The youngest clients who receive services from speech-language pathologists are neonates with medical needs. This area of care came into being during the last several decades as the survival rate of infants with medical needs improved and it became apparent that developmental delays would likely be prevalent among the survivors. Since 1970, for example, the survival rate of infants in some low birth weight categories jumped from 30% to 75%; among the survivors the occurrence of mental retardation is 22%–24% (Bernbaum and Hoffman-Williamson, 1991).

The prevalence of developmental delay among previously medically needy neonates resulted in federal and state laws that give these children legal rights to developmental services (Kern, Delaney, and Taylor, 1996). These laws identify the physical and mental conditions and the biological and environmental factors present at birth that are most likely to result in future developmental delay. The purpose in making this identification is to permit an infant to receive intervention services early in life, when brain development is most active and before the negative social consequences of having a developmental delay, including one in the speech domain, can occur (Bleile and Miller, 1994).

The most important federal legal foundation for developmental services for young children with medical needs is the Individuals with Disabilities Education Act (IDEA). This law gives individual states the authority to determine which conditions and factors present at birth place a child at sufficient risk for future developmental delay that the child qualifies for education services. Examples of conditions and factors that the act indicates place an infant at risk for future developmental delay are listed in Table 1. A single child might have several conditions and risk factors. For example, a child born with Down syndrome might also experience respiratory distress as a consequence of the chromosomal abnormality, as well as an unrelated congenital infection.

Many populations of newborn children with medical needs are at high risk for future speech disorders. In part this is because developmental speech disorders are common among all children (Slater, 1992). However, the medical condition or factor itself may contribute to the child having a speech disorder, as occurs with children with cerebral palsy, a tracheotomy, or cleft palate (Bleile, 1993), and the combination of illness and long-term stays in the hospital may limit opportunities for learning, including in the speech domain.

Children with hearing impairment and those with Down syndrome are two relatively large populations with birth-related conditions and factors that are likely to experience future speech disorders (see mental retardation and speech in children). Two additional relatively large populations of newborn children likely to experience future speech disorders are those born underweight and those whose mother engaged in substance abuse during pregnancy.

In the United States, approximately 8.5% of infants are born underweight (Guyer et al., 1995). The major birth weight categories are low birth weight, very low birth weight, extremely low birth weight, and micropremie. Birth weight categories as measured in grams and pounds are shown in Table 2. As the category of micropremie suggests, many low birth weight children are born prematurely. A typical pregnancy lasts 40 weeks from first day of the last normal menstrual cycle; a preterm birth is defined as one occurring before the completion of 37 weeks of gestation. The co-occurrence of low birth weight and prematurity varies by country; in the United States, 70% of low birth weight babies are also born prematurely.

Approximately 36%–41% of women in the United States abuse illicit drugs, alcohol, or nicotine sometime during pregnancy (Center on Addiction and Substance Abuse, 1996). Illicit drugs account for 11% of this substance abuse, and heavy use of alcohol or nicotine accounts for the other 25%–30%. Approximately three-quarters of pregnant women who abuse one substance also abuse other substances (Center on Addiction and Substance Abuse, 1996). For example, a pregnant woman who abuses cocaine might also drink heavily. When alcohol is an abused substance, more severely affected children are considered to have fetal alcohol syndrome. The hallmarks of fetal alcohol syndrome are mental retardation and physical deformities (Streissguth, 1997). Children with milder cognitive impairments and without physical deformities are considered to have fetal alcohol effect or alcohol-related neurodevelopmental disorder.

Regardless of the specific cause of the disorder, speech-disordered clients with birth-related conditions and factors receive services similar to those given other children. The clinician's primary responsibility is to provide evaluation and intervention services appropriate to the child's developmental abilities. A difference in care provision is that the child's speech disorder is likely to occur as part of a larger picture of medical problems and developmental delay. This may make it difficult to diagnose and treat the speech disorder, especially when the child is younger and medical problems may predominate. In addition to having thorough training in typical speech and language development, a speech-language clinician working with these children should possess the following:

A neonate identified as at risk for future developmental delay typically first receives developmental services in a hospital intensive care unit. Medical and developmental services are provided by a team of health care professionals. Often, a primary role of the speech-language clinician is to assess the oral mechanism to determine readiness to feed. Such evaluations are particularly important for clients at risk for aspiration. These include children with neurological and physical handicaps, as well as those born prematurely, whose immature systems of neurological control often do not allow orally presented food to be managed safely. The speech-language pathologist may also counsel the child's caregivers and offer suggestions about ways to facilitate communication development.

An early intervention program is initiated shortly after the child is born and the risk factor has been identified. The exception is a child born prematurely, whose nervous system may not yet be able to manage environmental stimulation. Such a child typically receives minimal stimulation until the time he or she would have been born if the pregnancy had been full term. Early intervention typically includes a package of services, including occupational and physical therapy, social services, and speech-language pathology. The role of the speech-language pathologist includes assessing communication development and implementing an early intervention program to facilitate the child's communication abilities. Interacting with the child's caregivers assumes increasing importance as medical issues resolve, allowing the family to give greater attention to developmental concerns.

The vast majority of children born with medical needs grow to possess the cognitive and physical capacity for speech. For higher functioning children, the clinician's role includes providing the evaluation and treatment services to facilitate speech and language development. The speech disorders of many high-functioning children resolve by the end of the preschool years or during the early grade school years. Such children are at risk for future reading problems and other learning difficulties, and their progress in communication should continue to be monitored even after the speech disorder has resolved. Speech may prove challenging for children with more extensive developmental problems. A general clinical rule of thumb is that a child who will speak typically will do so by 5 years of age (Bleile, 1995). Children with more limited speech potential may be taught to communicate through a combination of speech and nonoral options. Lower functioning children might be taught to communicate through an alternative communication system (see augmentative and alternative communication approaches in children). Some useful web sites for further information include www.asha.org; www.autism.org; www.cdc.gov; www.intelehealth.com; www.mayohealth.org; www.med.harvard.edu; www.modimes.org; www.ncbi.nlm.nih.gov/PubMed/; www .ndss.org; and www.nih.gov.