names and names of approximate meaning are used. Having a certain stock of words denoting various professions, children experience significant difficulties in differential designation for male and female individuals. Single paraphasias, sound transpositions, and less often syllables are noted; a small percentage includes perseverations and the addition of syllables and sounds.

Grammatical structure of speech: errors in the use of genitive and accusative plural nouns, complex prepositions; in some cases, violations of the agreement of adjectives with nouns, numerals with nouns are noted.

Phonetic and phonemical functions: sound pronunciation is close to normative. In isolation, sounds are pronounced normatively, but in the speech stream, they may undergo distortions and substitutions, creating the effect of a certain "smudged" articulation.

Coherent speech: in conversation or when composing a story, there may be violations of logical sequence, "getting stuck" on minor details, omissions of main events, repetition of individual episodes. Narrating life events and composing a story with elements of creativity, children use simple, uninformative sentences. Difficulties persist in planning their utterances and selecting appropriate language means.

Appendix A3.2. Characteristics of the main stages of normative early psycho-speech development

(CDC (Centers for Disease Control and Prevention) materials https://www.cdc.gov)

Appendix A3.3 G3. Adapted Diagnostic Algorithm for Early Detection of Mental Development Disorders and Identification of "Specific Risk Groups for Speech and Language Development Disorders (SLDD)"

Appendix A3.4. Speech profile map

Appendix A3.5. Speech therapy programs

Speech therapy and habilitation for SLDD (F80.0)

Speech therapy and habilitation for SLDD (F80.1, F80.2)

Level I of speech development

Areas of speech therapy rehabilitation:

Level II speech development

Areas of Speech Therapy Rehabilitation

Level III of speech development

Areas of Speech Therapy Rehabilitation

Appendix A3.6 Principles and areas of neuropsychological support for children with established mixed specific developmental disorder of scholastic skills (SRRR). Objective: formation of compensatory mechanisms for the development of higher mental functions in children with established SRRR.

Leading tasks: formation of the basic foundations of cognitive functions and support of energy tone; development (or restoration) of interhemispheric interaction.

Areas of work:

1. Formation of visual and auditory perception, sensorimotor activity.

2. Formation and correction of basic sensorimotor (simultaneous and reciprocal) interactions.

3. Development of visual, manual kinesthetic, and somatospatial gnosis and praxis.

4. Increasing the pace of activity through the automation of skills and the use of preserved analyzer systems.

5. Development of self-planning skills, formation of an algorithm for self-control and self-correction, motivational-need processes in accordance with age requirements.

6. Strengthening the priority of voluntary activity, increasing awareness and differentiation, volition and mediation of emotions and emotional experiences, formation of adequate self-esteem and "self-image".

7. Development of modality-specific types of attention, memory, and overcoming stereotypes.

8. Correction and improvement of adaptive and communicative skills, formation of the ability to establish and maintain stable and flexible relationships with emotionally significant people.

9. Overcoming anxiety-phobic spontaneous reactions and replacing them with constructive ones featuring an analytical component.

Areas of work differentiated by levels of speech development

LEVEL 1

- stimulation of orienting activity by drawing the child's attention to objects and phenomena and ensuring positive motivation;

- improving the skill of fixing gaze on an object, concentration, and tracking its movement in a small space;

- developing the ability to recognize everyday objects and toys, identify them among a set of diverse objects according to an adult's instruction and demonstration, and find identical ones;

- developing visual attention and visual memory while observing two objects;

- developing auditory concentration using sounding children's and musical toys;

- forming somatosensory agnosia in games involving touch localization;

- developing hand-eye coordination, teaching grasping, palpation, and object movement skills (joint movements are allowed initially, then the child performs them independently);

- mastering instrumental actions with objects that have a fixed meaning;

- encouraging visual contact, building the ability to listen to an adult, respond to address, and follow a simple instruction;

- developing the ability to pay attention to and respond to an adult's facial expressions, gestures, and intonations;

- developing the capacity for motor imitation;

- forming the self-image, the ability to recognize oneself in a mirror and choose one's reflection out of two (paired with another child);

- actualizing shared emotional experiences in various types of activities.

LEVEL 2

- developing the skill of identifying objects based on holistic perception without analyzing features and properties;

- forming the ability to correlate an object with its image, recognize it in a picture, and distinguish two objects based on an undifferentiated size feature;

- developing attention and memory, as well as the function of tracking the movement and displacement of objects relative to other objects;

- developing the ability for holistic perception of objects (working with two-part background-free cut-up pictures and paired pictures);

- developing spatial orientation, primarily regarding one's own body;

- developing auditory perception through distinguishing non-verbal sounds (a sequential series of 2-3 sounds) and recognizing objects and animals in pictures based on sound imitation;

- improving three-finger pinch, index finger, and thumb grip in sorting and carrying games with objects of various sizes and shapes;

- teaching matching actions in games with shape sorters, encouraging size orientation;

- forming the ability to fit a figure into a slot, act sequentially and purposefully, support an object with the other hand, and coordinate the movements of both hands (reciprocal coordination);

- mastering instrumental actions using auxiliary means or tools in problem situations;

- consolidating readiness for joint activities with an adult;

- developing the ability to imitate expressive movements and facial expressions of an adult in game situations;

- understanding gestures and expressive movements combined with or without verbal instructions;

- forming the ability to recognize oneself and loved ones in photographs;

- forming readiness to interact with peers in games involving a single shared object.

LEVEL 3

- forming visual perception through the differentiation of objects by shape and the identification of an object with a standard sample shape;

- encouraging practical trial-and-fitting, comparison using verbal instructions, generalization, and verbalization of actions;

- developing concepts of quantity, shape, and size;

- forming holistic visual perception;

- improving orientation in one's own body as well as the body parts of another person, a doll, toy animals, and their images;

- developing the ability to recognize and distinguish non-verbal sounds in a series of 3-4 signals;

- developing the ability to recognize and distinguish vowel sounds;

- developing orientation regarding loudness and duration of sounds in games;

- improving tactile agnosia through palpation of objects and their contours;

- developing stereognosis and the tactile recognition of objects varying in size, texture, and shape;

- improving matching actions in games with stackers and nesting dolls; - developing the ability to match pairs of objects by size;

- improving instrumental actions in problem situations;

- teaching the creation of a simple tool or auxiliary device;

- improving hand-eye coordination, consolidating object exploration skills: palpation, tracing the contour with a finger;

- refining the ability to recognize objects by tracing hand movements and pointing to them;

- developing constructive praxis when reproducing simple constructions by imitation and model;

- encouraging speech in various communicative situations;

- imitating articulatory movements and expressive movements in active games;

- mastering readiness for parallel play ("playing alongside"), encouraging children to interact during gaming activities.

LEVEL 4

- forming and improving color visual agnosia;

- teaching practical trial-and-fitting (applying) techniques with subsequent commentary and generalization of actions;

- developing optic-spatial functions in didactic games with cut-up pictures (image on a white background);

- improving shape perception when selecting volumetric geometric bodies and planar figures of more complex configurations (star, oval, polygon);

- improving shape perception in games with didactic toys: stackers, nesting dolls, matrices;

- developing spatial agnosia in construction by imitation and model using desktop building materials and counting sticks;

- forming complex spatial orientations;

- auditory orientation in the sounds of musical instruments: pipe, bell, tambourine, drum, metallophone;

- forming the ability to perceive and reproduce iterative rhythms (repetition rhythms where sounds are presented with equal time intervals) of no more than two signals;

- teaching orientation in pitch, loudness, timbre of the voice, as well as the location of the sound source;

- consolidating the ability to orient to the sound of vowels and perform specific actions in response to a sound signal.

- development of the ability to differentiate adult voice intonations and volume;

- improvement of tactile gnosis (temperature properties);

- training in the practical discrimination of texture features by touch, finding paired objects by touch according to texture and size;

- reinforcement of the skill of construction by imitation and by a model;

- improvement of matching and tool-using actions in object play;

- mastery of object-play actions in accordance with age norms;

- expansion of the range of joint activities with an adult in games with plot elements;

- improvement of expressive movement skills in dramatic play;

- formation of the ability to interact with peers in procedural and plot-based play.

Appendix B. Physician Action Algorithms

Appendix C. Patient Information

Parents or legal representatives of a patient with specific speech and language disorders (SSLD) need to be explained the nature, manifestations, diagnostic methods, and intervention approaches for this group of disorders in an accessible form.

Speech disorders are diverse; they manifest as disorders of pronunciation, grammatical structure of speech, and a limited vocabulary.

A child's fully developed speech is one of the main conditions for their development. Severe oral speech disorders can cause delays in cognitive development, difficulties in acquiring written language skills (reading and writing), and negatively affect the child's socialization.

In many cases, children with speech disorders need help not only from a speech therapist (logopedist) but also from other specialists—a medical psychologist, psychiatrist, neurologist. It is necessary to create a system of remedial and developmental classes aimed at eliminating the symptoms of the speech disorder and forming the ability for full speech communication, developing the cognitive sphere, basic mental processes, self-control skills, and general and fine motor skills.

Diagnosis of SSLD includes gathering anamnestic data, as well as assessing the current psychiatric status and the level of speech development. To clarify the diagnosis and increase the accuracy of clinical diagnostics, quantitative tests can be used, though their application is useful not so much for assessing the state of speech function, but for tracking dynamic changes resulting from complex therapy. There is currently no pharmacotherapy specifically for this group of disorders; existing pharmacotherapy is aimed at addressing various nonspecific problems such as behavioral disorders, decreased volitional drive, fatigue, etc.

Methods with proven efficacy and safety are described in these clinical guidelines. These interventions are effective for the majority of children with SSLD and are associated with better outcomes.

The use of intensive speech therapy in the early stages of speech development (at the age of 1.5–2 years and earlier) leads to an optimal outcome, i.e., normalization of development. The earlier assistance begins, the better the child's developmental prognosis.

It is important to warn parents against unjustified expectations associated with the use of treatment methods that lack studies confirming their effectiveness, as well as against a wait-and-see approach where they rely on the spontaneous disappearance of symptoms and do not seek help from specialists until the child reaches a certain age (most often older preschool age). Thus, methods with unproven efficacy include hippotherapy and dolphin therapy, pharmacotherapy not combined with targeted remedial and developmental classes, the method of brain bioacoustic correction (BAC), Tomatis neurosensory auditory stimulation (Méthode Tomatis), the Forbrain sensory stimulation method, and others. If parents insist on continuing the use of these methods, it is important to emphasize that they should not be used instead of the main habilitation program, which includes methods and approaches with scientifically proven efficacy.

It is important to convince the parents or legal representatives of a patient with SSLD that the success of the habilitation process depends on their active participation. Overcoming speech pathology requires systematic, prolonged classes not only in a specialist's office but also at home. Parents must follow all recommendations and organize conditions at home that promote the child's speech development. The child should not be isolated from communication with typically developing peers. It is important to maintain the child's motivation for speech communication. Given that children with SSLD often exhibit underdevelopment of all cognitive activities (perception, memory, attention, thinking, speech), it is necessary to create an environment for the child that stimulates development.