Identificación de niños con retraso del lenguaje y riesgo de Trastorno del Desarrollo del Lenguaje. Retos del presente y futuro

Auza B., Alejandra
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Para asegurar que un ni&#241;o con dificultades en el desarrollo del lenguaje reciba un tratamiento oportuno y efectivo&#44; resulta crucial identificar tempranamente su trastorno&#46; En muchos pa&#237;ses persiste el desaf&#237;o de reconocer los retrasos iniciales del lenguaje&#44; como los de los hablantes tard&#237;os &#40;HT&#41; o el Trastorno del Desarrollo del Lenguaje &#40;TDL&#41;&#46; Ante la ausencia de problemas cognitivos&#44; motores&#44; neurol&#243;gicos o de audici&#243;n en estos ni&#241;os &#40;<a class="elsevierStyleCrossRef" href="#bib0250">Leonard&#44; 2014</a>&#41;&#44; la tendencia prevalente&#44; incluso entre profesionales del desarrollo infantil&#44; es adoptar una aproximaci&#243;n de &#171;esperar y ver&#187;&#47;&#171;wait and see&#187;&#44; obsoleta desde hace varios a&#241;os&#46; Este enfoque se fundamenta en el temor de posibles inconvenientes al etiquetar a los ni&#241;os como los HT&#44; el tiempo adicional e &#171;innecesario&#187; para la evaluaci&#243;n&#44; el estr&#233;s de los padres&#44; desacuerdos entre ellos y el estigma social asociado &#40;<a class="elsevierStyleCrossRef" href="#bib0185">Singleton&#44; 2018</a>&#41;&#46; Los mitos arraigados&#44; como la creencia de que el retraso del lenguaje se corrige espont&#225;neamente o que el ni&#241;o est&#225; simplemente consentido o es perezoso para hablar&#44; contribuyen a las demoras significativas entre las primeras preocupaciones parentales y el diagn&#243;stico &#40;Auza&#44; 2021&#41;&#46; Esta demora se amplifica en el caso de ni&#241;os que son aprendices biling&#252;es &#40;<a class="elsevierStyleCrossRef" href="#bib0055">De Anda et al&#46;&#44; 2022</a>&#41;&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Aun cuando es innegable la importancia del lenguaje en el desarrollo humano&#44; este aspecto no se eval&#250;a de manera sistem&#225;tica en numerosos sistemas de salud y educaci&#243;n en diversos pa&#237;ses&#46; Adem&#225;s&#44; la prevalencia de los HT fluct&#250;a entre el 11 y el 18&#37; &#40;<a class="elsevierStyleCrossRefs" href="#bib0245">Horwitz et al&#46;&#44; 2003&#59; Rescorla y Dale&#44; 2013&#59; Sansavini et al&#46;&#44; 2021&#59; Thal et al&#46;&#44; 1997</a>&#41;&#46; Aunque el HT no se considera un diagn&#243;stico en s&#237; mismo &#40;<a class="elsevierStyleCrossRef" href="#bib0220">Zubrick et al&#46;&#44; 2007</a>&#41;&#44; sino una condici&#243;n con posibles etiolog&#237;as&#44; como el TDL &#40;<a class="elsevierStyleCrossRef" href="#bib0250">Leonard&#44; 2014</a>&#41;&#44; que tiene una prevalencia entre el 7 y el 12&#37; &#40;<a class="elsevierStyleCrossRef" href="#bib0205">Tomblin et al&#46;&#44; 1997</a>&#41;&#44; tambi&#233;n puede servir como indicador de otras alteraciones en el neurodesarrollo&#44; como el trastorno global del desarrollo&#44; la hipoacusia o el trastorno del espectro autista &#40;TEA&#44; <a class="elsevierStyleCrossRefs" href="#bib0035">Buschmann et al&#46;&#44; 2008&#59; Rescorla y Dale&#44; 2013&#59; Rescorla y Lee&#44; 2000</a>&#41;&#44; este &#250;ltimo con un rango de prevalencia del 1&#46;47 al 2&#46;24&#37; &#40;<a class="elsevierStyleCrossRefs" href="#bib0235">Baio et al&#46;&#44; 2018&#59; Fombonne et al&#46;&#44; 2016</a>&#41;&#46; Algunos ni&#241;os experimentan un retraso exclusivamente en el lenguaje expresivo &#40;<a class="elsevierStyleCrossRefs" href="#bib0240">Bishop et al&#46;&#44; 2012&#59; Dale et al&#46;&#44; 2003&#59; Paul y Roth&#44; 2011&#59; Rice et al&#46;&#44; 2008&#59; Sylvestre et al&#46;&#44; 2017</a>&#41;&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">La identificaci&#243;n del HT y la evaluaci&#243;n del desarrollo del lenguaje&#44; tanto expresivo como receptivo&#44; puede realizarse mediante cuestionarios parentales&#46; Dada la frecuencia significativa de estas condiciones&#44; resulta imperativo identificar estas dificultades en las etapas tempranas&#44; a trav&#233;s de instrumentos que involucren la perspectiva de los padres&#46; Cuando se logra identificar&#44; diagnosticar y abordar estos casos&#44; se logra no solo reducir las situaciones estresantes para la familia &#40;<a class="elsevierStyleCrossRef" href="#bib0150">Long et al&#46;&#44; 2008</a>&#41;&#44; sino tambi&#233;n prevenir y mitigar los problemas socioemocionales &#40;<a class="elsevierStyleCrossRef" href="#bib0275">Paul y Roth&#44; 2011</a>&#41;&#44; comportamentales o escolares asociados que pueden perdurar a lo largo de la vida del individuo &#40;<a class="elsevierStyleCrossRefs" href="#bib0130">Hong et al&#46;&#44; 2018&#59; Rescorla&#44; 2009&#59; Valera-Pozo et al&#46;&#44; 2021</a>&#41;&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Instrumentos parentales para la identificaci&#243;n de los retrasos y trastornos del lenguaje</span><p id="par0020" class="elsevierStylePara elsevierViewall">En la actualidad&#44; se han emprendido esfuerzos significativos para abordar la insuficiente identificaci&#243;n temprana del HT y del TDL&#46; Esta identificaci&#243;n se ha llevado a cabo principalmente mediante dos tipos de cuestionarios&#58; aquellos centrados en informaci&#243;n ling&#252;&#237;stica y aquellos que abordan informaci&#243;n biol&#243;gica y socioambiental&#46; Estos cuestionarios&#44; son especialmente adecuados porque son relativamente sencillos de responder&#44; autoadministrables y ofrecen informaci&#243;n sobre las observaciones y experiencias de los padres con sus hijos &#40;<a class="elsevierStyleCrossRefs" href="#bib0010">Auza et al&#46;&#44; 2023&#59; Bishop&#44; 2003&#59; Guiberson y Rodr&#237;guez&#44; 2010&#59; Guiberson et al&#46;&#44; 2011</a>&#41;&#46;</p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Cuestionarios de desarrollo ling&#252;&#237;stico</span><p id="par0025" class="elsevierStylePara elsevierViewall">Aunque existen varios cuestionarios disponibles&#44; un ejemplo destacado de estos esfuerzos fue la creaci&#243;n del Inventario de Habilidades Comunicativas McArthur Bates &#40;CDI&#44; por sus siglas en ingl&#233;s&#41;&#44; &#40;<a class="elsevierStyleCrossRefs" href="#bib0070">Fenson et al&#46;&#44; 1993&#59; Fenson et al&#46;&#44; 2007</a>&#41;&#44; adaptado aproximadamente a 80 lenguas diferentes&#46; Los CDI&#44; reconocidos por su validez y confiabilidad &#40;<a class="elsevierStyleCrossRefs" href="#bib0040">Can et al&#46;&#44; 2013&#59; Feldman et al&#46;&#44; 2005</a>&#41;&#44; son una herramienta ampliamente utilizada para la evaluaci&#243;n del desarrollo ling&#252;&#237;stico en ni&#241;os de 8 a 30 meses de edad &#40;<a class="elsevierStyleCrossRefs" href="#bib0080">Feldman et al&#46;&#44; 2005&#59; Kim et al&#46;&#44; 2014</a>&#41;&#46; Uno de los primeros CDI adaptados a una lengua diferente al ingl&#233;s fue desarrollado por Jackson-Maldonado et al&#46; 2003&#44; para el espa&#241;ol mexicano&#44; en colaboraci&#243;n con otros investigadores pioneros &#40;<a class="elsevierStyleCrossRefs" href="#bib0190">Thal et al&#46;&#44; 2000&#59; Jackson-Maldonado et al&#46;&#44; 2013</a>&#41;&#46; Con este inventario se analizan categor&#237;as l&#233;xicas y gramaticales&#44; as&#237; como pares de combinaciones sint&#225;cticas&#44; para evaluar la complejidad gramatical&#46; Adem&#225;s&#44; hay una secci&#243;n donde los padres pueden dar ejemplos de las oraciones m&#225;s largas que produce el ni&#241;o que complementan la informaci&#243;n sobre complejidad y contribuir a calcular la longitud media de las emisiones&#46; A partir de los puntajes en cada secci&#243;n&#44; se puede ubicar al ni&#241;o en un percentil de desarrollo&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Cuestionarios de informaci&#243;n biol&#243;gica y socioambiental</span><p id="par0030" class="elsevierStylePara elsevierViewall">Desde una perspectiva biopsicosocial&#44; los cuestionarios parentales han resultado ser herramientas invaluables para recopilar informaci&#243;n sobre aspectos biol&#243;gicos&#44; socioambientales y de interacci&#243;n social con el ni&#241;o&#46; Estos cuestionarios han sido esenciales para identificar factores protectores y de riesgo en el desarrollo del lenguaje&#44; los que proporcionan pistas sobre las posibles razones por las que algunos hablantes tard&#237;os experimentan un desarrollo desfasado&#46; Se reconoce que estos ni&#241;os no constituyen un grupo homog&#233;neo &#40;<a class="elsevierStyleCrossRefs" href="#bib0060">Desmarais et al&#46;&#44; 2008&#59; Desmarais et al&#46;&#44; 2010&#59; Rescorla&#44; 2011</a>&#41;&#46; Se ha evidenciado que factores intr&#237;nsecos al ni&#241;o&#44; como el sexo &#40;<a class="elsevierStyleCrossRef" href="#bib0205">Tomblin et al&#46;&#44; 1997</a>&#41;&#44; habilidades disminuidas en la comprensi&#243;n del lenguaje a los dos a&#241;os de edad &#40;<a class="elsevierStyleCrossRefs" href="#bib0155">Paul y Ellis Weismer&#44; 2013&#59; Rescorla y Dale&#44; 2013</a>&#41;&#44; el uso reducido de gestos comunicativos &#40;<a class="elsevierStyleCrossRefs" href="#bib0155">Paul y Ellis Weismer&#44; 2013&#59; Thal et al&#46;&#44; 1991&#59; Thal et al&#46;&#44; 2013</a>&#41;&#44; o la velocidad del procesamiento para reconocer palabras &#40;<a class="elsevierStyleCrossRef" href="#bib0095">Fernald y Marchman&#44; 2012</a>&#41;&#44; pueden ayudar a distinguir entre ni&#241;os con retrasos persistentes y no persistentes &#40;<a class="elsevierStyleCrossRefs" href="#bib0045">Chilosi et al&#46;&#44; 2019&#59; Dale et al&#46;&#44; 2003</a>&#41;&#46; Otros factores socioambientales&#44; como la educaci&#243;n materna &#40;<a class="elsevierStyleCrossRefs" href="#bib0015">Auza et al&#46;&#44; 2019&#59; Hoff&#44; 2006</a>&#41; o la asistencia a preescolar &#40;<a class="elsevierStyleCrossRef" href="#bib0015">Auza et al&#46;&#44; 2019</a>&#41;&#44; pueden actuar como factores protectores o de riesgo&#44; al influir en el desarrollo ling&#252;&#237;stico del ni&#241;o &#40;<a class="elsevierStyleCrossRefs" href="#bib0030">Bornstein y Putnick&#44; 2012&#59; Huttenlocher et al&#46;&#44; 2010&#59; Pe&#241;aloza et al&#46;&#44; 2021&#59; Vernon-Feagans et al&#46;&#44; 2012</a>&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Integraci&#243;n de la informaci&#243;n de ambos tipos de cuestionarios</span><p id="par0035" class="elsevierStylePara elsevierViewall">Lejos de reemplazar la evaluaci&#243;n cl&#237;nica&#44; los cuestionarios parentales act&#250;an como complementos de la primera&#46; La informaci&#243;n proporcionada por ambos tipos de cuestionarios enriquece y contextualiza las observaciones realizadas en el entorno cl&#237;nico&#44; permitiendo una comprensi&#243;n m&#225;s completa del desarrollo del lenguaje de un ni&#241;o&#46; Varios autores respaldan esta estrategia y destacan la utilidad de los cuestionarios parentales como herramientas de detecci&#243;n efectivas &#40;<a class="elsevierStyleCrossRef" href="#bib0120">Guiberson et al&#46;&#44; 2011</a>&#41;&#46; Son herramientas que demuestran ser eficaces y logran obtener niveles altos de sensibilidad&#44; especificidad y capacidad predictiva negativa&#44; inclusive en comparaci&#243;n con algunas evaluaciones directas del desarrollo ling&#252;&#237;stico infantil &#40;<a class="elsevierStyleCrossRef" href="#bib0180">Sim et al&#46;&#44; 2019</a>&#41;&#46; El empleo de unas cuantas preguntas sensibles relacionadas con la preocupaci&#243;n ling&#252;&#237;stica parental &#40;<a class="elsevierStyleCrossRef" href="#bib0010">Auza et al&#46;&#44; 2023</a>&#41;&#44; combinadas con una herramienta &#171;est&#225;ndar de oro&#187; como es el CDI&#44; puede elevar sustancialmente el reconocimiento de las dificultades en la comunicaci&#243;n no verbal&#44; como los gestos&#44; y&#47;o de las dificultades del lenguaje receptivo y expresivo&#44; propias de varias etiolog&#237;as&#46; Este es un m&#233;todo confiable para la detecci&#243;n de ni&#241;os con trastornos del lenguaje&#44; especialmente en entornos donde los instrumentos de evaluaci&#243;n estandarizados o los servicios de atenci&#243;n especializada son escasos&#46; Al utilizar estos instrumentos&#44; se busca no solo aliviar la carga de evaluaci&#243;n en entornos educativos&#44; sino tambi&#233;n identificar de manera eficaz&#44; posibles desaf&#237;os en el desarrollo del lenguaje&#46; Adem&#225;s&#44; es relevante explorar estas cuestiones en diferentes culturas que enfrenten problem&#225;ticas similares&#44; con el prop&#243;sito de aumentar la identificaci&#243;n temprana&#44; sobre todo en el mundo hispano&#46; En el caso de la identificaci&#243;n y evaluaci&#243;n en ni&#241;os biling&#252;es se vuelve un reto mayor&#44; en parte por las diferencias culturales entre el evaluador y el ni&#241;o&#44; la inseguridad de los evaluadores frente a la necesidad de evaluar el biling&#252;ismo y la heterogeneidad que surge de las diferencias ling&#252;&#237;sticas que influyen en el desarrollo de un aprendiz biling&#252;e &#40;<a class="elsevierStyleCrossRefs" href="#bib0105">Guiberson y Atkins&#44; 2012&#59; Singleton&#44; 2018</a>&#41;&#46; Estos desaf&#237;os pueden generar una sobre-identificaci&#243;n o sub-identificaci&#243;n de ni&#241;os biling&#252;es con y sin retrasos o trastornos del lenguaje &#40;<a class="elsevierStyleCrossRef" href="#bib0020">Banerjee y Guiberson&#44; 2012</a>&#41;&#46; Por ello&#44; tambi&#233;n se han desarrollado inventarios comunicativos para evaluar el conocimiento l&#233;xico del ni&#241;o biling&#252;e&#46; Esta evaluaci&#243;n incluye aspectos como las palabras que un ni&#241;o sabe sobre el mismo concepto en cada lengua&#44; el vocabulario total sumado de las dos lenguas habladas y el vocabulario conceptual o n&#250;mero de palabras que representan conceptos &#250;nicos en cualquiera de las dos lenguas habladas &#40;<a class="elsevierStyleCrossRef" href="#bib0055">De Anda et al&#46;&#44; 2022</a>&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Es crucial subrayar que la detecci&#243;n temprana del lenguaje desempe&#241;a un papel cr&#237;tico en el proceso de diagn&#243;stico de condiciones primarias&#44; como el TEA&#44; el TDL&#44; la discapacidad intelectual o la hipoacusia&#46; Este enfoque permite intervenciones m&#225;s tempranas y efectivas&#44; pues mejora las perspectivas de desarrollo y calidad de vida de los ni&#241;os afectados&#46; En resumen&#44; la integraci&#243;n de instrumentos de detecci&#243;n que pueden ser aplicados a gran escala&#44; como los cuestionarios parentales&#44; fortalece la posibilidad de abordar las necesidades de evaluaci&#243;n del lenguaje a nivel comunitario&#44; y contribuir con un enfoque m&#225;s eficiente y hol&#237;stico en el desarrollo ling&#252;&#237;stico infantil&#46; De cara al futuro&#44; y con evidencia cient&#237;fica en mano&#44; la aplicabilidad y el costo relativamente bajo de esta estrategia combinatoria pueden favorecer el avance de pol&#237;ticas p&#250;blicas en salud y educaci&#243;n que ayuden a universalizar y sistematizar los procesos de detecci&#243;n temprana &#40;<a class="elsevierStyleCrossRef" href="#bib0180">Sim et al&#46;&#44; 2019</a>&#41; de ni&#241;os monoling&#252;es o biling&#252;es en riesgo de desarrollar alguna condici&#243;n del neurodesarrollo&#46;</p></span></span></span>"
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