Given what I do for a living, I suppose it was bound to happen. I was going to end up evaluating a pediatric client who had severe COVID-19 and was left with effects of the virus.
Yeah, yeah, I’ve heard all the urban myths. COVID-19 doesn’t seem to affect children, or at least not as severely. If we’re looking solely at mortality, yes, that’s true. Children are not as likely to die from COVID-19 as adults. But, that does not mean children are not affected by the virus. This is not a cold or ‘the flu.’
It happened last week. I was asked to evaluate an almost 10 year old boy who had been diagnosed and hospitalized with COVID-19 in late January, 2022. He was discharged home after 6 weeks in the hospital. Estimates are that 28-30% of people hospitalized with the Omicron variant were pediatric patients.
COVID-19 caused seizures and encephalopathy in this child. Encephalopathy is an altered mental state caused by a disease process or injury that affects the brain. It has many causes, some of which are reversible and some of which are permanent. It remains to be seen which type of encephalopathy COVID-19 causes in children.
Encephalopathy is just one of the long-term brain disruptions COVID-19 can cause in children who are ill enough to be hospitalized. Here is a list of the others: severe headaches, seizures, coma, encephalitis, demyelinating disorders, aseptic meningitis, cerebellar ataxia, peripheral neuropathy leading to global proximal muscle weakness and reduced reflexes, stroke, dysphagia, and dysarthria. In addition to all of this, the CDC reports that children under 18 who are sick enough to be hospitalized with COVID-19 are 2.5 times more likely to develop diabetes approximately 30 days after COVID-19 exposure. The mean age of these patients is 9.5 years of age.
Still think COVID-19 doesn’t affect school-age children that severely?
Maybe we need to rethink that…
Because the client I evaluated last week presented with a mixed flaccid, hypokinetic dysarthria. You know, the acquired disorder we see in adults who have had a TBI or a stroke. Oh, that’s on top of a pre-existing developmental speech sound disorder.
Tell me, pediatric SLP colleague, when was the last time you brushed up on your knowledge of acquired motor speech disorders? Can you differentially diagnose a mixed dysarthria in a child with a pre-existing developmental speech-language disorder?
Let’s start at the beginning. The child had been placed with his current foster in a foster to adopt program at the age of 4-6 months. The family was aware of the history of prenatal exposure. They sought out EI and continued special education services throughout preschool because he had been identified as a late talker. As so often happens, the child continued to demonstrate speech-language delays which eventually evolved into a speech sound disorder involving lingering /r, l/ controlled vowels before his experience with COVID-19.
Note that the family mentioned the child had a history of being a late talker.
Fast forward to 2022. The child tested positive for COVID-19 in late January. Two days later the seizures started. He was admitted to the hospital locally, then transferred out of state. (Where I live, that’s really what you want – a medically complex child to be treated at one of the dedicated children’s hospitals in a neighboring state. Services here are somewhat lacking.) He was diagnosed with COVID-19 related seizures and encephalopathy. Due to the severity of the seizures, he was placed on an NG tube for feeding. But, he remained able to breathe spontaneously and was never intubated or placed on a vent. He was discharged home in mid-March 2022.
The referral I received stated that the child was recovering from COVID-19, needed to be seen at a park due to the family’s concerns about re-infection, and that he probably would not be eligible for services.
As it turns out, nothing could be farther from the truth.
Talking to his foster mom, I learned the child had demonstrated substantial “regression.” The foster mom reported that he “sounds like he’s a toddler again” and was using only 1-3 word messages. She reported that it was difficult for him to read – as if he’d lost his literacy skill. She reported that it seemed physically hard for him to talk now and that his voice had changed. The foster mom also reported that they were looking at having him complete homebound school as he recovered. We agreed to complete the eval over teletherapy because of her concerns about his ability to physically talk, the changes in his voice, and the fact that he was able to produce only 1-3 word messages.
On the day of the evaluation, the foster grandmother reported that her grandson, “sounds like a robot.” She reported that they used to have a difficult time getting their grandson to stop talking and now it was all they could do to get him to say more than a few words. She reiterated what the foster mom said – that it was like he had regressed back to being a toddler. In addition, the family reported that the child was very physically unsteady on his feet and was experiencing a lot of falls.
When it came time to evaluate the child, it was immediately apparent that oral speech was physically laborious for him. He was aware of what had happened to him and he was able to explain why he had an IEP and was in speech-language services in school. He generally used 1-3 word phrases to answer questions and his voice dropped off at the end of the phrases. When asked to describe how to start playing Minecraft, he provided this description (periods denote end of phrases):
“I got started with the temple. I pick my. character. Cloud. Cloud is my character. I fight. Random. Whoever. It says game. Then it tells us. when we. won.”
His voice quality was hypernasal, very robotic, and monotone. If he spoke more than 2-3 words at a time, his voice trailed off at the end of the utterance making it hard to hear what he said.
Administration of the GFTA-3 revealed the lingering issues with r-controlled vowels as expected. But, it also revealed a number of both consonant and vowel prolongations along with some epenthesis on syllable-initial consonant clusters and devoicing of intervocalic and syllable final voiced consonants. He also recognized when he had some difficulty sequencing the syllables in some of the multi-syllabic words.
This is a motor speech disorder. However, this is NOT childhood apraxia of speech (or whatever we’re calling it these days…). It’s dysarthria. In a 9 year old child.
Dysarthria occurs as the result of weakness or paralysis of the muscles of the oral musculature. It’s generally caused by damage to the brain – certain types of strokes, TBI, tumors, etc. It’s considered to be an acquired disorder of adults. Generally, the only time dysarthria is considered in children is when the child has cerebral palsy. Here is a link to dysarthria on ASHA’s website: Click Here
That is, until COVID-19 came along. Remember that list of sequelae that COVID-19 can cause? This list: severe headaches, seizures, coma, encephalitis, demyelinating disorders, aseptic meningitis, cerebellar ataxia, peripheral neuropathy leading to global proximal muscle weakness and reduced reflexes, stroke, dysphagia, and dysarthria.
The problem is, while this list of sequelae have been identified in general, there are no specifics regarding the types of dysarthria or where along the swallow mechanism children are experiencing as a result of COVID-19. There is no information regarding whether these issues are temporary or permanent in adults or children. Unfortunately, however, there is emerging evidence to suggest that at least some of these sequelae of COVID-19 are permanent in adults at least.
So, what is a pediatric-focused SLP to do?
Stay tuned for the next post…
Outside The Box 