Indian J Pediatr 1992; 59 : 615-618
Speech Disorders in Children Anu Bhardwaj and M. Raghunathan
Department of Otorhinolat3,ngology, Postgraduate Institute of Medical Education and Research, Chandigarh There is nothing more elemental in all existence than communication - it is the very essence of life. All creatures great and small, even unto the tiny amoeba, are connected in an endless ebb and flow of messages. But it is in humans that we see its ultimate expression in the marvellous vehicle of language. In a highly competitive, upwardly mobile society of ours, verbal skill is very essential. Effective speech is of the utmost importance if one is to gain and maintain a status in the society, or to get the material possessions which are constantly held up to us as goals to be desired. Disorders of speech and language in childhood are not uncommon. Therapy for them requires understanding of the processes involved in the normal development of speech and language function.
Development of Speech and Language Development of speech and language skills depend upon a broad range of activities of many organ systems. The first stage audition, requires an intact peripheral auditory lnechanism. The second stage is the transmission of sound from the organs of hearing to the brain and the organization of the transmitted impulses for a response. The third Reprint requests : Dr. M. Raghunathan, Associate Professor, Department of Otorhinolaryngology, Postgraduate Institute of Medical Education and Research, Chandigarh- 160 012.
stage, the verbal response, involves respiration, phonation, rcsonation, and articulation. A high degree of intricate cortical and neuromuscular integration is required for all these activities. 1 Maturation of a child's speech and language normally keeps pace with the maturation of the total organism, and follows a fairly predictable pattern up to the age of about six years. 2 0-6 months. The early stages of speech and language development reflect the child's reception of speech sounds and are revealed by his responses to them. By four to six months, the infant normally demonstrates ability to discriminate among speech sounds by beginning to babble close approximations of a number of early consonant sounds, principally m, n, p, b, k, g, t and d. 6-12 months. By six to eight months, tile child starts exhibiting a rather wide repertoire of babbling combinations of the consonants with a few vowels such as ba-ba, mama, da-da and so on. At ten to twelve months, the child begins to discover that particular combinations repeated often will bring his mother to pay some attention to him or to administer to some want. By twelve monll~s, he should be using atleast one to three such combinations meaningfully. 1-2 years. Between twelve and eighteen
616
THE INDIAN JOURNAL OF PEDIATRICS
months, there is relatively little increase in tide expressive vocabulary. The child is rapidly expanding his comprehension vocabulary, and the number and variety of his responses to meaningful vocalizations of others. In eighteen to twenty four months, he begins to try to put together many of tlde combinations he has been learning, and by the age of about twenty four months, two and three word phrases develop. He begins to use connected speech for a purpose, such as 'go', 'bye-bye', 'want cookie', and so on. 3-4 years. Between the ages of three and four years, the child becomes very conscious of the importance of speech and the power it gives him. Because his speech and language are unstable and he is non-fluent, the process of communication can be easily interfered with, and speech troubles may have their origin during this period. By the age of three years, the child should have mastered fide use of all vowels, and consonants like w, m, n, p, b, k, g, t and d. At this age he is generally 70-80% intelligible, and uses an average of three words sentences. At the age of four, he should be 100% intelligible and use four word sentences. 5-6 years. At five years, he should be using some sound clusters such as 'tr', 'bl', 'pr', "gr' and use of f, v, r and 1; generally without error but these may not be mastered until the age of six years. By tide age of six years tlde child's general language structure is stable, tile non fluency has passed, and he has mastered all the consonant sounds with the exception perhaps of sibilants and sibilant combinations, primarily 's' and 'z'. Any condition which seriously impairs or disrupts tide normal development Qf the child
Vol. 59, No. 5
physically, psychologically or socially, may disrupt the development of his speech and language skills. The major factors influencing the development of speech and language are as follows : (i) mental retardation; (ii) abnormalities of neuro-muscular functions, e.g. cerebral palsy; (iii) structural inadequacies, such as cleft palate and cleft lip; (iv) serious illness or brain injuries; (v) sensory deprivation such as deafness; (vi) emotional disorders such as childhood schizophrenia and infanlile autism and other (vii) social and environmenial factors.
Delayed Speech and Language Some children fail to acquire any usable language at all; riley may be speechless or echolalic or have at best a primitive and inadequate gesture language. Most of the profoundly mentally retarded belong to this category, but some emotionally disturbed or congenitally deaf children may also show little or no language. Tile second and largest group includes t/lose children who are delayed in language acquisition. They know of some language, but it is so deviant or infantile and inadequate in its structure that they are truly handicapped in communication. These include children who are hard of hearing to a lesser degree or emotionally disturbed, as also those who may possess other learning disabilities, problems in motor coordination, hyperactivity, or environmental deprivation. Finally, in the third group, we find children who once had possessed adequate hearing but have lost it, and children with aphasia or neurological impairments resulting from illness or trauma involving the central nervous system?
Speech Disorders The speech disorders can be broadly classi-
B t l A R D W A J A N D R A G H U N A T H A N : SPEECH DISORDERS IN C H I L D R E N
fled under three heads: articulation, voice and rhythm/fluency. Articulation disorders. Of all the speech disorders, those of articulation are found most frequently. In our own clinical experience, nearly 50-60% of file children reporting to the clinic for speech therapy, are those who have not mastered file phonology of our language and children who erroneously substitute one phoneme or another, or omit or distort other sounds. They are handicapped because their speech deviates from the norms of our society, a society that depends upon effective communication and demands it. There are three basic ways in which file speech sounds may be misarticulated, these are : omission of sounds; substitution of a standard sound for another and distortion; and the substitution of a non standard sound for a standard one. Two main types of articulation disorders are recognized: 4 (a) Phonetic disorders - the person cannot produce sounds acceptable due to structural, motor, or sensory impairments. (b) Phonemic disorders - file person is capable of producing sounds but uses them inconsistently and in an immature manner or contrived manner. These errors may be due to faulty learning of rules of the language. Voice disorders. While less frequently found than dlose of articulation, file disorders of voice can be truly a serious handicap despite the fact that our culture tends to be more tolerant of vocal deviations than those of language, fluency or articulation. In children, generally tile voice problems occur due to vocal abuse, i.e. the incorrect use of voice. Common types of vocal abuse include shouting, screaming, cheering, ex-
617
cessive talking, throat clearing and coughing which may result in vocal nodules or contact ulcers. This in turn may cause the voice to sound hoarse, harsh, or breathy or a combination of these features. 5 Other common voice disorders in children are hypernasality due to cleft palate; denasal quality due to enlarged adenoids and common cold; pitch aberrations due to mutation or psychological reasons. Some rare conditions include spastic dysphonia or ventricular dysphonia. Typical voice problems of children with severe hearing loss include breathiness, hypernasality, too high pitched, monotonous lacking in pitch inflections, inappropriate loudness-either too loud or too soft, and differences in quality such as harshness and hollow non resonant type. R h y t h m or fluency disorders. Stuttering or stammering is another commonly encountered speech disorder which is related to fluency. Here, tile fluency of speech is disrupted by abnormal repetitions, prolongations, hesitations or "silent blocks" of speech. Stuttering is related to various factors which are not yet understood thoroughly. There are many views regarding etiology and therapeutic measures which are not being concered in the present discussion. There appears a psychological and psychosocial aspect of stuttering in addition to hereditary, physical, linguistic and neurological bases involving file whole of the speech system including audition. Stuttering often begins during the nonfluent period, between tile ages of 2 and 5 years, more commonly in males. Adverse psychosocial and environmental factors during this period can prolong the nonfluency until it becomes a real dysfluency, and eventually a severe form of stuttering with asso-
THE INDIANJOURNALOF PEDIATRICS
Vol. 59,No. 5
elated abnormal features like facial grimaces and violent jerks of bodily organs. 6 A general advice to the parents of the preschool child who is having stuttering is, often to ignore it. But this alone may be inadequate, since it may be necessary to instruct the parents on how to ignore the speech dysfluencies. They must be helpful, treat the child as normal, understand that non-fluency is a normal developmental stage, accept the child's speech without showing concen~ and give full encouragement to the child during his fluent speech attempts. Most of the children pass through this non-fluent stage without much difficulty, if handled in a proper manner. 7 When the child has strong stuttering features, every effort should be made to seek the help of Speech Pathologist at the earliest.
guage, articulation, phonation and speech flow, and on the ability to resolve resistance to permanent use of improved speech skills. In case of multiple handicaps, e.g. cerebral palsy, mental retardation, hearing loss and aphasia, the therapy is a long term procedure and, for the total rehabilitation, the ideal team will include besides speech pathologist, the specialists from other disciplines~ like pediatrics, neurology, psychology, physiotherapy and occupational therapy as well as the parents of the handicapped children.
618
Speech T h e r a p y Speech therapy aims at ameliorating the speech handicap considering the patient's personality as a whole, and not just the defective aspect alone. Four basic modes of therapy are available, these are : (i) belmviour therapy for explicit modification of speech; (ii) behaviour therapy for reduction of anxiety; (iii) insight therapies to arouse irrational anxiety which, when extinguished, improves personal adjustment; (iv) directive counselling to help the handicapped to live gracefully with defects if it cannot be changed and to instruct clients, parents spouses and friends of ways by which they can facilitate rehabilitation. These rehabilitative procedures help in producing changes as desired by the speech handicapped, and modifying the observed behaviour. Methods of remediating speech ,are at hand where success depends largely on the ability to identify explicitly the behavioural dimensions to be managed of lan-
REFERENCES 1. Craft M. Normal speech. In : Speech Delay : Its Treatownt by Speech Play. Bristol : John Wright and Sons Ltd., 1969 : 3-9. 2. Aram DM. Disorders of hearing, speech and lauguage. In : Nelson WE, ed. Text book of Pediatrics. Philadelphia : W.B. Saunders & Co., 1987 : 95-101. 3. Martin JAM. Deficit and delay in the development of spoken lauguage. In : Arnold GE et al. eds. Voice, Speech and Language in the Child : Development and Disorder. New York : Springer Verlag Wien, 1981 : 136-149. 4. Van Riper C, Emerick L, eds. Disorders of articulation.In : Speech Correction : An Introduction to ,Speech Pathology and Audiology, New Jersey : Prentice ltall Inc., 1984 : 166-196. 5. Wilson DK. Voice Problems of Children. Baltimore : Williams and Wilkins, 1979 : 1-11. 6. Van Riper C, Emerick L, eds. Stuttering. In : Speech Correction : An Introduction to Speech Pathology and AudiOlogy. New Jersey : Prentice Hall Inc., 1984 : 262-320. 7. Renfrew C, Murphy K, eds. Stuttering. In : The Child Who Does Not Talk. Clinics in Developmental Medicine, No : 13, Spastics International Medical Publication, 1968 : 184-197.
Speech Disorders in Children Anu Bhardwaj and M. Raghunathan
Department of Otorhinolat3,ngology, Postgraduate Institute of Medical Education and Research, Chandigarh There is nothing more elemental in all existence than communication - it is the very essence of life. All creatures great and small, even unto the tiny amoeba, are connected in an endless ebb and flow of messages. But it is in humans that we see its ultimate expression in the marvellous vehicle of language. In a highly competitive, upwardly mobile society of ours, verbal skill is very essential. Effective speech is of the utmost importance if one is to gain and maintain a status in the society, or to get the material possessions which are constantly held up to us as goals to be desired. Disorders of speech and language in childhood are not uncommon. Therapy for them requires understanding of the processes involved in the normal development of speech and language function.
Development of Speech and Language Development of speech and language skills depend upon a broad range of activities of many organ systems. The first stage audition, requires an intact peripheral auditory lnechanism. The second stage is the transmission of sound from the organs of hearing to the brain and the organization of the transmitted impulses for a response. The third Reprint requests : Dr. M. Raghunathan, Associate Professor, Department of Otorhinolaryngology, Postgraduate Institute of Medical Education and Research, Chandigarh- 160 012.
stage, the verbal response, involves respiration, phonation, rcsonation, and articulation. A high degree of intricate cortical and neuromuscular integration is required for all these activities. 1 Maturation of a child's speech and language normally keeps pace with the maturation of the total organism, and follows a fairly predictable pattern up to the age of about six years. 2 0-6 months. The early stages of speech and language development reflect the child's reception of speech sounds and are revealed by his responses to them. By four to six months, the infant normally demonstrates ability to discriminate among speech sounds by beginning to babble close approximations of a number of early consonant sounds, principally m, n, p, b, k, g, t and d. 6-12 months. By six to eight months, tile child starts exhibiting a rather wide repertoire of babbling combinations of the consonants with a few vowels such as ba-ba, mama, da-da and so on. At ten to twelve months, the child begins to discover that particular combinations repeated often will bring his mother to pay some attention to him or to administer to some want. By twelve monll~s, he should be using atleast one to three such combinations meaningfully. 1-2 years. Between twelve and eighteen
616
THE INDIAN JOURNAL OF PEDIATRICS
months, there is relatively little increase in tide expressive vocabulary. The child is rapidly expanding his comprehension vocabulary, and the number and variety of his responses to meaningful vocalizations of others. In eighteen to twenty four months, he begins to try to put together many of tlde combinations he has been learning, and by the age of about twenty four months, two and three word phrases develop. He begins to use connected speech for a purpose, such as 'go', 'bye-bye', 'want cookie', and so on. 3-4 years. Between the ages of three and four years, the child becomes very conscious of the importance of speech and the power it gives him. Because his speech and language are unstable and he is non-fluent, the process of communication can be easily interfered with, and speech troubles may have their origin during this period. By the age of three years, the child should have mastered fide use of all vowels, and consonants like w, m, n, p, b, k, g, t and d. At this age he is generally 70-80% intelligible, and uses an average of three words sentences. At the age of four, he should be 100% intelligible and use four word sentences. 5-6 years. At five years, he should be using some sound clusters such as 'tr', 'bl', 'pr', "gr' and use of f, v, r and 1; generally without error but these may not be mastered until the age of six years. By tide age of six years tlde child's general language structure is stable, tile non fluency has passed, and he has mastered all the consonant sounds with the exception perhaps of sibilants and sibilant combinations, primarily 's' and 'z'. Any condition which seriously impairs or disrupts tide normal development Qf the child
Vol. 59, No. 5
physically, psychologically or socially, may disrupt the development of his speech and language skills. The major factors influencing the development of speech and language are as follows : (i) mental retardation; (ii) abnormalities of neuro-muscular functions, e.g. cerebral palsy; (iii) structural inadequacies, such as cleft palate and cleft lip; (iv) serious illness or brain injuries; (v) sensory deprivation such as deafness; (vi) emotional disorders such as childhood schizophrenia and infanlile autism and other (vii) social and environmenial factors.
Delayed Speech and Language Some children fail to acquire any usable language at all; riley may be speechless or echolalic or have at best a primitive and inadequate gesture language. Most of the profoundly mentally retarded belong to this category, but some emotionally disturbed or congenitally deaf children may also show little or no language. Tile second and largest group includes t/lose children who are delayed in language acquisition. They know of some language, but it is so deviant or infantile and inadequate in its structure that they are truly handicapped in communication. These include children who are hard of hearing to a lesser degree or emotionally disturbed, as also those who may possess other learning disabilities, problems in motor coordination, hyperactivity, or environmental deprivation. Finally, in the third group, we find children who once had possessed adequate hearing but have lost it, and children with aphasia or neurological impairments resulting from illness or trauma involving the central nervous system?
Speech Disorders The speech disorders can be broadly classi-
B t l A R D W A J A N D R A G H U N A T H A N : SPEECH DISORDERS IN C H I L D R E N
fled under three heads: articulation, voice and rhythm/fluency. Articulation disorders. Of all the speech disorders, those of articulation are found most frequently. In our own clinical experience, nearly 50-60% of file children reporting to the clinic for speech therapy, are those who have not mastered file phonology of our language and children who erroneously substitute one phoneme or another, or omit or distort other sounds. They are handicapped because their speech deviates from the norms of our society, a society that depends upon effective communication and demands it. There are three basic ways in which file speech sounds may be misarticulated, these are : omission of sounds; substitution of a standard sound for another and distortion; and the substitution of a non standard sound for a standard one. Two main types of articulation disorders are recognized: 4 (a) Phonetic disorders - the person cannot produce sounds acceptable due to structural, motor, or sensory impairments. (b) Phonemic disorders - file person is capable of producing sounds but uses them inconsistently and in an immature manner or contrived manner. These errors may be due to faulty learning of rules of the language. Voice disorders. While less frequently found than dlose of articulation, file disorders of voice can be truly a serious handicap despite the fact that our culture tends to be more tolerant of vocal deviations than those of language, fluency or articulation. In children, generally tile voice problems occur due to vocal abuse, i.e. the incorrect use of voice. Common types of vocal abuse include shouting, screaming, cheering, ex-
617
cessive talking, throat clearing and coughing which may result in vocal nodules or contact ulcers. This in turn may cause the voice to sound hoarse, harsh, or breathy or a combination of these features. 5 Other common voice disorders in children are hypernasality due to cleft palate; denasal quality due to enlarged adenoids and common cold; pitch aberrations due to mutation or psychological reasons. Some rare conditions include spastic dysphonia or ventricular dysphonia. Typical voice problems of children with severe hearing loss include breathiness, hypernasality, too high pitched, monotonous lacking in pitch inflections, inappropriate loudness-either too loud or too soft, and differences in quality such as harshness and hollow non resonant type. R h y t h m or fluency disorders. Stuttering or stammering is another commonly encountered speech disorder which is related to fluency. Here, tile fluency of speech is disrupted by abnormal repetitions, prolongations, hesitations or "silent blocks" of speech. Stuttering is related to various factors which are not yet understood thoroughly. There are many views regarding etiology and therapeutic measures which are not being concered in the present discussion. There appears a psychological and psychosocial aspect of stuttering in addition to hereditary, physical, linguistic and neurological bases involving file whole of the speech system including audition. Stuttering often begins during the nonfluent period, between tile ages of 2 and 5 years, more commonly in males. Adverse psychosocial and environmental factors during this period can prolong the nonfluency until it becomes a real dysfluency, and eventually a severe form of stuttering with asso-
THE INDIANJOURNALOF PEDIATRICS
Vol. 59,No. 5
elated abnormal features like facial grimaces and violent jerks of bodily organs. 6 A general advice to the parents of the preschool child who is having stuttering is, often to ignore it. But this alone may be inadequate, since it may be necessary to instruct the parents on how to ignore the speech dysfluencies. They must be helpful, treat the child as normal, understand that non-fluency is a normal developmental stage, accept the child's speech without showing concen~ and give full encouragement to the child during his fluent speech attempts. Most of the children pass through this non-fluent stage without much difficulty, if handled in a proper manner. 7 When the child has strong stuttering features, every effort should be made to seek the help of Speech Pathologist at the earliest.
guage, articulation, phonation and speech flow, and on the ability to resolve resistance to permanent use of improved speech skills. In case of multiple handicaps, e.g. cerebral palsy, mental retardation, hearing loss and aphasia, the therapy is a long term procedure and, for the total rehabilitation, the ideal team will include besides speech pathologist, the specialists from other disciplines~ like pediatrics, neurology, psychology, physiotherapy and occupational therapy as well as the parents of the handicapped children.
618
Speech T h e r a p y Speech therapy aims at ameliorating the speech handicap considering the patient's personality as a whole, and not just the defective aspect alone. Four basic modes of therapy are available, these are : (i) belmviour therapy for explicit modification of speech; (ii) behaviour therapy for reduction of anxiety; (iii) insight therapies to arouse irrational anxiety which, when extinguished, improves personal adjustment; (iv) directive counselling to help the handicapped to live gracefully with defects if it cannot be changed and to instruct clients, parents spouses and friends of ways by which they can facilitate rehabilitation. These rehabilitative procedures help in producing changes as desired by the speech handicapped, and modifying the observed behaviour. Methods of remediating speech ,are at hand where success depends largely on the ability to identify explicitly the behavioural dimensions to be managed of lan-
REFERENCES 1. Craft M. Normal speech. In : Speech Delay : Its Treatownt by Speech Play. Bristol : John Wright and Sons Ltd., 1969 : 3-9. 2. Aram DM. Disorders of hearing, speech and lauguage. In : Nelson WE, ed. Text book of Pediatrics. Philadelphia : W.B. Saunders & Co., 1987 : 95-101. 3. Martin JAM. Deficit and delay in the development of spoken lauguage. In : Arnold GE et al. eds. Voice, Speech and Language in the Child : Development and Disorder. New York : Springer Verlag Wien, 1981 : 136-149. 4. Van Riper C, Emerick L, eds. Disorders of articulation.In : Speech Correction : An Introduction to ,Speech Pathology and Audiology, New Jersey : Prentice ltall Inc., 1984 : 166-196. 5. Wilson DK. Voice Problems of Children. Baltimore : Williams and Wilkins, 1979 : 1-11. 6. Van Riper C, Emerick L, eds. Stuttering. In : Speech Correction : An Introduction to Speech Pathology and AudiOlogy. New Jersey : Prentice Hall Inc., 1984 : 262-320. 7. Renfrew C, Murphy K, eds. Stuttering. In : The Child Who Does Not Talk. Clinics in Developmental Medicine, No : 13, Spastics International Medical Publication, 1968 : 184-197.
