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Disorders of speech
The Journal o[ P E D I A T R I C S
15
Disorders of speech Ernest J. Burgi, Ph.D., and Jack Matthews, Ph.D. PITTSBURGH,
PA.
D I s o R DIg R S of speech constitute one of the most common handicapping;conditions of childhood. The major concern is not the speech disorder per se but the child who uses abnormal speech. This concept must always be kept in mind in order to understand the various social, psychologic, and physical aspects of disorders of speech in children. D I A G N O S I S OF SPEECH D I S O R D E R S Whether an apparent abnormality truly constitutes a speech problem depends primarily upon the effect of the child's speech, upon his behavior, and upon the functions speech serves in the child's life. Speech is the most efficient method by which the individual makes his ideas and feelings known. It is the primary means he has available to serve two basic needs: communication and adjustment. If either of these speech functions is affected, the child's total functioning may be seriously impaired and his speech should be considered abnormal. Defective speech may appear in the child who either exhibits no other abnormality or who has other defects which are major, or contributing, causal factors of the speech From the Speech Clinic and Department o[ Speech and Theatre Arts o[ the University o[ Pittsburgh, Pittsburgh, Pa.
disorder. Speech disorders also m a y occur in association with organic, or functional, abnormalities which are independent of the speech problem. It is important, in the diagnosis of speech disordei% to isolate all possible etiologic factors and to determine the relationship, if any, of the speech disorder to other aspects of the child's behavior. C L A S S I F I C A T I O N OF SPEECH D I S O R D E R S Speech disorders may be considered from the standpoint of: (1) articulation of individual sounds, (2) the sound of the voice (pitch, quality, and loudness), (3) the rhythm of connected speech, and (4) the use of speech for symbolic purposes. 9Some speech disorders m a y be classified on the basis of the major causal factor such as cleft palate speech, speech of the cerebral palsied, and the hard of hearing child. D I S O R D E R S OF A R T I C U L A T I O N The most common speech disorders of childhood are defects of articulation, the inability to use correctly one or more of the sounds of language. Vowels and diphthongs (two very closely blended vowel sounds) are easier to produce than consonant sounds and are less commonly defective in children's speech. Consonant sounds require more in-
1 6 Burgi and Matthews
tricate articulatory movements than do the vowels, are more difficult to learn, and are more commonly defective. Some consonant sounds are more difficult to produce and more frequently defective than others. The following are examples of commonly defective consonant sounds in children's speech: r as in run, burrow; s as in sun, miss; z as in zero, lazy; sh as in shine, wish; voiced th as in this, wreathe; voiceless th as in thing, faith; zh as in measure, garage, ch as in church, catching; consonant combinations such as st, t, sk, ks, rk, rs, kr, and others. When a child cannot use a sound correctly he may omit it fl'om his speech, may substitue another sound for it, or produce the desired sound incorrectly. T h e child with defective articulation will usually demonstrate all of these types of incorrect sound utilization. Errors of articulation, moreover, are likely to be inconsistent and m a y cause parents to assume that the child can produce the sound "when he wants to." A child m a y correctly imitate a sound in isolation but be unable to use it in speech. For example, he m a y be able to imitate the sound s but be unable to use it in the word "this." A child also may use a sound correctly in some word positions but not in others. H e may be able to use the sound at the beginning of words such as sun and cent but omit it at the end of words (thi--for this), or substitute another sound in the middle of words (bithicle for bicycle). The child may also distort the sound in such a manner that it is unrecognizable. I f a child is able to imitate a sound correctly in isolation, this may indicate favorable prognosis for treatment but should not lead to the assumption that he can use the sound in speech "if he wants to." Although disorders of articulation are frequently classified as "functional," or organic, the etiology of an individual disorder is not always clearly defined. Organic abnormalities of the teeth, tongue, lips, palate, auditory mechanism, or nervous system may" contribute to disorders of articulation. However, the differences
January 1963
among individual children, in terms of their abilities to compensate for abnormalities, are so great that care must be taken in assigning the cause of an articulation problem to a specific organic defect. Severe malocclusion, for example, m a y result in speech difficulties in one child while another child with similar, or even more abnormal, tooth relationships will compensate to the extent that his speech is normal. Speech disorders also m a y occur in children with abnormalities which are quite independent of the speech problem. For example, a child with severe malocclusion m a y exhibit defective articulation which is in no way related to the deviant tooth relationships. The majority of disorders of articulation are associated with no demonstrable organic pathology. Slow maturation, lack of motivation for speaking, poor speech models, and emotional disturbances are more commonly the cause of articulation defects. T h e child, his environment, and his speech, must all be evaluated thoroughly before assigning an etiology. In disorders of articulation, one first must determine whether a true defect exists or whether the speech is relatively normal. Here referral to the criteria of interference with communication and/or adjustment is useful. The child's age and what should reasonably be expected of him also must be considered in making a diagnosis of speech disorder or normalcy. The speech of children does not, in all respects, resemble that of the adult. The child of 30 months of age who says "I have a widdo wed ca" (I have a little red ear) likely is using normal speech for his age while the 6-year-old child producing the same errors is using defective speech. In any event, it is advisable for the pediatrician to refer the child for examination by a speech pathologist before deciding whether or not the child will "outgrow" his difficulty without treatment. Most children with functional articulation problems will be helped by speech therapy. Some will improve merely with further ma-
Volume 62 Number 1
turation alone. The prognosis in organic disorders often is good, if the objective of treatment is improvement, rather than attainment of normal speech. VOICE DISORDERS
A disorder of voice exists when the pitch, loudness, or quality deviates from the norms for the speaker's age and sex. Pitch m a y be abnormally high or low, the variations in pitch m a y be bizarre or absent. Loudness, or the variations in loudness, of voice, m a y be inappropriate for the expression of ideas and feelings. Deviations of quality m a y be related to abnormal phonation such as aphonia, partial or intermittent phonation, aspirate (breathy) quality, huskiness or hoarseness of voice. Other deviations of quality are related to vocal resonance, the most common of which is denasality or hypernasality. The etiology of voice disorders may be either organic or functional. However, with the exception of voice problems associated with orgaflic disorders, such as cleft palate and cerebral palsy, abnormalities of voice are relatively rare in children. The decision for treatment of voice disorders is made from the symptomatic evaluation by the speech pathologist and the medical diagnosis of the organic a n d / o r the functional problem. D E F E C T S OF RHYTHM
(STUTTERING)
Abnormalities in the coordinated, rhythmic flow of speech resulting in repetitions, prolongations and pauses which interfere with communication are classified as "stuttering." Interruptions in rhythm also are characteristic of the normal speech of children, and a decision to label the speech rhythm as abnormal must be considered with care. The speech of the child who stutters is characterized by clonic or tonic blocks, usually on initial sounds in words. There also m a y be labored or difficult repetitions of individual sounds or words. Clenching of the' fists, closing of the eyes, contortions of
Disorders of speech
17
the face or body, and whistling before initiation of sound also may occur. The symptoms of stuttering usually are not consistent. Just as normal speakers exhibit m a n y nonfluencies in their speech, most people who stutter are fluent for the majority of their total speaking time. Most of them have little difficulty with group speaking or singing. There is, as yet, no universally accepted theory of the cause of stuttering. Few authorities, however, view the cause as being organic. It is probable that different etiologic factors are operative in different stutterers and that more than one factor may contribute to the problem in any one individual. It is reasonable to assume that whatever the causes of stuttering m a y have been, some habitual behavior develops after the disorder has been present for some time. The diagnosis of stuttering usually is made by a lay person and this may be a primary causative factor in some eases. Repetitions and hesitations are numerous in the speech of normal children and the diagnosis of stuttering never should be made on the basis of observations of repetitions and hesitations alone. If these repetitions and hesitations appear effortless, or if the child seems unconcerned about them, it usually is better to consider the speech as normal. Whenever there is any suspicion of stuttering, the child should be referred to a speech pathologist for diagnosis but the referral should be handled in such a way that the child and his family will not become more concerned than they already are. It is emphatically emphasized, here, that proper handling of a child's normal nonfluencies seems to be a deterrent to the development of stuttering in some children. "An ounce of prevention is worth a pound of cure" can appropriately be applied to the condition of stuttering. Most stuttering begins between the ages of 2 and 5 years. The treatment of the young child who is beginning to stutter generally is preventative and the prognosis in m a n y cases is good. However, if the stuttering persists and other "secondary" symptoms
1 8 Burgi and Matthews
become established, the outcome is likely to be poor. DELAYED SPEECH AND LANGUAGE
Delayed speech is considered as the failure of speech to develop at all or of the persistence of infantile speech patterns. Most problems of delayed speech are associated with deficient language patterns such as infantile sentence structure, limited and deficient vocabulary, and idea formation characteristic of a younger child. Delayed speech and language is often related to organic defects of the central nervous system, retarded mental development, or auditory defects. Emotional disturbances, lack of motivation to talk, and unfavorable environmental conditions also may cause significant retardation of both speech and language. There is considerable variability in the ages at which children reach specific stages of speech and language development. This variability creates difficulties in defining criteria for a diagnosis of delayed speech or language. For example, the child who is using single words meaningfully but with articulation "errors" at 12 to 18 months of age is certainly within "normal" limits, while the child at 30 months who has no meaningful words is retarded in his language development. If the child does not use simple sentences by about 3 years of age, he also is likely retarded in his language development. Conversely, articulation should not be considered retarded if the child's use of a few difficult sounds is defective at the kindergarten or even the first or second grade level. Recommendations for speech treatment should be based on evaluation of the underlying etiology as well as on the diagnosis of the nature of the speech and language disorder. CLEFT
PALATE
SPEECH
Cleft palate speech is a term used to describe the characteristic speech disorder of a person with a cleft" palate or a shortened or nonfunctioning palate. Abnormalities of the
]anuary 1963
dental and nasal structures, and of the function of the tongue, may further contribute to the speech difficulties. The speech problem consists of articulation difficulties, usually accompanied by hypernasality. The treatment for the child with a cleft palate is best accomplished by a team of persons which usually includes a variety of medical and dental specialists and paramedical specialists in psychology, speech pathology, and audiology. The prognosis for speech improvement depends, at least in part, upon the extent of the structural abnormality and the intelligence, motivation, and adjustment of the child. The prognosis usually is good if rehabilitation procedures are instituted early and are coordinated. Recent advances in surgical and dental prosthetic procedures hold the promise of considerably improving the prognosis for near normal speech in these children. CEREBRAL
PALSY SPEECH
The speech problems of the child with cerebral palsy result from inability to control the breathing, voice, and articulatory musculature. "Cerebral palsy speech" may involve numerous difficulties in the production of consonant sounds, particularly those which require lifting the tongue tip (t, d, l, and r). Dysarthria is common. The voice frequently is labored, drawling, and husky in quality and tremulous and monotonous in pitch. The rhythm of speech is sometimes affected in a manner that superficially resembles stuttering. Delayed speech, resulting from such factors as mental retardation and parental overprotection may occur in children who have no involvement of the speech musculature. Prognosis for some speech improvement may be fair in the moderately involved cases, while prognosis for normal speech, especially in the severely affected child, is often poor. S P E E C H OF T H E H A R D OF H E A R I N G
AND DEAF
Speech difficulties resulting from deficits in hearing include a variety of articulation
Volume 62 Number 1
and voice problems or complete lack of speech, depending upon the kind and severity of the hearing loss and the age at which the loss was sustained. If the hearing loss is of more than moderate degree and was present from birth or shortly afterward it will, in all likelihood, interfere with language development as well as speech. A child who is born deaf will not learn to use speech for communication at all, unless he is given special training. (The speech of children with hearing defects will be considered more completely in succeeding portions of the Symposium. ) SUMMARY
The objective of this presentation has not been to answer all questions concerning dis-
Disorders o[ speech
19
orders of speech in childhood but rather to orient the pediatrician to tl~e subject. It is hoped that this orientation will provide the interest and motivation for further investigations by the pediatrician into the area of communication disorders. A final observation concerning the correction of speech disorders in children is in order. Speech treatment for most types of problems is quite lengthy and varies according to the nature of the difficulty. Usually the results of treatment are gradual rather than spectacular. The pediatrician can be of considerable help to the speech pathologist if he encourages parents to view the treatment program realistically and discourages their search for the spectaculal; or dramatic "cure."
15
Disorders of speech Ernest J. Burgi, Ph.D., and Jack Matthews, Ph.D. PITTSBURGH,
PA.
D I s o R DIg R S of speech constitute one of the most common handicapping;conditions of childhood. The major concern is not the speech disorder per se but the child who uses abnormal speech. This concept must always be kept in mind in order to understand the various social, psychologic, and physical aspects of disorders of speech in children. D I A G N O S I S OF SPEECH D I S O R D E R S Whether an apparent abnormality truly constitutes a speech problem depends primarily upon the effect of the child's speech, upon his behavior, and upon the functions speech serves in the child's life. Speech is the most efficient method by which the individual makes his ideas and feelings known. It is the primary means he has available to serve two basic needs: communication and adjustment. If either of these speech functions is affected, the child's total functioning may be seriously impaired and his speech should be considered abnormal. Defective speech may appear in the child who either exhibits no other abnormality or who has other defects which are major, or contributing, causal factors of the speech From the Speech Clinic and Department o[ Speech and Theatre Arts o[ the University o[ Pittsburgh, Pittsburgh, Pa.
disorder. Speech disorders also m a y occur in association with organic, or functional, abnormalities which are independent of the speech problem. It is important, in the diagnosis of speech disordei% to isolate all possible etiologic factors and to determine the relationship, if any, of the speech disorder to other aspects of the child's behavior. C L A S S I F I C A T I O N OF SPEECH D I S O R D E R S Speech disorders may be considered from the standpoint of: (1) articulation of individual sounds, (2) the sound of the voice (pitch, quality, and loudness), (3) the rhythm of connected speech, and (4) the use of speech for symbolic purposes. 9Some speech disorders m a y be classified on the basis of the major causal factor such as cleft palate speech, speech of the cerebral palsied, and the hard of hearing child. D I S O R D E R S OF A R T I C U L A T I O N The most common speech disorders of childhood are defects of articulation, the inability to use correctly one or more of the sounds of language. Vowels and diphthongs (two very closely blended vowel sounds) are easier to produce than consonant sounds and are less commonly defective in children's speech. Consonant sounds require more in-
1 6 Burgi and Matthews
tricate articulatory movements than do the vowels, are more difficult to learn, and are more commonly defective. Some consonant sounds are more difficult to produce and more frequently defective than others. The following are examples of commonly defective consonant sounds in children's speech: r as in run, burrow; s as in sun, miss; z as in zero, lazy; sh as in shine, wish; voiced th as in this, wreathe; voiceless th as in thing, faith; zh as in measure, garage, ch as in church, catching; consonant combinations such as st, t, sk, ks, rk, rs, kr, and others. When a child cannot use a sound correctly he may omit it fl'om his speech, may substitue another sound for it, or produce the desired sound incorrectly. T h e child with defective articulation will usually demonstrate all of these types of incorrect sound utilization. Errors of articulation, moreover, are likely to be inconsistent and m a y cause parents to assume that the child can produce the sound "when he wants to." A child m a y correctly imitate a sound in isolation but be unable to use it in speech. For example, he m a y be able to imitate the sound s but be unable to use it in the word "this." A child also may use a sound correctly in some word positions but not in others. H e may be able to use the sound at the beginning of words such as sun and cent but omit it at the end of words (thi--for this), or substitute another sound in the middle of words (bithicle for bicycle). The child may also distort the sound in such a manner that it is unrecognizable. I f a child is able to imitate a sound correctly in isolation, this may indicate favorable prognosis for treatment but should not lead to the assumption that he can use the sound in speech "if he wants to." Although disorders of articulation are frequently classified as "functional," or organic, the etiology of an individual disorder is not always clearly defined. Organic abnormalities of the teeth, tongue, lips, palate, auditory mechanism, or nervous system may" contribute to disorders of articulation. However, the differences
January 1963
among individual children, in terms of their abilities to compensate for abnormalities, are so great that care must be taken in assigning the cause of an articulation problem to a specific organic defect. Severe malocclusion, for example, m a y result in speech difficulties in one child while another child with similar, or even more abnormal, tooth relationships will compensate to the extent that his speech is normal. Speech disorders also m a y occur in children with abnormalities which are quite independent of the speech problem. For example, a child with severe malocclusion m a y exhibit defective articulation which is in no way related to the deviant tooth relationships. The majority of disorders of articulation are associated with no demonstrable organic pathology. Slow maturation, lack of motivation for speaking, poor speech models, and emotional disturbances are more commonly the cause of articulation defects. T h e child, his environment, and his speech, must all be evaluated thoroughly before assigning an etiology. In disorders of articulation, one first must determine whether a true defect exists or whether the speech is relatively normal. Here referral to the criteria of interference with communication and/or adjustment is useful. The child's age and what should reasonably be expected of him also must be considered in making a diagnosis of speech disorder or normalcy. The speech of children does not, in all respects, resemble that of the adult. The child of 30 months of age who says "I have a widdo wed ca" (I have a little red ear) likely is using normal speech for his age while the 6-year-old child producing the same errors is using defective speech. In any event, it is advisable for the pediatrician to refer the child for examination by a speech pathologist before deciding whether or not the child will "outgrow" his difficulty without treatment. Most children with functional articulation problems will be helped by speech therapy. Some will improve merely with further ma-
Volume 62 Number 1
turation alone. The prognosis in organic disorders often is good, if the objective of treatment is improvement, rather than attainment of normal speech. VOICE DISORDERS
A disorder of voice exists when the pitch, loudness, or quality deviates from the norms for the speaker's age and sex. Pitch m a y be abnormally high or low, the variations in pitch m a y be bizarre or absent. Loudness, or the variations in loudness, of voice, m a y be inappropriate for the expression of ideas and feelings. Deviations of quality m a y be related to abnormal phonation such as aphonia, partial or intermittent phonation, aspirate (breathy) quality, huskiness or hoarseness of voice. Other deviations of quality are related to vocal resonance, the most common of which is denasality or hypernasality. The etiology of voice disorders may be either organic or functional. However, with the exception of voice problems associated with orgaflic disorders, such as cleft palate and cerebral palsy, abnormalities of voice are relatively rare in children. The decision for treatment of voice disorders is made from the symptomatic evaluation by the speech pathologist and the medical diagnosis of the organic a n d / o r the functional problem. D E F E C T S OF RHYTHM
(STUTTERING)
Abnormalities in the coordinated, rhythmic flow of speech resulting in repetitions, prolongations and pauses which interfere with communication are classified as "stuttering." Interruptions in rhythm also are characteristic of the normal speech of children, and a decision to label the speech rhythm as abnormal must be considered with care. The speech of the child who stutters is characterized by clonic or tonic blocks, usually on initial sounds in words. There also m a y be labored or difficult repetitions of individual sounds or words. Clenching of the' fists, closing of the eyes, contortions of
Disorders of speech
17
the face or body, and whistling before initiation of sound also may occur. The symptoms of stuttering usually are not consistent. Just as normal speakers exhibit m a n y nonfluencies in their speech, most people who stutter are fluent for the majority of their total speaking time. Most of them have little difficulty with group speaking or singing. There is, as yet, no universally accepted theory of the cause of stuttering. Few authorities, however, view the cause as being organic. It is probable that different etiologic factors are operative in different stutterers and that more than one factor may contribute to the problem in any one individual. It is reasonable to assume that whatever the causes of stuttering m a y have been, some habitual behavior develops after the disorder has been present for some time. The diagnosis of stuttering usually is made by a lay person and this may be a primary causative factor in some eases. Repetitions and hesitations are numerous in the speech of normal children and the diagnosis of stuttering never should be made on the basis of observations of repetitions and hesitations alone. If these repetitions and hesitations appear effortless, or if the child seems unconcerned about them, it usually is better to consider the speech as normal. Whenever there is any suspicion of stuttering, the child should be referred to a speech pathologist for diagnosis but the referral should be handled in such a way that the child and his family will not become more concerned than they already are. It is emphatically emphasized, here, that proper handling of a child's normal nonfluencies seems to be a deterrent to the development of stuttering in some children. "An ounce of prevention is worth a pound of cure" can appropriately be applied to the condition of stuttering. Most stuttering begins between the ages of 2 and 5 years. The treatment of the young child who is beginning to stutter generally is preventative and the prognosis in m a n y cases is good. However, if the stuttering persists and other "secondary" symptoms
1 8 Burgi and Matthews
become established, the outcome is likely to be poor. DELAYED SPEECH AND LANGUAGE
Delayed speech is considered as the failure of speech to develop at all or of the persistence of infantile speech patterns. Most problems of delayed speech are associated with deficient language patterns such as infantile sentence structure, limited and deficient vocabulary, and idea formation characteristic of a younger child. Delayed speech and language is often related to organic defects of the central nervous system, retarded mental development, or auditory defects. Emotional disturbances, lack of motivation to talk, and unfavorable environmental conditions also may cause significant retardation of both speech and language. There is considerable variability in the ages at which children reach specific stages of speech and language development. This variability creates difficulties in defining criteria for a diagnosis of delayed speech or language. For example, the child who is using single words meaningfully but with articulation "errors" at 12 to 18 months of age is certainly within "normal" limits, while the child at 30 months who has no meaningful words is retarded in his language development. If the child does not use simple sentences by about 3 years of age, he also is likely retarded in his language development. Conversely, articulation should not be considered retarded if the child's use of a few difficult sounds is defective at the kindergarten or even the first or second grade level. Recommendations for speech treatment should be based on evaluation of the underlying etiology as well as on the diagnosis of the nature of the speech and language disorder. CLEFT
PALATE
SPEECH
Cleft palate speech is a term used to describe the characteristic speech disorder of a person with a cleft" palate or a shortened or nonfunctioning palate. Abnormalities of the
]anuary 1963
dental and nasal structures, and of the function of the tongue, may further contribute to the speech difficulties. The speech problem consists of articulation difficulties, usually accompanied by hypernasality. The treatment for the child with a cleft palate is best accomplished by a team of persons which usually includes a variety of medical and dental specialists and paramedical specialists in psychology, speech pathology, and audiology. The prognosis for speech improvement depends, at least in part, upon the extent of the structural abnormality and the intelligence, motivation, and adjustment of the child. The prognosis usually is good if rehabilitation procedures are instituted early and are coordinated. Recent advances in surgical and dental prosthetic procedures hold the promise of considerably improving the prognosis for near normal speech in these children. CEREBRAL
PALSY SPEECH
The speech problems of the child with cerebral palsy result from inability to control the breathing, voice, and articulatory musculature. "Cerebral palsy speech" may involve numerous difficulties in the production of consonant sounds, particularly those which require lifting the tongue tip (t, d, l, and r). Dysarthria is common. The voice frequently is labored, drawling, and husky in quality and tremulous and monotonous in pitch. The rhythm of speech is sometimes affected in a manner that superficially resembles stuttering. Delayed speech, resulting from such factors as mental retardation and parental overprotection may occur in children who have no involvement of the speech musculature. Prognosis for some speech improvement may be fair in the moderately involved cases, while prognosis for normal speech, especially in the severely affected child, is often poor. S P E E C H OF T H E H A R D OF H E A R I N G
AND DEAF
Speech difficulties resulting from deficits in hearing include a variety of articulation
Volume 62 Number 1
and voice problems or complete lack of speech, depending upon the kind and severity of the hearing loss and the age at which the loss was sustained. If the hearing loss is of more than moderate degree and was present from birth or shortly afterward it will, in all likelihood, interfere with language development as well as speech. A child who is born deaf will not learn to use speech for communication at all, unless he is given special training. (The speech of children with hearing defects will be considered more completely in succeeding portions of the Symposium. ) SUMMARY
The objective of this presentation has not been to answer all questions concerning dis-
Disorders o[ speech
19
orders of speech in childhood but rather to orient the pediatrician to tl~e subject. It is hoped that this orientation will provide the interest and motivation for further investigations by the pediatrician into the area of communication disorders. A final observation concerning the correction of speech disorders in children is in order. Speech treatment for most types of problems is quite lengthy and varies according to the nature of the difficulty. Usually the results of treatment are gradual rather than spectacular. The pediatrician can be of considerable help to the speech pathologist if he encourages parents to view the treatment program realistically and discourages their search for the spectaculal; or dramatic "cure."