INTRODUCTION

Speech and language are central to the human experience; they are the vital means by which people convey and receive knowledge, thoughts, feelings, and other internal experiences. Acquisition of communication skills begins early in childhood and is foundational to the ability to gain access to culturally transmitted knowledge, to organize and share thoughts and feelings, and to participate in social interactions and relationships. Speech and language skills allow a child to engage in exchanges that lead to the acquisition of knowledge in his or her community and the educational arena. Communication skills are crucial to the development of thinking ability, a sense of self, and full participation in society.

RPWD Act 2016 recognizes Speech and Language Disability as one of the 21 disabling conditions. It means a permanent disability arising out of conditions such as laryngectomy or aphasia affecting one or more components of speech and language due to organic or neurological causes.

The Individuals with Disabilities Education Act (IDEA) officially defines speech and language impairments as “a communication disorder such as stuttering, impaired articulation, a language impairment, or a voice impairment that adversely affects a child’s educational performance.” Each point within this official definition represents a speech and language subcategory. “A communication disorder such as stuttering” provides an example of a fluency disorder; other fluency issues include unusual word repetition and hesitant speech. “Impaired articulation” indicates impairments in which a child experiences challenges in pronouncing specific sounds. “A language impairment” can entail difficulty comprehending words properly, expressing oneself and listening to others. Finally, “a voice impairment” involves difficulty voicing words; for instance, throat issues may cause an abnormally soft voice.

Speech disorder is defined as disruption in the production of the phonetic aspects of words, phrases, and sentences so that communication is partially or, in severe cases, completely unintelligible to listeners. Stuttering is a form of speech disorder that involves disruptions in the rate and/or fluency of speaking due to hesitations and repetitions of speech sounds, words, and/or phrases.

Language disorder is defined as impairment of expression and comprehension because of a disruption in the acquisition of vocabulary (words), word endings, and sentence structure. In severe cases of language disorder, a child experiences extreme difficulty using correct words and proper grammar and may also have difficulty comprehending what others are saying.

COMMON TYPES OF SPEECH AND LANGUAGE DISORDERS

Delayed language

Children with delayed language learn words and grammar much more slowly than other children. There are many reasons for delays in speech and language. Hearing loss is a common reason. A child who cannot hear well or at all will have trouble learning, copying, and understanding language. Speech delays may also be caused by what is called “oral-motor” problems. Oral-motor problems are difficulties with using the lips, tongue, and jaw to make speech sounds. Sometimes these problems start in the areas of the brain that are responsible for speech and language development.

Children are different from each other in the way they develop. Some are faster, and some are slower, but they might all be developing normally. It is hard to tell if there is a real language delay. There are some guidelines about children’s speech and language skills that will help you decide if the child is delayed. These are known as “developmental milestones.” 

Articulation disorders

Articulation means making sounds and words. To do this, the lips, teeth, tongue, jaw, and palate (roof of the mouth) need to move together to make shapes. They change the movement of the air that comes from the vocal chords. That is how people make sounds, syllables, and words. A child has an articulation disorder when he makes sounds, syllables, and words incorrectly. The listeners do not understand what he is saying.

There are three types of articulation disorders. They are called omissions, substitutions, or distortions. Omission means leaving something out. An example of a speech omission is saying “at” for “hat” or “oo” for “shoe.” Substitution means putting something where something else belongs. An example of a speech substitution is the use of “w” for “r” and saying “wabbit” for “rabbit.” Another example is using “th” for “s” and saying “thun” for “sun.” Distortion means that the parts are mostly there, but they are a little wrong. The child says a word that sounds something like what it should, but it is not quite right. An example is “shlip” for “ship.”

Articulation disorders are not the same as “baby talk.” It is important to know the difference. Baby talk happens in young children who mispronounce words. That is normal and not a disorder. In older children it is no longer cute. Articulation problems then get in the way of good communication. Sometimes a different accent may be confused with articulation problems. An accent is a problem for a child only if it gets in the way of the child’s communication. As a general rule, a child should be able to make all the sounds of English by the age of 8.

Articulation problems may come from: 
   • Physical handicaps such as cerebral palsy, cleft palate, or dental problems
   • Hearing loss
   • Incorrect speech and language models for a child

Stuttering

Stuttering is when speech does not flow smoothly. People who stutter can experience the following types of disruption:

• Repetitions occur when people involuntarily repeat sounds, vowels, or words (for example, st-st-strong).
• Blocks happen when people know what they want to say but have difficulty making the necessary speech sounds. Blocks may cause someone to feel as though their words are stuck.
• Prolongations refer to the stretching or drawing out of particular sounds or words (for example, sssssssstrong).

When children stutter, they often blink their eyes quickly. Their lips might shake, or they might move in another way that shows they are struggling to get the word out. “Stuttering” is the same as “stammering;” the words mean the same thing.

Most children stutter a little when they learn to talk. It is most common in children between the ages of 2 and 6. They are just starting to develop their language and speech skills. Boys are three times more likely to stutter than girls. Stuttering when learning language is natural and common. Most children outgrow it.

Some children may stutter more in certain situations. They may stutter when they have to speak in front of many people or speak on the telephone. Some children who stutter may not do so when they talk to themselves or when they sing.

There are two main types of stuttering:

• Developmental stuttering affects young children who are still learning speech and language skills. Genetic factors significantly increase a person’s likelihood of developing this type of stutter.
• Neurogenic stuttering occurs when damage to the brain prevents proper coordination between the different regions of the brain that play a role in speech.

Stuttering may be caused by:
   • Developmental causes – Developmental stuttering happens when a child is learning to talk. He cannot find the words that
     he wants to say as fast as he thinks. This type of stuttering is normal. It goes away as the child grows. 

   • Neurogenic causes (causes that start in the nervous system) –Stuttering may be caused by problems in the brain,
     nerves, or muscles. The part of the brain that is responsible for speech and language development may be damaged by a
     stroke or by a head injury. The muscles that are responsible for forming sounds and words may be damaged. 

   • Psychogenic causes (causes that start in the way a person thinks or feels) – Stuttering may be caused by severe
     damage or stress to the mind. This type of stuttering happens in children with mental illness. Very few children stutter
     because of these causes.

   • Hereditary causes – Stuttering may run in the family and be passed to a child from her parents. Some experts disagree
     with this theory.

Voice disorders

A voice disorder happens because the vocal cords that produce sound are damaged. The vocal cords are the muscles in the throat that are responsible for making sounds and words. Children can damage their vocal cords by shouting, screaming, and talking extremely loudly and very often. Their voice may become harsh and they may find it very difficult to talk. Also, when they try to talk, their throat may hurt a lot. Voice disorders are sometimes called “voice abuse.”

Voice disorders in children can be corrected with speech therapy. In speech therapy, children are taught to speak softly. They are also taught not to scream, shout, or do anything that may hurt their vocal cords and affect their voice. Remember that children like to copy what the adults around them do. So if they see you speaking loudly or shouting, they will do the same. Practice speaking softly so that the children around you will do the same.

Voice disorders are not common in children. Also, they are usually temporary.

Aphasia

Aphasia is a language disorder. It is caused by injury to those parts of the brain that are responsible for language. This is mostly the left side of the brain. Aphasia may be caused suddenly, perhaps from a stroke or a head injury, or it may develop slowly, perhaps from a brain tumor.

Aphasia affects the way children talk and the way they understand what others are saying. It weakens a child’s ability to read and write.

Aphasia is very rare in children.

Apraxia

The brain controls every single action that people make, including speaking. Most of the brain’s involvement in speech is unconscious and automatic.

When someone decides to speak, the brain sends signals to the different structures of the body that work together to produce speech. The brain instructs these structures how and when to move to form the appropriate sounds.

For example, these speech signals open or close the vocal cords, move the tongue and shape the lips, and control the movement of air through the throat and mouth.

Apraxia is a general term referring to brain damage that impairs a person’s motor skills, and it can affect any part of the body. Apraxia of speech, or verbal apraxia, refers specifically to the impairment of motor skills that affect an individual’s ability to form the sounds of speech correctly, even when they know which words they want to say.

Dysarthria

Dysarthria occurs when damage to the brain causes muscle weakness in a person’s face, lips, tongue, throat, or chest. Muscle weakness in these parts of the body can make speaking very difficult.

People who have dysarthria may experience the following symptoms:

• slurred speech
• mumbling
• speaking too slowly or too quickly
• soft or quiet speech
• difficulty moving the mouth or tongue

There are two major types of language disorders. It’s possible for a child to have both.

Receptive: This is when your child finds it hard to understand speech. They may find it hard to:

• Follow directions
• Answer questions
• Point to objects when asked

Expressive : If your child has trouble finding the right words to express themselves, they may have this type of language disorder. Kids with an expressive disorder may find it tough to:

• Ask questions
• String words into sentences
• Start and continue a conversation

SYMPTOMS

Some children struggle with understanding and speaking and they need help. They may not master the language milestones at the same time as other children, and it may be a sign of a language or speech delay or disorder.

Language development has different parts, and children might have problems with one or more of the following:

• Understanding what others say (receptive language). This could be due to
• Not hearing the words (hearing loss).
• Not understanding the meaning of the words.
• Communicating thoughts using language (expressive language). This could be due to
• Not knowing the words to use.
• Not knowing how to put words together.
• Knowing the words to use but not being able to express them.

Language and speech disorders can exist together or by themselves. Examples of problems with language and speech development include the following:

• Speech disorders
• Difficulty with forming specific words or sounds correctly.
• Difficulty with making words or sentences flow smoothly, like stuttering or stammering.
• Language delay – the ability to understand and speak develops more slowly than is typical
• Language disorders
• Aphasia (difficulty understanding or speaking parts of language due to a brain injury or how the brain works).
• Auditory processing disorder (difficulty understanding the meaning of the sounds that the ear sends to the brain)

Language or speech disorders can occur with other learning disorders that affect reading and writing. Children with language disorders may feel frustrated that they cannot understand others or make themselves understood, and they may act out, act helpless, or withdraw. Language or speech disorders can also be present with emotional or behavioral disorders, such as attention-deficit/hyperactivity disorder (ADHD) or anxiety. Children with developmental disabilities including autism spectrum disorder may also have difficulties with speech and language. The combination of challenges can make it particularly hard for a child to succeed in school. Properly diagnosing a child’s disorder is crucial so that each child can get the right kind of help.

CAUSES

Causes of speech disorders can include:

• brain damage due to a stroke or head injury
• muscle weakness
• damaged vocal cords
• a degenerative disease, such as Huntington’s disease, Parkinson’s disease, or amyotrophic lateral sclerosis
• dementia
• cancer that affects the mouth or throat
• autism
• Down syndrome
• hearing loss

RISK FACTORS

Risk factors that can increase the likelihood of a person developing a speech disorder include:

• being male
• being born prematurely
• having a low weight at birth
• having a family history of speech disorders
• experiencing problems that affect the ears, nose, or throat

DIAGNOSIS

A speech-language pathologist (SLP) is a healthcare professional who specializes in speech and language disorders.

An SLP will evaluate a person for groups of symptoms that indicate one type of speech disorder. To make an accurate diagnosis, SLPs need to rule out other speech and language disorders and medical conditions.

An SLP will review a person’s medical and family history. They will also examine how a person moves their lips, jaw, and tongue and may inspect the muscles of the mouth and throat.

Other methods of evaluating speech disorders include:

• Denver articulation screening examination. This test evaluates the clarity of a person’s pronunciation.
• Prosody-voice screening profile. SLPs use this test to examine multiple aspects of a person’s speech, including pitch, phrasing, speech patterns, and speaking volume.
• Dynamic evaluation of motor speech skills (DEMSS) manual. The DEMSS is a comprehensive guide for helping SLPs diagnose speech disorders.

Tests to be Conducted for Speech and Language Disability Diagnosis

1. Speech Intelligibility Test

1. Perceptual Speech intelligibility rating scale (AYJNISHD, 2003) or

2. Perceptual Rating Scale (SRMC, Chennai)

2. Voice Test

1. Consensus Auditory Perceptual Evaluation of Voice (CAPE-V) or

2. Dysphonia Severity Index (DSI)

3. Language Test

1. Western Aphasia Battery (WAB) in Indian languages

TREATMENT

Children with language problems often need extra help and special instruction. Speech-language pathologists can work directly with children and their parents, caregivers, and teachers.

Having a language or speech delay or disorder can qualify a child for early intervention (for children up to 3 years of age) and special education services (for children aged 3 years and older). Schools can do their own testing for language or speech disorders to see if a child needs intervention. An evaluation by a healthcare professional is needed if there are other concerns about the child’s hearing, behavior, or emotions. Parents, healthcare providers, and the school can work together to find the right referrals and treatment.

The type of treatment will typically depend on the severity of the speech disorder and its underlying cause.

Treatment options can include:

• speech therapy exercises that focus on building familiarity with certain words or sounds
• physical exercises that focus on strengthening the muscles that produce speech sounds

We discuss some of the treatment options for speech disorders below:

Target selection

Target selection involves a person practicing specific sounds or words to familiarize themselves with particular speech patterns. Examples of therapy targets may include difficult words or sounds that trigger speech disruptions.

Contextual utilization

For this approach, SLPs teach people to recognize speech sounds in different syllable-based contexts.

Contrast therapy

Contrast therapy involves saying word pairs that contain one or more different speech sounds. An example word pair might be “beat” and “feet” or “dough” and “show.”

Oral-motor therapy

The oral-motor therapy approach focuses on improving muscle strength, motor control, and breath control. These exercises can help people develop fluency, which produces smoother speech that sounds more natural.

Ear device

Ear devices are small electronic aids that fit inside the ear canal. These devices can help improve fluency in people who have a stutter.

Some ear devices replay altered versions of the wearer’s voice to make it seem as though someone else is speaking with them. Other ear devices produce a noise that helps control stuttering.

Medication

Some speech disorders can cause people to develop anxiety disorders. Stressful situations can trigger anxiety, resulting in more pronounced speech disorder symptoms. Anxiety medications may help reduce symptoms of speech disorders in some people.