Kk&s Ch.41 Communication Disorders

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Language disorders include ? whereas speech disorders include ?r and ?

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Language disorders include expressive and mixed receptive-expressive language disorder, whereas speech disorders include phonological disorder and stutterin

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Disorder?
These children may struggle with limited vocabularies, speak in sentences that are short or ungrammatical, and often present descriptions of situations that are disorganized, confusing, and infantile. They may be delayed in developing an understanding and a memory of words compared with others their age.

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Children with expressive language disorders have difficulties expressing their thoughts with words and sentences at a level of sophistication expected for their age and developmental level in other areas

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Language competence spans four domains:

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phonology, grammar, semantics, and pragmatics.

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? refers to the ability to produce sounds that constitute words in a given language and the skills to discriminate the various phonemes (sounds that are made by a letter or group of letters in a language). To imitate words, a child must be able to produce the sounds of a word.

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Phonology

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? designates the organization of words and the rules for placing words in an order that makes sense in that language.

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Grammar

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? refers to the organization of concepts and the acquisition of words themselves. A child draws from a mental list of words to produce sentences. Children with language impairments exhibit a wide range of difficulties with ? that include acquiring new words, storage and organization of known words, and word retrieval.

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Semantics

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? has to do with skill in the actual use of language and the “rules” of conversation, including pausing so that a listener can answer a question and knowing when to change the topic when a break occurs in a conversation.

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Pragmatics

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Speech Development (+ nonverbal)
Normal for Age 1?

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Recognizes own name Stands alone
Follows simple directions accompanied by gestures (e.g., bye-bye) Takes first steps with support
Speaks one or two words Uses common objects (e.g., spoon, cup)
Mixes words and jargon sounds Releases objects willfully
Uses communicative gestures (e.g., showing, pointing) Searches for object in location where last seen

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Speech Development (+ nonverbal)
Normal for Age 2?

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Uses 200 to 300 words Walks up and down stairs alone, but without alternating feet
Names most common objects Runs rhythmically, but is unable to stop or start smoothly
Uses two-word or longer phrases Eats with a fork
Uses a few prepositions (e.g., in, on), pronouns (e.g., you, me), verb endings (e.g., -ing, -s, -ed) and plurals (-s), but not always correctly
Enjoys play with action toys Cooperates with adult in simple household tasks
Follows simple commands not accompanied by gestures

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Speech Development (+ nonverbal)
Normal for Age 3?

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Uses 900 to 1,000 words Rides tricycle
Creates three- to four-word sentences, usually with subject and verb but simple structure Enjoys simple “make-believe” play
Matches primary colors
Follows two-step commands Balances momentarily on one foot
Repeats five- to seven-syllable sentences
Speech is usually understood by family members Shares toys with others for short periods

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Speech Development (+ nonverbal)
Normal for Age 4?

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Uses 1,500 to 1,600 words Walks up and down stairs with alternating feet
Recounts stories and events from recent past Hops on one foot
Understands most questions about immediate environment Copies block letters
Uses conjunctions (e.g., if, but, because) Role-plays with others
Speech is usually understood by strangers Categorizes familiar objects

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Speech Development (+ nonverbal)
Normal for Age 5?

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Uses 2,100 to 2,300 words Dresses self without assistance
Discusses feelings Cuts own meat with knife
Understands most prepositions referring to space (e.g., above, beside, toward) and time (e.g., before, after, until) Draws a recognizable person
Plays purposefully and constructively
Follows three-step commands
Prints own name Recognizes part-whole relationships

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Speech Development (+ nonverbal)
Normal for Age 6?

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Defines words by function and attributes Rides a bicycle
Uses a variety of well-formed complex sentences Throws a ball well
Uses all parts of speech (e.g., verbs, nouns, adverbs, adjectives, conjunctions, prepositions)
Understands letter-sound associations in reading Sustains attention to motivating tasks
Enjoys competitive games

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Speech Development (+ nonverbal)
Normal for Age 8?

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Reads simple books for pleasure
Enjoys riddles and jokes Understands conservation of liquid, number, length, and so forth
Verbalizes ideas and problems readily Knows left and right of others
Understands indirect requests (e.g., “It's hot in here” understood as request to open window) Knows differences and similarities
Appreciates that others have different perspectives
Produces all speech sounds in an adult-like manner Categorizes same object into multiple categories

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In one large study of children with speech and language disorders by Lorian Baker and Dennis Cantwell, the most common comorbid disorders were

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attention-deficit/hyperactivity disorder (ADHD) (19 percent),
anxiety disorders (10 percent),
oppositional defiant disorder, and
conduct disorder (7 percent combined).
Children with expressive language disorder are also at higher risk for a speech disorder, receptive difficulties, and other learning disorders

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Delayed motor milestones and a history of ? are common in children with expressive language disorder

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enuresis

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The specific cause of developmental expressive language disorder is likely to be

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multifactorial

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Scant data are available on the specific brain structure of children with language disorder, but limited magnetic resonance imaging (MRI) studies suggest that language disorders are associated with a

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loss of the normal left-right brain asymmetry in the perisylvian and planum temporale regions

Results of one small MRI study suggested possible inversion of brain asymmetry (right > left)

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Left-handedness or ambilaterality appears (to be or not to be) associated with expressive language problems.

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is

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A recent report described a hypothesis of specific genes at ? that appear to be exquisitely sensitive to dosage alterations that can influence human language and visuospatial capabilities

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7q11.23

The Williams-Beuren syndrome (WBS) locus at 7q11.23 is susceptible to recurrent chromosomal rearrangements, including the microdeletion that causes WBS. WBS typically presents as a phenotype, including characteristic cardiovascular, cognitive, and behavioral features. It is hypothesized, however, that instead of microdeletions, reciprocal duplications of the WBS could also occur and may be associated with the phenotype of language dysfunction. Some studies have found that some individuals with WBS are at an increased risk of expressive language disorder.

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Expressive Lang Ds criteria DSM?

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1. The scores obtained from standardized individually administered measures of expressive language development are substantially below those obtained from standardized measures of both nonverbal intellectual capacity and receptive language development. The disturbance may be manifest clinically by symptoms that include having a markedly limited vocabulary, making errors in tense, or having difficulty recalling words or producing sentences with developmentally appropriate length or complexity.
2. The difficulties with expressive language interfere with academic or occupational achievement or with social communication.
3. Criteria are not met for mixed receptive-expressive language disorder or a pervasive developmental disorder.
4. If mental retardation, a speech-motor or sensory deficit, or environmental deprivation is present, the language difficulties are in excess of those usually associated with these problems.

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PDD vs express lang ds?

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In pervasive developmental disorders, in addition to the cardinal cognitive characteristics, affected children have no inner language, symbolic or imagery play, appropriate use of gesture, or capacity to form warm and meaningful social relationships. Moreover, children show little or no frustration with the inability to communicate verbally. In contrast, all these characteristics are present in children with expressive language disorder.

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Outcome of expressive language disorder is influenced by

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other comorbid disorders. If children do not develop mood disorders or disruptive behavior problems, the prognosis is better

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Recent literature has shown that children who demonstrate poor comprehension, poor articulation, or poor academic performance tend to continue to have problems in these areas at follow-up 7 years later. An association is also seen between particular language impairment profiles and

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persistent mood and behavior problems

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Exp Lang Ds general tx?

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Controversy exists among experts whether intervention for young children with expressive language difficulties should be initiated as soon as it is noted, or whether waiting until age 4 or 5 years is the optimal time to begin treatment. Treatment for expressive language disorder is still generally not initiated unless it persists after the preschool years.
S & Lang Therapist

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Specific tx for Exp Lang Ds?

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Direct interventions use a speech and language pathologist who works directly with the child.

Mediated interventions, in which a speech and language professional teaches a child's teacher or parent how to promote therapeutic language techniques, have also been efficacious.

Language therapy is often aimed at using words to improve communication strategies and social interactions as well. Such therapy consists of behaviorally reinforced exercises and practice with phonemes (sound units), vocabulary, and sentence construction. The goal is to increase the number of phrases by using block-building methods and conventional speech therapies

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Non-specific tx for exp lang ds

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Therapy to improve self-esteem
Support parents

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Which is more common: mixed or expressive lang ds alone?

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expressive lang ds alone

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Etiology associations for mixed recept-expressive lang ds?

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Several studies suggest an underlying impairment of auditory discrimination, because most children with the disorder are more responsive to environmental sounds than to speech sounds.

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DSM criteria for mixed receptive expressive language disorder

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1. The scores obtained from a battery of standardized individually administered measures of both receptive and expressive language development are substantially below those obtained from standardized measures of nonverbal intellectual capacity. Symptoms include those for expressive language disorder as well as difficulty understanding words, sentences, or specific types of words, such as spatial terms.
2. The difficulties with receptive and expressive language significantly interfere with academic or occupational achievement or with social communication.
3. Criteria are not met for a pervasive developmental disorder.
4. If mental retardation, a speech-motor or sensory deficit, or environmental deprivation is present, the language difficulties are in excess of those usually associated with these problems.

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Compare deafness to mix rec-exp lang ds?

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A child with mixed receptive-expressive language disorder usually appears to be deaf, but the child can hear. He or she responds normally to nonlanguage sounds from the environment, but not to spoken language

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What other ds go with mixed?

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seizure ds
reading ds
must do audiogram

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DDX of mixed receptive exp lang ds?

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phonological disorder or stuttering
hearing impairment
MR
acquired aphasia
PDD
severe environmental deprivation
LD

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Tx of preschooler with mixed?

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Preschoolers with mixed receptive-expressive language disorder optimally receive interventions designed to promote social communication and literacy as well as oral language

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School age? tx ox of mixed?

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For children at the kindergarten level, optimal intervention includes direct teaching of key prereading skills as well as social skills training. An important early goal of interventions for young children with mixed receptive-expressive language disorder is the achievement of rudimentary reading skills in that these skills are protective against the academic and psychosocial ramifications of falling behind early on in reading. Some language therapists favor a low-stimuli setting, in which children are given individual linguistic instruction. Others recommend that speech and language instruction be integrated into a varied setting with several children who are taught several language structures simultaneously. Often, a child with mixed receptive-expressive language disorder will benefit from a small, special-educational setting that allows more individualized learning.

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Children with ? disorder are unable to produce speech sounds correctly because of omissions of sounds, distortions of sounds, or atypical pronunciation

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phonological

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ypical speech disturbances in this disorder include omitting the last sounds of the word (e.g., saying mou for mouse or drin for drink), or substituting one sound for another (saying bwu instead of blue or tup for cup). Distortions in sounds can occur when children allow too much air to escape from the side of their mouths while saying sounds like sh or producing sounds like s or z with their tongue protruded.
Disorder?

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Phonological Disorder

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? (slurred speech because of incoordination of speech muscles) or ? (difficulty planning and executing speech)

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dysarthria (slurred speech because of incoordination of speech muscles) or dyspraxia (difficulty planning and executing speech)

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Developmental ? disorder, however, is the most common phonological disorder in children.

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articulation

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According to DSM-IV-TR, the prevalence falls to ? percent by mid to late adolescence.
Phono Ds

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0.5%

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A delay in reaching speech milestones (e.g., first word and first sentence) has been reported in some children with phonological disorder
(some, most) children with the disorder begin speaking at the appropriate age

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most

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Dysarthria results from

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an impairment in the neural mechanisms regulating the muscular control of speech. This can occur in congenital conditions, such as cerebral palsy, muscular dystrophy, or head injury or because of infectious processes.

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Apraxia or dyspraxia is characterized by

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difficulty in the execution of speech even when no obvious paralysis or weakness of the muscles used in speech exists.

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Poor motor coordination, laterality, and handedness (are or are not) associated with phonological disorder

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are NOT

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The essential feature of phonological disorder is a child's delay or failure to produce developmentally expected speech sounds, especially ?, resulting in

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consonants
sound omissions, substitutions, and distortions of phonemes

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correctly articulate m, n, ng, b, p, h, t, k, q, and d = age what normally?

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3

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correctly articulate f, y, ch, sh, and z ?

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age 4

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correctly articulate th, s, and r.

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age 5

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Phonological Ds DSM?

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1. Failure to use developmentally expected speech sounds that are appropriate for age and dialect (e.g., errors in sound production, use, representation, or organization such as, but not limited to, substitutions of one sound for another [use of /t/ for target /k/ sound] or omissions of sounds such as final consonants).
2. The difficulties in speech sound production interfere with academic or occupational achievement or with social communication.
3. If mental retardation, a speech-motor or sensory deficit, or environmental deprivation is present, the speech difficulties are in excess of those usually associated with these problems.

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? are thought to be the most serious type of misarticulation, with ? the next most serious, and ? the least serious type

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Omissions are thought to be the most serious type of misarticulation, with substitutions the next most serious, and distortions the least serious type

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explain omissions

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Omissions, which are most frequent in the speech of young children, usually occur at the ends of words or in clusters of consonants (ka for car, scisso for scissors).

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explain substitutions

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Distortions, which are found mainly in the speech of older children, result in a sound that is not part of the speaker's dialect. Distortions may be the last type of misarticulation remaining in the speech of children whose articulation problems have mostly remitted. The most common types of distortions are the lateral slip—in which a child pronounces s sounds with the airstream going across the tongue, producing a whistling effect—and the palatal or lisp—in which the s sound, formed with the tongue too close to the palate, produces a ssh sound effect.

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DDX of phono ds

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rule out normal dev
rule out physical ds
evalute recept/exp lang
rule out hearing problem

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Children with ?, a disorder caused by structural or neurological abnormalities, differ from children with developmental phonological disorder in that ? is less likely to remit spontaneously and may be more difficult to remediate. Drooling, slow, or uncoordinated motor behavior; abnormal chewing or swallowing; and awkward or slow protrusion and retraction of the tongue indicate ?. A slow rate of speech also indicates ?

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dysarthria

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Two tx approached to phono ds?

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phonological approach
traditional approach

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Explain phonological approach of treatment?

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The first one, the phonological approach, is usually chosen for children with extensive patterns of multiple speech sound errors that may include final consonant deletion, or consonant cluster reduction. Exercises in this approach to treatment focus on guided practice of specific sounds, such as final consonants, and when that skill is mastered, practice is extended to use in meaningful words and sentences.

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explain traditional approach to phonological ds

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or children who produce
P.1186

substitution or distortion errors in just a few sounds. In this approach, the child practices the production of the problem sound while the clinician provides immediate feedback and cues concerning the correct placement of the tongue and mouth for improved articulation. Children who have errors in articulation because of an abnormal swallowing resulting in tongue thrust and lisps are treated with exercises that improve swallowing patterns and, in turn, improve speech. Speech therapy is typically provided by a speech-language pathologist, yet parents can be taught to provide adjunctive help by practicing techniques used in the treatment.

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? is a condition in which the normal flow of speech is disrupted by involuntary speech motor events.

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Stuttering

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Approximately ? percent of young children who stutter are likely to have a spontaneous remission over time.

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80%

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Preschoolers and school-age children who stutter exhibit an increased incidence of

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social anxiety, school refusal, and other anxiety symptom

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Several studies using EEG found that stuttering males had ?-hemispheric alpha suppression across stimulus words and tasks; nonstutterers had ?-hemispheric suppression

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Several studies using EEG found that stuttering males had right-hemispheric alpha suppression across stimulus words and tasks; nonstutterers had left-hemispheric suppression.

Some studies of stutterers have noted an overrepresentation of left-handedness and ambidexterity

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Stuttering usually appears between the ages of ? months and ? years, with two sharp peaks of onset between the ages of ? years and ? years

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Stuttering usually appears between the ages of 18 months and 9 years, with two sharp peaks of onset between the ages of 2 to 3.5 years and 5 to 7 years

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Stuttering course, onset?

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Stuttering does not begin suddenly; it typically develops over weeks or months with a repetition of initial consonants, whole words that are usually the first words of a phrase, or long words. As the disorder progresses, the repetitions become more frequent, with consistent stuttering on the most important words or phrases. Even after it develops, stuttering may be absent during oral readings, singing, and talking to pets or inanimate objects.

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DSM criteria for stuttering?

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1. Disturbance in the normal fluency and time patterning of speech (inappropriate for the individual's age), characterized by frequent occurrences of one or more of the following:
1. sound and syllable repetitions
2. sound prolongations
3. interjections
4. broken words (e.g., pauses within a word)
5. audible or silent blocking (filled or unfilled pauses in speech)
6. circumlocutions (word substitutions to avoid problematic words)
7. words produced with an excess of physical tension
8. monosyllabic whole-word repetitions (e.g., “I-I-I-I see him”)
2. The disturbance in fluency interferes with academic or occupational achievement or with social communication.
3. If a speech-motor or sensory deficit is present, the speech difficulties are in excess of those usually associated with these problems.

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How many phases are there in stuttering?

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4

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Stuttering phase 1

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Phase 1 occurs during the preschool period. Initially, the difficulty tends to be episodic and appears for weeks or months between long interludes of normal speech. A high percentage of recovery from these periods of stuttering occurs. During this phase, children stutter most often when excited or upset, when they seem to have a great deal to say, and under other conditions of communicative pressure.

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Stuttering phase 2

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Phase 2 usually occurs in the elementary school years. The disorder is chronic, with few if any intervals of normal speech. Affected children become aware of their speech difficulties and regard themselves as stutterers. In phase 2, the stuttering occurs mainly with the major parts of speech—nouns, verbs, adjectives, and adverbs.

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Stuttering phase 3

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Phase 3 usually appears after the age of 8 years and up to adulthood, most often in late childhood and early adolescence. During phase 3, stuttering comes and goes largely in response to specific situations, such as reciting in class, speaking to strangers, making purchases in stores, and using the telephone. Some words and sounds are regarded as more difficult than others.

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Stuttering phase 4

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Phase 4 typically appears in late adolescence and adulthood.

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DDX of Stuttering?

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Differential Diagnosis
Normal speech dysfluency in preschool years is difficult to differentiate from incipient stuttering. In stuttering occurs more nonfluencies, part-word repetitions, sound prolongations, and disruptions in voice airflow through the vocal track. Children who stutter appear to be tense and uncomfortable with their speech pattern, in contrast to young children who are nonfluent in their speech but seem to be at ease. Spastic dysphonia is a stuttering-like speech disorder distinguished from stuttering by the presence of an abnormal breathing pattern.
Cluttering is a speech disorder characterized by erratic and dysrhythmic speech patterns of rapid and jerky spurts of words and phrases. In cluttering, those affected are usually unaware of the disturbance, whereas, after the initial phase of the disorder, stutterers are aware of their speech difficulties. Cluttering is often an associated feature of expressive language disorde

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Tx of stuttering?

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Two distinct forms of intervention have been used in the treatment of stuttering. Direct speech therapy typically targets modification of the stuttering response to fluent-sounding speech by systematic steps and rules of speech mechanics that the person can practice. Another form of therapy for stuttering targets diminishing tension and anxiety during speech. These treatments utilize breathing exercises and relaxation techniques, to help children slow the rate of speaking and modulate speech volume.

Current interventions for stuttering use individualized combinations of behavioral distraction, relaxation techniques, and directed speech modification
Tx anxiety, mood

One example of this approach is the self-therapy proposed by the Speech Foundation of America. Self-therapy is based on the premise that stuttering is not a symptom, but a behavior that can be modified. Stutterers are told that they can learn to control their difficulty partly by modifying their feelings about stuttering and attitudes toward it and partly by modifying the deviant behaviors associated with their stuttering blocks.

Recently developed therapies focus on restructuring fluency. The entire speech production pattern is reshaped, with emphasis on a variety of target behaviors, including rate reduction, easy or gentle onset of voicing, and smooth transitions between sounds, syllables, and words.
Benzo no data

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Speech production parts?

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Operationally, speech production can be broken down into five interacting subsystems, including respiration (airflow from the lungs), phonation (sound generation in the larynx), resonance (shaping of the sound quality in the pharynx and nasal cavity), articulation (modulation of the sound stream into consonant and vowel sounds with the tongue, jaw, and lips), and suprasegmentalia (speech rhythm, loudness, and intonation).