Lecture # 113:
Speech and Language Disorders

copyright 2008 Cheryl K. Hosken, BSN, MS Psych.

Objectives:
1.The student will understand the difference between a speech disorder and a language disorder.
2. The student will know treatment for stuttering.
3. The student will become familiar with normal language development.

Personal Description
Mark leaps from the mattress on his bedroom floor and dresses for another day at kindergarten. He talks nonstop to his little sister as he dresses. The shirt he pulls out of the pile at the foot of his mattress is a little rumpled and has a spot of chocolate on the front, but he wants to get to kindergarten. He eats a little breakfast, gives his mom a kiss, and warns his sister to stay away from his trucks.

When he gets on the bus, Mark gives a high-five to several of the kids on the bus and then sits right behind the driver. He leans over the bar that separates him from the driver. He starts talking. Talking and smiling all the way, he rides a few blocks to school.

Not everyone understands all of Mark's words and he even leaves some words out of his sentences. But the bus driver is a good listener and has learned to understand most of what Mark has to say. Children are usually not as patient. Often, they leave Mark out of school activities where children talk to one another. Mark is sometimes very assertive about getting attention from other children. He uses gestures and raises his voice. He prefers talking with adults who try to understand him.

Meditate Word By Word On These Verses:
Exodus 4:10-11, 6:28 - 7:2.

In the classroom, Mark works on letters of the alphabet. Two years ago, he was not talking. Now he is not only talking, but also learning to read. He and his mother are proud of this achievement. In class the speech-language pathologist who works with him on his articulation and language skills joins him. She includes the other children in his group activity. Soon they are all describing the actions in a story and using longer and more complete sentences.

During recess, he tends to play by himself. He really likes to swing, but the swings are all occupied this morning. He waits, but no one wants to give up a swing. He goes to the sandbox where several others are playing. Suddenly, he jumps up and runs for the swing, someone has given it up for the sandbox. He smiles as he pushes himself back and forth.

Question:
1. Why is it easier for Mark to speak with adults rather than children?

Definition
Speech and language disorders are observed disturbances in the normal speech, language, or hearing process. Disordered communication calls attention to itself, interferes with communication and makes both the speaker and the listener uncomfortable. A speech or language impairment means a communication disorder such as stuttering, impaired articulation, a language impairment, or voice impairment that adversely affects a child's educational performance.

Difference Between Speech and Language Disorders
A speech disorder is a problem in sending, or delivering messages verbally. A language disorder is a problem with receiving, understanding, and formulating messages. Specifically, a speech disorder is an impairment of speech sounds, fluency, and/or voice. For example, sound production and language use may be appropriate for the child's age, but if he stutters he has a speech impairment. The child's speech lacks the usual rhythm and flow, fluency, and is labored in its production.

A language disorder is an impaired comprehension and/or use of spoken, written, and other symbol systems. Mark has both a speech impairment and a language impairment. His speech is not readily understood, deviates from the usual way in which sounds are produced, and is inappropriate for his age. His sentence structure and vocabulary are sufficiently different from others his age to be a language disorder.

Not everyone who has a speech or language difference has a language disorder. Those with speech or language differences may have developed a language and speech style in a culture different from the listener's. Dialects and culture-specific uses do not constitute speech or language disorders. Everyone at some time has a language difference, depending on the listener. There are differences among groups of people who speak the same language. Also there are differences in language from one part of a country as compared to another part. In contrast, however, there are some groups of people who seem to have more speech and language problems than the norm.

Question:
2. a) A speech disorder is ________. b) A language disorder is _________.

Describing Characteristics
Speech and language acquisition is a highly complex procedure that involves many systems that work together. To become an effective communicator requires a mastery of all the systems and rules that contribute to daily speech and language.

Speech is the expression of language in sounds. There are three components to the development of speech: producing the speech sounds, voicing the speech, and giving fluency to speech. In many children, the components develop naturally.

The ability to produce sounds is a normal part of speech acquisition. Speech sounds are created as air passes through the vocal tract (larynx, pharynx, mouth and nose). The sounds are formed by varying the position of the lips, tongue and lower jaw.

During their early years, children quickly learn speech sounds as well as rules for their language. In the first eight years of life, children must learn to produce all the consonants, vowels, and diphthongs that make up the words of their language. Learning these sounds usually proceeds in a fairly consistent sequence, but there may be as much as a three-year variance between the time that some children learn a particular sound and the time when others learn the same sound.

Michelle, Mark's younger sister, is developing speech and articulation at the typical rate. She is using the vowel and consonant sounds appropriate for three-year-old speech. She might be substituting earlier learned sounds for ones she will learn later or omitting sounds entirely. In producing words that contain blends, she may omit a sound from the blend. She will add these sounds later as she uses them in her language system.

Each of us develops an individual voice that is as unique as a fingerprint. Our voices are made up of a number of elements, but it is primarily how we use pitch, loudness, and resonance. Pitch is determined by the rate of vibration of the vocal cords, which in turn is determined by the mass, tension, and elasticity of the vocal cords.

The intensity of the unique voice is determined by the air pressure coming from the lungs though the vocal cords. Actually, intensity is a perception of the listener, but the loudness of a voice is controlled by the air pressure coming through the vocal cords.

Resonance is determined by the way in which the tone coming from the vocal cords is modified by the cavities of the throat, mouth, and nose. The distinct sound of a newborn compared to the cry of an older infant is partially a result of growth and changes in these cavities during the first few months of life.

The quality of the voice is a result of a combination of factors in the way the voice is produced and involves all the above elements.

Match these terms with the definitions below:
A. Resonance, - B. Pitch, - C. Intensity.

3.1. Air pressure coming from the lungs through the vocal cords.
A, B, C.

3.2. Rate of vibration of vocal cords.
A, B, C.

3.3. Modification of tone in cavities of throat, nose, mouth.
A, B, C.

Infants at early ages differentiate these various features to recognize and prefer their mothers' voices. By four to eight months of age, they recognize the differences in voice quality that indicate anger, happiness, and sadness. They can use their own voices to indicate their satisfaction, happiness and anger.

Typical speech development also includes the development of fluency of speech. Fluency is easy, smooth flowing, effortless speech. Many children have problems with fluency as they learn speech. They repeat words or sounds as they try to express ideas or concepts more advanced than their language or speech skills. This is much like their early efforts at walking. We watch youngsters learning to run and often see them trip and fall. Compare that development with learning to express ideas in longer sentences. When children make mistakes as they learn to talk, they are dysfluent. (The prefix dys- means a problem in medical terms)

Question:
4. What qualities of voice do great singers of classical music have that distinguish them from most of us?

Characteristics of Speech Impairments
Impairments in the development of a child's speech can include disorders of articulation, voice, and fluency. These disorders can appear in combination with each other or with other disorders. Students with hearing losses or cerebral palsy often have articulation or voice disorders. Articulation, voice, and fluency disorders can also be single disorders.

Articulation Disorders
Articulation disorders are the largest group of speech and language impairments. Articulation is the production of speech sounds. If a person's articulation is disordered, there are substitutions, omissions, additions, and distortions in his language. A child may substitute an appropriate phoneme with a sound that is easier for him to make. For example, a child may say "faghetti" instead of "spaghetti". The "f" sound is easier to say than "sp". Comedians sometimes do this to make us laugh. Omissions occur when a child leaves a phoneme out of a word. If a young child has a brother or sister, he may call to him/her using the sounds he knows in the name. An example is the name "Polina". A child may say "Pola" rather than the full name. Additions are also part of articulation disorders. These are simply sounds that are added to words. They may distort the sound so it sounds different, but is still recognizable as the same sound.

Mark had many articulation errors when he first began his preschool language program. A large number of his words were one consonant and one vowel. He was omitting most of the sounds in his words.

Voice disorders Voice disorders affect the quality of the voice itself. As noted before there are four dimensions of voice: quality (breathy or strident), resonance (nasal or denasal), pitch (high or low), intensity (loud or soft). Voice quality is affected by problems of breath support or vocal cord functioning. Yelling and other forms of vocal abuse cause students' most common voice disorders. Vocal nodules develop when the voice is used incorrectly. The nodules are somewhat like little calluses that form on the vocal cords and they do not allow them to vibrate normally or come together completely. Because the cords cannot vibrate normally, the sound of a person's voice changes. When the cords cannot come together and nodules are too large, the person loses his voice altogether. Sometimes, therapy helps these conditions, but often surgery followed by therapy is necessary. Therapy is designed to help the person talk in a way that is less damaging to his vocal cords.

Voice disorders related to resonance are characterized by hypernasality and hyponasality. People with hypernasality sound as if they are speaking through their noses. Usually, the air for all sounds except "m", "n", and "ng" is directed through the mouth. With hypernasality, the air is allowed to pass through the nose on other sounds as well. As a result, the letter "b" sounds like "m" and the letter "d" like "n". With hyponasality, air cannot pass through the nose and therefore "m" sounds like "b", and "n" like "d". Everyone with a stuffy nose due to allergy or a cold has experienced temporary hyponasality.

Question:
5. a) Articulation is the production of ______ ______. b) Voice disorder affects the ______ __ _________.

Fluency disorders
The final group of speech disorders is the disorders of fluency, frequently referred to as stuttering. Fluent speech is a smooth, forward-moving, unhesitant, and effortless speech. Dysfluency is any break in speech. All children are dysfluent on occasion. Normal dysfluency becomes stuttering when the disruptions in speech are accompanied by awareness, anxiety, or compensatory behaviors. Stuttering is often accompanied by tension and anxiety. The types of dysfluencies in stuttering may also be different. There are sound or syllable repetitions, silent stops, prolongations of a sound, and facial grimaces.

Many children have a period of normal non-fluency between the ages of 2 and 5 years. The frequency of dysfluency can be 10% or greater when they speak. The dysfluencies can be a whole word or phrase repetitions. The word is repeated just once or twice and is repeated easily. It has been suggested that the cause of this non-fluency may be a combination of increased language development, development of speech motor control, and environmental stresses that can occur in typical busy families. Some children grow out of these dysfluencies and others do not.

There have been many theories about the causes of stuttering and many misconceptions exist. Currently, it is believed that a number of factors can be grouped and classified as mental, environmental, and communication factors. There is evidence that stuttering occurs in families over generations. There is also evidence that stuttering is due to a disorder in the movement of speech muscles, a defect in how the child hears himself speak, and a lack of cerebral control over language functions. Researchers using special scanning of the brain found that all three of these causes contribute to stuttering. Stutterers show a shift in the brain activation from the left to the right side of the brain that suggests these people process language differently.

There are a lot of myths about stuttering and here are some facts:

There are as many different treatment approaches to stuttering as there are causes. It usually is different depending on the age of the stutterer. There is no "cure" for stuttering. Stuttering can be helped in preschooler and young borderline stutterers though environmental changes and parent counseling. Environmental manipulation involves finding variables in the child's environment that increase his dysfluencies and then reducing or eliminating them. Some variables might include: competition for talking time, interruptions when a child is talking, pressure to speak or perform, loss of a listener (a parent moves away when a child tries to speak to him), fast-paced, busy environment, and a high level of excitement.

When speaking with a person who stutters it is helpful to focus on what they say rather than how. Modify your own speaking rate to one that is slightly slower and pausing periodically helps the stutterer. Be relaxed and attentive. Don't look away if they have to pause for a time, but don't stare intently at them. Try not to interrupt or finish their sentences. Advice to "slow down" or "relax" is not helpful. It often increases tension and stuttering.

Question:
6. The cause of stuttering is:
(Select the best answer.)
a) inattentive parents.
b) may be a disorder of speech muscles and lack of control in the brain.
c) an emotional or psychological disorder.

As noted above, there is some new research that supports the physical cause for stuttering. The speech muscles of stutterers do not perform the correct sequence of movements necessary to produce fluent speech. A device that is somewhat like a hearing aid reduces stuttering by modifying the physical factors that affect speech. This gives the brain the ability to control the speech muscles more effectively. The device also lets the person to hear his own vocal tone when he speaks. Vocal tone is what the brain uses to guide the muscles used in speech. Vocal tone is a buzzing type of sound that is generated by vibrations of vocal cords in the larynx that is transferred to the ears through the soft tissues, cartilage, and bones of the throat and skull. Vocal tone is a natural, internal component of speech and provides a background sound that is always present in our bodies when we talk.

Here is an example of what is meant by vocal tone. If you have ever heard a tape recording of your speech, you are aware of the fact that you do not sound the same during a tape playback as you do when you are in the process of talking. The reason for this difference is that a tape recorder does not capture the vocal tone that travels inside your body from your throat to your ears, yet you hear this sound when you speak. That is also why it is difficult to hear yourself when you use a microphone with the speakers directed away from you. You do not get feedback of your voice and how it sounds.

The device that helps control stuttering has a miniature microphone to detect vocal tone vibrations. The words said are amplified and processed by electronic circuitry in a small hearing aid case that fits behind the ear. A tiny plastic tube carries the sound to the ear where a small earpiece gives louder sound to the ear so that signals to the brain are more accurate. The device does not interfere with normal hearing.
Website for the device, Fluency Master: http://www.stutteringcontrol.com

Typical Language Development
The language development of a child is highly complex but fairly predictable progression of changes. Here are examples:

Birth to 6 months
Different cries that express emotions and needs such as pain and hunger
Laughs
Responds to voices and other sounds differentially
Tries vocalizing

6 to 12 months
Listens to new words
Understands own name and "No"
Uses sounds differentially and with inflection - babbles
Imitates sound patterns and motor acts such as waving good-bye
Responds to simple commands such as "come here" and "give me"
Recognizes names of familiar people and objects

12 to 18 months
Names familiar objects with single words
Mixes jargon speech (sounds with inflection) with single words
5-50 word vocabulary
Identifies one to three body parts
Points to pictures named in a book

18-24 months
Strings two or more words together
200-300 word vocabulary by 24 months
Understand possessives
Uses plurals
Uses simple adverbs and adjectives - nice, good, big
Uses some verbs
Understands simple directives - but may ignore them!
Listens to parents' speech and imitates parts of it

24-36 months
Understands objects according to their use, such as, "what do we eat with?"
Understands simple questions and pronouns
Follows two-step directions
Listens to stories
Uses two-word and longer phrases
Has a vocabulary of 900-1000 words
Asks simple questions
Understands the prepositions - in, under, up, down
Recounts events

36-48 months
Tells stories, both real and imaginary
Understands most compound and complex sentences and may use some
Can explain and describe events
Asks "why" questions
Uses communication to begin play with others, "let's play with the cars"
Can complete some verbal analogies - "Dima is a boy and Sveta is a _________"
May have some articulation difficulties with sounds l, s, ch, sh

4 to 5 years
Uses the prepositions in, on, under
Understands if, because, when, and why
Uses more complex sentences
Can give name, gender, and phone number

5-6 years
Vocabulary of 2,500-2,800 words
Uses comparative adjectives (big, bigger, biggest)
Uses irregular verbs correctly
Tells familiar stories and imaginative tales
Shares personal thoughts and feelings verbally
Talks about what is happening to him rather than acting out thoughts or feelings
Uses the telephone with ease
Recognizes jokes