Finals Study Guide
Finals Study Guide 1230.0
Popular in INTRODUCTION TO COMMUNICATION DISORDERS
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This 33 page Study Guide was uploaded by Emily Clark on Friday December 11, 2015. The Study Guide belongs to 1230.0 at Bowling Green State University taught by Lynne Hewitt in Fall 2015. Since its upload, it has received 23 views. For similar materials see INTRODUCTION TO COMMUNICATION DISORDERS in Language at Bowling Green State University.
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Date Created: 12/11/15
Finals Study Guide - Chapter 8: Fluency Disorders • The Nature of Fluent Speech - The term fluency is used to describe speech that is effortless in nature. - The term disfluency is used to describe speech that is marked by phrase repetitions, interjections, pauses and revisions. - An inaudible sound prolongation where the mouth is in position for the sound for an extended period of time but no sound is coming out is referred to as a block. - Stuttering is the most common form of fluency impairment but it is not the only type of fluency disorder. • There are two types: - Acquired (neurogenic) - Developmental • What is Stuttering - It is characterized by an unusually high frequency or duration of repetitions, prolongations, and/or blockages. - The interruptions are often combined with excessive mental and physical effort to resume talking. - Primary Stuttering Behaviors Sometimes referred to as ‘core behaviors’ which are the stuttering-like speech disfluencies. • - Rapid repetitions of sounds. - Prolongations - Blocks or silent prolongations. - Secondary Stuttering Behaviors • They are counterproductive adaptations that people who stutter make as they try to get through primary stuttering behaviors or to avoid them altogether. - These secondary behaviors can actually be more distracting than the primary stuttering behaviors. - Incidence and Prevalence of Stuttering • Prevalence is the percentage of people who stutter at any given point in time. • Incidence is the percentage of people who report having stuttered at some point in their lives. • Individuals Who Stutter - Individual Variability • Not all individuals stutter in the same manner or with the same manner of frequency. Most individuals who stutter fall somewhere between the extremes. • - The severity of their stutter can change over time. 1 • Speech disfluency tends to be worse when the speaker puts pressure on themselves to be fluent, when speaking long and complicated utterances, speaking with figures of authority, or when the speaker is in a hurry. • Most people who stutter are notably fluent when they sing, use fake voices, are engaged in choral reading or when talking to babies or animals. - Differences Between Individuals Who Do and Do Not Stutter. • Stuttering tends to increase in relation to the importance and complexity of the information being expressed. • People who stutter use their brains a bit differently during speech production. - They have unusual neural activation in speech motor, language processing and memory areas of the brains. - There have been findings of excess neural activity in the right hemisphere and in motor areas in individuals who stutter. • Decreased connectivity between auditory processing and motor speech areas could interfere with the intricate timing necessary for fluent speech. • The Etiology of Stuttering - Research has yet to reveal an exact cause of stuttering • Some theories that seem to be reasonable have been proven false. - Current Thinking About the Etiology of Stuttering • Current models of stuttering depict the disorder as arising from complex dynamic relationship between internal (neurological and cognitive) factors and external conditions. • While these factors may prompt the onset and development of stuttering, it is not necessarily the cause for every single person. • The Development of Stuttering - Early Stuttering • The speech of preschool age children is often marked by phrase repetition, interjections, revisions and pauses. • For the majority of children, the amount of disfluency declines over time. • For some children, stuttering seems to develop over time before anyone, even themselves, notice it. - Genetic Influences • There is strong evidence for genetic influences on the development of stuttering. - Environmental Demands and the Capacity for Fluency • Four interrelated mechanisms contribute to the capacity for fluency: - Neural development that supports sensory-motor coordination - Language development - Conceptual development 2 - Emotional development • Slowed neurological development and less efficient patterns of neural activation could result in a diminished capacity for producing fluent speech. - The Influence of Learning • In some instances, children's speech disfluencies may be more physically tense than they are in other instances. • Our brains work so efficiently that patterns of behavior, even undesirable patterns such a stuttering, can strengthen and stabilize rather quickly. • Factors that Contribute to Chronic Stuttering - Fortunately, stuttering resolves in 60% to 80% of individuals who stutter during childhood. - The resolution of stuttering is probably related to growth spurts and developmental domains such as speech motor control, language, cognition, and temperament. - The term chronic stuttering is often used to refer to individuals who may stutter from childhood into adolescence and adulthood. - Contributing Factor: Genetics • Genetics possibly influence whether children will continue to start or after they begin. - Contributing Factor: Negative Feelings and Attitudes • People who stutter often report that they are frustrated and embarrassed by their inability to say what they want to say in the way they want to say it. - Contributing Factor: Avoidance • Individuals who stutter sometimes avoid stuttering by changing the words they plan to say as they talk. • Some people who stutter simply refuse to answer the telephone, introduce themselves, ask questions, or speak in front of groups of people. - Contributing Factor: Difficulties with Speech Motor Control • Some people who stutter evidence unusual patterns of breathing, vocalizing, and speaking even when they're not stuttering. - Contributing Factor: Difficulties with Language Formulation • Although motors aspects of stuttering have received considerable attention, research studies indicate that linguistic variables such as phonology, semantic, and syntax may also contribute childhood stuttering. 3 • Assessment of Stuttering - Evaluations of individuals who are excessively dysfluent are designed to determine whether the person is a stutterer, to describe the patterns of dysfluency that are exhibited, and determine what therapy procedures to use. - Cultural Considerations • Clinicians should never assume that the communication traditions and patterns from one culture are more correct than those from another culture. - Language considerations • Typically if a person stutters in one language they will stutter in both native language and second languages, assessment and treatment should allow for evaluation in both languages. - Assessment Procedures and the Information they Yield • Interviews and case history - The case history should reveal information about environmental conditions, reactions to speech disfluency, the consistency of speech dysfluency behaviors across situations, and changes in dysfluencies over time. • Tests of Stuttering - Clinicians often give standardized test to help them determine whether children have a disorder or not. • Provides an objective measure of the core disfluencies that characterize stuttering. - The stuttering severity instrument-4 can help clinicians determine the severity of stuttering. • Speech Samples - Stuttering evaluations should include the collection and analysis of speech samples from a variety of speaking contexts, including dialogue, monologue, and oral reading. • Consistency and adaptation - Some clinicians ask individuals who stutter to read a short passage over and over again. • Screening - As with every evaluation, the clinician needs to ensure that hearing sensitivity is within normal limits and that the structure and function of the oral mechanisms are adequate to support speech. • Treatment - Adults who receive treatment are not cured often, but it does happen. - The good news is that many children, adolescents, and adults who receive treatment become fluent to the point where they can communicate effectively. 4 - There are two types of treatment for stuttering. • Stuttering modification procedures help the stutterer change or modify his stuttering so that it is relaxed and easy. Fluency shaping procedures establish a fluent manner of speaking that replaces stuttering. • - One of the main differences between those two approaches is focus on attitudes and emotions related to stuttering. - Stuttering Modification Therapy • Stuttering modification therapy is used to teach the person who stutters to change the way he stutters. • This treatment uses the acronym MIDVAS which stands for motivation, identification, desensitization, variation, approximation, and stabilization. • The primary goal of this therapy is to help stutters acquire a speech style they find to be acceptable. - Fluency shaping therapy • Fluency shaping therapy is used to teach a new speech style that is free of stuttering. • Most procedures involve lower rates of speech, relaxed breathing, easy initiation of sounds, and smoother transitions between words. - Integrating stuttering modification and fluency shaping methods • One of the major differences between stuttering modification and fluency shaping methods is that in fluency shaping, the focus is only on speech production, whereas in stuttering modification, the focus is also on attitudes and beliefs about speech production. - Therapy for Children who Stutter • Therapy for children between three and eight years of age involves many of the basic concepts and procedures from stuttering modification and fluency shaping approaches. • It is critical that clinician to work with young children involved families in the therapy process as much as possible that way the families will know how to help the child. 5 - Chapter 9: Motor Speech Disorders -Motor Speech Disorders • Some speech disorders are the result of damage to parts of the nervous system responsible for the planning and programming movements for speech, - Or they are the result from the impairment of the ability of muscles to produce speech because they are weak, paralyzed, or uncoordinated. • Childhood Apraxia of Speech (CAS) - Experts do not agree on its characteristics or cause. - CAS has been given several labels, including developmental apraxia and developmental dyspraxia of speech. • CAS does not occur often. - Typically these children demonstrate a severe speech disorder with the words dominated by • simple syllable • vowel errors • sounds that develop shapes early - Children with apraxia may use gestures because of difficulty with communicating words. - Most children with the disorder will eventually develop intelligible speech - Children with CAS do not demonstrate significant sensory loss, structural abnormalities, or emotional disorders - Reliable identification of children with CAS is difficult because clinicians do not agree on what characteristics set the disorder apart from other childhood disorders. - Children with a CAS are in treatment for an extended period of time, frequently several years due to the severity of the disorder and lack of proven treatment techniques. - Treatment includes drill based work on speech movement, phonological process remediation approaches, and tactile/gestural approaches. • Acquired Apraxia of Speech - Acquired apraxia of speech AOS is a disorder in the planning and programming of speech movement due to left frontal lobe brain damage. - AOS has a controversial history because researchers could not agree on whether the disorder could occur independently of Broca's aphasia, a language disorder. • In most cases AOS does not occur independently from Broca's aphasia. - AOS is characterized by slow rate, prolonged consonants and vowels, pauses between words, and even stress on syllables. 6 - Speakers with AOS tend to substitute less complex consonants for more complex consonants. - Treatment for a proxy of speech focuses on improving the ability to program movements of increasingly more demanding syllables, words, and phrases. • Other approaches focus on rate, intonation, and rhythm to facilitate production of sequences of syllables. • Dysarthria in children - It is most commonly associated with cerebral palsy. • In adults it results from cerebrovascular or progressive neurological disease. - Frequently, the neuromuscular problems that underlie dysarthria cause difficulties in swallowing as well as speech. • Cerebral palsy - Injury to the nervous system that occurs before, at the time of, or shortly after birth can cause cerebral palsy. • This syndrome causes deficits in visual, auditory, intellectual, and motor functions in the critical early development for speech and language. - The primary causes of cerebral palsy are anoxia, in which the brain has a restricted oxygen supply. • The causes are divided into three groups prenatal, perinatal, and postnatal. - Classification of Cerebral Palsy • There are several ways of classifying cerebral palsy - By the limbs affected - By neuromuscular characteristics - By the severity of the disorder • Orthopedic Classification - Based on the limbs affected • Neuromuscular Characteristics - Damage to the pyramidal tract and the extrapyramidal system leads to Spastic Cerebral Palsy This type includes arms that are bent upward and legs that are positioned like a • scissors. - Damage to the basal ganglia and associated components of the extrapyramidal tract leads to Athetoid Cerebral Palsy. 7 • Which is characterized by a writhing and twisting motion. - Damage to the cerebellum results in Ataxic Cerebral Palsy. • Characterized by errors in speed, direction, and accuracy. - There are two other types of cerebral palsy: Rigid and Tremor. • These types have a low frequency of occurrence and rarely occur alone. • Severity - Ranges from mild to severe and is usually determined by an overall judgement of the level of impairment. • Based on the degree of independence in communication, ambulation and self-help skills. - Motor Development in Children with Cerebral Palsy • Motor deficits are the focal point of a diagnosis of cerebral palsy. - Delayed motor development is most frequently observed in children with that disorder. - Children have developmental delays in sitting, standing, walking, and speech development related to the motor impairment. - Speech and Language Development in Children with Cerebral Palsy • Speech disorders in cerebral palsy result from weakness and incoordination • ALL aspects of speech are effected. • Respiration - Is characterized by reduced vital capacity and impaired ability to generate and maintain pressure below the vocal folds. Phonation • - Intermittent breathiness and strangled harshness in voice quality as vocal fold tension increases and decreases. • Resonance - Hypernasality and nasal emission during speech production is caused by a gradual premature opening of the soft palate during the productions of syllables. • Articulation - Because of hyperextension of the articulators, individuals with cerebral palsy frequently have significant articulation problems. • Speech Development - The highest frequency of errors are on fricatives and glides requiring tongue movement. - The latest developing sounds in normal children are the most delayed in children with cerebral palsy. - The melody of speech (prosody) is also affected and causes a reduction in speech intelligibility. 8 - Recommended treatment includes behavioral adjustments that are compensatory, such as reducing speech rate and augmentative communication systems. • Acquired Dysarthria - This disorder differs from cerebral palsy in several respects. - Primitive reflexes do not contribute significantly to the speech deficits that are observed. - Adult patients usually present sensory problems related to the aging process. - Classification of Acquired Dysarthria • Historically, acquired dysarthias were categorized by the causative disease process or the part of the body affected. • Flaccid Dysarthria - Interruption of normal input to the muscles from the peripheral nervous system causes muscle weakness and atrophy (wasting). - The problem in flaccid dysarthria may be impulses from the central nervous system are interrupted as they course down to the muscle fibers. - Motoneurons can be injured by trauma, or they can deteriorate from degenerative disease. - Depending on what parts of the motor unit are affected, individuals with flaccid dysarthria demonstrate reduced muscle tone, with atrophy and weakness and reduced muscle reflexes. - Speech rate is slow with breathy phonation, hypernasality, weak production of stops and fricatives, articulatory imprecision and reduced phrase length. • Spastic Dysarthria - When the pyramidal and extrapyramidal tracts are damaged on both side of the brain surface, impaired innervation to the muscles causes them to be weak causing hypertoncity and hyperreflexia. • This leads to the types of muscle spasms that are characteristic of spastic dysarthria. - All four limbs as well as the trunk, head and neck are affected. - Speech is characterized by articulatory imprecision, slow rate, short phrases, and a harsh voice quality. - A variety of conditions can lead to spastic dysarthria. • Ataxic Dysarthria - The primary characteristics of ataxic dysarthria relate to coordination. - Movements are inaccurate and dysrhythmic. • However, reflexes are normal and there is only minimal weakness. - Ataxic dysarthria results from damage to the cerebellum, which functions to coordinate the direction, extent, and timing of movements. - Prosody tends to be monotonous and there are disruptions in stress patterns. 9 - The good news is that speech intelligibility frequently is only mildly affected. • Hypokinetic Dysarthria - The individual’s muscles are hypertoned and rigid, resulting in reduced movement. - Many people experience a resting tremor that disappears with voluntary movement. - People with this type of dysarthria have difficulty starting and stopping movements. - Parkinson’s disease is a primary example of a disorder that results in this type of dysarthria. - The speech movements are small but the rate is often fast. • Hyperkinetic Dysarthria - When the basal ganglia of the extrapyramidal system are damaged, involuntary movements are a telltale sign. - These movements can be slow or fast, rhythmic or dysrhythmic, involve the whole body or just isolated parts. - People often have breakdowns in the flow of speech, which sounds like hesitations in unusual places. - The voice quality of these individuals may be breathy or strangled depending on the state of fluctuating tonicity of the laryngeal musculature and degree of breath support. Mixed Dysarthrias • - Several disease processes affect more than one part of the motor system at the same time. • Two such diseases are multiple sclerosis and amyotrophic lateral sclerosis (Lou Gehrig’s disease). - The Oral-Peripheral Examination • This is how an SLP determines the anatomic and functional integrity of speech production structures. - It entails a careful examination of structures such as the tongue, jaw and lips at rest and during nonspeech and speech activities. • The SLP should also assess respiration during non-speech related and speech related tasks. • The SLP should assess articulatory structures of the upper airway, including muscles of the tongue, jaw and lips to determine whether they are weak, atrophic or uncoordinated. - The Speech Examination Provides important information about the type and extent of dysarthria. • • These samples serve as assessment vehicles to estimate articulatory precision, speech rate, prosodic patterning, and other perceptual features. • The severity of impairment to any major component of the system may have major effects on speech intelligibility. 10 • Treatment of individuals with Dysarthria - A team of individuals including physicians, SLPs, occupational therapists, audiologists, special educators, and physical therapists works to help children with dysarthria develop independence. - Surgery and drugs are beneficial for some disorders in which dysarthria is a symptom. • Sometimes the two treatments can be beneficial in motor performance. - Surgical and prosthetic management may be used to improve speech performance directly. - Postural supports are necessary to place the individuals into the best position for speaking. - Speech therapy often is geared toward improving speech intelligibility. • Treatment focuses on the development of coordinated volitional control of the speech production system. - For individuals with good intelligibility, the focus of treatment may change to improving the naturalness of speech. - The focus could also be on comprehensibility, the adjustments the speaker and communication partner make, and the environmental alterations undertaken for successful conversation. • Augmentative Communication - Augmentative refers to supplementing speech using various techniques and aids. - Individuals with dysarthria use these types of systems all the time. - These types of systems take many forms. • Two systems that use devices are aided and unaided. - There can also be non-electronic (gestures) or electronic (scanning systems) - Augmentative communication differs in several important respects from oral speech. • If a person uses a communication board then the two communicators cannot sit face to face. If the individuals use gestures than the partner must interpret what the gestures mean. • - For individuals with dysarthria augmentative communication may be the primary means of conveying message. - To help an individual decide which system to use, SLPs need to assess intellectual, sensory, motor, and academic skills. - The overriding goal is to develop an augmentation system within the capabilities of the user that meets communication needs with maximum efficiency. - A period of training with the system is essential. - The initial focus of rehabilitation should be to maximize oral speech function and to augment or to substitute an alternative communication system only if necessary. 11 - Chapter 10 Dysphagia -Dysphagia • Is a difficulty in swallowing or an inability to swallow. When patients have dysphagia, they are unable to consume enough food or liquids safely and • efficiently. Examples of Dysphagia • - When food enters the airway it is called aspiration. • May occur because the weak or paralyzed pharyngeal and laryngeal muscles cannot control the food. • Role of the SLP - Communication and swallowing problems frequently occur together. • Stages of Swallowing - The process of swallowing is viewed in stages. - The Anticipatory Stage • Occurs before the food reaches the mouth. • The senses allow the person the opportunity to prepare to eat. - The Oral Stage Marks the beginning of events that led up to the swallow. • • There are two parts of this stage and both are under voluntary control. - The preparatory part is when a bolus (the chewed food) is being readied for a safe swallow. - The second part is called the transport phase, begins when the tongue pushes the bolus against the palate to move it back toward the pharynx. • The oral stage is completed when the bolus passes the anterior faucial arches and enters the pharyngeal area. - The Pharyngeal Stage • Begins with the triggering of the pharyngeal swallow. • There are two purposes. - Protect the airway. - Direct the bolus to the stomach. • The motor pattern is initiated by sensory information sent from the mouth and oropharynx to the brainstem. • When the swallow is triggered, the contraction of the muscles of the pharyngeal constrictors transport the bolus through the pharynx toward the esophagus. - The Esophageal Stage • Begins with the lowering and backward movement of the larynx and resumption of breathing. 12 • The upper esophageal sphincter contracts to prevent food from reentering the pharynx. • Dysphagia in Adults - Swallowing requires both cognitive and motor skills. - A person must be able to recognize the need to eat and decide what to eat. - When an illness or injury affects either the cognitive or the motor skills, there is a high risk for dysphagia. - Left Hemisphere Cerebrovascular Accident • Individuals who suffer cerebrovascular accidents (CVAs) to the left hemisphere of the brain often have an oral stage difficulty resulting from weakened or paralyzed facial musculature. - Including labial, lingual, and mandibular function. - Right Hemisphere Cerebrovascular Accident • Often have oral stage difficulties resulting from reduction in labial, lingual and mandibular strength. • Often have delayed pharyngeal swallow which can cause aspiration. - Brainstem Stroke • Often have oral stage difficulties resulting from reduced labial, lingual, and mandibular sensation and strength. • Delayed or absent pharyngeal swallow. - Traumatic Brain Injury • Dysphagia symptoms resulting from traumatic brain injury vary according to the location and severity of the injury. • Problems usually exist at each stage of the swallow. - Dementia Causes cognitive deficits such as reduced attention, reasoning, judgement, and poor • orientation skills. • Significantly affect the initiation of the eating process. • Food may be held in the mouth for an extended period of time and not recognized as something to be swallowed. - Neuromuscular Disease • Some progressive neuromuscular diseases that cause changes in strength, rate and efficiency of muscular movement are: - Multiple sclerosis, amyotrophic lateral sclerosis, Parkinson’s disease, myasthenia gravis, and muscular dystrophy. - Cancer • Can cause several types of swallowing problems. Due to surgery the anatomic structures used for swallowing change. • 13 • Radiation can cause tissues such as those in the mouth and throat to become irritated and dry, which makes swallowing very uncomfortable. • Management of Adult Dysphagia - The patient and family are a huge part of the dysphagia team. - A dysphagia assessment is composed of a review of the patient’s history, a bedside examination, and an instrumental examination. - Review of History Prior to the Accident • Upon receiving the referral for a dysphagia evaluation, the SLP needs to collect relevant feeding, behavioral, and medical information. • The SLP needs to know whether the patient had swallowing problems prior to the illness or accident. - Current Medical Status • The next step in a dysphagia evaluation is to review the patient’s current medical condition. • The SLP needs to know whether the patient is medically stable, the respiratory status, which medications have been prescribed, and the current level of cognitive functioning. • The SLP also needs to know how the patient is currently receiving nutrition. - Noninstrumental Clinical Exam (Bedside Clinical Assessment) The SLP meets with the patient and assesses the ability to take food off the plate, prepare • the bolus, and safely swallow in the NICE also called the BCA. A safe swallow occurs when the larynx moves upward and forward while opening the upper • esophageal sphincter at the top of the esophagus. This process cannot be directly observed, but the SLP can observe several “signs”. • - 1. Watching the neck along with placement of two fingers under the chin to determine whether there is upward and forward laryngeal movement. - 2. Listening for coughing, which could mean that the bolus or part of it is going the wrong way. - 3. Listening for a “gurgly” sound after swallowing. - Instrumental Assessment of Dysphagia • The most common instrumental procedure is the modified barium swallow (MBS) - A fluoroscopic image that is recorded on videotape. - While the patient is sitting in a chair that is positioned for optimal eating the SLP places barium-coated food in the patient’s mouth. An MBS allows the dysphagia team to understand the cause of the dysphagia to make • recommendations for treatment. Another common procedure is endoscopy (FEES). • - A flexible scope is inserted through the nose and positioned just above the epiglottis. 14 - The patient is given food mixed with dye so that the examiner can observe the pharyngeal structures and functions through the scope. - Treatment Planning • The entire dysphagia team reviews the information that has been gathered about the patient and writes a treatment plan to help keep the patient well-nourished and safe. • The treatment plan has to be able to reflect the changes and improvements that can occur throughout the treatment. • Dysphagia in Children - In cases of pediatric dysphagia, the SLP treats children who have yet to acquire eating skills. • Or medical conditions, genetic disorders, or illness that have been present from birth or shortly after birth can prevent the development of normal swallowing skills. - The goal of dysphagia assessment and treatment with children is to aid in the development of skills needed to keep the child safe and well-nourished. - Prematurity • The ability to suck and swallow develops prenatally. • These reflexes also develop during the last 4 to 8 weeks of gestation. - Cerebral Palsy Children with cerebral palsy have a wide range of feeding problems. • • The type and severity of the feeding problem depend on the degree of motor deficit. • Cognitive deficits can also result in problems that affect all stages of the swallow. • Children with cognitive deficits may have inadequate velopharyngeal closure, which causes a delay in the pharyngeal swallow. • Pediatric Dysphagia Evaluation - The assessment procedures for children are similar to those for adults. - The SLP reviews part medical history and current medical status. - Then they perform a NICE and if warranted, proceeds to do an instrumental examination. - Review of Medical and Feeding History and Current Feeding Methods • An understanding of underlying medical conditions and how these conditions may contribute to current feeding problems is the focus of management in pediatric dysphagia. • The SLP must gather information about the child’s prenatal history, birth history, early feeding problems preferred positioning, preferred textures, types of utensils, respiratory status, use of alternative feeding methods, medications, seizures, and signs of distress during eating. • The SLP looks for lip, tongue, and jaw movements, along with any changes on respiratory function. - Instrumental Assessment • Currently the MBS procedure is used to a much greater degree than endoscopy. 15 - Pediatric Treatment Planning • Based on the information gained from the review of the child’s medical and feeding history, NICE, and MBS, the dysphagia team formulates a treatment plan designed to meet two major goals. - The first goal is a way for the child to meet current nutritional needs while remaining safe - The second is focused on techniques or strategies that will improve both oral-motor and pharyngeal stage functioning to help normalize eating and swallowing skills. 16 - Chapter 11: Language Impairment in Children -Language Impairment in Children • Some children experience significant difficulties in learning and using language. Unfortunately when these difficulties learning persist into the early school-age years, they are at • risk for social impairment, behavior problems, academic failure, and vocational disadvantages. • It is important for SLPs to diagnose and treat language impairment in children as soon as possible. • What is Language Impairment? - Impairment refers to any loss or abnormality of psychological, physiological, or anatomic structure or function. - Language Impairment means significant delays in the development of language comprehension or production related to vocabulary and sentence structure. - It is common for young children to make phonological errors, morphological errors, and syntactic errors as they are learning language. - Language impairment should be diagnosed when a child’s language skills are significantly poorer than the language that is typically expected of his or her same-age peers. • Patterns of Language Impairment - Language has three interrelated components: form, content, and use. • Form refers to the structure of language including syntax, morphology, and phonology. Content refers to the meaning of language or semantics. • • Use refers to the social aspects of language or pragmatics. - Each of these aspects are important for individuals to be successful in understanding and producing language. • What Constitutes a Problem with Language Form? - Infants and Toddlers (Birth to 24 Months) • Limited vocalizations and restricted syllable productions during babbling are risk factors that are predictive of later language impairment. • Infants and toddlers with language impairments may not combine words to express relationships until well after 2 years of age. - Preschoolers During preschool period most children exhibit rapid growth in aspects of language form. • • Children with impairments often use a limited number of grammatical morphemes and have special difficulties using morphemes like: - The past tense ‘-ed’ - The auxiliary ‘is’ • Preschoolers with language impairments may have difficulties understanding more complex sentences spoken by others and may produce a limited variety of constructions in their own language. 17 • Children with language impairment make more grammatical errors than typically developing children who are their same age. - School Age • Children experience substantial growth in their understanding and use of language form, including advanced morphological structures and complex sentences. • School-age children with language impairment are likely to use fewer complex sentences Children whose conversational speech is noticeably ungrammatical and does not contain a • significant number of complex sentences should be referred for a language evaluation to assess the nature of their difficulties in language form. • Many children with language impairment have difficulties developing phonological awareness skills sufficiently for use in decoding. • These children may have difficulties making connection between letters and the sounds they represent. • Morphologically complex forms are often the focus of language intervention for adolescents who have language impairment. • What Constitutes a Language Problem in the Area of Content? - Infants and Toddlers • Children usually start producing their first words between 10 and 14 months of age • Children with language impairments often have a limited number of words that they understand and use. • Delays in the appearance of first words and difficulty learning and using new words are very noticeable to parents. - Preschoolers • During the preschool years, children with language impairments may have trouble comprehending basic concepts. - They may have a limited range of semantic relations such as possession, recurrence and location. • They often learn words slowly, and may have trouble comprehending or producing words that are known and used routinely by others their same age. - School-Age Children Children should know 6,000 root words by the time they are in second grade. • • Vocabulary in the school years can be divided into three tiers. - Tier 1. Words that are very common and occur frequently in oral language. - Tier 2. Sophisticated words used to express concepts that children already understand. - Tier 3. Complex words found in science, social studies and other curricular content of older school age children. • Children with language impairments may have difficulty learning and using words from all three tiers. 18 • What Constitutes a Language Problem in the Area of Language Use? - Infants and Toddlers • One of the earliest manifestations of a language use impairment is found in children older than 6 months who fail to engage in intentional actions related to the world around them. • They may not point to objects they want, or use words to express a wide range of meanings. • These differences show a restricted range of communicative functions and lack of communicative initiation. - Preschoolers • By the time children are 3 years of age, they are able to use phrases and sentences to initiate and to respond during conversations. • Some children with language impairments interrupt often, fail to initiate or respond appropriately to questions or comments by others, or seem to be proficient in talking about specific topics. - School-Age Children • Children with language impairments experience difficulties understanding and creating coherent narratives. • They demonstrate significant difficulty understanding and producing inferences during comprehension of discourse. • Frequently have difficulties understanding the expository texts they read for their classes. - They might not understand cause-and-effect relationships. • Diagnostic Conditions That Are Characterized by Language Impairment - Language impairments may result from deficits in the growth and development of the brain. - They may also be associated with neurocognitive disorders like TBIs or sensory disorders. - They can also be related to neglect or abuse, behavioral problems, or emotional problems. - Specific Language Impairment • An SLI is indicated by significant delays or deficits in comprehension or production of language form, content, or use that cannot be attributed to hearing, intellectual, emotional or acquired neurological impairments. • Other common terms for an SLI are language disorder and developmental language disorder. • They are believed to result from subtle genetic, neurological and environmental factors that lead to difficulties learning and using language. • Late talkers whose deficits persist into the school-age years are usually identified as SLI. - Intellectual Disabilities Indicated by severe deficits in intellectual functions and adaptive behaviors that appear • during childhood or adolescence. • Often these children have obvious motor, language or social delays before they are 2 years old. 19 • Can be caused by genetic conditions like Down syndrome or Fragile X syndrome, maternal infections during pregnancy, complications during delivery or environmental factors. • These children are significantly delayed in learning words and tend to use short, simple sentences well into the school-age years. - Autism Spectrum Disorder • Children diagnosed with ASD must have pervasive and sustained difficulties with reciprocal social communication, sharing of interests and emotions, and initiating or responding to social interactions. • They must also present restricted or repetitive patterns of behavior, interests or activities such as repetitive motor movements, insistence on sameness or inflexible adherence to routines. • These symptoms are present from early childhood, and they interfere with daily activities and the ability to learn. • The most reliable diagnoses are made soon after children are 2 years old. • There is not one single cause of ASD. - Specific Learning Disorder • These are characterized by persistent difficulties learning academic skills. • They have problems with word decodeding, reading comprehension, spelling, writing, number facts, or mathematical reasoning which are substantially below the expectation of their peer group. • They cannot be explained by intellectual disabilities, visual or hearing problems, other mental or neurological disorders or poor instruction. • There is a great overlap between the kinds of language deficits that occur across neurodevelopmental, neurocognitive and sensory disorders. • Children diagnosed with different disorders often have similar kinds of language deficits. • Assessment - Two important roles of SLP are to evaluate children’s language development and to determine whether or not they have a language impairment. - SLPs use the chronological age to determine a child’s comparative age. • This is done by subtracting the child’s birthdate from the date of assessment. - Norm-reference tests are administered to compare a child’s skill in a given area with that of other children who are the same chronological age. - Most test provide index scores that are standardized for a mean of 100 and a standard deviation of 15. Children who earn index scores of 90 or above are performing at or above the expected • levels of their age. • Children who earn index scores below 90 are performing below age expectation. • Children who earn index scores below 82 on two different measures of language ability are likely to have a language impairment. 20 - In interprofessional approaches to assessment, evaluations may be conducted simultaneously or independently by professionals from different disciplines. • Assessing Children’s Language - Infants and Toddlers • The most severely involved infants and toddlers with known etiologies for their impairment are the easiest to diagnose. Infants and toddlers with less overt developmental delay, such as late talkers, are not as • easily diagnosed. Parent reports are often the best way to explore vocabulary knowledge in infants and • toddlers. There are very few measures available to determine whether infants and preschoolers • demonstrate delayed or impaired pragmatic language development. - Preschoolers • A combination of assessment tools and analyses is needed in order to gain a full understanding of a preschooler’s receptive and expressive language skills. • Criterion-referenced approaches to assessment are used to help clinicians develop better descriptions of performance and to plan intervention. - This includes checklists of language behaviors, inventories, and language sampling analyses. • For vocabulary development, a standardized test may tell clinicians whether the child is performing below his or her expected chronological age. - School-Age Children • When classroom teachers have concerns about a child’s language ability, they must do their best to help the child in the classroom using scientific, research-based intervention methods before they refer the child for special education testing. • Before any testing can begin, the child’s parents should be informed of the reasons why the child was referred and the tests that will be administered. • One of the most critical aspects of a speech and language evaluation is the language sample. • Clinicians can tell where children are in the language development process by analyzing the length and types of their utterances. - Nonbiased Assessment • SLP should make sure their assessment is culturally and linguistically appropriate. The possibility of a mismatch between parental and SLP expectations and beliefs makes it • important for clinicians to understand variation in language learning and in socialization practices. Some of these problems occur because the process of learning a second language or dialect • variations is not well understood. Other problems may occur because interaction styles reflective of different cultures do not • match mainstream expectations for test-taking behavior. 21 • Language Intervention - A number of laws affect the way language intervention services are provided to children. - The Individuals with Disabilities Education Act requires states to offer a range of identification and intervention services for children from birth through age 19. - When children with disabilities enter the public school system at age 4 or later, they receive an Individualized Education Program (IEP) This IEP helps the diagnosis team with making decisions about the best way to provide the • child with a free and appropriate public education in the least restrictive environment. - Early Intervention with Infants, Toddlers, and Preschoolers • Research shows that early intervention services make a difference in the development of language skills for children who may be at risk for language impairment. • There are three basic models of early language intervention services. - Child-centered approaches are where the clinician and child engage in conversations during play. - Clinician-centered models are based on behavioral principals of learning in which the stimulus is designed to produce a correct response. - Hybrid approach is a combination where the clinician selects the activities and materials and responds to the child’s communication to model and highlight the specific forms targeted for intervention. - Language Intervention with School-Age Children • Language intervention in school settings should focus on social-interactive and academic uses of language in pragmatically relevant situations. • Strategies for improving communication skills have included modeling, practice and role- playing, discussion of behaviors, and caregiver training. - Literature-Based Language Intervention • Many clinicians use book discussions as the primary context for language intervention with school-age children. • Activities usually include prereading discussions about concepts that are contained in the books, reading and rereading the story on a number of occasions and retelling the story. - Classroom Collaboration Many SLPs who work in public school settings conduct language intervention in the regular • classroom. Classroom collaboration is helpful when clinicians want to integrate their language-learning • goals with the expectations of the academic curriculum. SLPs and classroom teachers work together to plan and carry out language-learning • activities with the whole class. 22 - Chapter 13 Hearing Science • Hearing is the sense of perceiving sound. • Fundamentals of Sound - The physical bases include measurements of: • Frequency • Intensity • Phase - The Psychological or perceptual measures are: • Pitch • Loudness • Timbre - Generating Sound To be a sound source, an object must have mass and elasticity. • • The more elastic the object, the more likely it will be a good sound source. - Measuring Sound • A waveform is the graph that represents the passage of time, showing when the vibrations start and stop. - Shows all characteristics of a simple sound to be quantified. - The four quantities that are considered: Frequency Duration • • • Amplitude • Starting phase - Frequency is the number of cycles of vibration that occur in 1 second. - Amplitude is the measure of distance of how far away from the resting position the soundwave moves. - Duration is how long the sound lasts. - Starting phase describes the position of the sound source when the vibration begins. - Simple and Complex Sounds The four quantities characterize simple sounds, which is a sound that vibrates at a single • frequency. • Complex sounds are vibrations that contain two or more frequencies. - Rather than using waveforms, complex sounds use spectrum to depict them. - Sound Propagation • The process of sound propagation is when air molecules closest to the sound source vibrate and bounce off of the surrounding air molecules, sending the sound energy in all directions. • The Auditory System: Structure and Function - Vertebrates, such as mammals are the only animals that have an auditory system per se. - The auditory system consists of two parts: the ear (the outer, middle, and inner ear) and the auditory nervous system (neural pathways, associated nuclei and the brain). - The Outer Ear 23 • Consists of the pinna and external auditory meatus (EAM) - Pinna is the visible flap of skin attached to the head. • The pinna funnels outside sounds into the EAM - EMA is a tube that is closed off at one end by the eardrum • The Pinna and EAM have the capacity to selectively boost or amplify sounds. - The Middle Ear • The tympanic membrane or eardrum forms the boundary between the outer and middle ear. • Attached to the TM is the malleus, which is connected to the incus which is connected to the stapes. - These three bones are known as the ossicular chain and are the smallest bones in a human. At the floor of the middle-ear cavity is a passageway that connects the middle ear to the back • of the throat. - The passageway is call the Eustachian Tube. • The ossicles provide a pathway for sound to travel from the outer ear to the inner ear. • An important role of the middle ear is overcoming the impedance mismatch between the air and fluid in the middle ear. - The Inner Ear • Like the middle ear, the inner ear resides in a hollowed out portion of the temporal bone. • The inner ear consists of a series of inter connected cavities known as the bony or osseous labyrinth. • The osseous labyrinth is divided into three distinct areas: - The cochlea - Vestibule - Semicircular canals • The cochlea is a coiled tube that houses the membranous labyrinth and basilar membrane. - The basilar membrane is a thin ribbon of tissue. One edge is attached to a lip of bone called the osseous spiral lamina. • • The other edge is supported by the spiral ligament. - The basilar membrane is stiff at one end and loose at the other so it doesn’t move in unison. • This pattern is called the traveling wave. • The cochlea performs another function that is essential to hearing, it converts mechanical energy to electrical energy. • The process of converting that energy is called transduction and is accomplished by hair cells which rest of the basilar membrane. 24 • The bottom of the hair cells are rooted in the basilar membrane while their tips are embedded in the tectorial membrane. - The Auditory Nervous System • Sound is now in an electrochemical form that can be interpreted by the brain. • Information is transmitted from the cochlea by the auditory nerve, through the brainstem, then the midbrain, and finally to the auditory cortex. - The eighth nerve, which consists of approximately 30,000 neurons, carries the electrochemical impulses through this channel. • Information is not transmitted directly to the brain by the eighth nerve. - Parallel neural pathways run on both sides of the head. 25 - Chapter 14 Hearing Disorders • Hearing Loss - The impact that hearing loss has on daily life is influenced by the age of onset, severity of the loss and other factors specific to the individual. - For infants and young children the loss can interfere with typical development of speech, language and social skills. - However hearing loss is not always present at birth. - Adults can acquire hearing loss at any age. - Hearing loss varies in configuration and severity from person to person. - Difficulties can leas individuals with hearing loss to withdraw from activities in their normal lives. • Hearing tests - Audiologist receive specialized training in graduate school to learn how to perform and interpret the tests used to diagnose hearing loss. - The type of hearing loss is determined by identifying which part or parts of the ear are involved. - A rudimentary knowledge of the anatomy and physiology of the ear is needed to recognize how the different tests contribute to defining the type of loss. - Sound Pathways • Sound travels through the air as a series of waves, with their respective compressions and refractions. • Those sounds reaching the head are gathered by the pinna and carried down the EAM to the tympanic membrane. • The cochlea acts as a microphone to convert mechanical energy into electrical energy that is then sent to the brain. - People do not hear with their ears but with their brains; the ear is just a means of enabling hearing. • Sound energy could also reach the inner ear by vibrating the bones of the skull with bone conduction to bypass the conductive mechanism. - Measurement References for Decibels • Hearing levels are measured with an audiometer. • The audiometer uses dBs to introduce the concept of hearing level. • Whereas SPL (sound-pressure level) has a specific intensity reference, HL refers to the intensity necessary to evoke a threshold response from persons with normal hearing. • Any threshold greater that 15 dB HL is considered to demonstrate a hearing loss by air conduction, bone conduction or both. - Pure-Tone Audiometry • Pure-tone air and bone conduction testing is performed for each ear individually using an audiometer to determine hearing thresholds at different frequencies measured in Hertz. 26 • The frequencies that are generated are usually available at octave intervals aver a wide frequency range. • This type of testing is completed in a sound-treated booth and is a behavioral test. - Behavioral hearing thresholds can typically be obtained at approximately 6 months of age. • Air conduction thresholds provide information about the degree of hearing loss. - When they are obtained in conjunction with bone conduction thresholds, the type of hearing loss can be determined. • Hearing sensitivity is displayed on an audiogram - Audiograms are inverted, meaning larger numbers are near the bottom and lower are near the top. • Audiologists plot where the horizontal and vertical axes intersect to show the patient’s threshold for each frequency for each ear by both types of conduction. - Right ear is in red and shown using a circle - Left ear is in blue and shown using an X • Sound can cross-over to the other ear when hearing is not symmetrical and when bone conduction testing is being performed. - Speech Audiometry Hearing loss not only results in difficulty hearing certain sounds because of reduced audibility, • but also can affect the clarity of sounds. - The speech recognition threshold (SRT) assesses how intense speech must be to be audible. - The word recognition score (WRS) assesses how well speech can be discriminated when loud enough to be heard. • STRs are customarily measured using two-syllable words called spondees, where both syllables are uttered with the same stress. • Most clinicians measure WRS using lists of 50 one-word syllable phonetically balanced words, so called because they contain all the phonemes of the language with their approximate frequencies in connected discourse. - WRSs are measured in percentages rather than in dBs. - People with normal hearing usually have very high WRSs. • People with conductive hearing loss usually have high WRSs.
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