speech disorder

speech disorder
any conspicuous speech imperfection, or variation from accepted speech patterns, caused either by a physical defect in the speech organs or by a mental disorder, as aphasia, stuttering, etc.

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      any of the disorders that impair human speech.

The study of speech disorders

Prevalence of speech disorders
      A comprehensive evaluation of knowledge and research in speech and hearing, published in 1969 by a section of the U.S. Public Health Service, under the title Human Communication and Its Disorders—An Overview, revealed that approximately 9,000,000 Americans were reported to have hearing impairments of handicapping magnitude; another 2,000,000 were said to suffer from central processing disorders from neurologic disease; and 10,000,000 to have speech disorders. The cost of coping with these problems was about $500,000,000 per year, while the annual deficit in earning power among such impaired persons approximated nearly $2,000,000,000. The disorders of articulation among young children were numerically most frequent.

      No data in similar detail are available from other countries; however, from experience in Germany, Austria, and other Central European countries, it may be said that the incidence and prevalence of speech disorders follow similar patterns among other Western nations. Certain deviations from these trends are equally typical. The incidence of cleft palate is very high among American Indians, while it is much lower among Negroes than in Caucasians. stuttering is more frequent in northern countries, such as in Scandinavia, than it is in southern regions—e.g., Italy. Similar trends have been noted in the Far East. Nonorganic, functional, or emotional disorders of voice and speech reflect psychological tensions exerted by the environment. For such reasons, vocal nodules (growths on the vocal cords), contact ulcer, vocal fatigue, etc., occur with greater incidence in metropolitan areas and are conspicuously less frequent in rural regions.

Classification of speech disorders
      In accordance with physiological considerations, disorders of communication are first classified into disorders of voice and phonic respiration, disorders of articulated speech, and disorders of language. It has been known for a long time that the majority of communication disorders are not caused by local lesions of the teeth, tongue, vocal cords, or regulating brain centres. Since these predominant disorders of voice and speech develop from derangements of the underlying physiological functions of breathing, use of the voice, speaking habits, or emotional disorders, this group has been labelled as functional. The remainder of the communication disorders with clearly recognizable structural abnormalities in the total speech mechanism has been termed organic.

      While this empirical grouping has certain implications for the selection of the appropriate treatment, it is not satisfactory because organic structure and living function can never be separated. Certain functional disorders of the voice caused by its habitual abuse may very well lead to secondary structural changes, such as the growths (polyps and nodules) of the vocal cords, which develop as a result of vocal abuse. On the other hand, all of the obviously organic and structural lesions, such as loss of the tongue from accident or surgery, almost inevitably will be followed by emotional and other psychological reactions. In this case, the functional components are of secondary nature but to a great extent will influence the total picture of disturbance, including the patient's ability to adjust to his limitation, to relearn a new mode of appropriate function, and to make the best of his condition.

      Within these major groups, the various types of communication disorders have for a long time, and in most parts of the world, been described by the listener's perceptual impression. Most languages employ specific words for the various types of abnormal speech, such as stuttering, stammering, cluttering, mumbling, lisping, whispering, and many others. The problem with such subjective and symptomatic labels is the fact that they try to define the final, audible result, the recognizable phenomenon, and not by any means the underlying basis. This general human tendency to describe disorders of communication by what the listener hears is analogous to the attempts of early medicine (medicine, history of) to classify diseases by the patient's symptoms that the diagnosing (diagnosis) physician could see or hear or feel or perhaps smell. Before the great discoveries of the 19th century had erected a logical basis for medical pathology, the various diseases were classified as numerous types of fevers, congestions, dyscrasias, etc. Thus, malaria was originally thought to be caused by the evil emanations (miasma) of the bad air (mal aria) near swamps until it was recognized to be caused by a blood parasite transmitted by the mosquito.

      The various approaches of medical, psychiatric, psychological, educational, behavioral, and other schools of speech pathology have made great advances in the recent past and better systems of classification continue to be proposed. They aim at grouping the observable symptoms of speech disorders according to the underlying origins instead of the listener's subjective impressions. While this is relatively easy in the case of language loss from, for example, a brain stroke because the destroyed brain areas can be identified at autopsy, it is more difficult in the case of the large group of so-called functional speech disorders for two reasons: first, they are definitely not caused by gross, easily visible organic lesions, and, second, many functional disorders are outgrown through maturation or appropriate learning (laboratory study of the involved tissues in such cases would reveal no detectable lesions). It is hoped that refined methods of study in the areas of both “functional” psychology and “organic” neurophysiology will eventually reveal the structural bases for the prevalent disorders of voice and speech.

Treatment and rehabilitation
      The selection of methods in the medical treatment or educational rehabilitation of communication disorders depends primarily on the underlying basis for the disturbance. Any case of chronic hoarseness should be evaluated first by a laryngologist to establish a precise diagnosis. This is particularly important in the older age groups in which an incipient laryngeal cancer is often overlooked because the patient does not pay attention to his deteriorating voice. The prognosis of all cancers becomes rapidly poorer the longer the disease remains unrecognized. As soon as disease of the larynx is excluded as a cause of the vocal complaint, vocal rehabilitation by a competent speech pathologist should be considered.

      Malformations, diseases, or injuries of the peripheral speech mechanism are treated by appropriate specialists; the plastic surgeon repairs a cleft of the palate; the neurologist and internist treat the stroke patient until he has recovered sufficiently to be referred for re-education of his language abilities. The pediatrician treats the child with mental retardation, while the geneticist counsels the family regarding the possible inheritance of the disorder and its future avoidance. deafness or severe hearing loss in early childhood is a typical cause for severe delay of language development and should be promptly recognized through appropriate examination by the ear surgeon (otologist) and hearing specialist (audiologist). Cases of childhood autism (withdrawal, severe eccentricities) or early schizophrenia are now being recognized with increasing frequency by speech pathologists, child psychiatrists, pediatricians, and clinical psychologists. This multitude of various professional interests in the recognition and rehabilitation of such exceptional children is well served by the coordination of these efforts in the modern team approach. But again, the largest group of disorders of voice and speech has causes other than these grossly organic lesions. They belong within the province of speech rehabilitation by experts in speech pathology and other functional practitioners.

Development of speech correction
      That mankind has been troubled by speech afflictions since the beginning of recorded history can be gleaned from numerous remarks in the books of the Bible. Further, many scientific and medical writers from the time of antiquity to the Middle Ages reported observations of speech and voice disorders. The recommended remedies merely reflected the inadequacies of the philosophical or empirical notions of their times. Scientifically oriented speech pathology originated in Germany during the latter part of the 19th century, following closely the development of otolaryngology. Three names stand out in this respect: C.L. Merkel (Anthropophonik; 1857), Adolph Kussmaul (The Disorders of Speech; 1877), and Hermann Gutzmann, Sr., who became the first professor of speech pathology at the University of Berlin Medical School around 1900.

      During the same time, the new science of experimental phonetics was developed by Jean-Pierre Rousselot in Paris, who promptly recognized the great contributions that experimental phonetics could make to the study of normal and disturbed speech. This close collaboration of medical speech pathology with experimental phonetics has remained typical for the European continent where speech correction is customarily carried out under the direction of physicians in the ear, nose, and throat departments of the university hospitals. The designation of speech and voice pathology as logopedics and phoniatrics with its medical orientation subsequently reached many other civilized nations, notably in Japan and on the South American continent. The national organizations in most of these areas are now represented in the International Association of Logopedics and Phoniatrics, which was founded in Vienna in 1924.

      The evolution of speech correction in the Anglo-Saxon countries followed a different trend. Although Great Britain has had a long tradition in general and experimental phonetics, its College of Speech Therapists was organized as an examining and supervisory body in 1945. Similar organizations followed in other areas of the British Commonwealth.

      American speech pathology elected a different way. The American Speech and Hearing Association (ASHA), founded in 1925 in New York City, became the organizing, examining, and supervisory body for a rapidly growing membership, which surpassed 12,000 by 1970. More than 200 colleges and universities in the United States, many accredited by ASHA, offer degrees in speech pathology and audiology, some including work at the doctoral level. The large majority of ASHA members hold the master's degree and work as speech clinicians in the public school systems. A smaller number with master's degrees and a still smaller number with doctoral degrees staff the more than 300 clinics that deal with communication disorders and that are usually affiliated with hospitals, colleges, universities, and occasionally with civic organizations.

      Russian (Union of Soviet Socialist Republics) speech correction originally followed the developments of European logopedics and phoniatrics and is now directed by the Department of Logopedics in the Government Institute of Defectology of the Academy of Pedagogical Sciences in Moscow. One facet of speech pathology in Russia is its emphasis on Pavlovian theory (conditioning and retraining) and intensive use of neuropsychiatric methods, including pharmacology, sleep therapy, and other intensive treatment programs during hospitalization. Similar trends operate in the eastern European countries, such as in the Czech Republic, where the first independent medical department of logopedics and phoniatrics was organized at the Faculty of Medicine of Charles University in Prague.

Major types of speech disorders

Voice disorders
      In international terminology, disorders of the voice are described as dysphonia. Depending on the underlying cause, the various types of dysphonia are subdivided by the specifying adjective. Thus, a vocal disorder stemming from paralysis of the larynx is a paralytic dysphonia; injury (trauma) of the larynx may produce traumatic dysphonia; endocrine dysphonia reflects the voice changes resulting from disease of the various endocrine glands such as the pituitary. The various dysphonias of clearly organic origin from systemic disease (e.g., muscular, nervous, or degenerative disease afflicting the entire body) or from local laryngeal changes differ in their visible symptomatology, as well as in the perceptual impression produced by the abnormal voice. Nevertheless, it has not yet been possible to define the acoustical alterations in the vocal spectrum that would allow a clear and objective differentiation among the subjective graduations of an abnormal voice as hoarse, harsh, husky, breathy, grating, gravelly, gritty, etc.

      Because a large group of dysphonias have no visible laryngeal causes, they are grouped as nonorganic. Two main types of these so-called functional voice disorders may be distinguished: the habitual dysphonias that arise from faulty speaking habits and the psychogenic dysphonias that stem from emotional (emotion) causes. Both of these types of dysphonia again occur in two basic subtypes, the hyperkinetic (overactive) and the hypokinetic (underactive) since emotional disorders interfere with voluntary vocal function by causing either excessive or depressed physiological activity. In the hyperkinetic disorders, the highly coordinated patterns of phonation regress to the primitive, forceful, and exaggerated sphincter action of the larynx as seen during gagging. The result is hyperkinetic dysphonia, the gratingly harsh vocal disorder due to excessive muscular action in a constricted larynx. In the second subtype, the movements for phonation regress even more deeply to the original function of respiration; the sluggish larynx remains more or less open, and the glottis is incompletely closed for phonation, leading to hypokinetic dysphonia with subdued, breathy huskiness.

Disorders of language development
      The most frequent speech disorders are those that disturb the child's acquisition or learning of language. While those concerned with modern terminology are striving for an improved classification according to the etiologic (causative) factors, it is still customary to classify these disorders on the basis of the complaint: absence of speech, baby talk, poorly intelligible articulation, lisping, etc. Recent studies of large numbers of children with such developmental language disorders have shown that at least two chief classes of these disorders may be distinguished: general language disability from genetic factors with a familial (inherited) pattern chiefly from the paternal side, and acquired language disorders due to damage sustained before, during, or shortly after birth (i.e., perinatally).

      These latter perinatal damages encompass the gamut of toxic, infectious, traumatic, nutritional, hormonal, and other damages that may hurt the growing fetus or young infant. Major and minor birth injury is not an infrequent factor. Hereditary (heredity) factors also encompass a great variety of genetically predetermined influences, including familial tendency to exhibit slow language development, lesser endowment in the brain area for language, inferior function in the highest brain areas of auditory performance without organic damage to the ears, slow maturation of motor function (including clumsiness and deviation from normal cerebral dominance), and other signs of delayed cerebral growth. Additional environmental causes include poor language patterns used by the family, parental neglect, emotional maladjustment, general weakness from prolonged disease, as well as various socioeconomic, cultural, and other psychological influences.

      While some otherwise perfectly normal children, particularly boys, may not elect to begin talking until age three, making good progress in every respect from then on, the absence of speech after age two may be caused by any of the conditions mentioned thus far and would appear to merit prompt investigation. If an organic cause can be detected, the symptomatic description of delayed language development then yields to a specific etiologic (causal) diagnosis. Although it is best to describe the absence of speech in early childhood as simply delayed language development, some American investigators tend to refer to this condition as congenital (present at birth) aphasia, a term rejected by most European scholars who argue that there cannot be an inborn or early acquired aphasia before a language has been learned.

      Many children encounter unusual difficulties in mastering the patterns of articulation of their mother tongue and are said to manifest articulatory immaturity (infantile dyslalia). If no organic cause can be found, the probable cause may be delayed maturation of psychomotor skills.

      Marked delays of language development are often followed by a period of inability to learn the rules of grammar and syntax at the usual age (dysgrammatism). Though this is often a sign of inherited language disability, it may reflect mental retardation (intellectual disability) or other types of brain damage.

      Some children who have suffered such laboured language development may then go through a period of retarded reading and writing disability, a condition often defined as dyslexia. Again, there are two chief varieties: the primary or developmental reading and writing disability due to constitutional (organic) and hereditary factors, and a large secondary group of symptomatic reading disorders acquired through any of the influences that retard language development in general, including troubles with vision. Practically all investigators agree that primary or developmental dyslexia shows a marked hereditary tendency (is familial) and is typically associated with other disorders of psychomotor development, deviation from the prevalent right handedness, and poor function in the auditory area in the brain, often associated with lack of musical talent. Primary dyslexia is significantly associated with other developmental speech disorders.

Articulatory disorders
      Those who have followed large numbers of children with language disabilities for a long time are impressed by the fact that these various manifestations of an underlying developmental disorder often terminate in a peculiar impediment of speech that has been well known to European speech pathologists for many years but is not yet fully recognized in American speech literature: cluttering (or tachyphemia), the hasty, sloppy, erratic, stumbling, jerky, and poorly intelligible speech that may somewhat resemble stuttering (see below) but differs from it markedly in that the clutterer is usually unaware of it, remains unconcerned, and does not seem to fear speaking situations. Its association with other past or persistent signs of subnormal language development also differentiates congenital cluttering from emotional stuttering. Experts are strikingly unanimous in stressing the hereditary nature of cluttering.

      Although lisping belongs among the articulatory disorders and usually has the same causes as articulatory disorders (dyslalia) in general, it differs from other disorders of articulation in several respects. For one, lisping occurs in various varieties: with the tongue tip protruding between the front teeth, with a slurping noise in the cheek pouch, with the tongue too far back along the palatal midline, with excessive tongue pressure against the teeth; in several snorting and nasal subtypes, as well as through substitute hissing deep in the throat or even within the larynx, such as in cleft-palate speech. Moreover, the causes of lisping include a diverse group of particular conditions: abnormal number or position of teeth; imitation of other lispers; deficiency of palatal closure; slight hearing loss in the high frequencies; as well as several psychologic causes, such as effeminate affectation, infantile mannerisms, or mental disturbance. Lisping is less easily outgrown than the other infantile dyslalias and may persist into adult life if not corrected.

stuttering, or stammering
      Academically known as dysphemia, what is called stuttering in the United States is usually named stammering in Great Britain. While everyone seems to know what stuttering sounds like, experts do not agree about what really causes it. In the age groups after puberty, stuttering is the most frequent and conspicuous type of disturbed speech encountered. This is one reason why among the studies dealing with speech pathology in the world literature those devoted to stuttering are the largest single group. Despite numerous and intensive studies of the problem, findings and conclusions are far from unanimous. A great number of theories have been proposed to explain the origin and nature of stuttering, which range from the premise that subtle physical disturbances in the nervous system (so-called neurogenic asynchronies) are responsible to the opinion that psychological maladjustment alone is to blame. The report issued by the U.S. Public Health Service (see above Prevalence of speech disorders (speech disorder)) concludes that “stuttering remains an enigma while illustrating the type of disorder which does not have either a clean-cut organic cause or a clearly habitual basis.”

      Research findings indicate (as is the case with many developmental speech disorders, particularly language disability, articulatory disorders, reading disability, and cluttering) that trouble with stuttering affects the male sex at least four times more frequently than the female. Hereditary predisposition has been noted in many studies of large groups of stutterers, with evidence for an inherited tendency found among as many as 40 percent of the stutterers studied. Some experts insist that stuttering is not a single disease entity but that it comprises several types of the disorder with different causes. According to such views, the familial occurrence of stuttering represents a combination of the stuttering symptom with a cluttering tendency that is inherited. Although imitation of another stutterer may form the basis for acquiring the habit, purely psychological explanations that stress parental attitudes in training their children fail to reveal why many stutterers have siblings (brothers or sisters) with perfectly normal speech.

      The treatment of stuttering is difficult and often demands much skill and responsibility on the part of the therapist. The possibility of some specific medical cure seems remote at the present time. Even the most advanced methods of modern psychiatry have failed to produce superior results in treatment. For a time it was hoped that new psychopharmacological drugs (e.g., tranquillizers) might facilitate and accelerate recovery from stuttering, but these efforts have been disappointing thus far. The typical program of management in this disorder is a strict program of psychotherapy (talking freely with a psychiatrist or psychologist so as to reduce emotional problems) supported by various applications of learning theory or behavioral theory (in retraining the stutterer) and other techniques depending on the therapist's position. It is widely agreed that the patient must acquire a better adjustment to the problems of his life and that he needs to develop a technique for controlling his symptoms and fears. Prognosis (predicted outcome of treatment) thus is held to depend greatly on the patient's motivation and perseverance. It is interesting to note that experienced investigators no longer aspire to a “cure” of stuttering through an etiologic (causal) approach. Instead of focussing on underlying causes, they aim at making the patient “symptom-free” via symptomatic therapy.

      Prevention of stuttering may be aided through parent counselling. The normal, immature speech of many children is characterized by various nonfluencies; these include hesitations, syllable repetition, groping for the right word, and vocalizations between words such as “ah-ah.” Some misguided parents castigate these normal signs of developing speech with various admonitions and, even worse, try to forbid the nonfluencies by mislabelling them as stuttering. In some children, this parental interference associates normal nonfluency with feelings of insecurity and fear, tending to make the child become a real stutterer. Much research has been devoted to this probable etiology for one type of stuttering; its elimination through parental guidance indeed has been reported to help in reducing the number of stutterers.

Dysphasia and aphasia
      Dysphasia means the partial or total loss of language as a result of lesions in those parts of the brain that are directly related to language function. stroke in elderly patients and head injury in younger ones are typical causes. aphasia is seen most frequently when the left side of the brain is afflicted, as evidenced by paralysis of the right arm and leg. Evidence indicates that the left hemisphere (laterality) is dominant in all right-handed individuals and in some left-handers as well. Some experts even believe that the left brain hemisphere is dominant for language in most individuals regardless of handedness and that dominance of the right brain is exceptional in some left-handers. According to other opinions, dominance for language is more evenly distributed in both hemispheres in left-handed persons. As explained before, two major brain areas are recognized as intimately associated with language function: Broca's area in the third frontal convolution and Wernicke's area in the posterior third of the upper temporal convolution. The angular gyrus at the junction of the temporal (side), parietal (top), and occipital (back) lobes of the brain is believed to be related to graphic language as used for reading and writing.

      Aphasiology, the science of aphasic language loss, is studied by neurologists, neurosurgeons, some phoniatrists, certain speech pathologists, as well as some psychologists and linguists. This diversity of research background accounts, in part, for the great diversity in theoretical approaches to aphasia. Numerous classification schemes that have been proposed vary from simple groupings into a few main types of aphasia to complicated systems with many forms and subtypes of aphasic disturbances. Similar to research in stuttering, the literature on aphasia is exceptionally large and growing.

      The essence of aphasia is the loss of memory for the meaning of language and its production. Thus, in the predominantly expressive or motor forms, the patient can no longer remember the intricate patterns for articulation; he can no longer form a word in speaking or writing, even though he may know what he wants to express. In the predominantly receptive or sensory forms, the patient can talk freely, sometimes excessively and incessantly (logorrhea), although with numerous errors and meaningless clichés, but he no longer comprehends what is said to him or what he tries to read. Those who recover from receptive forms of the disorder are likely to explain that during their aphasia spoken language sounded like an unintelligible, alien tongue. The degree to which there is combination of expressive and receptive symptoms varies greatly with the type and extent of brain lesion. There may be total loss of all language functions (global aphasia) to slight residual errors or misunderstandings when the brain damage is only slight or temporary. A major complication of aphasia is the frequent association with right hemiplegia, in which the paralyzed hand is no longer serviceable for writing. Retraining of the left hand for writing may then become necessary.

      Management of aphasia has two goals: one, the physical recovery of the patient through treatment by the internist, neurologist, and possibly brain surgeon, and two, the re-education of the brain functions that are still present, the aim of which is to help the patient relearn some use of language under the guidance of the speech pathologist. The better the patient's recovery from the brain lesion, the more chances there are of prompt and complete return of language. When the brain losses are permanent, the patient must relearn each word, sentence, and phrase like the young child, albeit in a more cumbersome manner, apparently using parts of the brain that still function. He is repeatedly shown the picture of an object along with its printed name; these words are spoken to him by his teacher over and over in the hope that the patient will learn to repeat the word or phrase until he can say it spontaneously. Words that are relevant to the patient's everyday life are emphasized first with due consideration for his interests and past occupation; later he may advance to the use of abstract concepts and of higher levels of language. Various types of automated training programs are available, including a simple play-back device that shows an inserted card with a picture on it, the name of the pictured object printed next to it, and the audible word recorded on a strip of magnetic tape. Devices of this type enable the patient to practice at his own pace.

Symptomatic speech disorders
      Under this heading may be summarized various types of communication disorders that develop on the basis of known structural lesions or metabolic disturbances. Etiologic classifications group these impediments according to the types of organic diseases, as well as in respect to the afflicted effector organs (such as the tongue). Disturbed speech from lesions in the various parts of the nervous system is known as dysarthria. Mental retardation usually limits the development of linguistic ability to the same extent as it does intellectual capacity; this language disorder has been described as dyslogia. Mental disturbances can also manifest themselves in linguistic symptoms, such as in the peculiar (dysphrenic) mode of speech among sufferers of schizophrenia. Hearing loss dating from early childhood leads to a typical distortion of the speech pattern for which various names have been coined, such as audiogenic dyslalia. Visible defects in such oral articulators as the lips and teeth limit the mechanics of articulation and thus reduce the quality and intelligibility of speech; such speech problems are known collectively as dysglossia.

      Damage to those parts of the nervous system that regulate the actions of voice and speech cause distinctive alterations of the speech pattern. The most important disorder of this type is cerebral palsy from brain injury before, during, or soon after birth. The majority of cerebral palsy victims retain normal intelligence but are handicapped by distortions of voluntary movements, including those for speaking. Just as walking may be stilted and jerky and arm movements crude and uncontrolled, the patterns of voice and speech will reflect the same distortions. Great advances in rehabilitation have been achieved in the recent past, such as with the well-known Bobath method, which is based on learned suppression of primitive reflexes.

      Another type of dysarthria is observed in cases of Parkinson's disease (Parkinson disease). This affliction of the nervous system makes body movements either excessively rigid or tremulously repetitive, such as with the so-called “pill-rolling” sign of hand tremor. Voice and speech reflect the same patterns, sometimes appearing as the first obvious symptoms of the disease. Brain surgery is used in an attempt to improve these abnormal body movements, often with good general results, although speech may be little improved or even made worse. Neurologists also are collecting observations on promising drug treatments for Parkinson's disease, such as with L-Dopa.

      When a neurologic disease damages the bulbar nuclei (in the brain stem) of the nerves innervating the organs for speech, the effect of bulbar dysarthria is heard. In severe cases, the voice may be reduced to a faint grunting, while articulation deteriorates into mumbling or total muteness. chorea, another neural disorder manifested in sudden jerky movements of the entire body, may be associated with bizarre, explosive disruptions of the speech flow. Cerebellar dysarthria results from disease of the brain part called the cerebellum (which regulates fine motor coordination), leading to various disorganizations of speech including a “drunken” (ataxic) quality.

      Major advances in the science of inheritance (genetics) and in biochemistry have clarified a number of inborn metabolic causes of many types of mental retardation (see human behaviour). Some of these forms of retardation can be avoided through genetic counselling of prospective parents or prevented by prompt treatment following early diagnosis. (In some cases a change in diet is effective.) Improved prenatal care may reduce the size of another group of mentally retarded individuals whose problem stems from brain damage sustained during fetal life. The number of unknown causes in other cases of retardation is still considerable, however.

      The total management of the mentally retarded child concerns a large group of specialists: pediatrician, geneticist, clinical psychologist, audiologist and speech pathologist, and special educators in institutions for such children. Following classification on the basis of a level of educability, the child undergoes a composite training program geared to his capabilities. Intensive training in language usage not only tends to improve his communication skills but also forms a bridge to increased general learning. There has been recent stress on the not infrequent combination of mental retardation with hearing loss; in such cases, the audiologist prescribes a hearing aid and auditory training to improve the receptive aspects of communication.

Language and mental disorder
      Expert analysis of the bizarre speech patterns associated with certain psychiatric disturbances is of primary diagnostic significance. If a mute child persists in stereotyped rituals and strange behaviour, a diagnosis of childhood autism is likely to be made. Some experts distinguish this from a similar disorder called childhood schizophrenia, in which previously good general and linguistic development falls apart in association with similarly bizarre behaviour. In adolescence, a sudden change of voice to a shrill falsetto or weird chanting may herald the outbreak of juvenile schizophrenic disease. Infantile lisping, strange distortions of articulation, and various eccentricities in verbal expression are other signs of schizophrasic speech in the adult schizophrenic. Linguistic study may help the psychiatrist in analyzing the patient's ways of thinking and to provide a measure of the sufferer's progress under therapy. Great therapeutic stress is placed on establishing contact with the autistic child by eliciting from him some sort of communication. Language is felt to be one of the best bridges to break open the closed inner world of such children.

Speech of the hard of hearing
      Hearing loss that dates from childhood hinders the normal development of language because the most important sensory portal for speech learning remains deficient. Such children learn to say the sounds of speech as they hear them—that is, in a muffled, distorted, or even inaudible fashion. The articulatory disorder (audiogenic dyslalia) usually reflects the measured (audiometric) pattern of hearing loss. If sound waves at high frequencies cannot be heard, speech sounds with formants in that high-frequency region will be affected. The hissing sibilants contain the highest formants and are therefore most typically disturbed by high-frequency hearing loss. The lower frequencies that can still be heard limit the audible formants to this residual range, which transposes the normal formant patterns into the abnormally lowered frequency band. As a result, a sharp hissing S is spoken as a muted Sh, and the light vowels are transformed into their darker counterparts (for example, the word “set” may be pronounced as “shot” or “shöd” as if it were German).

      The voice reflects analogous changes. In the case of conductive hearing loss (in which neural structures for hearing are intact), the patient hears himself well through the bones of his skull but cannot hear others. Because his bone conduction remains good, his voice will sound loud to him, and he tends to keep it subdued. The opposite occurs with neural (or perceptive) hearing loss in which there is nerve dysfunction. In this case, the patient hears his own voice as poorly as that of others, and he tends to talk in an overloud and screeching voice.

      Correction of audiogenic dyslalia may be possible through early fitting of a suitable hearing aid, intensive auditory training, and speech exercises aided by audiovisual playback devices (auditory trainers, tape recorders, visible speech devices, etc.).

      Profound or total deafness going back to early childhood without special training inevitably leads to deaf-mutism, the absence of oral language development as a direct result of deafness. Deaf-mute children have traditionally been educated in special schools for the deaf, where the oral method (showing how to shape the oral structures for each speech sound) of teaching speech has competed with the older manual method of allowing the deaf to communicate through their own gestural or finger spelling. Recent advances in training include the liberal use of amplification devices (e.g., group hearing aids) in all school situations as well as the earliest possible fitting of hearing aids following definite diagnosis. This can be accomplished even when the patient cannot communicate that he hears (e.g., in very young babies) through such methods as recording brain-wave patterns in response to measured sound stimulation (EEG response audiometry).

Speech impediments from defective articulators
      Dysglossic (from defective oral structures) disorders in articulation have interested mankind for the longest time; the biblical and poetical interchange of the words for “tongue” and “speech” in many languages has kept alive the assumption that speech originates within the fleshy tongue. For the same reason, the popular term tongue-tied still persists to refer to an abnormally immobile tongue and some assumed resulting limitation of linguistic ability. Even the academic designation of the science of languages as “linguistic” is traditionally based on the Latin word lingua for tongue.

      In practice, the condition of a true tongue-tie (ankyloglossia) occurs only rarely and is quite easily corrected through a simple operation. Even when the shortened band beneath the tongue tip is permitted to persist, very little speech disturbance, if any, is audible in such persons. The only limitation of articulation to be expected is the decreased ability to protrude the tongue tip between the teeth for the English Th and the trilling lingual R in southern German, Latin, and Slavic languages. In any event, a true tongue-tie never causes stuttering, lisping, or any other of the major speech disorders.

Loss of tongue
      Major defects of the tongue from paralysis, injury, or surgery reduce the articulation of the lingual sounds to the same extent that the tongue's mobility is visibly limited. Spontaneous compensation is usually quite prompt, depending on the patient's general linguistic talent. One exception is complete bilateral (both sides) paralysis of the tongue, which causes a very severe disorder of chewing and swallowing as well as severe limitation of speech intelligibility. The total loss of the tongue (true aglossia) from injury or surgery is often amazingly well compensated. Patients can learn to use residual portions of a tongue stump as well as other oral structures to substitute for the missing tongue; indeed, some persons without a tongue have relearned to speak so well that the listener would not suspect its absence.

Nasal speech
      Several types of nasal speech are not easily diagnosed; even specialized physicians are often not fully aware of the differences.

      Increased nasal resonance leads to open nasality (hypernasal speech), affecting all oral speech sounds that should not be nasal. Organic causes impair the accuracy of palatal occlusion during emission of the nonnasal sounds. Among these are paralysis, congenital malformation, injury, or defects of the palate. The functional causes of palatal sluggishness include imitation, faulty speech habits, dialectal influences, hearing loss, mental retardation, or psychiatric disorders.

      Decreased nasal resonance produces closed nasality (hyponasal speech), which muffles the three nasal resonants (M, N, and Ng). The best known organic causes are an acute cold, hay fever, large adenoids, and all other nasal diseases that obstruct the airway. Functional causes are less frequent, in the form of a rare, faulty speech habit; occasionally the problem comes from mental retardation or from severe language disability.

      Mixed nasality poses a serious problem; it stems from the combination of one cause of open nasality with another of closed nasality (one may be of organic type and the other functional, or both may be organic). A typical combination is the open nasality from paralysis (paresis) of the palate (or its congenital deficiency) combined with closed nasality from obstruction of the nasopharynx by adenoids. The resulting mixed nasality causes the nasal resonants to sound muffled and subdued, while careful testing reveals slight open nasality on all oral sounds.

      Treatment of nasal speech is unlikely to be successful without prudent balancing of all factors involved. This responsibility rests primarily with the diagnosing otolaryngologist or phoniatrist. The complaint of “talking through the nose” should never warrant a tonsil and adenoid (adenoids) operation without complete evaluation. If this were done in the example cited just above, removal of the obstructing adenoids would alleviate only the closed nasality, while making the open component more severe with marked deterioration of the patient's speech. This dilemma is often present when adenoids cause chronic middle-ear disease with hearing loss, while the palate is incompetent, as from a slight congenital malformation or paresis. In such case, the patient's general health and his hearing must be weighed against the possibility of making his speech worse.

Cleft palate speech
      This type of organic dysglossia has also been named rhinoglossia (Greek rhin, rhis: “nose”) because it is an organic cause of excessively nasal speech. Clefts of the lip, upper jaw, and hard and soft palate occur in various types and combinations. Cleft palate is a congenital (present at birth) malformation that develops for various reasons during the early weeks of embryonic life. The causes may be grouped as follows: inheritance in some cases; embryonal damage from various environmental causes in others; while still other cases of cleft palate are part of a syndrome of general or multiple malformation, which may again be hereditary, the result of chromosomal aberrations, or of environmental origin. Genetic influences (heredity) are inferred from evidence that North American Indians (Montana) show a high incidence of cleft palate, but blacks (as on the island of Jamaica) show an unusually low incidence.

      The speech disorder in cleft palate cases is complex. As a direct, mechanical result of the absent velopharyngeal (soft palate-pharynx) closure, voiced sounds assume an abnormal nasal quality from the unusual resonance of the nasal chambers. The influence of nasality on the perceptual and acoustic characteristics of the speech sounds has been discussed earlier. A second component is a mechanical limitation in articulating plosive sounds (e.g., P) because the necessary intra-oral pressure cannot be achieved. For the same reason, the sibilant sounds (e.g., S) are greatly distorted because the articulating air escapes through the nose before it can produce the characteristic hissing noise at one of the places of constriction. The child with an unrepaired cleft palate seems unconsciously to attempt to overcome these mechanical limitations in several ways. He tries to constrict the nostrils through facial grimaces, and he attempts to increase the expiratory air pressure. He also succumbs to the “law of centripetal regression of articulation”; that is, he shifts the articulation of the oral sounds below the point of deficient palatal occlusion, down into the pharynx or even the larynx. It is easy to demonstrate by X-ray fluoroscopy how the larynx becomes constricted during each plosive or sibilant sound in such cases.

      These mechanical limitations of articulation in cleft palate lead to secondary modifications of behaviour. Linguistic ability is retarded through general limitation of speech learning; emotional reactions to the handicap may complicate the clinical picture; a vicious circle is thus established, which in turn impedes the sufferer's general intellectual and special linguistic development.

      Other coincidental disorders complicate the pattern of cleft-palate speech. Many cleft-palate patients also suffer from middle-ear infection, and the resulting hearing loss may add the component of audiogenic dyslalia. In other cases, the structural malformation may be complicated by mental retardation. Coincidental genetic factors may aggravate the speech problem when the syndrome of familial (neurally inherited) language disability is superimposed. In such cases, the mechanical speech disorder of rhinoglossia becomes complicated by the additional signs of delayed speech development, articulatory dyspraxia, dysgrammatism, reading and writing disability, etc. This combination is evident in some cases following the successful surgical correction of the palatal deficiency. Although the nasality is promptly alleviated in such cases, the various speech disorders from language disability may persist, since they have nothing directly to do with the previous cleft palate.

      Management of cleft palate is the task of a well-coordinated team. The plastic surgeon closes the palatal deficiency, the psychologist analyzes the intellectual endowment, the speech pathologist corrects the various components of disordered speech, the audiologist determines coincidental hearing loss, and the otolaryngologist cares for the health of nose and ears. Tonsils and adenoids may be diseased, leading to the frequent complication of middle-ear infection with hearing loss. This condition may require removal of tonsils and adenoids to preserve hearing. A dilemma is then created; removal of tonsils and adenoids is generally contra-indicated in cases of deficient palatal closure because this operation increases the degree of open nasality. The child's welfare then should be carefully considered in order to avoid any harm.

      When surgical repair is not feasible, the palatal defect may be covered by a special prosthetic plate (obturator) similar to false dental appliances. This technique has been known for many centuries, and various models of obturators have been constructed in the course of time. Cleft-palate care therefore includes the services of a prosthodontis (prosthodontics)t (who makes false teeth) for the optimal construction of such appliances. If worn by children, obturators should be regularly altered to maintain continuous fit as the patient grows.

      Well-organized centres for the management of cleft palate are able to offer excellent care so that the speech impediment can be ideally or almost completely corrected in many cases. The problem of cleft palate thus demonstrates once more that human speech requires complex detailed study of its normal functions and manifold approaches for the correction of its imperfections.

Godfrey Edward Arnold Ed.

Additional Reading
R. Luchsinger and G.E. Arnold, Handbuch der Stimm- und Sprachheilkunde, 3rd ed. (1970; Eng. trans., Voice, Speech, Language, 2nd ed., 1972), the largest text on disorders of communication with extensive references and international orientation; R. Carhart (ed.), Human Communication and its Disorders: An Overview (1969), an important report of the U.S. Department of Health, Education and Welfare on statistics, established facts, and research needs; L.E. Travis (ed.), Handbook of Speech Pathology (1957), a fundamental American publication by many leading contributors; C. Van Riper, Speech Correction: Principles and Methods, 6th ed. (1978), a widely used text for study and references; R.W. West and M. Ansberry, The Rehabilitation of Speech, 4th ed. (1968), another classic in the field of speech pathology. Later monographs include John K. Darby (ed.), Speech Evaluation in Medicine (1981); John E. Bernthal and Nicholas W. Bankson, Articulation Disorders (1981); Betty Byers Brown, Speech Therapy (1981); Joyce S. Taylor, Speech-Language Pathology: Services in the Schools (1981); Elizabeth Carrow-Woolfolk and Joan I. Lynch, An Integrative Approach to Language Disorders in Children (1982); Andrew Sekey (ed.), Electroacoustic Analysis and Enhancement of Alaryngeal Speech (1982); Norman J. Lass et al. (eds.), Speech, Language, and Hearing, 3 vol. (1982); C. Woodruff Starkweather, Speech and Language: Principles and Procedures of Behavior Change (1983); and Franklin H. Solverman, Legal Aspects of Speech-Language Pathology and Audiology: An Overview of Law for Clinicians, Researchers, and Teachers (1983). See also recent issues of these journals: American Speech and Hearing Association (ASHA) Journal (monthly); Journal of Speech and Hearing Disorders (quarterly); Journal of Speech and Hearing Research (quarterly); Cleft Palate Journal (quarterly); Folia Phoniatrica (bimonthly, Basel); and British Journal of Disorders of Communication (semi-annual).

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