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162 Marković J, et al. Mental health problems and speech development

University of Novi Sad, Faculty of Medicine, Novi Sad1 Original study

Clinical Center of Vojvodina, Novi Sad Originalni naučni rad
Department of Psychiatry2 UDK 613.86-056.24-053.2 i
General Hospital “Dr Laza K. Lazarević”, Šabac3 UDK 616.89-008.434/.435-056.24-053.2
DOI: 10.2298/MPNS1506162M

MENTAL HEALTH PROBLEMS AND SPEECH DEVELOPMENT IN TODDLERS WITH

PHYSICAL ILLNESSES

PROBLEMI MENTALNOG ZDRAVLJA I RAZVOJ GOVORA KOD DECE SA TELESNIM BOLESTIMA

U PERIODU RANOG DETINJSTVA

Jasminka MARKOVIĆ1,2 and Teodora ROMIĆ3

Summary Sažetak
Introduction. Mental health problems develop more and more Uvod. Problemi mentalnog zdravlja su sve učestaliji kod dece
frequently in children and adolescents. Children with physical ill- i mladih. Deca sa telesnim bolestima su pod posebnim rizikom
nesses are at a particular risk of developing associated mental health i za pojavu problema mentalnog zdravlja i ispitivanje njihove
problems and it is important to study this association in order to povezanosti je posebno značajno zbog pravovremenog otkriva-
detect and treat these problems on time. This study was aimed at nja i tretmana problema. Cilj rada je da se utvrdi da li postoje
determining whether there were differences in the presence of razlike u izraženosti problema mentalnog zdravlja i kašnjenja
mental health problems and delayed speech development in chil- u razvoju govora kod dece sa telesnim bolestima uzrasta 18−36
dren with physical illnesses between 18 and 36 months of age com- meseci u odnosu na izraženost ovih problema kod zdrave dece.
pared to the presence of these problems in healthy children. Mate- Materijal i metode. Istraživanje je vršeno po tipu opservacio-
rial and Methods. The study was carried out as an observational ne studije preseka. Uključeno je 100 dece, oba pola, uzrasta do
cross-sectional study. It included 100 children, of both sexes, aged 3 godine. Ispitivanu grupu činilo je 50 dece sa telesnim bole-
up to 3 years. The first group consisted of 50 children with physical stima, lečenih u Institutu za zdravstvenu zaštitu dece i omladi-
illnesses that were hospitalized at the Institute for Child and Youth ne Vojvodine u Novom Sadu, dok je kontrolnu grupu činilo 50
Health Care of Vojvodina, and the control group consisted of 50 zdrave dece, istog uzrasta, koja pohađaju predškolsku ustanovu
healthy children of the same age who attended kindergarten “Ra- Radosno detinjstvo u Novom Sadu. Instrument studije bio je
dosno detinjstvo” in Novi Sad. The instrument of the study was “A Lista provere dečjeg ponašanja za decu od 1,5 do 5 godina.
checklist of child behavior for children aged 1.5 to 5 years”. The Hipoteza je proveravana pomoću t-testa za nezavisne uzorke.
hypothesis was checked with t-test for independent samples. “A Za procenu razvoja govora korišćena je Anketa o razvoju govo-
survey of language development for children aged 18 to 35 months” ra za decu starosti od 18 do 35 meseci. Drugi deo hipoteze je
was used for assessing the language development. The second part proveravan pomoću c2 testa. Rezultati. Statistički značajna
of the hypothesis was checked with chi-square test. Results. A razlika je utvrđena na sledećim dimenzijama upitnika: emoci-
statistically significant difference was detected in the following onalna reaktivnost, anksioznost/depresivnost, povlačenje, agre-
dimensions of the questionnaire: emotional reactivity, anxiety / sivnost, stres, internalizacija, eksternalizacija i ukupni proble-
depression, withdrawal, aggression, stress, internalization, exter- mi. Statistički značajna razlika je prisutna i u oblasti razvoja
nalization, and total problems. A statistically significant difference govora. Zaključak. Konstatujemo da su problemi mentalnog
was also found in the area of language delay. Conclusion. It has zdravlja kao i kašnjenje u razvoju govora više izraženi kod dece
been concluded that mental health problems, as well as the language sa telesnim bolestima u odnosu na kontrolnu grupu dece.
delay, are more pronounced among the children with physical ill- Ključne reči: Mentalno zdravlje; Poremećaji razvoja govora;
nesses than in the control group of children. Odojče; Predškolsko dete; Psihopatologija; Bolest
Key words: Mental Health; Language Development Disorders;
Infant; Child, Preschool; Psychopathology; Disease

Introduction throughout the world, and mental and behavior dis-

orders during childhood have become a serious pub-
Mental health is the basis of the child’s social and lic health problem. According to the World Health
emotional development, and, consequently, their Organization (WHO), child’s mental or behavioral
well-being and functioning throughout life. Although disorders will become one of five causes of morbi-
it represents the fundamental component of general dity, mortality and incapacity by 2020 [1].
health, mental health of children is often neglected
Corresponding Author: Doc. dr Jasminka Marković, Klinika za psihijatriju,
21000 Novi Sad, Hajduk Veljkova 1-7, E-mail: markovicjasminka71@gmail.com
Med Pregl 2015; LXVIII (5-6): 162-167. Novi Sad: maj-juni. 163

Abbreviations delay in both groups of children. The hypothesis

CBCL – Child Behavior Checklist was that those problems occurred more often in
children with physical illnesses than in healthy chil-
Mental health of children is particularly neglect- dren of the same age, with a significant presence of
ed in their early childhood and preschool age. How- speech development delay.
ever, not sufficient research work has been done
regarding this age, which can result in many prob- Material and Methods
lems for several reasons. Firstly, some disorders
such as oppositional defiant disorder (ODD), and This research was conducted as an observation-
hyperkinetic disorder begin in this period and they al study of interface from October 2012 until No-
are relatively stable over time with a long term vember 2013 at the Institute of Child and
negative consequences. Then, some psychopatho- Youth Health Care of Vojvodina and the preschool
logical syndromes change under the influence of facility ‘Radosno Detinjstvo’. The study sample
developmental changes in the domain of cognition, consisted of a hundred children of both genders
language and emotional regulation. For example, who were divided into two groups: there were 50
oppositional defiant disorder in the preschool pe- children with physical illnesses in the study group
riod can be a precursor of developing anxiety and and 50 healthy children in the control group, their
depression later. The third important fact is that average age being 29.6 and 27.4 months, respec-
there is clear evidence of efficiency of the treatment tively. The exclusion criterion was the age under 18
at this age, and the studies about the problems in men- and over 36 months.
tal health of preschool children are the first step to The study instrument was the Child Behavior
understanding the burden of these illnesses as well Check List (CBCL/1.5-5) questionnaire for assess-
as planning early interventions and prevention. ment of behavior of the children between 18 months
Physical, acute or chronic illness of a child may to 5 years of age [13]. This is one of widely used
be the cause of the child’s mental health problem as standardized instruments for identifying child’s be-
confirmed by the earlier studies [3–6]. Rutter found havior and emotions. It has proved its efficiency and
that children with asthma, epilepsy and neurological reliability in many international studies. The ques-
disorders in general were far more prone to these tionnaire was completed voluntarily and anonymous-
problems. A national research conducted in Great ly by the parents. In both groups the questionnaires
Britain indicated a large percentage of mental health were mainly completed by mothers (in 92%) and in
problems among the children with physical handi- 8% of fathers. One part of the questionnaire used for
cap [3]. Almost all children with severe physical this study was the Problem scale consisting of 100
disability had a mental health problem. Children statements. Each statement offered three replies: 0
with emotional difficulties experienced problems = Not True (as far as I know), 1 = Somewhat or
with digestive tract, migraines, headaches, most Sometimes True, 2 = Very True or Often True to give
probably reflecting the somatic symptoms associated the best description of the child at the time of the
with anxiety and depression [3]. study or over the last two months. Using factor anal-
Speech development is an important component ysis of 100 items of the Problem scale, 7 empirically
of child’s cognitive and social development in the based syndrome scales were constructed: emotional
early childhood, and its assessment serves as es- reactivity, anxiety/depression, somatic complaints,
sential component of the psychomotor development detachment, sleeping disorders, attention deficit and
assessment. Speech development delay is associ- aggression. The scale syndrome was further organ-
ated with intellectual disability, hearing impairment ized into large problem groups (based on the second
and pervasive developmental disorders. It is also a order factor analysis): Internalizing (internal prob-
central symptom of the specific language impair- lems of the person, individual) and Externalization
ment [7, 8]. Previous studies have confirmed that (problems with other people). Internalizing group of
every child who spontaneously pronounces less than problems were the first four syndrome scales: emo-
50 words and does not combine sentences by the tional reactivity, anxiety/depression, somatic com-
age of 2 (two), shows a distinct delay in speech de- plaints and detachment. Externalizing group of prob-
velopment [8, 9]. Factors associated with disorders lems were the last syndrome scales: attention deficit
in speech development of 30-month-old children and aggression. The total number of problems on the
are male gender, behavioral and developmental Problem scale was the sum of scores on all items
problems of the child or a member of the family, which could range from 0 to 200 [14]. Each syndrome
and a bilingual environment [10]. Earlier studies scale was determined by the T score with a margin
confirmed a connection between a delay in speech of normal, borderline and clinical cases. According
development of the children and high level of timidity, to the author, the T score syndrome scale over 70 was
fear and problematic behavior [11, 12]. considered clinically significant, whereas the scores
The aim of this research was to determine from 65 to 69 were marginal/borderline scores. T
whether there was a difference in the extent of the score under 64 was considered normal. Internaliza-
problems of mental health among the children with tion and Externalization scales and the total number
physical illnesses between 18 and 36 months of age, of problems had slightly lower T score rates, which
and if there was a difference in speech development was the reason why the results on these scales were
164 Marković J, et al. Mental health problems and speech development

Table 1. Causes of children’s hospitalization by wards at the Institute of Child and Youth Health Care of Vojvodina
Tabela 1. Prikaz uzroka hospitalizacije dece po odeljenjima u Institutu za zdravstvenu zaštitu dece i omladine Vojvodine
Ward Cause of hospitalization Number of children
Odeljenje Uzrok hospitalizacije Broj dece
Post-streptococcal glomerulonephritis/Poststreptokokni glomerulonefritis 1
Nephrology Nephrotic syndrome/Nefrotski sindrom 1
Nefrologija Hydronephrosis/Hidronefroza 1
Urinary tract infection/Urinarna infekcija 2
Diabetes mellitus type 1/Dijabetes melitus tip 1 1
Endocrinology Growth hormone deficiency/Nedostatak hormona rasta 1
Endokrinologija True precocious puberty/Pravi prevremeni pubertet 1
Gastroenterology Diarrhea and vomiting/Proliv i povraćanje 5
Gastroenterologija
Cardiology/Kardiologija Congenital heart defect/Urođena srčana mana 1
Loss of consciousness/Kriza svesti 1
Neurology/Neurologija Epilepsy/Epilepsija 2
Pneumonia/Upala pluća 5
Bronchitis/Bronhitis 2
Pulmonology Asthma/Astma 2
Pulomolgija Purulent angina/Gnojna angina 1
Acute otitis media/Upala srednjeg uva 7
Cough/Kašalj 6
Fever/Povišena telesna temperatura 7
General/Opšte Exhaustion/Malaksalost 2
Poisoning/Trovanje 1
Total/Ukupno 50

interpreted as clinical for scores over 64, marginal for Gastroenterology Ward with 10% (per ward) of the
scores from 60 to 63, and normal for those under 60. total number of hospitalized children (Table 1).
The second part of the questionnaire was ‘Lan- Statistical data analysis yielded the results indi-
guage Development Survey-LDS’ for the children cating that the children with physical illnesses had
from 18 to 35 months of age serving as a screening higher scores compared to the children in the con-
tool for detection and identification of speech delay trol group within the following syndrome scales:
in children. It included 310 words organized in 14 emotional reactivity, anxiety/depression, detach-
semantic categories [15]. It provided the words pro- ment, aggression, stress, internalization, externali-
nounced by a child correctly or in ‘baby talk’. Iden- zation and overall problems (p<0.05). No statisti-
tification of the language delay in children was cally significant difference in expression of emo-
when they knew less than 11 words (boys) or less tional and behavior problems of the children with
than 25 words (girls) at 18 to 23 months of age; physical illnesses and the children from the control
when they knew less than 40 words (boys) or less group was found on the following syndrome scales:
than 84 words (girls) at 24 to 29 months of age; and somatic complaints, sleeping disorders and attention
when they knew less than 88 words (boys) or less deficits (p<.05) (Table 2).
than 115 words (girls) at 30 to 35 months of age. The largest difference between the two groups
The database was created in Microsoft Excel 2010. was found on the internalization scale (p<0.00004)
The analysis was done using ADM, Microsoft Excel and the smallest one was seen on the attention deficit
and SPSS programs. Hypothesis testing was done us- scale (p<0.26). These two groups of children differed
ing an independent samples t-test and chi-square test. more in the dimension of internalization (p<0.00004)
than in externalization dimension (p<0.0089). Inter-
Results estingly, the problems in the dimension of stress seem
to be predominant in the group of children with
The research included 100 children of both gen- physical illnesses (AS 55.48) as well as in the control
ders, 50 with physical illnesses and 50 healthy chil- group of children (AS 53.24) (Table 2).
dren. The study group had 44% of girls and 56% of It is important to stress that, regardless of the
boys whereas the control group had 48% of girls high scores of the study group in almost all dimen-
and 52% of boys. The majority of the children were sions, these scores, nevertheless, did not reach the
hospitalized at the Pulmonary Diseases Ward (46%), borderline level (the highest value of T score was
a large number with symptoms of middle ear infec- 55), and therefore fell into the category of normal
tion (30%) and cough (26%), and at the General results (Table 2).
Pediatrics Ward (20%) with the highest number of As for speech development delay, out of 50 children
cases of fever (70%), followed by Nephrology and in the study group 14 had speech delay: 6 boys and 8
Med Pregl 2015; LXVIII (5-6): 162-167. Novi Sad: maj-juni. 165

Table 2. Testing differences in T scores on the syndrome scales using t-test

Tabela 2. Prikaz testiranja razlike u T-skorovima na skalama sindroma pomoću t-testa
Dimensions of the CBCL/Dimenzije CBCL* Groups/Grupe AS SD t df p
Emotional reactivity Study/Ispitivana 55,14 5,6928 3,39 98 0,0009
Emocionalna reaktivnost Control/Kontrolna 51,96 3,3924
Anxiety/Depression Study/Ispitivana 54,94 5,1603 3,70 98 0,0003
Anksioznost/Depresivnost Control/Kontrolna 51,82 2,9602
Somatic complaints Study/Ispitivana 53,86 5,1627 1,67 98 0,0972
Somatske žalbe Control/Kontrolna 52,34 3,8151
Withdrawal Study/Ispitivana 55,26 6,6511
Povlačenje 2,49 98 0,0141
Control/Kontrolna 52,44 4,4131
Sleeping problems Study/Ispitivana 54,26 5,3597 1,59 98 0.1133
Problemi sa spavanjem Control/Kontrolna 52,82 3,4504
Attention problems Study/Ispitivana 54,26 5,6597
Problemi pažnje 1,12 98 0,2628
Control/Kontrolna 53,14 4,1748
Aggressiveness Study/Ispitivana 53,82 4,8221 2,69 98 0,0083
Agresivnost Control/Kontrolna 51,60 3,2763
Stress Examined/Ispitivana 55,48 5,5152 2,31 98 0,0229
Stres Control/Kontrolna 53,24 4,0736
Internalization Study/Ispitivana 52,26 8,8359
Internalizacija 44,76 8,6768 4,28 98 0,00004
Control/Kontrolna
Externalization Study/Ispitivana 50,08 8,6751 2,66 98 0,0089
Eksternalizacija Control/Kontrolna 45,62 8,0226
Total problems Study/Ispitivana 51,20 8,9897
Ukupni problemi 3,71 98 0,0003
Control/Kontrolna 44,92 7,9020
CBCL - lista provere dečjeg ponašanja

girls. Namely, speech development delay was observed of the extent of mental health problem in both
in 6 children (3 boys and 3 girls) between 18 to 23 groups were within a normal range.
months of age, in 3 children (2 boys and 1 girl) be- Studies addressing the similar issue established
tween 24 to 29 months of age and 5 children (1 boy a statistically significant difference in the manifes-
and 4 girls) aged from 30 to 35 months (Table 3). tation of mental health problem between the chil-
The total number of children with speech devel- dren with physical illnesses and the healthy children
opment delay in the control group was 5 (3 boys and from the control group [14, 16, 17]. Lavigne and
2 girls) out of 50. Speech development delay was Faier-Routman’s study has shown a connection be-
observed in 3 children (1 boy and 2 girls) between tween the physical illness of a child aged 2 to 5
18 and 23 months of age, and in one boy from the years with later occurrence of disorder in the form
age group 24 to 29 months and 30 to 35 months, of opposition and defiance, disturbed parent-child
each (Table 3). relationship, hyperkinetic disorder and depression
Chi-square test indicated a statistically signifi- [18]. The only study performed in our environment,
cant difference in speech development delay be- which used CBCL/1.5-5 questionnaire to assess the
tween the children with physical illnesses and mental health problem rate among children from 4
healthy children in early childhood (Table 4). to 11 years of age, has not found a connection be-
tween these problems and chronic illnesses, which
Discussion can be explained by methodological factors. In ad-
dition, this study included older children and did
This study was aimed at determining whether not take into account the acute physical illnesses
there was a statistically significant difference in found in most children in our study.
manifestation of mental health problems among the The difference was not determined in the fol-
children with physical illnesses in early childhood lowing dimensions: somatic complaints, sleeping
in comparison to their healthy peers. The results of disorders and attention deficit. Somatic complaint
our research showed a statistically significant dif- dimension had a low reliability (Cronbach’s alpha
ference between the two groups of children thus measured only 0.28) in a study conducted on a large
indicating that the children with physical illnesses number of children in our environment, which can
had higher scores on scales assessing the emotion- explain the absence of difference in this dimension.
al and behavior problems than the control group. In It is definitely an unexpected result to see that the
spite of the difference between these two groups, it children with physical illnesses have similarly man-
is important to stress that the results of assessment ifested attention deficit and sleeping problems as
the healthy children. One explanation could be that
166 Marković J, et al. Mental health problems and speech development

Table 3. Language delay in children by age

Tabela 3. Prikaz kašnjenja razvoja govora kod dece po uzrastima
Age/groups/Uzrast/grupe Study/Ispitivana Control/Kontrolna
Boys/Dečaci Girls/Devojčice Boys/Dečaci Girls/Devojčice
18 – 23 months/meseci 3 3 1 2
24 – 29 months/meseci 2 1 1 /
30 – 35 months/meseci 1 4 1 /
Total 6 8 3 2
Ukupno 14 5

the children were more bedridden because of the ed between 18 and 23 months of age, so these data
physical illnesses, less active, aching, which could should be accepted with reservation. Furthermore,
be the reason for the lack of differences in these in the population with a middle socio-economic
dimensions. It could also be that the children at this status, the speech development delay rate at the age
age have more pronounced problems with sleeping of 2 is 10% [8]. A delay was recorded in 21% of
and attention at this stage of development, and these cases in this study group. Typical delay in speech
dimensions are not sensitive enough to produce a development at the age of 3 occures in 3-5% of chil-
clear picture of difference existing between these dren, that being less than at the age of two. This is
two groups of children. expected because some children who have a delay
The biggest difference was obtained in the inter- in speech development at 2 years of age can have
nalization dimension which is very important for the normal development when they are 3 years old [8].
clinical practice. Since these problems are less visible However, speech development delay was reported
and they often pass unnoticed, they should be ap- in 36% of children from this study sample. An in-
proached with more sensibility and their possible creasing number of studies have been dealing with
existence in children with physical illnesses should the association between the middle ear infection
be studied thoroughly. Early recognition is a prereq- and potentially resulting hearing loss, speech de-
uisite for timely treatment of these problems that can velopment, language and cognitive skills. Regard-
be serious obstacles in a child’s daily functioning. less of the methodological flaws in certain studies,
The association between a mental health prob- an increasing data volume indicates the presence of
lem and physical illnesses can be explained by high- a significant association [19, 20]. This study had the
concern parental behavior which commonly occurs largest number of children who were hospitalized
when a child is sick. This concern is related to pa- because of the middle ear infection which affected
rental perception of the child being extremely vul- their speech development.
nerable when physically ill, including a hyper pro- Among previously mentioned risk factors con-
tective attitude which contributes to the occurrence tributing to speech development delay is also the
of a mental health problem in children. male gender [10]. However, this study recorded a
Another aim of this study was to determine large number of girls in the study group who had
whether the speech development delay was more this problem, whereas the control group had a large
pronounced in children with physical illnesses in number of boys with this problem, that being in
their early childhood than in the healthy children of accordance with the literature data [10]. It is impor-
the same age. Almost one third of the children in tant to stress that this research did not include test-
the study group had a speech development delay in ing of children’s IQ since the speech development
comparison to 10% of the children from the control delay, according to earlier studies, is related with
group. According to the opinion of the author [9], the intellectual disability as the significant cause of
an attempt to determine the speech development this problem [7, 8].
delay before the child is 2 years old can lead to Nevertheless, it is hard to explain the differences
falsely positive results. This study showed that the in speech development delay by connecting it mere-
largest number of children with speech development ly with physical illness because more than a half of
delay, in both study and control group, was record- children had an acute physical illness which, ac-

Table 4. Testing differences between the study and control group using chi-square test
Tabela 4. Prikaz testiranja razlike između ispitivane i kontrolne grupe pomoću c2 testa
Groups/Grupe Observed number/Posmatrani broj Expected number/Očekivani broj Residual/Ostatak
Study/Ispitivana 14 9,5 4,5
Control/Kontrolna 5 9,5 -4,5
Total/Ukupno 19
c2 =0.039 df=1 p<0,05
 Med Pregl 2015; LXVIII (5-6): 162-167. Novi Sad: maj-juni. 167

cording to the diagnostic criteria, did not last long and months. Another contribution is the confirmation
often left no permanent consequences. In addition, of association between physical illnesses and men-
speech development assessment test may not have tal health problems of young children for the first
been explicit enough for our environment because time in our environment. In order to establish more
its standardization has not been done yet. Therefore, precise association between certain physical ill-
these results should be considered with more cau- nesses and some mental health problems, further
tion. Another explanation could be that, although studies with more samples should be conducted.
these illnesses were acute, they required hospitali-
zation due to their severe clinical manifestations, Conclusion
which is not the case with minor acute illnesses
treated in outpatient departments. Besides, younger Based on these results, it can be concluded that
children often react to acute physical illness with emotional problems and behavior problems are
transient regression which can be manifested in more pronounced in children (up to 3 years of age)
speech regression, so the testing and parent assess- with physical illnesses than in their healthy peers.
ment covered this moment of speech regression. It In addition, children with physical illnesses have
would certainly be interesting to look into the caus- more pronounced problems associated with speech
es of such results through further research by con- development delay.
trolling variables that relate to the course of illness. Research results can have significant clinical im-
The main contribution is that this is the first plications in the form of sensitization and education of
study performed in our region so far that applied pediatricians helping them to recognize emotional and
CBCL/1.5-5 questionnaire in children aged 18 to 36 behavior problems in children with physical illnesses.
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