1 Chapter 14: Disorders of Speech and Articulation Darrel L. Teter ...

Chapter 14: Disorders of Speech and Articulation
Darrel L. Teter
Speech and Language Delay
It is not uncommon for the parent of a 2- to 3-year-old child to present to the
physician the complaint that the child is not talking. Too often the response to the parent is,
"Wait, he or she will talk when ready".
The process of developing speech and language is a complicated one essential to a
normal existence. The acquisition of speech and language is linked to age readiness, requiring
early intervention and management of the child with abnormal speech and language
development.
Diagnostic Approach
Subjective Complaints
Speech and language delay is not commonly seen on a developmental basis and will
often resolve itself with time and sufficient environmental stimulation. Several pertinent areas
need be examined by the physician before determining the necessity and course of further
evaluation.
1. Language and speech are more often delayed in males. A general "rule of thumb"
places the male child 3-6 months behind the female.
2. Delay is more common in second children and markedly more common when the
first child is female and the second is male. This most probably is due to several factors,
including the fact that the normal sex differences are more noticeable when an older sister's
language is being compared to a younger brother's developing language.
3. Often a youngster's speech and language will not develop in a normal manner
because he or she has no need for language. If a child's immediate needs are all being
anticipated and met without requiring structured verbal output, then there will be no need for
structured verbal output and normal development will not occur. The child must receive
language stimulation and be required to respond. He must also be rewarded for responding
if language and speech are to develop.
Objective Findings
If it appears that the delay is developmental, more parental stimulation and patience
should be suggested and the child's development should be reevaluated in 90 days. If,
however, it appears that adequate stimulation is present and the child is more than 6 months
delayed, then referrals for further evaluation are necessary. (For Language Developmental
Chart see English, G. M.: Otolaryngology, Chapter 52, pp 573-576, Harper & Row, 1976).
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Assessment
If familial or birth history suggests predisposition or high risk for hearing loss, then
audiometrics are always indicated. In the hands of skilled personnel, very accurate
audiometrics can be obtained from children as young as 7 months, without the use of highly
sophisticated instrumentation.
If the subjective complaint is one of speech problems (poor articulation) the oralperipheral
mechanism should be evaluated to make certain that the mechanism is normal. The
tongue should have sufficient range of motion to protrude through the teeth, to touch the
lateral apex of the lips, and to curl and touch the alveolar ridge. If such a range is not
possible, a paresis or a short lingual frenulum must be suspected and ruled out.
If the child is not developing normal expressive and/or receptive language, then
referral should be to a competent speech and language pathologist.
Plan
Referral for audiometrics and speech and language evaluations should be made
whenever it appears to the primary care physician that the delayed speech and language is not
within normal developmental limits.
The audiometric evaluation will reveal whether auditory acuity is within normal limits
for the acquisition of speech and language. The presence of any conductive hearing loss will
necessitate medical and/or surgical intervention, and most probably otologic referral.
The presence of any significant sensorineural hearing loss will necessitate
amplification in the form of a hearing aid and, perhaps, immediate placement for long-term
language and educational needs.
Often, it is determined by a professional evaluation that the child presents with specific
delays, either in acquiring normal articulation or in acquiring and using expressive and
receptive language. In such instances, the speech and language pathologist will design and
institute the program best suited for the long-term needs of the child.
Stuttering
One of the most perplexing and important questions facing the primary care physician
arises when the parents of a child developing speech become concerned that he or she is
going to stutter. Of all the speech problems possible, the one of most concern to the general
population is stuttering.
Diagnostic Approach
Subjective Complaints
The problem arises when the child developing speech and language begins to repeat
words or phrases. Many parents instantly become concerned that the child is going to develop
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into a stutterer. The presenting complaint is always, "He or she is starting to stutter". The
universal response is, "Don't worry, it will go away". Such may not be good advice since the
development of stuttering is, in part, dependent upon the family attitudes toward the child's
developing speech. Several important facts concerning the normal dysfluencies of developing
speech need to be known before advice can be given to the parents of a youngster.
1. Normal developmental dysfluencies occur in all children as they acquire speech.
2. Normal dysfluencies occur as the child (a) develops speech; (b) meets intense
changes in his or her life; or (c) enters the educational system.
3. Normal dysfluencies can occur as word, sound, or phrase repetitions; as hesitations;
or as sound prolongations. Dysfluencies may occur as often as 20% of the time.
4. Normal dysfluencies are not accompanied by any secondary characteristics (such
as head movements or facial grimaces).
5. When the family and/or child begins to react to the dysfluencies in a negative
manner, then the reinforcement that occurs may lead to true pathology.
Objective Findings
When the complaint is heard that a child is beginning to "stutter", several areas of
concern need to be reviewed:
1. What form is the dysfluency taking? Is the child repeating words or phrases, or is
he or she prolonging words?
2. What percentage of the utterances are dysfluent? Is it occurring more than 25-30%
of the time (more than 30 dysfluencies out of every 100 words or phrases)?
3. Is the child reacting to the dysfluencies? Are the family members beginning to react
by asking the child to talk differently?
4. Has the child developed any secondary characteristics that accompany the
dysfluencies?
If the primary care physician feels that the parental concerns center around normal
developmental dysfluencies, then they can be counseled that with caution, the problem should
resolve itself. If, however, they are unduly concerned, or the child is beginning to respond
negatively to the dysfluencies, then referral to a qualified speech pathologist should be made.
Plan
The speech pathologist will review the situation and make a decision either to
indirectly treat the child through family counseling, or to treat the child directly with therapy.
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Indirect treatment through counseling will be recommended if:
1. The dysfluencies are within normal range of development.
2. No secondary characteristics are developing.
3. The child has shown no anxiety concerning his dysfluencies.
Under these circumstances, the parents will be counseled so that they do not negatively
reinforce the dysfluencies and do attempt to establish an atmosphere conducive to good
speech development. Such an atmosphere allows for expression of thoughts and ideas at the
child's pace.
Direct treatment through therapy will be suggested if:
1. The child has developed secondary characteristics.
2. If the child's dysfluency rate exceeds the 20% expected dysfluency rate.
3. If parental counseling fails to produce a reduction in the amount of dysfluencies or
in the anxiety level felt by the child and/or family.
Adult Aphasoid Disorders
On occasion, the physician will be presented with language disorders in an adult
whose problem masks itself as a hearing problem or a problem of memory loss secondary to
fatigue. It is of essence that measures be taken to ascertain if the complaint is one of a
developing aphasia that could be related to involvement of the central nervous system.
Diagnostic Approach
Subjective Complaints
Often the physician may be presented with complaints such as: (1) "I can't understand
the words people say to me", or (2) "I can't seem to recall the names of objects or
individuals", or (3) "I try and say the name of something and another word comes out", or
(4) "I get very confused when I must deal with numbers or abstract concepts".
When such subjective complaints are related, formal evaluation is immediately
indicated.
Objective Findings
The patient complaining of receptive or expressive language problems should be
referred for neurologic evaluation and for language evaluation. The referral should be made
as quickly as possible and a definitive diagnosis of the neurologic and language status made
as quickly as possible.
Plan
The neurologic evaluation should be done to rule out cortical involvement secondary
to neoplastic disease, trauma, or occlusive or degenerative vascular disease. The language
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evaluation should be made to determine the specific areas of expressive and/or receptive
involvement and the nature of the involvement. Such information is essential to providing
immediate and long-term care for the patient with aphasoid disorders.
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