Indian 97. Pediat. 42: 200, 1975
A CLINICAL ANALYSIS OF SPEECH DEFECTS IN CHILDREN* K . KALRA, A.M. SUKHIANY,U.C. MISRA AND R.S. DAYAL Agra "He gave man speech and speech created thought which is the measure of the universe". P.B. SH•LL•V Speech is the p r i m a r y mode of communication by which an individual exchanges his ideas and feelings. It is the means of persuasion, appreciation, inspiration, mental development and entertainment. Speech defects such as delayed speech, defective articulation, stuttering, multiple speech defects, aphasia and rhinolalia are common amongst children. These defects tend to be frustrating, demoralising and lead to abnormal psychological reactions. We m a d e an a t t e m p t to study the prevalence of speech defects and the factors responsible for them.
M a t e r i a l and Methods Survey T h e study was done at the c o m m u n i t y and school levels o f Agra City to cover various socio-economic, religious and linguistic groups. Each child was interviewed in the presence of his/her parents or teacher and the conversation was assessed. Card test, book r e a d i n g and other tests were applied according to the age group and the co-operation achieved. I f the presence o f a speech defect was detected then a sweep-up a u d i o m e t r y test was per*From the Department of Paediatrics, S.N. Medical College, Agra. Paper presented at the XI National Conference of t h e Indian Academy of Paediatrics, Kanpur, 1974. Received on April 12, 1975.
formed. T h e children having speech defects were registered and advised to attend our clinic for further investigations and therapy. T h e parents were requested to explain the nature and age of onset of the handicap or defect. A detailed antenatal, natal and post-natal history was obtained. A history of any relevant past illness if present was taken into account. Developmental milestones, physical as well as mental, were noted. Speech development, viz. age of expression of vowels and consonants, the age of onset of monosyllabic and polysylla. bic speech, and subsequent speech and language development were taken into account. A family history of mental retarda. tion, speech or hearing defects, socioeconomic and educational status of the parents were inquired into. T h e clinical examination of each case was done. Psychological assessment was done whenever indicated. Speech and hearing ability was assessed by applying the following tests:-1. Conversation articulation test 2. Speech discrimination test 3. Articulation skill test 4. Book reading test 5. 6.
M e m o r y material test Pure-tone audiometry
KALRA ET AL.--A
CLINICAL ANALYSIS OF SPEECH
DEFECTS IN CHILDREN
was 3:1. Defective articulation was the commonest (71.1%) and was observed in 45 male and 19 female children. A majority of the children was below 12 years o f age. Stuttering was the next most c o m m o n defect and was detected in 15 cases (16.6%). Multiple speech defects were present in 6, delayed speech in 4 a n d rhinolalia in 1 case(s) as shown in T a b l e 1.
For rehabilitation the cases were subjected to the following type of therapy depending upon the type of defect, viz. speech and auditory training, lip reading, medical, surgical and physiotherapy. Observations
T h e present study was carried out from J a n u a r y , 1970 to March, 1973. T h e cases were picked up from the community, schools and paediatrie out-patient department of the S.N. Hospital, Agra. A total number o f 754 cases o f various speech defects were registered in our departmental speech and hearing clinic. Community
201
School
Survey
A total of 3247 children was surveyed. T h e study included schools o f various varieties, viz. Mahapalika " f r e e " schools where generally children o f the lowest soeio-economic strata studied; schools where children of " m i d d l e class" families attended, and a few sophisticated ones. 343 o f them had various speech defects. 259 were male and 84 female. T h e highest incidence was in the age group of 6 to I2 years. Defective articulation was the commonest defect, seen in 267 children. The
Survey
A total o f 726 families with a total population size of 4017 were covered by a 'door to door' survey. O u t of these, 2053 were up to 18 years o f age. T h e n u m b e r of male children was 1125. Ninety children out o f 2053 had speech defects (4.3%). T h e male: female ratio
Types o/'speech defects in the community.
T a b l e 1,
Age group and sex Types o f speech defects
3-6 v rs. M F
6-9 yrs. M F
9-12 yrs. M F
12-15 yrs. M F
15-18 yrs. M F
Total M F 45
Defective articulation
15
6
18
3
6
5
5
5
1
--
Stuttering
2
1
3
1
6
--
1
--
1
--
Multiple speech defect
l
3
Delayed speech
4
--
2
.
.
2
5
1
m
--
1
--
67
.
w
21
13
!
Rhinolalia Total
.
19
8
24
4
14
6
6
5
2
23
202
INDIAN JOURNAl. OF PEDIATRICS
VOL. 42, No. 330
m a x i m u m n u m b e r of children was between 6 to 9 years o f age. Stuttering was observed in 45 children, and the most vulnerable age was between 9 to 12 years. After the age of 12 years, the incidence of speech defects as a whole declined. M u l t i p l e speech defects and rhinolatia were present in 22
Registered
of the
Clinic
lation a n d the r e m a i n i n g 78 to the rural areas. In the lowest socio-economic group
a n d 9 children respectively ( T a b l e 2).
Table
Cases
A total of 754 cases had speech defects. T h e r e were 518 m a l e and 236 female children, the ratio being 2:1 ( T a b l e 3). 676 belonged to the u r b a n section of the popu.
there were 373 cases; only 4 cases were
Types of speech defects in school children.
2.
Age group and sex Types of speech defects
4 - 6 yr. M F
6-9yr. M F
9-12 yr. M F
12-15 yr. "M F
15-18 yr. M F
Defective articulation
33
13
70
24
52
18
32
Stuttering
2
1
8
2
16
3
10
m
Multiple speech defects
1
10
1
8
1
1
--
2
1
2
--
1
2
1
90
28
78
22
44
10
11
Total M F
I
--
Rhinolalia Total:
36
14
Table
3.
17
7
1
(194)
7~
3
--
39
6
20
2
6
3
259
84
-1
Age and sex ratio of cases registered at the clinic
Age (years)
Male
Below
249
116
365
48.5
6--9
110
52
162
21.3
9--12
113
44
157
20.8
12--15
32
19
51
6.7
15--18
14
5
19
2.5
6
Female
Total
Percentage
KALRA ET AL.~A CLINICALANALYSISOF SPEECH DEFE~TS IN CHILDREN T a b l e 4.
203
Socio-economic status
Socio-economic groups
No. of cases
Percentage
A
4
0.5
B
175
23.2
C
202
26.7
D
373
49.4
reported from the high socio-economic group* (Table 4). Delayed speech was the commonest finding and was present in 361 (47.8%) cases. Defective articulation was present in 163 (21.6%) cases, stuttering in l l8 (15.6%), multiple speech defects in 81 ( 1 0 7 % ) , rhinolalia in 16 (2.1%), and aphasia in 15 (1.9%) cases (Table 5). D e l a y e d Speech Delayed speech was detected in 361 cases. 264 (73.1%) cases were between 3 to 6 years of age. 150 children had acquired speech up to the level o f vowels and consonants, e.g. a, e, o, p, m, b, etc. 125 had acquired only monosyllables e.g, papa, mama, jiji, aaja, etc. *Socio-economic status of the family was assessedby the monthly income and class,fled according to the Indian Council of Medical Research. Gropp A - Family monthly income of above
Rs 1000/Group B--Family monthly income of Rs, 501/- to
1000/Group C--Family monthly income of Ks. 201]- to
5001Group D--Family monthly income of Rs. 2001- or below,
86 cases had acquired speech competence u p to t w o - w o r d levels, e.g. papa aa,
papa de, mam de, etc. Associated mental retardation was present in 155 cases, congenital i m p a i r m e n t of hearing in 103, cerebral palsy in 21 and acquired impairment o f hearing in 5 cases. O t h e r non-specific factors were present in 77 cases. Defective A r t i c u l a t i o n This speech defect was observed in 244 cases. O u t o f t h e s e , 81 children had associated speech defects, viz. stuttering (66), puberphonia (12), and hoarseness o f voice (3); and the remaining
163 had only an
articulation defect. Articulation defect was categorised into different groups, viz. substitution, distortion and omission. T h e commonest variety of articulation defect was substitution and was present 384 times in children. These children had an articular defect o f various consonant series, i.e. velar, sibilant, alveolar, palatal, retroflex and dental. Among these, a defect of the velar series (k, kh, g, gh) was the commonest and was observed 109 times as substitution, and as distortion and omission 15 and 7 times respectively.
204
INDIAN JOURNAL
OIF P E D I A T R I C S
T a b l e 5.
VOL.
42,
No.
330
Types of speech defects in clinic cases. Age groul~s and sex
Speech defects
3-6 yr. M F
6-9 yr. M F
9-12 yr. M F
12-15 yr. M F
15-18 yr. M F
Total
Delayed speech
183
81
37
21
22
10
1
3
2
1
Defective articulation
21
14
34
23
33
20
6
7
2
3
163
Stuttering
23
5
20
5
32
5
15
3
9
1
118
Multiple speech defects
16
6
19
2
23
3
9
2
1
Rhinolalia
3
3
--
1
2
5
1
1
16
Aphasia
3
7
1
1
--
3
15
113
44
32
19
Total
249
116
110
52
T a b l e 6.
14
361
n
81
5
754
Types of articulation dejects.
J.
Consonant series
Distortion
Omission
109
15
7
Sibilants
78
21
8
Alveolar
72
22
7
Palatal
45
16
4
Retroflex
43
12
9
Dental
37
10
7
384
96
42
Velar
9
i
Total
Substitution
ill i i
A C L I N I C A L A N A L Y S I S O F S P E E C H D E F E C T S IN C H I L D R E N
Out of 244 children, 177 had no organic lesion, while 67 had associated problems like mental retardation in 28, acquired impairment of hearing in 15, cleft palate in 12, congenital impairment of hearing in 9 and cerebral palsy in 3 cases. It was observed that the substitution type o f articulation defect was mainly present in those cases who had no organic lesion, while distortion and omission types were encountered in cases having mental retardation, cleft palate, congenital impairment of hearing or cerebral palsy.
Stuttering Stuttering was present in 118 cases; it was p r i m a r y in nature in 28, and secondary in 90 cases all o f whom were between 6 and 18 years. T h e majority of the cases were below 12 years and as the age advanced
205
was also associated with defective articulation. Bilateral conductive i m p a i r m e n t of hearing up to 40 dB was present in cases of cleft palate and up to 30 dB in 4 cases.
Aphasia Aphasia was present in 15 cases (10 congenital and b acquired). In the 'congenital' group two were born o f eclamptie mothers. In another two, history of difficult labour with delayed crying suggestive of anoxia was available, in 6 cases no cause could be attributed. In the acquired group, the causative factors were encephalitis in 2, enteric encephalopathy in 2, and head injury in one case. All the cases had an expressive type of aphasia.
Rehabilitation Rehabilitation could be attempted in
there was a lower incidence of this speech defect. Repetition of initial letters were observed in 73 cases, and pausing of nonfilled and filled type in 52 and 34 children respectively. Associated secondary mannerrisms were observed in 34 cases. A family history of stuttering was present in 66 cases (31 siblings, 35 other relatives). A history of enteric fever before the onset of stuttering was present in 26 cases. A history of stuttering precipitated by sudden fear could be established in 3 cases. The conductive type of hearing loss (up to 50 dB in both ears) was present in 7 cases. In 15 cases psychological and functional factors were responsible. Associated mental retardation was present in one case.
296 cases. T h e period o f rehabilitation varied in each individual depending upon various factors viz. type o f speech defect, a u d i t o r y ability, co-operation and intelligence of the child and parents. T h e cases with only speech defects acquired normal speech after 10 to 20 sittings. Normal speech could not be attained even after 20-40 sittings in cases having associated o r g a n i c defects.
Rhlnolalla
Sixty-four cases o f stuttering were advised breathing excercises, besides speech training. O u t of these 24 cases showed good progress while mild improvement was noted in 22 cases.
Nasal twang was present in 16 cases. Out of these, cleft palate was observed in 12 and chronic tonsillitis with adenoids in 4 cases. Rhinolalia in cases of cleft palate
Seventy-three cases o f defective articulation had undergone speech therapy for rehabilitation. O u t of these, 61 cases completely recovered. T h r e e cases o f congenital i m p a i r m e n t of hearing with defective articulation also showed some improvement in their speech.
206
INDIAN JOURNAL OF PEDIATRICS
Forty-two cases of mixed speech defects had undergone speech therapy. 20 were fully rehabilitated by speech therapy and 11 showed slight improvement. Cases with associated mental retardation and cerebral palsy did not show much improvement because it was difficult to give them training and they were not cooperative. Out of 63 cases only 9 cases could be trained up to the two-word level and 15 up to monosyllables. Two children with cerebral palsy could learn to speak monosyllables such as baba, papa and aaloo.
Surgical management and physiotherapy Patients with otitis media were treated surgically. Wax was removed in 3, tonsillectomy was performed in 5 and eustachian blockage was relieved in 5 patients. Children with mental retardation and cerebral palsy underwent regular physiotherapy. During this period 4 patients with cerebral palsy learnt to walk and 2 could stand without support.
Discussion T h e present study consisted of 754 cases of various speech defects. The incidence was higher in males as compared to females, the ratio being 3:1. Blanton (1916) and Milles and Streit (194'2) also noted that the incidence of speech defects was higher in males than in females. The prevalence of speech defects in the community was 4.3%, while amongst school children it was 10.9% . A survey conducted by Abrol et al. (1971) in a rural community revealed that 3.8% of the total population (210) had various speech defects. Viswanath etal. (1971) in a school survey of 410 children reported the incidence to be 3.9% with a male to female ratio of 4:l.
VOL. 42, No. 330 Speech development and achievement in infancy and childhood is influenced by environmental factors, socio-economic status and education. Davis (1937) observed a high percentage of good articulation amongst children from the high soeio-economic strata. Beckey (1942) reported a high incidence of speech defects in children who belonged to poor occupational groups. In our study we also observed that the incidence of speech defects was common amongst children from the lower socio-economic strata. By and large the parents of this group were either illiterate or had education only up to the primary level. Their children either remained retarded in speech or had various speech defects because of lack of attention and training. Delayed speech was the commonest defect and was present in 361 (47.8%) eases out of 754. Raj (1967, 1968) in two different series reported an incidence of delayed speech to be 4.1~o and 9.6~o respectively. 21.4% cases of speech defects had associated psychiatric and]or environmental problems. Sub-normal intelligence was present in 20.3%; the I. Q . ranged from 20 to 67. 2.7% cases suffered from cerebral palsy. Beagley and Margaret (1970) studied cases of delayed speech and reported psychiatric abnormality in 18.7~ subnormal intelligence in 17.7% and spasticity and/or motor incoordination in 3.8~/o of cases. In our series defective articulation was the next most common speech defect and was present in 21.3~o Templin and Steer (1939) observed that none of the 51 children of a nursery school made all sounds correctly. Roe and Millison (1942) in their study of articulation defect in
KALRA ET A L . ~ A CLINICAL ANALYSIS OF SPEECH DEFEC~[S IN CHILDREN
elementary school children found that 772 children made at least one error. The percentage of speech defects decreased from children of grade II to VII. The incidence of defective articulation was more common in males as compared to females. Ainsworth (1948) and Johnson et al. (1948) classified functional articular defects into four categories: (i) substitution (ii) distortion (iii) omission and (iv) addition. In the present study, the substitution type of articular defect was the most common, followed by distortion and omission. The substitution type of defect was more often seen in children who had normal intelligence. Distortion or omission were more common in children who had associated mental retardation, cerebral palsy or impairment of hearing. Bags (1942) reported that the omission type of articulation defect was mainly present in "aments" as compared to normal children. In our series, stuttering was present in 118 cases. A family history of stuttering was present in 66 cases. Wepman (1939) also reported a familial incidence of stuttering. Franks (1956) and Eysenck (1957) suggested that an individual who had a labile sympathetic nervous system was more prone to develop stuttering. The precipitating factors could be stress, anxiety and phobic reaction. In our series a history of stuttering, precipitated by sudden fear, could be established in 3 cases. Aphasia was observed in 2% of cases. The probable aetiological factors in our series were post-eclampsia, anoxia, encephalitis and head injury. Blanton (1916) and Pronovost (1951) reported the incidence of aphasia as 1.7% and 0.5% respectively.
207
Rhinolalia was present in 2% of cases. The possible pathological causes were cleft palate in 12 and chronic tonsillitis with adenoiditis in 4 cases. Pronovost (1951) reported that 1.2 % of all cases with speech defects showed rhinolalia and the aetiological factor was cleft palate in all of them. Baker (1963) stated that congenital cleft palate and lip produce the gross speech disturbances of articulation and resonation. Summary
A clinical study of speech defects was conducted from January, 1970 to March, 1973. The incidence was higher in males. The maximum incidence .was in the age group of 6 to 12 years. Thereafter there was a gradual decline. Delayed speech was the commonest abnormality and was present in 47.8%, defective artict~lation in 21.6%, stuttering in 15.6%, multiple speech defects in I0.8%, rhinolalia in 2.1% and aphasia in I. 9% of cases. The possible aetiological or associated factors were: mental retardation in 184, impairment of hearing in 143, psychological and environmental factors in 130, cerebral palsy in 24 and cleft palate in 12 cases. Rehabilitation could be attempted in 296 cases with the help of speech therapy, lip reading, auditory training, psychotherapy and physiotherapy. References
Abrol, B.M. (1971). Rural survey for speech and hearing defecls. The Silent World, 6, I. Ainsworth, S. (1948). Speech correction methods. Prentice Hall, New York. Backer, H.K. (1953). Speech problems of the person with cleft palate and cleft lip. Speech Pathology, p. 597, Appleton, New York, Bangs, J.L. (1942). A clinical analysis of the articulation defect of the feeble minded ~7. Speech Disord. 7, 343.
208
INDIANJOURNAL OF PEDIATRICS
Beagley, H.A. and Margaret W. (1970). Clinical follow up of 192 normally hearing children with delayed speech. 07. Laryng. & Otolar. 10, 10001. Beckey, R. (1963). A survey report in cases of speech defects. Speech Pathology. Travls, L.E. Appleton, New York. Blanton, S (1916). A survey of speech defects.
07. Educ. Psycho. 7, 581. Davis, E.A, (1937). The development of linguistic skill in twins, singletons with siblings, from age 5 to 1-0 years. Univ. of Minn. Press. Minneapolis. Eysenck, H.J. (1957). Dynamics of anxiety and hysteria, Kegan Paul. Rultledge, London. Franks, C.M. (1956). Conditioning and personality; a study of normal and neurotic subjects. 3. Abnorm. Soc, Psychology, 52, 143. Johnson, W. (1948). Speech handicapped school children, Harper. New York.
VOLo 42, No. 330 Mills, A. and Streit, H. (1942). Report of a speech survey, Holyoke. 07. Speech Disord. 7, 161. Pronovost, W. (1951). A survey of services for the speech and hearing handicapped in New England. 07. Speech Disord. 16, 148. Raj,J. Bharath (1970). The role of clinical psychologist in speech and hearing clinic, aT. All India [nstt. of Speech. Hearing, Mysore. I, 2, Roe, V. and Millison, R., The effect of maturation upon defective articulation in elementary grades.
07. Speech disord. 7, 37. Templin, M. and Steer, M.D. (1939). Studies of growth of speech of preschool children. 7" Speech Disord. 4, 71. Vishwanath, N.S. (1971). Naguvanalli ScreeningA pilot project. 07. All India Instr. of Speech Hearing Mysore, 2~ 2. Vepman, 07. (1939), Familial incidence in *tammering. 3. Speech Disord. 4, 199.
A CLINICAL ANALYSIS OF SPEECH DEFECTS IN CHILDREN* K . KALRA, A.M. SUKHIANY,U.C. MISRA AND R.S. DAYAL Agra "He gave man speech and speech created thought which is the measure of the universe". P.B. SH•LL•V Speech is the p r i m a r y mode of communication by which an individual exchanges his ideas and feelings. It is the means of persuasion, appreciation, inspiration, mental development and entertainment. Speech defects such as delayed speech, defective articulation, stuttering, multiple speech defects, aphasia and rhinolalia are common amongst children. These defects tend to be frustrating, demoralising and lead to abnormal psychological reactions. We m a d e an a t t e m p t to study the prevalence of speech defects and the factors responsible for them.
M a t e r i a l and Methods Survey T h e study was done at the c o m m u n i t y and school levels o f Agra City to cover various socio-economic, religious and linguistic groups. Each child was interviewed in the presence of his/her parents or teacher and the conversation was assessed. Card test, book r e a d i n g and other tests were applied according to the age group and the co-operation achieved. I f the presence o f a speech defect was detected then a sweep-up a u d i o m e t r y test was per*From the Department of Paediatrics, S.N. Medical College, Agra. Paper presented at the XI National Conference of t h e Indian Academy of Paediatrics, Kanpur, 1974. Received on April 12, 1975.
formed. T h e children having speech defects were registered and advised to attend our clinic for further investigations and therapy. T h e parents were requested to explain the nature and age of onset of the handicap or defect. A detailed antenatal, natal and post-natal history was obtained. A history of any relevant past illness if present was taken into account. Developmental milestones, physical as well as mental, were noted. Speech development, viz. age of expression of vowels and consonants, the age of onset of monosyllabic and polysylla. bic speech, and subsequent speech and language development were taken into account. A family history of mental retarda. tion, speech or hearing defects, socioeconomic and educational status of the parents were inquired into. T h e clinical examination of each case was done. Psychological assessment was done whenever indicated. Speech and hearing ability was assessed by applying the following tests:-1. Conversation articulation test 2. Speech discrimination test 3. Articulation skill test 4. Book reading test 5. 6.
M e m o r y material test Pure-tone audiometry
KALRA ET AL.--A
CLINICAL ANALYSIS OF SPEECH
DEFECTS IN CHILDREN
was 3:1. Defective articulation was the commonest (71.1%) and was observed in 45 male and 19 female children. A majority of the children was below 12 years o f age. Stuttering was the next most c o m m o n defect and was detected in 15 cases (16.6%). Multiple speech defects were present in 6, delayed speech in 4 a n d rhinolalia in 1 case(s) as shown in T a b l e 1.
For rehabilitation the cases were subjected to the following type of therapy depending upon the type of defect, viz. speech and auditory training, lip reading, medical, surgical and physiotherapy. Observations
T h e present study was carried out from J a n u a r y , 1970 to March, 1973. T h e cases were picked up from the community, schools and paediatrie out-patient department of the S.N. Hospital, Agra. A total number o f 754 cases o f various speech defects were registered in our departmental speech and hearing clinic. Community
201
School
Survey
A total of 3247 children was surveyed. T h e study included schools o f various varieties, viz. Mahapalika " f r e e " schools where generally children o f the lowest soeio-economic strata studied; schools where children of " m i d d l e class" families attended, and a few sophisticated ones. 343 o f them had various speech defects. 259 were male and 84 female. T h e highest incidence was in the age group of 6 to I2 years. Defective articulation was the commonest defect, seen in 267 children. The
Survey
A total o f 726 families with a total population size of 4017 were covered by a 'door to door' survey. O u t of these, 2053 were up to 18 years o f age. T h e n u m b e r of male children was 1125. Ninety children out o f 2053 had speech defects (4.3%). T h e male: female ratio
Types o/'speech defects in the community.
T a b l e 1,
Age group and sex Types o f speech defects
3-6 v rs. M F
6-9 yrs. M F
9-12 yrs. M F
12-15 yrs. M F
15-18 yrs. M F
Total M F 45
Defective articulation
15
6
18
3
6
5
5
5
1
--
Stuttering
2
1
3
1
6
--
1
--
1
--
Multiple speech defect
l
3
Delayed speech
4
--
2
.
.
2
5
1
m
--
1
--
67
.
w
21
13
!
Rhinolalia Total
.
19
8
24
4
14
6
6
5
2
23
202
INDIAN JOURNAl. OF PEDIATRICS
VOL. 42, No. 330
m a x i m u m n u m b e r of children was between 6 to 9 years o f age. Stuttering was observed in 45 children, and the most vulnerable age was between 9 to 12 years. After the age of 12 years, the incidence of speech defects as a whole declined. M u l t i p l e speech defects and rhinolatia were present in 22
Registered
of the
Clinic
lation a n d the r e m a i n i n g 78 to the rural areas. In the lowest socio-economic group
a n d 9 children respectively ( T a b l e 2).
Table
Cases
A total of 754 cases had speech defects. T h e r e were 518 m a l e and 236 female children, the ratio being 2:1 ( T a b l e 3). 676 belonged to the u r b a n section of the popu.
there were 373 cases; only 4 cases were
Types of speech defects in school children.
2.
Age group and sex Types of speech defects
4 - 6 yr. M F
6-9yr. M F
9-12 yr. M F
12-15 yr. "M F
15-18 yr. M F
Defective articulation
33
13
70
24
52
18
32
Stuttering
2
1
8
2
16
3
10
m
Multiple speech defects
1
10
1
8
1
1
--
2
1
2
--
1
2
1
90
28
78
22
44
10
11
Total M F
I
--
Rhinolalia Total:
36
14
Table
3.
17
7
1
(194)
7~
3
--
39
6
20
2
6
3
259
84
-1
Age and sex ratio of cases registered at the clinic
Age (years)
Male
Below
249
116
365
48.5
6--9
110
52
162
21.3
9--12
113
44
157
20.8
12--15
32
19
51
6.7
15--18
14
5
19
2.5
6
Female
Total
Percentage
KALRA ET AL.~A CLINICALANALYSISOF SPEECH DEFE~TS IN CHILDREN T a b l e 4.
203
Socio-economic status
Socio-economic groups
No. of cases
Percentage
A
4
0.5
B
175
23.2
C
202
26.7
D
373
49.4
reported from the high socio-economic group* (Table 4). Delayed speech was the commonest finding and was present in 361 (47.8%) cases. Defective articulation was present in 163 (21.6%) cases, stuttering in l l8 (15.6%), multiple speech defects in 81 ( 1 0 7 % ) , rhinolalia in 16 (2.1%), and aphasia in 15 (1.9%) cases (Table 5). D e l a y e d Speech Delayed speech was detected in 361 cases. 264 (73.1%) cases were between 3 to 6 years of age. 150 children had acquired speech up to the level o f vowels and consonants, e.g. a, e, o, p, m, b, etc. 125 had acquired only monosyllables e.g, papa, mama, jiji, aaja, etc. *Socio-economic status of the family was assessedby the monthly income and class,fled according to the Indian Council of Medical Research. Gropp A - Family monthly income of above
Rs 1000/Group B--Family monthly income of Rs, 501/- to
1000/Group C--Family monthly income of Ks. 201]- to
5001Group D--Family monthly income of Rs. 2001- or below,
86 cases had acquired speech competence u p to t w o - w o r d levels, e.g. papa aa,
papa de, mam de, etc. Associated mental retardation was present in 155 cases, congenital i m p a i r m e n t of hearing in 103, cerebral palsy in 21 and acquired impairment o f hearing in 5 cases. O t h e r non-specific factors were present in 77 cases. Defective A r t i c u l a t i o n This speech defect was observed in 244 cases. O u t o f t h e s e , 81 children had associated speech defects, viz. stuttering (66), puberphonia (12), and hoarseness o f voice (3); and the remaining
163 had only an
articulation defect. Articulation defect was categorised into different groups, viz. substitution, distortion and omission. T h e commonest variety of articulation defect was substitution and was present 384 times in children. These children had an articular defect o f various consonant series, i.e. velar, sibilant, alveolar, palatal, retroflex and dental. Among these, a defect of the velar series (k, kh, g, gh) was the commonest and was observed 109 times as substitution, and as distortion and omission 15 and 7 times respectively.
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OIF P E D I A T R I C S
T a b l e 5.
VOL.
42,
No.
330
Types of speech defects in clinic cases. Age groul~s and sex
Speech defects
3-6 yr. M F
6-9 yr. M F
9-12 yr. M F
12-15 yr. M F
15-18 yr. M F
Total
Delayed speech
183
81
37
21
22
10
1
3
2
1
Defective articulation
21
14
34
23
33
20
6
7
2
3
163
Stuttering
23
5
20
5
32
5
15
3
9
1
118
Multiple speech defects
16
6
19
2
23
3
9
2
1
Rhinolalia
3
3
--
1
2
5
1
1
16
Aphasia
3
7
1
1
--
3
15
113
44
32
19
Total
249
116
110
52
T a b l e 6.
14
361
n
81
5
754
Types of articulation dejects.
J.
Consonant series
Distortion
Omission
109
15
7
Sibilants
78
21
8
Alveolar
72
22
7
Palatal
45
16
4
Retroflex
43
12
9
Dental
37
10
7
384
96
42
Velar
9
i
Total
Substitution
ill i i
A C L I N I C A L A N A L Y S I S O F S P E E C H D E F E C T S IN C H I L D R E N
Out of 244 children, 177 had no organic lesion, while 67 had associated problems like mental retardation in 28, acquired impairment of hearing in 15, cleft palate in 12, congenital impairment of hearing in 9 and cerebral palsy in 3 cases. It was observed that the substitution type o f articulation defect was mainly present in those cases who had no organic lesion, while distortion and omission types were encountered in cases having mental retardation, cleft palate, congenital impairment of hearing or cerebral palsy.
Stuttering Stuttering was present in 118 cases; it was p r i m a r y in nature in 28, and secondary in 90 cases all o f whom were between 6 and 18 years. T h e majority of the cases were below 12 years and as the age advanced
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was also associated with defective articulation. Bilateral conductive i m p a i r m e n t of hearing up to 40 dB was present in cases of cleft palate and up to 30 dB in 4 cases.
Aphasia Aphasia was present in 15 cases (10 congenital and b acquired). In the 'congenital' group two were born o f eclamptie mothers. In another two, history of difficult labour with delayed crying suggestive of anoxia was available, in 6 cases no cause could be attributed. In the acquired group, the causative factors were encephalitis in 2, enteric encephalopathy in 2, and head injury in one case. All the cases had an expressive type of aphasia.
Rehabilitation Rehabilitation could be attempted in
there was a lower incidence of this speech defect. Repetition of initial letters were observed in 73 cases, and pausing of nonfilled and filled type in 52 and 34 children respectively. Associated secondary mannerrisms were observed in 34 cases. A family history of stuttering was present in 66 cases (31 siblings, 35 other relatives). A history of enteric fever before the onset of stuttering was present in 26 cases. A history of stuttering precipitated by sudden fear could be established in 3 cases. The conductive type of hearing loss (up to 50 dB in both ears) was present in 7 cases. In 15 cases psychological and functional factors were responsible. Associated mental retardation was present in one case.
296 cases. T h e period o f rehabilitation varied in each individual depending upon various factors viz. type o f speech defect, a u d i t o r y ability, co-operation and intelligence of the child and parents. T h e cases with only speech defects acquired normal speech after 10 to 20 sittings. Normal speech could not be attained even after 20-40 sittings in cases having associated o r g a n i c defects.
Rhlnolalla
Sixty-four cases o f stuttering were advised breathing excercises, besides speech training. O u t of these 24 cases showed good progress while mild improvement was noted in 22 cases.
Nasal twang was present in 16 cases. Out of these, cleft palate was observed in 12 and chronic tonsillitis with adenoids in 4 cases. Rhinolalia in cases of cleft palate
Seventy-three cases o f defective articulation had undergone speech therapy for rehabilitation. O u t of these, 61 cases completely recovered. T h r e e cases o f congenital i m p a i r m e n t of hearing with defective articulation also showed some improvement in their speech.
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INDIAN JOURNAL OF PEDIATRICS
Forty-two cases of mixed speech defects had undergone speech therapy. 20 were fully rehabilitated by speech therapy and 11 showed slight improvement. Cases with associated mental retardation and cerebral palsy did not show much improvement because it was difficult to give them training and they were not cooperative. Out of 63 cases only 9 cases could be trained up to the two-word level and 15 up to monosyllables. Two children with cerebral palsy could learn to speak monosyllables such as baba, papa and aaloo.
Surgical management and physiotherapy Patients with otitis media were treated surgically. Wax was removed in 3, tonsillectomy was performed in 5 and eustachian blockage was relieved in 5 patients. Children with mental retardation and cerebral palsy underwent regular physiotherapy. During this period 4 patients with cerebral palsy learnt to walk and 2 could stand without support.
Discussion T h e present study consisted of 754 cases of various speech defects. The incidence was higher in males as compared to females, the ratio being 3:1. Blanton (1916) and Milles and Streit (194'2) also noted that the incidence of speech defects was higher in males than in females. The prevalence of speech defects in the community was 4.3%, while amongst school children it was 10.9% . A survey conducted by Abrol et al. (1971) in a rural community revealed that 3.8% of the total population (210) had various speech defects. Viswanath etal. (1971) in a school survey of 410 children reported the incidence to be 3.9% with a male to female ratio of 4:l.
VOL. 42, No. 330 Speech development and achievement in infancy and childhood is influenced by environmental factors, socio-economic status and education. Davis (1937) observed a high percentage of good articulation amongst children from the high soeio-economic strata. Beckey (1942) reported a high incidence of speech defects in children who belonged to poor occupational groups. In our study we also observed that the incidence of speech defects was common amongst children from the lower socio-economic strata. By and large the parents of this group were either illiterate or had education only up to the primary level. Their children either remained retarded in speech or had various speech defects because of lack of attention and training. Delayed speech was the commonest defect and was present in 361 (47.8%) eases out of 754. Raj (1967, 1968) in two different series reported an incidence of delayed speech to be 4.1~o and 9.6~o respectively. 21.4% cases of speech defects had associated psychiatric and]or environmental problems. Sub-normal intelligence was present in 20.3%; the I. Q . ranged from 20 to 67. 2.7% cases suffered from cerebral palsy. Beagley and Margaret (1970) studied cases of delayed speech and reported psychiatric abnormality in 18.7~ subnormal intelligence in 17.7% and spasticity and/or motor incoordination in 3.8~/o of cases. In our series defective articulation was the next most common speech defect and was present in 21.3~o Templin and Steer (1939) observed that none of the 51 children of a nursery school made all sounds correctly. Roe and Millison (1942) in their study of articulation defect in
KALRA ET A L . ~ A CLINICAL ANALYSIS OF SPEECH DEFEC~[S IN CHILDREN
elementary school children found that 772 children made at least one error. The percentage of speech defects decreased from children of grade II to VII. The incidence of defective articulation was more common in males as compared to females. Ainsworth (1948) and Johnson et al. (1948) classified functional articular defects into four categories: (i) substitution (ii) distortion (iii) omission and (iv) addition. In the present study, the substitution type of articular defect was the most common, followed by distortion and omission. The substitution type of defect was more often seen in children who had normal intelligence. Distortion or omission were more common in children who had associated mental retardation, cerebral palsy or impairment of hearing. Bags (1942) reported that the omission type of articulation defect was mainly present in "aments" as compared to normal children. In our series, stuttering was present in 118 cases. A family history of stuttering was present in 66 cases. Wepman (1939) also reported a familial incidence of stuttering. Franks (1956) and Eysenck (1957) suggested that an individual who had a labile sympathetic nervous system was more prone to develop stuttering. The precipitating factors could be stress, anxiety and phobic reaction. In our series a history of stuttering, precipitated by sudden fear, could be established in 3 cases. Aphasia was observed in 2% of cases. The probable aetiological factors in our series were post-eclampsia, anoxia, encephalitis and head injury. Blanton (1916) and Pronovost (1951) reported the incidence of aphasia as 1.7% and 0.5% respectively.
207
Rhinolalia was present in 2% of cases. The possible pathological causes were cleft palate in 12 and chronic tonsillitis with adenoiditis in 4 cases. Pronovost (1951) reported that 1.2 % of all cases with speech defects showed rhinolalia and the aetiological factor was cleft palate in all of them. Baker (1963) stated that congenital cleft palate and lip produce the gross speech disturbances of articulation and resonation. Summary
A clinical study of speech defects was conducted from January, 1970 to March, 1973. The incidence was higher in males. The maximum incidence .was in the age group of 6 to 12 years. Thereafter there was a gradual decline. Delayed speech was the commonest abnormality and was present in 47.8%, defective artict~lation in 21.6%, stuttering in 15.6%, multiple speech defects in I0.8%, rhinolalia in 2.1% and aphasia in I. 9% of cases. The possible aetiological or associated factors were: mental retardation in 184, impairment of hearing in 143, psychological and environmental factors in 130, cerebral palsy in 24 and cleft palate in 12 cases. Rehabilitation could be attempted in 296 cases with the help of speech therapy, lip reading, auditory training, psychotherapy and physiotherapy. References
Abrol, B.M. (1971). Rural survey for speech and hearing defecls. The Silent World, 6, I. Ainsworth, S. (1948). Speech correction methods. Prentice Hall, New York. Backer, H.K. (1953). Speech problems of the person with cleft palate and cleft lip. Speech Pathology, p. 597, Appleton, New York, Bangs, J.L. (1942). A clinical analysis of the articulation defect of the feeble minded ~7. Speech Disord. 7, 343.
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INDIANJOURNAL OF PEDIATRICS
Beagley, H.A. and Margaret W. (1970). Clinical follow up of 192 normally hearing children with delayed speech. 07. Laryng. & Otolar. 10, 10001. Beckey, R. (1963). A survey report in cases of speech defects. Speech Pathology. Travls, L.E. Appleton, New York. Blanton, S (1916). A survey of speech defects.
07. Educ. Psycho. 7, 581. Davis, E.A, (1937). The development of linguistic skill in twins, singletons with siblings, from age 5 to 1-0 years. Univ. of Minn. Press. Minneapolis. Eysenck, H.J. (1957). Dynamics of anxiety and hysteria, Kegan Paul. Rultledge, London. Franks, C.M. (1956). Conditioning and personality; a study of normal and neurotic subjects. 3. Abnorm. Soc, Psychology, 52, 143. Johnson, W. (1948). Speech handicapped school children, Harper. New York.
VOLo 42, No. 330 Mills, A. and Streit, H. (1942). Report of a speech survey, Holyoke. 07. Speech Disord. 7, 161. Pronovost, W. (1951). A survey of services for the speech and hearing handicapped in New England. 07. Speech Disord. 16, 148. Raj,J. Bharath (1970). The role of clinical psychologist in speech and hearing clinic, aT. All India [nstt. of Speech. Hearing, Mysore. I, 2, Roe, V. and Millison, R., The effect of maturation upon defective articulation in elementary grades.
07. Speech disord. 7, 37. Templin, M. and Steer, M.D. (1939). Studies of growth of speech of preschool children. 7" Speech Disord. 4, 71. Vishwanath, N.S. (1971). Naguvanalli ScreeningA pilot project. 07. All India Instr. of Speech Hearing Mysore, 2~ 2. Vepman, 07. (1939), Familial incidence in *tammering. 3. Speech Disord. 4, 199.
