Typical & Disordered Communication – Key Vocabulary

Role of Culture and the Environment

  • Cultural identity & communication
    • Communication styles, linguistic codes, and disorder‐perception are filtered through one’s cultural lens.
    • A behavior considered “typical” in one culture (e.g., avoiding direct eye contact with an elder) can be misinterpreted as pragmatic language impairment by clinicians unfamiliar with that culture.

  • Influencing variables
    • Age, socioeconomic status, geographical background, ethnicity, gender, ability/disability, religion, and peer group norms collectively shape communicative expectations.
    • The intersection of variables (e.g., rural + low SES + bilingual) may compound differences.

  • Cultural competency
    • Requires sensitivity to variables above, continuous self-reflection about bias, and use of culturally appropriate assessment materials.
    • Ethical mandate: ASHA’s Code of Ethics calls for clinicians to practice only when adequately prepared to serve diverse populations.

  • Environment
    • “Where, with whom, and during what event?” affect the register, modality, volume, and lexical choices.
    • Example: A speaker in a large, noisy family gathering may use exaggerated gestures and louder voice vs. a quiet library conversation.

  • Reflective question posed in lecture (Pg 4)
    • “Can you think of a communication difference that is culturally based but might seem disordered to an unaware person?”
    • Purpose: stimulates metacognitive awareness; reminds clinicians to separate disorder from difference.

Aspects of Communication

  • Macro-components
    • Language, Speech, Voice, Swallowing, Non-verbal Communication, Hearing.

  • Language (detailed)
    • Definition: Socially shared, rule-governed, arbitrary code representing concepts; generative & dynamic.
    • Six hallmark traits: socially shared tool, rule governed, arbitrary, generative, dynamic, conceptual representation.

  • Ingredients of language
    • Form – Phonology\text{Phonology} (sound rules), Morphology\text{Morphology} (word formation), Syntax\text{Syntax} (sentence structure).
    • Content – Semantics\text{Semantics} (meaning).
    • Use – Pragmatics\text{Pragmatics} (social function).

  • Speech – Neuromuscular production of sounds (articulation, rate, fluency).

  • Voice – Pitch, loudness, and quality generated by laryngeal & respiratory systems.

  • Swallowing – Coordinated sensorimotor act; impairment is “dysphagia.”

  • Non-verbal communication – Kinesics, proxemics, chronemics, oculesics, haptics.

  • Hearing – Reception/processing of acoustic signals; basis for oral language development.

Communication & Swallowing Disorders (Overview)

  • Language disorders
    • Form: phonological delay/disorder.
    • Content: semantic deficits, aphasia (often post-stroke).
    • Use: pragmatic impairments; e.g., autism spectrum disorder conversational breakdowns.

  • Speech disorders
    • Dysarthria (neuromotor), apraxia of speech, articulation (phonetic) errors, fluency disorders (fillers, hesitations, prolongations, stuttering).

  • Voice disorders
    • Abnormal pitch, loudness, quality (e.g., vocal nodules, spasmodic dysphonia).

  • Swallowing disorder
    • Dysphagia across oral, pharyngeal, or esophageal phases.

  • Hearing disorders
    • Conductive (outer/middle ear), sensorineural (inner ear/auditory nerve), mixed.

Expanded Hearing & Related Deficit Matrix (Pg 10)

  • Conductive ↔ sensorineural ↔ mixed create cascading effects on language acquisition.

  • Auditory perceptual deficits: processing, attention, decoding, integration, organization, comprehension.

  • Working-memory & cognitive deficits: hinder complex sentence comprehension & discourse.

  • Motor control deficits: speech articulation, respiratory coordination.

  • Reading & writing deficits: phonological awareness, spelling, text composition.

  • Non-linguistic deficits: praxis, executive functions impacting communication indirectly.

Non-Verbal Communication (Pg 11)

  • Kinesics: gestures, facial expressions, posture.

  • Proxemics: culturally bound physical distance norms (intimate, personal, social, public).

  • Chronemics: perception of time (e.g., “monochronic” vs. “polychronic” cultures) influences turn-taking & punctuality.

Defining “Normal” (Break-Out Discussion)

  • “Normal” = statistical average, socially preferred, or absence of impairment?

  • Encourages clinicians to scrutinize their own standard and embrace neurodiversity.

Assessment Fundamentals

  • Assessment (definition): systematic process to verify strengths/weaknesses, identify etiology, and guide treatment.

  • Key diagnostic questions
    • Does a problem exist?
    • Diagnosis & differential?
    • Severity, consistency, strengths, probable causes, prognosis.

  • Case history / interview
    • Chart review (HPI, labs, imaging).
    • Family/caregiver perspectives—vital for premorbid function & cultural-linguistic background.

  • Multidisciplinary data: PT/OT notes, nursing vitals, physician updates ensure holistic view.

Sample Chart Elements (Pg 17–18)

  • Vitals: Temperature, O2\text{O}_2 saturation, WBC, breath sounds, imaging.

  • History & Physical (Billie, 73 y/o, s/p CABG)
    • Highlights: postoperative dysphagia, NG tube, moderate pharyngeal dysphagia on MBSS, COPD comorbidity, NPO order.
    • Illustrates necessity of respiration-swallow coordination awareness.

Screening & Evaluation Types

  • Screen – Pass/fail; flags need for full evaluation.

  • Formal evaluation
    • Norm-referenced: compare to age/peer sample (e.g., WAB, CELF-5).
    • Criterion-referenced: performance against pre-set criterion.

  • Informal evaluation
    • Probes, language sampling, dynamic assessment.

  • Data -> measurable goals.

Assessment Tools Mentioned

  • WAB-R (Western Aphasia Battery-Revised) – classifies aphasia type via spontaneous speech, comprehension, repetition.

  • SLUMS – cognitive screener sensitive to mild neurocognitive disorder vs. dementia; education-adjusted norms.

Example SLUMS Items (selected)

  • Immediate recall, animal fluency, serial subtraction, clock drawing, story recall; scoring matrix:
    • High school normal=27–30\text{normal} = 27–30 vs. < HS normal=25–30\text{normal} = 25–30.

Language Evaluation Template (Pg 22)

  • Receptive hierarchy: single → multi-step commands, complex Y/N, object ID, paragraph recall.

  • Expressive hierarchy: automatic sequences, phrase completion, picture description, naming, verbal fluency.

  • Qualitative markers: paraphasias (semantic/phonemic), neologisms, perseveration, tangentiality.

Simucase Reflections (Roberts & Confidentiality)

  • Collaboration with spouse yields context (premorbid communication patterns, functional goals).

  • Secure PHI: encrypted devices, no identifiers in public spaces, log-out procedures.

  • Always conduct chart review before patient contact to anticipate precautions (e.g., sternal, infection control).

  • If unfamiliar EMR data emerges: consult literature, ask senior staff; never guess.

  • Safety risks of skipping chart review: missing NPO status, isolation precautions → aspiration or infection.

Intervention & Treatment Principles

  • Objective: facilitate functional improvement within real-world contexts.

  • Characteristics: automatic + volitional tasks, build self-awareness, culturally responsive.

  • Progress must be optimal yet reasonable in timeframe; document with measurable outcomes.

Behavioral Objectives / SMART Framework

  • Audience (A) – who?

  • Behavior (B) – observable action.

  • Condition (C) – context/cues.

  • Degree (D) – accuracy/independence (e.g., 80%80\%).

  • Expected date (E) – time-bound.

  • Function (F) – participation rationale.

Template

(A)  Pt will  (B)  do what?  (C)  given what cues?  (D)  with x% accuracy  (E)  by when?  (F)  in order to…(A)\;\text{Pt will}\;(B)\;\text{do what?}\;(C)\;\text{given what cues?}\;(D)\;\text{with }x\%\text{ accuracy}\;(E)\;\text{by when?}\;(F)\;\text{in order to…}

Example Goal (lecture)

  • “Patient will produce automatic speech tasks independently with 80%80\% accuracy within one week to improve verbal expression skills.”

Additional Examples (Pg 30)

  • Single sentence formulation with target words (80%80\%, min cues).

  • Pharyngeal exercises (100%100\%, min cues) → swallow function.

  • WH-question answering from paragraph (80%80\%, min cues).

  • Caregiver diet-recommendation understanding (max cues) → home generalization.

Treatment Plan Design

  • Built off goals; establish baselines.

  • Hierarchical progression (easy → hard).

  • Environmental modifications (quiet room, visual aids).

  • Systematic cueing: verbal → tactile → visual; aim to fade cues.

  • Family education integral for carry-over.

Simucase – Don (Aphasia) Discussion Prompts

  • Rapport building increases trust, motivation, and accurate performance.

  • Interview findings (e.g., occupation, hobbies, communication frustrations) direct personalized goals.

  • Possible goals:
    • “Don will name everyday objects with 70%70\% accuracy with semantic cues in 3 sessions.”
    • “Don will use gestures/AE to repair breakdowns in 4/54/5 opportunities.”

  • Challenges with aphasia: social isolation, role change, employment loss; families experience role reallocation and communicative burden.

Ethical & Practical Implications

  • Misdiagnosing a cultural difference as a disorder violates Principle I of ASHA ethics (do no harm).

  • Failing to secure PHI breaches HIPAA; penalties $100–$50,000\$100–\$50,000 per violation.

  • Clear, measurable goals justify billing, guide intervention, and support inter-professional communication.

Connections & Real-World Relevance

  • Links to prior coursework:
    • Phonetics (supports articulation assessment).
    • Anatomy & Physiology (voice & swallow physiology).
    • Research methods (evidence-based choice of assessments).

  • Clinical rotations will require application of SMART goal writing & cultural competence daily.