Speech and language impairment

Speech and language impairment are basic categories that might be drawn in issues of communication involve hearing, speech, language, and fluency.

A speech impairment is characterized by difficulty in articulation of words. Examples include stuttering or problems producing particular sounds. Articulation refers to the sounds, syllables, and phonology produced by the individual. An example may include substituting one sound for another or leaving out sounds. Voice, however, may refer to the characteristics of the sounds produced—specifically, the pitch, quality, and intensity of the sound. Often, fluency will also be considered a category under speech, encompassing the characteristics of rhythm, rate, and emphasis of the sound produced.

A language impairment is a specific deficiency in understanding and sharing thoughts and ideas, i.e. a disorder that involves the processing of linguistic information. Problems that may be experienced can involve the form of language, including grammar, morphology, syntax; and the functional aspects of language, including semantics and pragmatics.

An individual can have one or both types of impairment. These impairments/disorders are identified by a speech and language pathologist performing a direct observation of the child, using interviews and questionnaires completed by parents/teachers and an assessment of their learning ability.

Speech disorders

The following are brief definitions of several of the more prominent speech disorders:

Apraxia of speech

Apraxia of speech is the acquired form of motor speech disorder caused by brain injury, stroke or dementia. In this condition, the brain is unable to send the correct movement instructions to the muscles involved in speech, such as the lips, jaw, and tongue.

Developmental verbal dyspraxia

Developmental verbal dyspraxia refers specifically to a motor speech disorder. This is a neurological disorder. Individuals with developmental verbal apraxia encounter difficulty saying sounds, syllables, and words. The difficulties are not due to weakness of muscles, but rather on coordination between the brain and the specific parts of the body. Apraxia of speech is the acquired form of this disorder caused by brain injury, stroke or dementia.

Interventions are more effective when they occur individually at first, and between three and five times per week. With improvements, children with apraxia may be transitioned into group therapy settings. Therapeutic exercises must focus on planning, sequencing, and coordinating the muscle movements involved in speech production. Children with developmental verbal dyspraxia must practice the strategies and techniques that they learn to improve. In addition to practice, feedback can be helpful to improve apraxia of speech. Tactile feedback (touch), visual feedback (watching self in mirror), and verbal feedback are all important additions. Biofeedback has also been cited as a possible therapy. Biofeedback is a process where electronic monitoring of an automatic function is used to train an individual to acquire voluntary control of that function. Functional training involves placing the individual in more speech situations, while providing him/her with a speech model, such as the SLP. Because the cause is neurological, however, some patients do not progress. In these cases, AAC may be more appropriate.

Dysarthria

Dysarthria is a motor speech disorder that results from a neurological injury. Neurodegenerative conditions like Parkinson's disease, amyotrophic lateral sclerosis, and progressive supranuclear palsy frequently transpire in association with dysarthria. Some stem from central damage, while other stem from peripheral nerve damage. Difficulties may be encountered in respiratory problems, vocal fold function, or velopharyngeal closure, for example.

Orofacial myofunctional disorders

Orofacial myofunctional disorders refers to problems encountered when the tongue thrusts forward inappropriately during speech. While this is typical in infants, most children outgrow this. Children that continue to exaggerate the tongue movement may incorrectly produce speech sounds, such as /s/, /z/, /ʃ/, /tʃ/, and /dʒ/. For example, the word, "some," might be pronounced as "thumb".

The treatment of OMD will be based upon the professional's evaluation. Each child will present a unique oral posture that must be corrected. Thus, the individual interventions will vary. Some examples include: increasing awareness of muscles around the mouth increasing awareness of oral postures improving muscle strength and coordination improving speech sound productions improving swallowing patterns

Speech sound disorder

Speech sound disorders may be of two varieties: articulation (the production of sounds) or phonological processes (sound patterns). An articulation disorder may take the form of substitution, omission, addition, or distortion of normal speech sounds. Phonological process disorders may involve more systematic difficulties with the production of particular types of sounds, such as those made in the back of the mouth, like "k" and "g".

Naturally, abnormalities in speech mechanisms would need to be ruled out by a medical professional. Therapies for articulation problems must be individualized to fit the individual case. The placement approach—instructing the individual on the location in which the tongue should be and how to blow air correctly—could be helpful in difficulties with certain speech sounds. Another individual might benefit more from developing auditory discrimination skills, since he/she has not learned to identify error sounds in his/her speech. Generalization of these learned speech techniques will need to be generalized to everyday situations. Phonological process treatment, on the other hand, can involve making syntactical errors, such as omissions in words. In cases such as these, explicit teaching of the linguistic rules may be sufficient.

Some cases of speech sound disorders, for example, may involve difficulties articulating speech sounds. Educating a child on the appropriate ways to produce a speech sound and encouraging the child to practice this articulation over time may produce natural speech. Likewise, stuttering does not have a single, known cause, but has been shown to be effectively reduced or eliminated by fluency shaping (based on behavioral principles) and stuttering modification techniques. These techniques include, but are not limited to: Identification: understanding how they stutter in relation to when they are speaking Desensitization: by direct confrontation Modification: go back to the disfluent words and say them with preferred techniques

Stuttering

Stuttering is a disruption in the fluency of an individual's speech, which begins in childhood and may persist over a lifetime. Stuttering is a form of disfluency; Disfluencies may be due to unwanted repetitions of sounds, or extension of speech sounds, syllables, or words. Disfluencies also incorporate unintentional pauses in speech, in which the individual is unable to produce speech sounds.

While the effectiveness is debated, most treatment programs for stuttering are behavioral. In such cases, the individual learns skills that improve oral communication abilities, such as controlling and monitoring the rate of speech. SLPs may also help these individuals to speak more slowly and to manage the physical tension involved in the communication process. Fluency may be developed by selecting a slow rate of speech, and making use of short phrases and sentences. With success, the speed may be increased until a natural rate of smooth speech is achieved. Additionally, punishment for incorrect speech production should be eliminated, and a permissive speaking environment encouraged. Electronic fluency devices, which alter the auditory input and provide modified auditory feedback to the individual, have shown mixed results in research reviews.

Because stuttering is such a common phenomenon, and because it is not entirely understood, various opposing schools of thought emerge to describe its etiology. The Breakdown theories maintain that stuttering is the result of a weakening or breakdown in physical systems that are necessary for smooth speech production. Cerebral dominance theories (in the stutterer, no cerebral hemisphere takes the neurological lead) and theories of perseveration (neurological "skipping record" of sorts) are both Breakdown theories. Auditory Monitoring theories suggest that stutters hear themselves differently from how other people hear them. Since speakers adjust their communication based upon the auditory feedback they hear (their own speech), this creates conflict between the input and the output process. Psychoneurotic theories posit repressed needs as the source of stuttering. Lastly, Learning theories are straightforward—children learn to stutter. It should be clear that each etiological position would suggest a different intervention, leading to controversy with the field.

Voice disorders Voice disorders range from aphonia (loss of phonation) to dysphonia, which may be phonatory and/or resonance disorders. Phonatory characteristics could include breathiness, hoarseness, harshness, intermittency, pitch, etc. Resonance characteristics refer to overuse or underuse of the resonance chambers resulting in hypernasality or hyponasality. Several examples of voice problems are vocal cord nodules or polyps, vocal cord paralysis, paradoxical vocal fold movement, and spasmodic dysphonia. Vocal cord nodules and polyps are different phenomena, but both may be caused by vocal abuse, and both may take the form of growths, bumps, or swelling on the vocal cords. Vocal fold paralysis is the inability to move one or both of the vocal cords, which results in difficulties with voice and perhaps swallowing. Paradoxical vocal fold movement occurs when the vocal cords close when they should actually be open. Spasmodic dysphonia is caused by strained vocal cord movement, which results in awkward voice problems, such as jerkiness or quavering.

If nodules or polyps are present, and are large, surgery may be the appropriate choice for removal. Surgery is not recommended for children, however. Other medical treatment may suffice for slighter problems, such as those induced by gastroesophageal reflux disease, allergies, or thyroid problems. Outside of medical and surgical interventions, professional behavioral interventions can be useful in teaching good vocal habits and minimizing abuse of vocal cords. This voice therapy may instruct in attention to pitch, loudness, and breathing exercises. Additionally, the individual may be instructed on the optimal position to produce the maximum vocal quality. Bilateral paralysis is another disorder that may require medical or surgical interventions to return vocal cords to normalcy; unilateral paralysis may be treated medically or behaviorally.

Paradoxical vocal fold movement (PVFM) is also treated medically and behaviorally. Behavioral interventions will focus on voice exercises, relaxation strategies, and techniques that can be used to support breath. More generally, however, PVFM interventions focus on helping an individual to understand what triggers the episode, and how to deal with it when it does occur.

While there is no cure for spasmodic dysphonia, medical and psychological interventions can alleviate some of the symptoms. Medical interventions involve repeated injections of Botox into one or both of the vocal cords. This weakens the laryngeal muscles, and results in a smoother voice. Psychological interventions may include speech therapy, counseling, and mindfulness.

Language disorders