Lecture # 114:
Speech and Language Disorders, Continued

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

Objectives:
1. The student will understand the components of language and how children may make mistakes.
2. The student will understand the causes of speech and language disorders.
3. The student will know some of the therapies used to help children with speech and language problems.

Dimensions of Language
The five dimensions that work together to produce language are phonology, morphology, syntax, semantics, and pragmatics. Each dimension is an integral part of the theories that explain how children acquire language. These theories are psycholinguistic, behavioral, and socio-linguistic (or social interactional). Each of these regards a different dimension as critical to learning communication. Although each theory is separate from the others, most professionals combine or synthesize the theories when talking about how a child develops language skills.

To become an effective communicator, a child must master all these systems and rules that are used in daily communication. Every day, we all use phonology, grammar, syntax, semantics, and pragmatics quite naturally. In the following descriptions, you will see the components of each dimension and how a child's speech can be impaired.

Meditate Word By Word On These Verses:
Isaiah 32:1-4, Luke 7:18-23.

Phonology
Phonology regulates the sequence of the sounds in a word so that the speaker can pronounce words and use them in a way that is consistent with the language he speaks. A phoneme is the smallest basic consonant or vowel sound that can change the meaning of a word. For example, in the word bill, there are three phonemes: /b/, /i/, /l/. By changing any one of the phonemes the speaker can produce a word with a different meaning such as: pill, ball, or bin.

Phonology describes the way people group sounds to make meaningful words and how sounds function to signal a change of meaning. Until about the age of 4 years, children often reduce phonemes in words so they are easily pronounced. They may omit final sounds and also reduce the number of syllables in a word.

Many of the errors made by children are phonological errors. When evaluating a child who may have phonological problems, the professional tries to determine if the child has (1) trouble producing a sound or (2) trouble using the sounds to produce words. Mark may make errors in phonology when he tries to simplify the series of sounds that make up a word. He may omit sounds by dropping the last letter of a word or reduce the sounds in a blend when he says sov for stove.

Morphology
Morphology refers to the rules that govern how a speaker combines basic meaningful units into words. Phonemes do not carry much meaning alone, but they can be grouped into syllables and words that have meaning. Other morphological rules include adding plural markings, using inflections, prefixes, and suffixes.

Morphology rules also determine derivations and emphasis. Derivations are words made from other words, such as teacher from the word teach. These rules also explain how to use emphasis in a sentence to convey meaning. A child continues to learn these rules of morphology throughout the school years and usually by graduation from secondary school most children know the rules.

Children who have disorders related to morphology cannot easily use the structure of words to get or give information. They may make errors in the number and tense of verbs or in case and gender of nouns, pronouns and adjectives (if the language contains such features). They may also have difficulty understanding adjective comparisons as in big, bigger, and biggest. Derived nouns may also be difficult for them to understand.

Question:
1. Phonology and morphology are dimensions of speech that use basic units of sound called ___________.

Syntax
Syntax refers to the rules for combining words into sentences. Most children begin to use the rules of syntax to help with meaning at about the age of three years. The ability to use syntax is both a receptive and expressive skill. Mark had to learn that word order has significance and has to learn to use word order appropriately. He also had to learn that there are lexical classes such as nouns, pronouns, and prepositions, etc.

The rules of syntax allow us to make an unlimited number of sentences using a finite number of words. Grammatical sentences are sentences that follow syntactic rules. One of the real mysteries of language acquisition is how children master the varied and complex rules of syntax.

Errors of syntax are errors in word order such as:

  1. difficulties in putting words in proper order
  2. incorrect structures, such as the misuses of negatives
  3. omission of structures where they should be used, such as the omission of prepositions

When Mark started to speak, he used one-word sentences and did not have the structures of syntax. Because he could not use the rules of syntax, the length of his sentences grew slowly. Without assistance, Mark's delays in using complex sentences might have caused him to use fewer and simpler rules to speak sentences. For example, his first sentences were simple statements of an actor and action, "It rains. I wear raincoat." And he gradually learned with help, more complex sentences using if or because: "Because it is raining, I must wear a raincoat." Mark needed to learn sentence structure for more complex sentences.

Question:
2. Syntax:
(One or more of the following answers may be correct.)
a) combines words into sentences.
b) uses phonemes.
c) is a language dimension that uses word order.

Semantics
Semantics are two types of rules and systems: word meanings and the relationship between words that conveys meaning. Semantic development has both receptive and expressive parts. Children must first understand the meaning of words and word combinations and then use words and sentences meaningfully. Their semantic knowledge allows them to label and categorize and form mental dictionaries. Children begin with a small number of words that represent a large number of objects they see. For example, toddlers often call all animals they see as "doggies". Through development of semantic rules, they differentiate dogs from horses and cats. Eventually, they are able to tell the difference between types of animals and even breeds of dogs.

The rules of semantics, or how words work together to form meaning also determine how negative sentences, question sentences, and imperative sentences are formed.

Children who have problems with semantics usually don't have problems with individual words. Their problems begin when they try to put words together in a sentence. They have difficulty with words, double meanings of words, abstract terms, synonyms, and idioms. Such children have trouble with words that express time and space concepts (night, dark) cause and effect (cold, snow), and inclusion versus exclusion (all, none).

Students with semantic language disorders use words with nonspecific meanings (thing, one) because of limited vocabularies or word-finding difficulties. They may substitute words incorrectly for other words or fail to use synonyms, homonyms, and antonyms. They have problems using conjunctions, negatives, and prepositions. Mark's language evaluation has an example: "Can they come in the house when you get it built?" Each of the clauses is correct, but the way they are used together does not show Mark's intent.

Question:
3. Semantics is the dimension of language about _________ and __________.

Pragmatics
Pragmatics focuses on a person's ability to communicate ideas and maintain interaction with others. Communication and interaction consist of commenting, requesting, asking, demanding, blaming, excusing, denying, and thanking. The goal of pragmatics is to get information, convey opinion, or get help. Even caregivers and infants use pragmatics in their interactions. For example, a baby coos and a father answers back.

Children begin to use language socially at a very early age. For example, a three-week old baby has a social smile. This is a simple social act of communication. This speech has instrumental functions (used to get help from someone) and regulatory functions (those that control the behavior of others). Eventually, children learn discourse skills, requests for objects or information, protesting the actions of another, greeting, answering requests, and acknowledging another person's comments.

A pragmatic view of communication focuses on the speaker, the listener, and the environmental context of communication. A student who asks questions but does not acknowledge the answers or whose comments are not related to the topic may have problems with pragmatics. See the conversation below:
Speaker: "I have a headache."
Listener: "Do you have an aspirin to relieve the pain or can you lie down for a few minutes?"
Speaker: "And my mother just broke her leg on the icy sidewalk."

In such a conversation, the listener would most likely give the speaker a questioning look, but the speaker may not notice this look of confusion and continue as if everything is understood. A child with a pragmatic disorder may also have difficulty taking turns in conversation. That is, not give opportunities for the conversation partner to comment or answer, or not understand something the partner has said requires a response.

Question:
4. Pragmatics in conversing provides:
(One or more of the following answers may be correct.)
a) a goal for communicating.
b) logically coming to the goal of what a person is communicating.
c) a smile.

Effects of Speech and Language Disorders
The impact of a speech and language disorder is evident in many aspects of a person's life. Children with speech and language disorders have problems with academic work. Those who have language problems as preschoolers are more likely to have problems in writing, reading, and with interaction with other children.

Relationships are based on shared communication. If children are difficult or impossible to understand, they will not be accepted as social partners by classmates. To maintain a relationship, a child needs to develop language and social interaction. Having language skills helps the child to control conversations with everyone in his environment - parents, classmates, siblings, teachers, relatives and other caregivers.

The presence of a speech or language disorder can have an impact long after school years. Each person has the capacity to do about 7,000 different jobs successfully if they do not have a communication disorder. 80% of most jobs require reasonable communication skills. Now you can understand how difficult it is for a person with a communication disorder to get a job interview and then be considered the best applicant for the job offered.

Causes of Speech and Language Disorders
For most children, the cause of their speech and language problem is unknown. Researchers have divided the disorders into two classifications;

  1. Functional disorders - those that do not have an identifiable organic or neurological cause.
  2. Organic disorders - those that are caused by some identifiable problem in the neuromuscular mechanisms of a child.

Such problems may originate in the nervous system, the muscular system, or the formation of the nose and mouth, and other structures necessary for speech. Organic disorders are the result of prenatal injury, toxic substances, seizures, trauma, infectious diseases, and vascular damage.

Articulation disorders may be functional or organic. Children who substitute one letter for another have a functional disorder. However, children with cerebral palsy often make sound substitutions because of neuromuscular disabilities.

These disorders can also be classified according to the time of onset of the disorder. Disorders such as cleft palate and cleft lip or cerebral palsy are present at birth. Acquired disorders are those that develop after a normal period of communication or after the neo-natal period. The disorder can be an accident or it may seem to be a change in normal development.

Language disorders are also functional and organic. Mark's language disorder is functional because the doctors cannot point to a neurological or physical reason for it. If our ability to examine the neurological system were better, we might be able to identify the cause of these disorders. Organic disorders are due to a physical cause. For example, a trauma to the head with decreased blood flowing to the brain may cause aphasia, apraxia, or dysarthria.

Apraxia is a motor (muscle) disorder where voluntary movement is impaired without muscle weakness. The ability to select and sequence muscle movement is impaired. Oral apraxia affects one's ability to move the muscles of the mouth for non-speech purposes. Someone with apraxia would have trouble coughing, swallowing, wiggling his tongue or blowing a kiss when asked to do so. Verbal apraxia of speech is the inability to sequence sounds. Apraxic speakers search for the correct word and make several attempts to say a word before they say it correctly.

Acquired apraxia happens as the result of brain damage. This can result from stroke, toxins, brain tumors, head injury and stroke. It can be so severe that a person cannot speak or so mild that a person has occasional difficulties in conversation when he tries to say multi-syllable words.

Treatment depends on the severity of the impairment. For people with moderate apraxia, therapy may start by saying individual sounds and contrasting them, thinking how the lips and tongue should be placed. Tapping or clapping out a rhythm helps some speakers to speak more clearly. Contrastive stress drills use natural rhythm of speech. In this exercise, the same sentence is repeated with different stress patterns, changing the meaning of the sentence. People with mild apraxia use these exercises to help them produce longer words that are troublesome to speak. Augmentive speech systems are used for severe apraxia.

Developmental apraxia is present from birth. There is no specific cause noted in brain studies. Apraxia in children is hard to diagnose because of their limited vocabulary. Therapy usually focuses on combinations of sounds and movement patterns. Children also benefit from pairing speech with other rhythmic motor activities like clapping hands or marching. See website: http://home.ica.net/~fred/

Question:
5. In apraxia, the muscles:
(Select the best answer.)
a) are paralyzed.
b) are weakened.
c) cannot move voluntarily.

Dysarthria is a speech disorder that is due to a weakness or lack of coordination of the speech muscles. Speech is slow, weak, imprecise or uncoordinated. It can affect both children and adults. "Childhood dysarthria" can be congenital or acquired. It is often a symptom of a disease such as cerebral palsy, Duchenne muscular dystrophy or Bell's palsy. In both adults and children, it can also result from head injury.

In adults, dysarthria can be caused by stroke, degenerative disease (Parkinson's, Huntington's disease, multiple sclerosis, myasthenia gravis), infections, and toxins (drug or alcohol abuse, lead poisoning, carbon monoxide).

In order for speech to be clear, a number of neuromuscular systems must work together. A weakness in any one of the systems can result in dysarthria. Non-coordination between systems is also a cause. The lungs supply the air necessary for the power of the speech system. The voice box or larynx sets the air vibrating and creates voice. The soft palate conducts air to the oral and nasal cavities to produce sound quality. The lips, tongue, teeth, and jaw shape sounds into the various vowels and consonants.

If the respiratory system is week, then speech may be too quiet. If the larynx is damaged, speech may be too breathy and slow. If the soft palate is not working the voice may sound too nasal or nasal sounds may be missing. If the articulatory system (lips, tongue, etc.) is not working speech sounds slurred and has many errors.

Therapy focuses on maximizing the function of all the systems. Frequent pauses for breath, over articulation, and pausing before important words all help make their speech clearer. If there is muscle weakness oral-facial exercises help to strengthen the muscles of the face and mouth that are used for speech. If all of these options fail, an assistive device or augmentive device is used in the place of speech.

Augmentive devices can be low technology or high technology. Low technology examples are the picture symbols that are used in communicating with children who have Autism. But they are also helpful for the person who cannot talk. High tech systems include ordinary computers and computerized voice output devices that can be used to type out and display messages. Often they are very small and easy to operate. The voice output device produces spoken words. There may be a series of pre-recorded phrases that ask questions or give answers by pushing a key.

Most dysarthric speakers need more time to give out a message. It helps to allow them extra time and listen face to face. When you have not understood what they have said, it is better to say so than pretend you understood. It helps to repeat the part of a question or statement that you did understand as a question. For example, if you hear "I would like a _________," rather than saying "Pardon, I did not understand what you said," try asking, "You would like a... what? Then the dysarthric person can simply say the last word of the question.

The person with aphasia has sounds, but rarely speech. The causes of aphasia are strokes and brain injuries. Most of these people are trained to use augmentive communication.

Question:
6. Dysathria is a result of:
(Select the best answer.)
a) brain injury.
b) tumor.
c) trauma.

What are Evaluation Procedures?
Identifying and seeking to help speech and language problems is not easy, but the earlier it is identified, the better chance for planning and implementing special education. This can be done in several ways. Preschool teachers may notice the problem and ask for a speech pathologist to assess the child's speech. Doctors, a parent, family friends may notice that the child's skills are not the same as those of other children. In Mark's case, a friend with a child the same age as Mark suggested that the family have Mark evaluated. At that time, Mark was three years old and used only a few single word sentences, which most listeners could not understand. Often when children visit the doctor, their parents ask for help with this problem.

Assessments of Communication in Infants and Preschool Students
If a parent notices that his infant is not responding to language, he may ask for an assessment by a speech pathologist. The type of assessment that is done is ecological - an evaluation of the caregiver's and child's abilities to form communication partnerships in a variety of situations. In normally developing babies, the early partnership between the parent and child is typically a form of turn-taking. Sometimes the baby and parents are unable to be partners because they cannot talk in rhythm to one another. This disjointed communication is not pleasant for the parent or baby and perhaps either one gives up effort to develop this fundamental skill.

When the child is in preschool, the speech pathologist may be asked to evaluate a child. Before doing so, there are questions about the child's physical status. A examination of hearing, motor functioning, oral and respiratory systems, cognitive functioning, and developmental history before they begin the assessment of a child's ability to communicate.

The speech assessment may determine the presence of articulation, voice, or fluency problems. Articulation is assessed by evaluating the child's abilities to produce the sounds of speech in single words and sentences. The child speaks through picture naming, speech repetition tasks, storytelling, and conversation with the therapist, who listens for omissions, substitutions, additions and distortions of speech sounds. An evaluator may also use a formal testing tool to pinpoint these errors. These tests help the evaluator to assess the child's production of consonants in the initial, middle, and final positions of a word.

Determining the Nature and Extent of Special Education
The goal for the initial assessment is to identify the student's strengths and weaknesses and then make decisions about his education, speech services, and placement. Mark attended a preschool for children with speech and language impairments for two years. When he reached school age, the family had three choices for education - a kindergarten without any speech and language services, a regular kindergarten with speech and language services, and a special kindergarten for speech and language disorders. Based on Mark's skills and needs, his family chose the regular kindergarten with speech and language services.

The Speech pathologist evaluated Mark for his specific strengths and needs. He gathered the information through natural conversation and a language sample recorded on videotape. The evaluator then compared Mark's language ability to rules of pragmatics, syntax, semantics, morphology, and phonology. At present there are computer programs that assist the pathologist with this comparison. Mark was evaluated after his preschool years and his speech gains were impressive.

Question:
7. When can language problems first be noticed in a child?

Curriculum and Methods
It is not always easy to find the best curriculum and methods to help students effectively. There are several factors to consider. For example, most often students with speech and language problems are in a regular classroom. The regular teacher and the speech pathologist then have to plan and coordinate their goals for the child.

For some children, such as Mark, his only disability is speech and language skills. His physical development is normal. If Mark had other physical problems such as cerebral palsy, he would probably not be in the regular classroom, but in the special education classroom.

There are three options when determining the appropriate curriculum to use to improve speech. These are prevention, remediation, and compensation. Prevention intervention is designed to prevent the occurrence of some future speech or language impairment. For instance, a speech pathologist will talk with parents of a baby born prematurely. The pathologist will focus in the responses a baby uses so that the parents can respond supportively to the baby. A baby in a incubator needs stroking, singing, and speaking so that he can respond to his parents. These activities help the baby to develop responses and eventually language.

Remediation interventions are the most common. The goal is to change a pattern that is not developmentally correct or that is not helping the student. Examples are correcting misarticulations or vocal abuse or improving language skills.

Compensation interventions are designed to provide alternatives for skills that are not possible to remediate. A child may not ever be able to talk, thus he needs an alternative communication system. This type of system circumvents the communication impairment and gives alternative means for communication at school and home.

Methods
Most students with speech and language disorders use verbal practice. For others who simply cannot speak, manual signing or augmentive communication is used, which can be assistive technology such as head gear that scans for letters and words and is controlled by some type of gesture or a communication board that has symbols or words that a child points out to indicate his thoughts or needs. Students with autism, traumatic brain injury, or stroke use these systems.

Match these terms with the definitions below:
A. Compensation, - B. Remediation, - C. Prevention.

8.1. a) alternative communication system.
A, B, C.

8.2. b) stroking, singing, speech.
A, B, C.

8.3. c) change a pattern that is not correct.
A, B, C.

Collaboration
Most students with speech and language problems are in the general classroom so that professional teachers and speech pathologists need to work together to give the child the therapy he needs. There are a variety of ways this can be done:

  1. the speech pathologist teaches in a self-contained classroom - this is common in preschool situations,
  2. the speech pathologist teaches with the classroom teacher - their is a joint sharing of objectives for the children with speech problems in the classroom,
  3. the speech pathologist works with the child one-to-one in the classroom and uses the curriculum of the classroom as a base for services,
  4. the speech pathologist provides staff and curriculum for the school so that the classroom teacher is not burdened with extra work related to children with special needs,
  5. the speech therapist comes to work with the child on a regular schedule in the special education classroom.

In Mark's case, he was in a good preschool program in the morning and an afternoon program for underprivileged children. The government supported his preschool for children with handicapping conditions. The preschool and the afternoon program teachers coordinated their efforts at helping Mark.

Family Collaboration
Usually, a family member is the first to understand that a child has speech and language difference from normal. Parents are included in planning the goals for their children and help them with pronunciation and speech. They also are able to provide information to the professionals about the child's skill levels. Mark's mother brought information to the teachers and their plan for him was shared with her. She was able to incorporate her part of therapy into her daily conversations with Mark.

Peer and Community Collaboration
People who cannot communicate well are often greeted with impatience, embarrassment, and disregard. Because they have speech limitations, people sometimes think they are also incompetent. Legislation has helped to make the community more accessible to those with speech or language disorders.

Businesses can provide auxiliary aids or services to ensure effective communication with their clients, customers, patients, or participants who have communication disorders. This does not mean that systems to help such people are complicated and have elaborate technology-based equipment. MacDonald's restaurants have started using a picture menu system. An individual who is unable to speak to order food can point to a selection on a picture menu. This is a plastic coated card that has breakfast menu items on one side and lunch menu items on the other side. MacDonald's has also trained their employees to understand yes-no indications for desired food items and to scan the food items for a person who cannot speak. Simply making a pencil and paper available for a written message can provide access for some people.

Question:
9. It is important for the family to:
(Select the best answer.)
a) be patient.
b) know the rehabilitation speech plan and use it at home.
c) teach the child to order food at McDonald's.

Technological Services
Telephone devices for the deaf are an example of how technology can be used to help a person with a communication disorder. Language impaired children can type out their messages to a friend. Captioning of television programs and direct service for computer modems also assist these people.

Peer communication is difficult since children often do not understand the need to be patient and accepting of a child who cannot speak normally. Usually, a teacher or parent has to help. However, as adults, we can do the following:

What are Program Options?
In the preschool and kindergarten years, teachers work with small groups of children to work on articulation skills. Each child has time to learn the skills he needs. Therapy is also done in natural settings such as eating lunch together with the teacher, who can observe and correct their speech. Additionally, each child gets one or two private sessions every week with the language therapist.

In the elementary years, students get help with language development. By this age, the child should have mastered the articulation skills that include correctly using all the phonemes of his native language. Reading and spelling are particularly difficult for these children; therefore, the focus of therapy is on these two subjects.

Often in the high school years, these students decide they will not have any further treatment. Hopefully, they will have overcome their initial problems. As a result, they can be busy with their own academic and after school interests. The special education classroom is still available to these students when they need help with writing or finishing assignments on time.

After high school, young people generally seek their own services for language help if necessary. Most of the time, the student has learned compensatory strategies so they can pursue their goals. Most colleges and universities have on-campus offices to aid these students when they have a problem. For those who do not decide on college education, job-training programs employ speech language therapists for such problems as traumatic head injury and other injuries where language has been impaired.

Question:
10. What kind of qualities do you need when talking with someone who has a language disorder?

A Hope for the Future
At the present, Mark wants to be a policeman. He thinks that he would like to help protect the lives of children and adults. His mother thinks that he has good personal characteristics for this profession. He understands people, he has a practical type of mind that helps him problem solve in difficult situations, and he likes to talk with people.

His mother has optimism for Mark. She worries about the exposure that Mark has to drugs and violence, because his family lives in low-income housing. But she knows that Mark has come very far from his earlier days when he spoke no words at all. Presently, he has only occasional problems with speech and language.