Exam 2 Pediatric Speech Sound Disorders

structure and function of the speech and hearing mechanism

Understanding the factors that may be associated with speech sound disorders (SSDs) may help us better understand the underlying nature of these disorders.

Factors affecting the structure and function of the speech and hearing mechanism can affect how speech sounds are acquired.

otitis media with effusion (OME)

frequent build up of liquid in middle ear

result in a temporary conductive hearing loss in children

research finding is mixed

clinicians should be aware of a likely connection between OME and SSDs- collect a thorough case history to provide best diagnosis and prognosis

speech sound perception/discrimination

ability to discriminate among the individual sounds of a language

30-40% of children with SSDs have poor speech perception

gauging a child’s speech perception abilities

 the specific phonemes that a child is misarticulating

 the context in which the child is producing the phonemes

 the receptive vocabulary skills of the child

 the child’s motoric abilities

 the child’s ability to externally monitor their speech productions

 the child’s ability to internally monitor their speech productions

perception and production training can improve both production and discrimination

lips (structural variations of speech mechanism)

Structural variations that would prevent lip rounding or approximation could impact articulation.

teeth (structural variations of speech mechansism)

Malocclusions (irregular teeth position) can affect speech production, but not in all cases.

tongue (structural variations of speech mechanism)

Ankyloglossia (tongue-tie) impacts speech sound production only in severe cases.

 Macroglossia (enlarged tongue) can cause speech sound production difficulties, but most individuals are able to compensate.

hard palate (structural variations of speech mechanism)

Removal of any part may increase the difficulty of producing speech sounds.

soft palate or velum (structural variations of speech mechanism)

Not closing off the velopharyngeal port will lead to issues

with speech sound production.

nasal emission, hypernasality, hyponasality

tonsils (structural variations of speech mechanism)

hypernasality may be caused by enlarged tonsils or complications from tonsillectomy

Unrelated to speech sound development and disorders.

diadochokinetic (DDK) rate (motor abilities)

Used to assess motor function in typical and disordered populations.

 Requires the rapid production of syllables (puh, tuh, kuh).

 Some links between speech sound production skills and DDK rate have been found (specifically in children with apraxia)

Studies of children with SSDs have largely found no difference in tongue strength between children with and without SSDs.

tongue thrust (motor abilities)

Can present in three ways:

1. The tongue has an anterior gesture at the initiation of a swallow.

2. The tongue unnecessarily moves between or against the front teeth during speech.

3. The tongue lays on or between the anterior teeth during rest.

 More sibilant distortions

children who have all 3 presentations of tongue thrust- have most difficulty with speech sound production, specifically in sibilant distortions and dentition

obligatory in infancy but resolves by age 1- if not sooner

Treatment for BOTH tongue thrust and SSD:

 Speech sound therapy

 Oral myofunctional therapy (OMT)

intelligence (cognitive-linguistic factors)

Weakly associated with speech sound disorders.

 Individuals with significant cognitive impairments (i.e., low intelligence) have a high prevalence of speech sound disorders.

 Acquisition of speech sounds occurs at a much slower rate, often corresponding to mental age.

 Errors are often inconsistent and may involve deletion of consonants.

phonological memory (cognitive-linguisitc factors)

Phonological short-term memory: refers to the ability to briefly hold information in memory for later recall.

 Phonological working memory: includes manipulation of the information before recall.

children with SSDs lack the ability or experience a weakness in holding and or manipulating phonological info for consistent and accurate use during speech production

phonological encoding (cognitive-linguistic factors)

Required for long-term memory storage.

 Children with speech delays perform poorly on encoding tasks, such as syllable repetition tasks.

langauge development (cognitive lingusitic factors)

Specific components of language influence phonology:

• syntax and morphology.

•The more syntactically complex a sentence is, the more phonological errors produced.

•Mixed results on treatment of co-occurring morphosyntax and phonology deficits.

studies have shown that the more syntactically complex a sentence is, the more phonological errors a child with a language impairment will produce

research has yielded mixed results in terms of how to treat co-occurring morphosyntax and phonology deficits

some researchers have found that treating only the morphosyntax piece of the disorder will generalize to phonology

most researchers have found that phonology tends to be treated directly in order to see any change in speech sound production

academic performance (cognitive-linguistic factors)

•Academic performance

 Difficulties with reading, spelling, and phonological awareness.

children with SSDs with spelling difficulties exhibit similar error patterns within their spelling as they do in their speech

psychosocial factors

Age

▪English speech sounds mastered by 9 years of age or earlier.

▪Gender

▪Acquisition of speech production faster in girls than boys.

▪Family background

▪SES: No strong correlation between SSDs and SES by itself.

▪Familial tendencies:

▪ Approximately 46% have a family member with a SSD.

▪ Monozygotic (identical) twins more highly correlated than dizygotic (fraternal) twins.

▪Personality

▪Some children with SSDs are too sensitive (per parent report)

categories of SSDs

Known Origin

• Organically based disorders: SSDs that can be linked

to an obvious etiology or cause. ex. cleft palate

• Unknown Origin

• Idiopathic speech sound disorders

lips (major structural variations)

Children with a cleft lip are at risk for an SSD

• Not as common as one might assume

tongue (major structural variations)

Compensates when part of the organ is missing, like in the case of a glossectomy

• Down syndrome: relative macroglossia can affect intelligibility., or when tongue is too large for the small oral cavity

hard palate (major structural variations)

surgical correction

dental appliance- An obturator fills in the gaps, intelligible speech with no hypernasality

not having a hard palate→ serious problems with speech intelligibility

soft palate (major structural variations)

Velopharyngeal incompetence and Cleft palate→

both can reduce intelligibility by causing hypernasality and specific phoneme substitution, for ex. glottal stop

nasopharynx (major structural variations)

Tonsils

• Adenoids

can affect speech quality when present or after removal

down syndrome (genetic disorders)

caused by an extra copy of chromosome 21 which results in cognitive delays and relative macroglossia, reduced muscle tone, frequent otitis media, and abnormal speech patterns

• Abnormal speech patterns

fragile X syndrome (genetic disorders)

caused by mutation in part of the X chromosome that results in cognitive impairments which lead to delayed or disordered speech production.

Beckwith-Wiedemann syndrome (genetic disorders)

a rare genetic and epigenetic overgrowth disorder present at birth that affects growth and increases the risk of certain childhood cancers

Macroglossia- enlarged tongue

• Hemihyperplasia- one side of body or one side of substructures is overdeveloped

difficulties with production of interior sounds

glactosemia (genetic disorders)

stops body from breaking down simple sugar glucose

causes cognitive and speech deficits

hearing loss

ability to hear speech and language of others in our environment, as well as hear our own attempts at speech production, are necessary for typical speech and language

Aspects of hearing loss that affect speech perception and

production:

• Level of hearing sensitivity

• Speech production

• Age at which hearing was lost or diagnosed

• Age at which amplification was received

• Amount and quality of intervention

dysarthria (neuromotor disorders)

Characterized by slow and uncoordinated speech motor movements.

• The uncoordinated movements affect the respiratory, prosodic, phonatory, and articulatory systems.

apraxia of speech (neuromotor disorders)

An impairment in motor programming that specifically affects speech motor movement

childhood apraxia of speech (neuromotor disorders)

Diagnostic markers

• Inconsistent errors on repeated attempts of the same words.

• Difficulty with prosody in phrases and words.

• Lengthened and disrupted transitions between syllables and words

controversial diagnosis

classification by etiology

Genetic

• Otitis media with effusion

• Psychosocial

• Motor speech involvement

• Speech errors: sibilants

• Speech errors: rhotics

ideological perspective (idiopathic SSDs)

refers to classification system developed by Schrieberg and colleagues, whereby children are sub-grouped based on possible ideaologies

classification by psycholinguisitc deficit (SSDs of unknown origin)

Refers to the underlying deficits that these children may be experiencing.

• Children may be classified based on where in the speech processing chain the problem is occurring

classification by symptomology (SSDs of unknown origin)

using surface error patterns to explain the disorder

Four subgroups:

1. Articulation disorder- child produces consistent errors on just a few phonemes

2. Phonological delay- delayed resolution of common phonological patterns

3. Consistent atypical phonological disorder- child produces typical error patterns along with non-developmental patterns and these errors are produced consistently

4. Inconsistent phonological disorder- produces typical error patterns along with non-developmental pattern, but produces them inconsistently

5. Childhood Apraxia of Speech-which is when a child has multiple phonological and phonetic planning deficits along with implementation of the motor program

comorbidity

Comorbidity of disorders is common.

• Children with SSDs often present with multiple areas of need.

• Knowing any possibly comorbid disorders is important for diagnosis, etiology, and treatment

knowing any possibly comorbid disorders is important for diagnosis, ideology, and treatment

SSDs and language disorders

Co-occurrence: 20%-60%

• Children with SSDs may be more likely to also have an

expressive language disorder.

SSDs and stuttering (comorbidity)

Both are motor-based problems.

• The child has a limited capacity in managing several

aspects of communication at the same time.

connection through language- phonology

due to child’s limited capacity to manage several aspects of communication at the same time

SSDs and voice disorders (comorbidity)

Reduced intelligibility may lead to a voice disorder.

• A voice disorder may lead to reduced intelligibility

suggested that children with SSDs due to reduced intelligibility, overcompensate by straining the vocal mechanism

voice disorder causes limited or inadequate feedback necessary for appropriate speech-sound development so SSD comes first

SSDs and emotional/psychiatric disorders (comorbidity)

Have received less attention.

• ADHD, ADD, anxiety disorder, or conduct disorder have

been shown to co-occur.

• 60% of school based SLPs provide treatment to

children with a diagnosis of ADHD.

unclear which disorder might come first in individual cause

speech sound disorders are at risk for other kinds of disorders

relationship between speech sound perception and speech sound errors

Speech sound perception transforms an acoustic signal into units. This allows people to take those signals and turn it into understanding what someone is saying.

When someone perceives speech well, they can detect when speech sound errors occur and what they need to do to fix it

ways to asses speech perception abilities `

phoneme specific assessments- targets a child’s ability to comprehend specific phonemes and recognize when they say certain phonemes incorrectly.

context-specific assessments- targets the child’s ability to perceive speech when they are in different environments

relationship between phonological disorders and morphosyntactic language

disorders may co-occur, but one does not guarnatee the other is present

together in development and treatment

speech sound disorder and academic performance

They may have difficulties with reading and spelling later on, since oral language skills are crucial in development related to literacy. They may fall behind

age and speech sound development

Children continue to improve articulatory and phonological skills until they turn 9 years old. In some cases, improvement in articulatory and phonological skills may continue past 9 years old, but in the case of typical development, children aren’t able to improve speech sound acquisition past age 9

hearing loss and speech sound development

can lead to someone having difficulty with the perception of words and may have difficulty decoding the signal.

When someone has had _since birth, they may have difficulty with regular acquisition of language through the five domains.

If someone develops _after they have learned language, their articulatory skills will decline over time

. An individual with _speech can be hard for others to understand.

They often struggle with vowels and consonants, which leads to frequent speech sound errors.

Their speech can be said at a much slower rate with constant pauses and transitions with articulation is also much slower

common speech errors

Omission of final consonants, /s/, and initial consonants

Voiced for voiceless consonants

Nasal for oral consonants

Hypernasality with vowel productions
Imprecision in vowel articulation

uncommon speech errors

Initial consonant deletion

Glottal stop substitution

Backing

Vowel Substitution

Diphthong simplification

controversy with category childhood apraxia of speech

Researchers have had disagreements over the characteristics of childhood apraxia of speech and if they even exist.

Characteristics that were found often fit with other disorders too.

These struggles have led to some believing that this disorder does not need its own specific and unique diagnosis

3 broad causes and core problem with CAS

1. it may coexist with a neurological condition.

2. it may coexist with neurobehavioral disorders.

3. CAS is unknown

core problem of CAS is the difficulty of planning and programming speech movements

diagnostic markers for CAS

inconsistent consonant and vowel speech sound errors; tries to produce the same word, and it leads to different productions as a result

having problems with prosody; may use excessive stress with two-syllable words

disrupted transition between sounds and syllables and lengthening of statement.; will have longer pauses before consonant clusters and more pauses in between each cluster

factors underlying idiopathic SSDs and search for subgroups

Idiopathic SSDs have an unknown origin. I

In the beginning, SLPs said idiopathic SSDs were in one single group and treated them the exact same way.

When linguists came into the picture, SLPs realized pattern existed in these collections of sound errors.

Some studies revealed unique differences, but others showed results that contradicted previous results.

This led to considering the possibility that these needed to be studied through distinct subgroups

3 perspectives for classifications of SSDs

The first perceptive for classification of SSDs is by possible etiology. This perspective focuses on the distal cause (comorbid problem), casual correlates (factors in case histories), and diagnostic markers (characteristics of each subgroup) (Bernthal 173).

The second perspective for classification of SSDs is classification by psycholinguistic development. This perspective focuses on underlying difficulties the child has with speech processing in their brain (Bernthal 178-179).

The third perspective for classification of SSDs is classification by symptomology. This perspective focuses on how error patterns or symptoms show disorder and provide classification

3 broad categories of speech disorder classficiation system

The first broad category is level of representation of sensory or auditory information that goes with words and sounds

The second broad category is planning and programming difficulties with execution of motor movements

The third broad category is the incapability to carry out or execute motor movements

subgroups of speech disorder classificaiton systems

The second broad category is planning and programming difficulties with execution of motor movements (Bernthal 174-175).

 

The third broad category is the incapability to carry out or execute motor movements (Bernthal 175).

 

The first three subgroups are classified as speech delay, which is when the children’s speech production is behind what it should be developmentally (Bernthal 175).

 

The next subgroup is speech delay- otitis media with effusion, which is when children often have frequent cases of otitis media with effusion (Bernthal 175- 176)

 

The next subgroup is speech delay-psychological involvement, which shows how children interact with others and how they present with aggression or withdrawal when interacting

The next two subgroups speech errors- sibilants and speech errors-rhotic, which focuses on how that children try to master speech sounds before they are ready for it

 The next subgroup is motor speech delay, which focuses on when a child has a delay in precision and stability of speech skills of motor

The next subgroup is childhood dysarthria, which is when a child has neurological impairments that can cause uncoordinated movements of muscles that are involved with speech

 The next subgroups is childhood apraxia of speech, which uses idiopathic origin with males outnumbering females

 The final subgroup is a combination of CD and CAS, which is when a child shows symptoms of both childhood dysarthria and childhood apraxia of speech

why different communication disorders might coexist in same individual

First explanation of coexistence is there are certain disorders that lead to other disorders (Bernthal 181).

Second explanation of coexistence is communication is complex and different components are put into use together and at the same time (Bernthal 181).

Third explanation of coexistence is comorbid conditions could often be different aspects of language interact (Bernthal 181).