Speech & Language Disorders

(2-3-15)

Communication

• Vocal communication
  • verbal
  • nonverbal
• Nonvocal communication
  • gestures
  • signs

The Structure of Oral Language

Phonology: the system of speech sounds used in an oral language, the sounds (phonemes) and how these sounds can be used and combined

• Phonological awareness or processing predicts reading ability
• “Some researchers believe that the movements of our throats, tongues, mouths, and faces in speech are as important as the sound of speech. They hold that at some level, speech is also gesture.” (Kenneally, 2007, p. 155)

Syntax: the rules governing sentence structure–how words may be combined into phrases and sentences within a language

“All the words in the following sentence make perfect sense by themselves, but because of the way they are lined up defies the syntax of English, there is no larger meaning: the the are up way they meaning line there no syntax English defies larger of.” 

(Kenneally, 2007, p. 155)

Sequencing of motor behaviors, interrupting motor (or thought) sequences, and switching from one sequence to another reflects activity in the basal ganglia of the brain, a very old neurological formation

Morphology: the form and internal structure of words–how words are transformed in respect to tense and number Semantics: the meaning of language units (“words”); lexical aspects of language: the vocabulary Discourse skills/Narrative Discourse: carrying on a conversation, telling a story, explaining

Human communication seems fundamentally cooperative:

“Reciprocation is fundamental to the interactions of our species. Offering is not instinctive for humans, but is taught by parents to children, who learn it easily. And crucially, we offer not only food and other objects but information and experience as well.” 

(Kenneally, 2007, p. 128)

Pragmatics: the use of language in social context to accomplish a purpose; the rules of how to use language for communication, including “communication repair”

Ultrasound studies of speakers’ tongues by Hohenberger suggest that so called “sound exchanges”, often called spoonerisms (“jeef berky” for “beef jerky”), may result from attempts to pronounce the two sounds at the same time rather than substitution of one whole speech segment for another:

“a collision of motor commands rather than as substitutions of mental symbols”

(Erand, 2007, p. 1676)

Thought, Speech, and Language Development

Vygotsky discussed how early thinking in infants developed independently of speech, and speech could serve emotional and social functions independently of thinking in the child, “less than one year old.”

“But the most important discovery is that at a certain moment at about the age of two the curves of development of thought and speech, till then separate, meet and join to initiate a new form of behavior. Stern’s account of this momentous event was the first and best. He showed how the will to conquer language follows the first dim realization of the purpose of speech, when the child ‘makes the greatest discovery of his life,‘ that ‘each thing has its name‘ [40, p. 108].

This crucial instant, when speech begins to serve intellect, and thoughts begin to be spoken, is indicated by two unmistakable objective symptoms: (1) the child’s sudden, active curiosity about words, his question about every new thing, ‘What is this?’ and (2) the resulting, rapid, saccadic increases in his vocabulary.”

(Vygotsky, Thought and Language, 1934, translation 1962)

Speech, Language, and the FOXP2 gene

The FOXP2 gene was initially focused on after studies of a British family in London who had an especially high family history of speech and language disorders found that in many affected family members, one of their two copies of FOXP2 had been inactivated by a mutation.

Scientists continue to work at understanding the effects of FOXP2 on brain development.

Studies have suggested that virtually every human in the world has the same allele of FOXP2, suggesting that it may have conferred a major survival value and swept through the population within the last 200,000 years. It has been speculated that this spread of FOXP2 lead to neurological changes that could have accounted for the major change in human behavior 50,000 year ago that lead Homo sapiens populations to expand and move out of Africa, with the emergence of improved language abilities being a likely candidate.

A recent report that FOXP2 had been found in analysis of Neanderthal DNA has further fueled debates about the origins of language and the role of FOXP2. Neanderthals and modern humans lineages diverged approximately 350,000 years ago. They dominated Europe until the arrival of modern humans about 45,000 years ago. Many believe they were likely driven to extinction by modern humans approximately 30,000 years ago from their last refuges in Spain and Portugal.

Further complicating this issue are recent reports of evidence that Homo sapiens and Homo neanderthalensis may have interbred to some degree, with a small percentage of DNA in humans of European descent showing evidence of Neanderthal origin

Communication Disorders

Communication problems have repeatedly been found to be a risk factor for later academic and/or behavior/emotional difficulties

• Children with language impairments frequently develop later reading problems. Estimates up to 6 times baserate for control children are found for reading problems (Ingram, Mason, Blackburn, 1970). As many as 40% of kindergartners with impaired language also show math difficulties and reading problems in elementary school (Aram & Nation, 1980).
• Other terms encountered in the literature: Specific Language Impairment

Speech Disorders vs. Language Disorders

Speech Disorders

• Prevalence: approximately 5% of school-aged children (Maxmen & Ward, 1995)
  • Related concepts: “intelligible speech”, “unclear speech” (see Coplan & Gleason, 1988)
• Course: often improve over time, usually positively respond to treatment
  • some association with risk for social-emotional disorder, but significantly less than that of language disorders (Cantwell & Baker, 1991)
• Multicultural issues in speech evaluation
• Diagnostic categories:
  • Phonological Disorder or Articulation Disorder: the most common speech problem
    • There is distortion or omission of certain speech sounds or combination of sounds
    • (DSM-IV includes Phonological Disorder along with language disorders in a group called “communication disorders.”
    • phonological disorders involve problems with sound production
    • tend to decrease/resolve with age over developmental years
    • tend to improve with speech therapy
  • Stuttering
    • Male to female ratio 3:1 (Maxmen & Ward, 1995)
    • Majority improve over time (Maxmen & Ward, 1995)
    • Stuttering is one of a group of Fluency Disorders–which involve problems in the flow of speech.
    • Another Fluency Disorder is Cluttering, a disorder of speech rate and intelligibility: the child speaks very rapidly, often in short “bursts”, and may slur speech–making it difficult for others to understand them
    • Speech pathologists differentiate a number of fluency disorders: stuttering, cluttering, neurologic or cortical fluency disorder, psychological or traumatic fluency disorder (Blood, 1998)
  • Voice Disorders
    • Problems of voice quality, resonance, pitch, or intensity
    • “inappropriate vocal components” may involve respiration (shallow, breathy, etc.), phonation (hard glottal attacks, glottal fry, diplophonia), resonation (hypernasal, hyponasal, assimilative nasality, cul-de-sac nasality), pitch (too high, too low, monotone), loudness (too loud, too soft), and rate (too fast, too slow) [Stemple, 1998, p. 193)
    • Stemple (1998) suggests that voice disorders may result from vocal misuse, medically related etiologies, primary disorder etiologies, and personality related etiologies
      • vocally abusive behavior, such as shouting, loud talking, screaming, coughing, throat clearing
      • medically related etiologies, such as laryngeal and oral abnormalities, systemic disease, allergies, gastroesophageal reflux
      • primary disorder etiologies where the vocal changes are secondary to the primary disorder, such as cerebral palsy, deafness, dysarthria
      • psychological etiologies involving environmental stress, conversion behavior, and identity conflict
      • The prevalence of “clinically significant” voice disorders in school-age children may be in the 5-9% range and these youth may be chronically underserved (Leeper, 1992)
  • Delayed Speech
    • “Perhaps the most common referral complaint to any pediatric speech-language pathologist is that of delayed speech and language development.” (Schery & Garber, 1998, p. 45)
    • Late Talkers: “young children who present significantly restricted expressive language by 2 years of age” (Schery & Garber, 1998, p. 46)
      • risk factors for continued speech delay into the school years (from Schery & Garber, 1998, p. 48):
        • family history of language delay
        • lower socioeconomic status
        • female gender
        • lower ratio of consonants to total babble in prelinguistic vocalizations
        • lack of symbolic activities, including symbolic play and gestures
      • mutism & hearing loss
      • Selective Mutism [DSM 5] (Elective Mutism [DSM 3], Voluntary Silence [Great Britain])–probably best construed as an anxiety disorder but often discussed in the context of speech problems
    • Communication Disorders Not Otherwise Specified

Language Disorders

• Disturbances in the use of a symbol system for communication
• “Simply put, language concerns message formulation whereas speech concerns message transmission.” (Cohen, 2001, p. 6)
• Other terms: “specific language impairment”, “language impairment” “developmental dysphsia”
• Language Delay vs. Language Disorder: this distinction has proven difficult to support and its usefulness has been questioned (Cohen, 2001), however this differential is still commonly cited (Hardman, Drew, & Egan, 2005).
• Prevalence: approximately 3-10% of school-aged children (Maxmen & Ward, 1995)
• Demographics: more males than females
• Course: often more chronic than speech disorders
• Comorbidity:
  • Academic Correlates:
    • High comorbidities are reported with reading problems, math difficulties, and other learning disabilities (Cohen, 2001; Teeter & Semrud-Clikeman, 1997).
    • Speech disorders may be found in association with language disorders; however, many/most children with speech disorders show no evidence of difficulties with language.
  • Social-Emotional Correlates:
    • High comorbidities are reported with behavioral and emotional problems (Cantwell & Baker, 1991; Cohen, 2001); however, the association between language disorders and social-emotional difficulties in children without associated learning disabilities (which are strongly comorbid with specific language disorders) is less well established (Teeter & Semrud-Clikeman, 1997).
    • The developmental interaction between language development, affective self-regulation and self-control, social skills and awareness, identity and self-esteem, and adjustment are complex and not fully understood. Children with langauge disorders have consistently been found to be at risk for psychiatric, behavioral, social, and emotional disturbance relative to matched control groups, but the reason for this risk continues to be debated. It is also clear that some children do quite well despite significant language challenges, and the factors which contribute to their resiliency are also incompletely understood. The lack of well-standardized measures for many important areas of language functioning (pragmatics, social cognition) contributes to our limitations in advancing understanding.
  • Cognitive-Processing Correlates:
    • “Rate-processing deficits” have been commonly found in children with language impairments: auditory processing deficits involving difficulty with signals having short segments and/or rapid presentation in a series (Teeter & Semrud-Clikeman, 1997). This has been suggested as the “basic deficit” underlying many of the neuropsychological and cognitive features associated with language disorders (Stark & Tallal, 1988).
    • In typical development language (a system of symbolic representation of objects, events, relationships) comes to serve many aspects of cognitive processing and self-regulation.
  • Disturbances in pragmatic aspects of communication:
    • “The ultimate goal of speech and laguage is usually not just to produce verbal language but to communicate, to influence the social world, to relay information, desires, feelings, and inquiries. Poor pragmatic communication can severely limit a child even in the face of intact molecular language skills. The excessice wordiness of some hearing-impaired children or youth with nonverbal learning disabilities and the stilted and empty speech of some autistic children show deficits in the pragmatic aspects of language – the use of oral language to interact with the world. In contrast, the agrammatical and jargon-riddled speech of streetwise children of low socioeconomic status often shows poor formal language characteristics but is dramatically effective in the real job of language – to affect our world. How well does the child get his or her point across or message communicated? This is the question addressed by the pragmatic aspects of language use. In my experience good pragmatic communication is a powerful and positive prognostic variable. Effective symbolic communication, even in the presence of speech or language limitations, reflects the intact operation of vital cognitive processes and predicts relatively good outcome. Li, Walton, and Nuttall (1999) have discussed the challenges of assessing young culturally and linguistically diverse chilidren.” (House, 2002).
• Diagnostic categories
  • Expressive language disorder
    • Reduced verbal fluency, word finding difficulties, restricted vocabulary, deficits in grammer/tense/sentence structure
    • Normal intelligence and receptive language abilities (relatively)
  • Receptive language disorder (Mixed Receptive-Expressive Language Disorder)
    • Comprehension as well as expression limitations
    • “pure” receptive language disturbances without some associated problems in expressive language are unusual
    • Less frequent than expressive language disorders and more impairing
  • Aphasias (like language disorders generally) can be expressive or receptive, and receptive aphasias usually also have difficulty with expression. Several classification systems for aphasias have been proposed by speech/language pathologists, neurologists, and neuropsychologists (Darley, 1982; Strub & Black, 1988).
    • Global aphasia: most severe, profound comprehension deficit and near total absence of speech production
    • Wernicke’s aphasia (receptive aphasia): fluent speech that is often meaningless due to a severe comprehension disturbance
    • Broca’s aphasia: dysfluent speech with adequate comprehension
    • Conduction aphasia: fluent aphasia with good comprehension, only major difficulty is the repetition of speech
    • Transcortical aphasia: able to repeat but have difficulty with either speech production (transcortical motor aphasia) or comprehension (transcortical sensory aphasia) or both
    • Anomic aphasia: difficulty in naming objects and in word finding in running speech. Anomia refers to the inability to retrive the name of an object due to brain injury; dysnomia refers to difficulty in retrieving the name of an object due to brain injury (“word finding difficulty”, “blocking”)
  • A related category of disturbance is Childhood Apraxia of Speech (also referred to as dyspraxic speech): a disorder of the brain affects the ability to sequence and say sounds, syllables, or words. Dyspraxic speech is a specific type of speech disorder: the child knows what they want to say but their brain does not effectively control the muscles and body parts needed to produce the intended sounds. What is different about dyspraxic speech (vs. any other speech disorder is that a specific etiology is implicated (or speculated): brain injury or dysfunction.

Speech and Language Therapy

• American Speech-Language-Hearing Association (ASHS)
• survey of speech-language pathologists

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Multicultural issues in speech evaluation

(2-4-11)

“To appropriately provide differential diagnosis to culturally and linguistically diverse populations, communications disorders must be defined within the context of the client’s cultural and linguistic community. They must be distinguished from social dialects and variables expected because of normal development.”

(Battle, 1998, pp. 6-7)

Battle (1998, p. 7) offers Taylor’s view of a “culturally sensitive definition” of communication disorder:

• (a) deviates sufficiently from the norms, expectations and definitions of the indigenous culture or language group;
• (b) is considered to be disordered by the indigenous culture or language group;
• (c) operates outside of the minimal norms of acceptability of that culture or language group;
• (d) interferes with communication within the indigenous culture or language group; or
• (e) calls attention to itself within the indigenous culture or language group (Taylor, 1986, p. 13)

Gives example of low vocal intensity that might be diagnosed as voice disorder for speaker of Standard American English (SAE), but would not be considered a problem in some Asian cultures, such as Chinese or Indian

The American Speech-Language-Hearing Association in their Position Paper on Social Dialects (ASLHA, 1982) took the position that no dialectal variety of English is a disorder or pathological form of speech or language: “Therefore, a person who uses a social dialect that is appropriate to his or her indigenous community should not be identified as having a communication disorder.” (Battle, 1998, p. 9)

African American English (AAE) is used in many, not all, working-class African American families in informal speaking situations. There are distinctive differences between SAE and AAE in intonation pattern, speaking rate, lexicon, consonant and vowel patterns, and word choice (Battle, 1998). “A common error in diagnosis of phonologic and morphologic development in African American children is that all differences observed are related to the use of AAE.” (Battle, 1998, p. 9)

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Survey of speech-language pathologists

Survey of ASHA speech-language pathologists case loads of elementary school children by type of communication disorders

Distribution of communication disorders served in elementary school children by speech-language pathologists: percentage of case load

Disorder	Grades K-3	Grades 4-6
speech sound production	58.2 %	48.7 %
spoken lang. production	47.5	48.2
spoken lang. comprehension	39.4	41.9
intelligibility	16.9	3.6
fluency	3.4	8.8
pragmatics	1.7	1.6
voice	0.6	0.5

percentage totals exceed 100% due to students being served for multiple problems

(American Speech-Language-Hearing Association, 2001)