Language and Communication Skills (SPED 3164)
2. Disorders of Communication and Dysphagia
2.1. Disorders of Speech: Dysfluency, Dysphasia, Articulation and Phonological Disorders, Cleft
Lip and Palate, Voice Disorders
2.2. Disorder of Speech of Neurogenic Origin: Dyspraxia, Dysarthria
2.3. Disorders of Language: Language Delay and Deviance, Specific Language Impairment
2.4. Disorders of Language of Neurogenic Origin: Childhood Aphasia, Aphasia, Dementia, TBI
2.5. Feeding and Swallowing Disorders
Disorders of Speech
Speech disorders affect the way a person talks. A person with a speech disorder usually knows exactly
what they want to say and what is appropriate for the situation, but they have trouble producing the
sounds to communicate it effectively. Speech disorders include a variety of conditions that affect
children and adults alike. They can range from trouble pronouncing a specific letter or sound to the
inability to produce any understandable speech. Some are the result of a physical deformity. Others are
the result of damage to the speech mechanism (larynx, lips, teeth, tongue, and palate) caused by injury
or diseases, such as cancer. Often the cause of a speech disorder is not known.
Dysfluency: Dysfluency" is any break in fluent speech. Everyone has dysfluencies from time to time.
"Stuttering" is speech that has more dysfluencies than is considered average.
Dysfluency occurs when the normal flow and smooth delivery of speech are disrupted. Often, normal
speech dysfluencies, such as silent pauses and non-lexical vocalizations (e.g., “uh” or “um”), can
usefully add emphasis or draw attention to the content of upcoming utterances. In some people speech
dysfluencies are pathological and interfere with speech communication to such an extent that a fluency
disorder is diagnosed. The most commonly diagnosed fluency disorder is developmental stuttering,
which is distinguished from acquired or neurogenic stuttering that is associated with brain disease or
injury.
Stuttering: Stuttering, also known as stammering, the most common fluency disorder, is an
interruption in the flow of speaking characterized by repetitions (sounds, syllables, words,
phrases), sound prolongations, blocks, interjections, and revisions, which may affect the rate
and rhythm of speech. Stuttering is often accompanied by tension and anxiety, negative
reactions, secondary behaviors, and avoidance of sounds, words, or speaking situations.
Stuttering is often more severe when there is increased pressure to communicate (e.g.,
competing for talk time, giving a report at school, interviewing for a job). Social settings and
high-stress environments can increase the likelihood that a person will stutter. Public speaking
can be challenging for those who stutter.
Symptoms of Stuttering: Stuttering is characterized by repeated words, sounds, or
syllables and disruptions in the normal rate of speech. For example, a person may repeat the
same consonant, like “K,” “G,” or “T.” They may have difficulty uttering certain sounds or
starting a sentence.
Signs and symptoms of stuttering include primary behaviors, such as
•
Monosyllabic whole-word repetitions (e.g., "why-why-why did he go there?")
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Part-word or sound/syllable repetitions
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Prolongations of sounds
•
Audible or silent blocking (filled or unfilled pauses in speech)
•
Words produced with an excess of physical tension or struggle
Secondary, avoidance, or accessory behaviors that may impact overall communication
include
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Physical changes like facial tics, lip tremors, excessive eye blinking, and tension in the face and
upper body, jaw tightening.
•
Frustration when attempting to communicate
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Hesitation or pause before starting to speak
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Refusal to speak
•
Distracting sounds (e.g., throat clearing, insertion of unintended sound)
•
Head movements (e.g., head nodding)
•
Movements of the extremities (e.g., leg tapping, fist clenching)
•
Sound or word avoidances (e.g., word substitution, insertion of unnecessary words,
circumlocution)
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Reduced verbal output due to speaking avoidance
•
Avoidance of social situations
•
Fillers to mask moments of stuttering. Interjections of extra sounds or words into sentences,
such as “uh” or “um”
Cluttering: Cluttering is a fluency disorder characterized by a rapid and/or irregular speaking
rate, excessive disfluencies, and often other symptoms such as language or phonological errors and
attention deficits. Cluttering involves excessive breaks in the normal flow of speech that seem to
result from disorganized speech planning, talking too fast or in spurts, or simply being unsure of
what one wants to say. In cluttering, the breakdowns in clarity that accompany a perceived rapid
and/or irregular speech rate are often characterized by deletion and/or collapsing of syllables (e.g.,
"I wan watevision") and/or omission of word endings (e.g., "Turn the televise off"). The
breakdowns in fluency are often characterized by more typical disfluencies (e.g., revisions,
interjections) and/or pauses in places in sentences not expected grammatically, such as "I will go to
the/store and buy apples".
Signs and symptoms of cluttering include
•
Rapid and/or irregular speech rate;
•
Excessive coarticulation resulting in the collapsing and/or deletion of syllables and/or word
endings;
•
Excessive disfluencies, which are usually of the more nonstuttering type (e.g., excessive
revisions and/or use of filler words, such as "um");
•
Pauses in places typically not expected syntactically;
•
Unusual prosody (often due to the atypical placement of pauses rather than a "pedantic"
speaking style, as observed in many with ASD).
Dysphasia: Dysphasia is an acquired disorder of spoken and written language (Greek: dys-,
disordered; phasis, utterance). Dysphasia is a type of disorder where a person has difficulties
comprehending language or speaking due to some type of damage in the parts of the brain responsible
for communication. The symptoms of dysphasia vary based on the region of the brain that was
damaged. There are different regions responsible for understanding language, speaking, reading, and
writing, though typically they are found in the left side of the brain. Sometimes dysphasia is also
referred to as aphasia, though generally it's considered a less severe version of aphasia.
Types and Symptoms: There are different categories of dysphasia, separated based on their symptoms.
Receptive Dysphasia: Receptive dysphasia results from lesions in Wernicke's area. Speech is fluent
but makes little sense, consisting of word fragments, substitutions and neologisms (nonsense words).
Since comprehension is affected, patients may be unaware of their own errors.
People with receptive dysphasia have difficulties comprehending or receiving language. Imagine this
form of dysphasia as feeling like people are always speaking to you in a foreign language. That would
be so frustrating! Sometimes it can be easier to break sentences down into short, simple segments to
prevent overwhelming the person with dysphasia, and it can also help to communicate in places
without background noise or distractions. A person with receptive dysphasia may also have trouble
reading out loud, whether the material was written by them or someone else, and they may forget
information quickly.
Expressive Dysphasia: Lesions involving Broca's area cause expressive dysphasia, which is nonfluent. Speech is hesitant, fragmented and ‘telegraphic’, with word-finding difficulty and a paucity of
grammatical elements such as verbs and prepositions. Since comprehension is relatively spared,
patients tend to become frustrated as they struggle to express themselves.
People with expressive dysphasia have trouble expressing themselves in words. Some people with this
form of dysphasia may not be able to verbally speak or communicate at all. Or, if they can speak, they
may have trouble finding the right word they want to use or may accidentally use the opposite word of
the one they’re looking for, or may not make sense at all, but not realize it. In addition to verbal
communication, they may also struggle with reading and writing. Imagine having clear thoughts that
you can’t effectively communicate to the outside world. In many cases, this is what having expressive
dysphasia feels like.
Mixed Dysphasia or Global Dysphasia: A combination of receptive and expressive features is called
global dysphasia (or aphasia). Specific problems repeating sentences (e.g. ‘no ifs, ands or buts’)
despite normal fluency and comprehension. People with mixed dysphasia suffer from the symptoms of
both receptive and expressive dysphasia. They experience multiple complications understanding
language and communicating successfully. They can have trouble receiving information and
expressing information and it can affect both verbal and nonverbal communication.
Articulation and Phonological Disorders: Speech sound disorders may be subdivided into
two primary types, articulation disorders (also called phonetic disorders) and phonemic disorders (also
called phonological disorders).
Articulation Disorders: Articulation disorders (also called phonetic disorders, or simply "artic
disorders" for short) are based on difficulty learning to physically produce the intended phonemes.
Articulation disorders have to do with the main articulators which are the lips, teeth, alveolar ridge,
hard palate, velum, glottis, and the tongue. If the disorder has anything to do with any of these
articulators, then it is an articulation disorder. There are usually fewer errors than with a phonemic
disorder, and distortions are more likely (though any omissions, additions, and substitutions may also
be present). They are often treated by teaching the child how to physically produce the sound and
having them practice its production until it (hopefully) becomes natural. Articulation disorders should
not be confused with motor speech disorders, such as dysarthria (in which there is actual paralysis of
the speech musculature) or developmental verbal dyspraxia (in which motor planning is severely
impaired).
In children with no associated condition, articulation disorders may be treatable with speech therapy.
In individuals who have trouble articulating due to another condition, the prognosis of that condition
will likely affect their progress in correcting their disordered articulation.
Errors produced by children are typically classified into four categories:
Omissions/Deletion: certain sounds are not produced. Entire syllables or classes of sounds may be
deleted; e.g., fi' for fish or 'at for cat, “p_ay” for “play”; “_top” for “stop”
Additions (or Epentheses/Commissions): insert an extra sound within a word. Examples: “buhlue”
for “blue”; “doguh” for “dog” puh-lane for plane.
Distortions: Sounds are changed slightly so that the intended sound may be recognized but sounds
"wrong," or may not sound like any sound in the language or produce a sound in an unfamiliar manner.
Examples: “cao” for “car”.
Substitutions: One or more sounds are substituted for another or replacing one sound with another
sound e.g., wabbit for rabbit or tow for cow. “wed” for “red”; “thun” for “sun”; “sot” for “sock”; “baf”
for “bath”
Phonological Disorder or Phonemic Disorders: In a phonemic disorder (also called a
phonological disorders) the child is having trouble learning the sound system of the language, failing to
recognize which sound-contrasts also contrast meaning. For example, the sounds /k/ and /t/ may not be
recognized as having different meanings, so "call" and "tall" might be treated as homophones, both
being pronounced as "tall." This is called phoneme collapse, and in some cases many sounds may all
be represented by one e.g., /d/ might replace /t/, /k/, and /g/. As a result, the number of error sounds is
often (though not always) greater than with articulation disorders and substitutions are usually the most
common error.
Or Phonological disorder is a type of speech disorder known as an articulation disorder. Children
with phonological disorder do not use some or all the speech sounds expected for their age group.
Phonological processes are patterns of sound errors that typically developing children use to simplify
speech as they are learning to talk. A phonological disorder occurs when phonological processes
persist beyond the age when most typically developing children have stopped using them or when the
processes used are much different than what would be expected.
Three types of phonological process
Substitution Processes: when one class of sounds is replaced for another class of sounds.
Syllable Structure Processes: sound changes that modify the syllabic structure of words.
Assimilation Processes: one sound changes to become more like another sound, usually its
neighboring sound.
Cleft: A cleft is an abnormal opening or a fissure in an anatomical structure that is normally closed?
Cleft Palate: Cleft palate is a condition in which the two plates of the skull that form the hard
palate (roof of the mouth) are not completely joined. The soft palate is in these cases cleft as well. In
most cases, cleft lip is also present. A cleft of the lip and/or palate is a congenital condition (present at
birth due to either an inherited condition or something that occurred during the pregnancy).
Types of Cleft Palate:
Incomplete cleft palate: A cleft in the back of the mouth in the soft palate.
Complete cleft palate: A cleft affecting the hard and soft parts of the palate. The mouth and nose
cavities are exposed to each other.
Submucous cleft palate: A cleft involving the hard and/or soft palate, covered by the mucous
membrane lining the roof of the mouth. May be difficult to visualize.
Complete Cleft Palate
A "complete" cleft involves the entire primary and secondary palates. It extends from the uvula all the
way into the alveolar ridge. It involves both the primary palate and secondary palate. A complete cleft
palate can be unilateral or bilateral. If the cleft palate is bilateral, both sides may be complete, or one
side may be complete, and the other side may be incomplete.
Problems associated with Clef Palate
Feeding: Feeding difficulties may occur in newborns with cleft lip and/or palate as the normal
anatomy of the mouth is disrupted. Each baby is different in their ability to feed. In the presence of a
cleft lip, the child may be unable to form a seal around the nipple of a bottle. Children with cleft
palates have difficulty in generating suction because of the opening between the mouth and the nose.
Speech: Children with unrepaired cleft palates will have speech difficulties. Normal speech is the goal
of surgery. Many children will require speech therapy after the operation, and some may need a second
procedure if speech difficulties persist.
Cleft Lip: Cleft Lip: Cleft Lip is a visible gap or narrow opening on one or both sides of the upper
lip that extend all the way to the base of the nose. When the upper lip is short and/or the premaxilla is
protrusive, there may be bilabial incompetence, which is the inability to close the lips naturally at rest.
If lip closure is difficult to accomplish at rest, it makes sense that there will also be difficulties with the
production of bilabial sounds (/p/, /b/, /m/) with speech. As a result, the individual may compensate by
producing these sounds with labiodental placement. This usually results in little auditory distortion but
can be visually distracting to the listener.
Voice: Voice is the ability to make sounds by vibrating the vocal cords. The buzzing sound made by
the vibrating vocal cords is called the voice. Air from the lungs moves up through the windpipe
(trachea) and between the vocal cords inside the voice box (larynx). The larynx is that part which
forms the bulge in the front of our necks which is sometimes called the ‘Adam’s apple’. Inside the
larynx are two strips of tissue called the vocal folds or vocal cords. As the air from the lungs pushes
upwards and passes between the vocal folds they vibrate. They move backwards and forwards
extremely quickly, releasing small puffs of air up into the throat. This creates a buzzing sound or voice.
The air moving upwards through the throat can escape in one of two ways either through the oral
cavity and out of the mouth, or through the nasal cavity and out of the nose. These cavities act like
amplifiers, making the voice louder.
If the vocal folds in the larynx did not vibrate normally, speech could only be produced as a whisper.
There are three vocal characteristics: frequency, intensity, and phonatory quality.
Effective voice production involves at least three things:
1. An appropriate breathing technique to provide the air support required to produce speech
(diaphragmatic breathing)
2. Easy onset of the vibration of the vocal folds when speaking
3. Projecting the voice effortlessly without any strain or pushing
Voice Disorders: Disorders of the voice involve problems with pitch, loudness, and quality. Pitch
is the highness or lowness of a sound based on the frequency of the sound waves. Loudness is the
volume (or amplitude) of the sound, while quality refers to the character or distinctive features of a
sound. Many people who have normal speaking skills have great difficulty communicating when their
vocal apparatus fails. This can occur if the nerves controlling the larynx are impaired because of an
accident, a surgical procedure, a viral infection, or cancer.
Abnormalities or changes in the vibratory system result in voice disorders. Voice disorders refer to
breakdowns in the vibratory system. Breakdowns can affect any one or all the three subsystems of
voice production.
Air Pressure System: If the airflow source is weak or inefficient (making it difficult to push enough
air out of lungs), the voice will be weak and hampered by shortness of breath. For example: Patients
with asthma, lung cancer, emphysema and other lung conditions often find it difficult to speak loud or
for long periods of time.
Vibratory System: Any compromise or change to vocal fold vibration causes hoarseness and other
voice symptoms. For example: Patients with stiffness in the vocal folds from swelling from a common
cold develop hoarseness. For example: When focal folds cannot come perfectly together from partial
nerve input loss, air leak occurs, and the voice is "breathy."
Resonating System or Vocal Tract: A breakdown of the vocal tract can affect voice quality. For
example, when nasal passageways are swollen and inflamed during the "common cold," the voice
takes on a nasal quality.
The result of impairment may be that one or more acoustic features are affected.
Pitch Disorders: If the mass of the vocal folds (vocal cords) is increased, then the pitch of the voice
will be too low. This could occur briefly, for example, because of a heavy cold in which there is an
excessive buildup of mucous on the vocal folds. Growths on the vocal folds, such as vocal nodules or
polyps, will lead to the pitch being too low over an extended period.
If the vocal folds are held under too much tension, then the pitch will likely be too high. Similarly,
variable tension in the vocal folds will lead to the pitch being unstable and possibly lead to pitch breaks.
Monopitch: A voice that lacks normal inflectional variation and to change pitch voluntarily
Inappropriate pitch: A voice judged to be outside the normal range of pitch for age and/or gender
Pitch breaks: Sudden, uncontrolled changes in pitch
Loudness Disorders: Forcing air from the lungs through the larynx with excessive pressure can lead
to the voice sounding too loud. This is increased if the vocal folds are also held with excessive tension.
Insufficient air pressure passing up through the larynx, together with weak vocal fold tension, creates a
voice that is too quiet. Variable vocal fold tension and/or variable air pressure can lead to breaks in
loudness.
Monoloudness: A voice that lacks normal variations of intensity and the inability to change vocal
loudness voluntarily
Loudness Variation: Extreme variations in vocal intensity in which the voice is either too soft or
too loud
Resonance Disorder: Resonance refers to the way airflow for speech is shaped as it passes through
the oral (mouth) and nasal (nose) cavities. During speech, the goal is to have good airflow through the
mouth for all speech sounds except m, n, and ng. To direct air through the mouth, the soft palate (back
part of the roof of the mouth) lifts and moves toward the back of the throat. This movement closes the
velopharyngeal valve (opening between the mouth and the nose). See the diagram below.
A resonance disorder occurs when there is an opening, inconsistent movement, or obstruction that
changes the way the air flows through the system. Structural and functional impairments that affect the
hard or soft palate typically create hypernasality. The voice is said to be hypernasal because too much
air escapes through the nose when speaking. There is excessive nasality. In some instances, the
escaping air creates an audible sound known as nasal escape or nasal emission. A cleft palate or
neurological weakness affecting the movements of the soft palate are two conditions that may result in
hypernasal resonance.
Any condition which obstructs the airways above the larynx typically results in hyponasality. In
contrast to hypernasality, the voice is hyponasal (i.e. lacking nasality) because insufficient air escapes
through the noise when speaking. Most of us will have experienced hyponasality at some time when
we have had a heavy cold or flu which has resulted in a blocked nose. Other conditions such as
growths in the nasal cavity (e.g. nasal polyps) may result in hyponasal resonance.
Hyper-Nasality: Too much sound coming from the nose during speech.
Hypo-Nasality: Hyponasal speech, denasalization or rhinolalia clausa is a lack of appropriate nasal
airflow during speech, such as when a person has nasal congestion. Some causes of hyponasal
speech are adenoid hypertrophy, allergic rhinitis, deviated septum, sinusitis, myasthenia gravis.
Cul-de-Sac Resonance: Airflow through the mouth is obstructed, often by enlarged tonsils,
resulting in a “muffled” speech quality.
Quality Disorders: Any conditions which disrupt the regular vibration of the vocal folds will likely
lead to changes in quality. The noise that we perceive in someone’s voice because of disorganized
vocal fold vibrations is known as hoarseness.
Inadequate closure of the glottis (the space between the vocal folds) results in a breathy voice. Muscle
weakness because of multiple sclerosis or Parkinsonism may result in breathiness.
If the vocal folds are squeezed together with excessive force "hyperadduction" then the voice
acquires a typically creaky or harsh quality. As well as neurological conditions such as cerebral palsy,
general muscle tension and anxiety states can lead to harsh voice.
In contrast to hyperadduction, if the vocal folds do not come together (adduct) at all then the voice is
whispered. Paralysis of the recurrent laryngeal nerves of the larynx can lead to this condition. If the
failure to fully adduct the vocal folds is intermittent, then the whispery voice comes and goes as some
stretches of talk are voiced and others are voiceless.
Hoarseness/Roughness: A voice that lacks clarity and is noisy. Hoarseness is most often caused
by beign conditions, such as a cold, sore throat or vocal over use and usually goes away on its own.
Hoarseness that persists for several weeks may represent a more serious problem that requires
medical and therapeutic attention.
Harshness: is due to the very strong tension of the vocal folds (especially medial compression and
adductive tension), which results in an excessive approximation of the vocal folds. When the whole
larynx is subjected to this extremely high tension, the upper larynx becomes highly constricted
with the ventricular folds pressing on the upper surfaces of the vocal folds, making their vibration
ineffective.
Breathy Voice: The perception of audible air escaping thru the glottis during phonation. Muscular
tension is low, with minimal adductive tension, weak medial compression and medium longitudinal
tension of the vocal folds. Vocal fold vibration is inefficient, and, because of the incomplete
closure of the glottis, a constant glottal leakage occurs which causes the production of audible
friction noise. Air flows through the vocal folds at a high rate.
Strain and Struggle: related to problems with initiating and maintaining voice.
Flexibility: Flexibility refers to the ability to effortlessly vary paralinguistic features (particularly of
pitch and loudness) to create an interesting and colorful voice capable of expressing a range of
intellectual and emotional meanings. Consequently, conditions which limit variations in the pressure of
the airflow through the larynx, the tension of the vocal folds, the strength of adduction and/or the
lengthening and shortening of the vocal folds through rotational and sliding movements of the
arytenoid cartilages can lead to reduced flexibility.
Nonphonatory Vocal Disorders
Stridor: noisy breathing or involuntary sounds that accompany inspiration and expiration
Consistent Aphonia: a persistent absence of voice perceived as whispering
Aphonia: uncontrolled and unpredictable aphonic breaks in voice
Aphonia: Aphonia refers to an inability to produce voice naturally (i.e., due to physical impairment)
and/or inability to produce voice by using a speech prosthesis (e.g., Passy-Muir valve, electrolarynx,
tracheoesophageal puncture) due to physical disability or absence of larynx.
Dysphonia: is a descriptive medical term meaning disorder (dys-) of voice (-phonia). There are many
causes of dysphonia. Fortunately, more than half of people with voice complaints have a benign (noncancerous) cause.
Functional Aphonia: It is common amongst women aged between puberty and age 40 and causes a
high degree of breathy hoarseness, whispery voice, and aphonia during intentional vocalization, such
as in conversations. Glottal closure is insufficient, and because aspirated air flows out of the glottal gap,
the vocal cords do not vibrate. Although no voiced sound is produced during vocalization, a voiced
sound is often produced when the patients cries, laughs, or coughs.
Hypotonic Voice Disorders: These conditions produce a very weak, faint voice. If the airflow rate
decreases due to vocalization muscle fatigue caused by psychosomatic factors, voice misuse, and/or
respiratory organ disease, subglottal pressure does not rise, causing asthenic hoarseness. These
conditions occur in neurological/muscular disorders such as myasthenia gravis and muscular dystrophy.
Conversion Voice Disorders: Any loss of voluntary control over normal voice muscle or a
consequence of environmental stress or interpersonal conflict. This disorder exists when there is
psychological trauma. In the case of conversion dysphonia or aphonia (complete loss of voice), there
may be a single traumatic event such as an accident, death, or psychologically damaging event, and
there is change of voice within a short time. Or, there may be a long term psychologically damaging
circumstance, such as sexual abuse, that may be manifested soon or many years later. In the case of
conversion disorder, the individual may undergo functional voice therapy to gain control over his or
her voice, but in most cases the voice disorder will not resolve unless there is also psychotherapy to
address the underlying problem.
Conversion Dysphonia: Characterized by an unreliable voice, Unpredictable pitch, amplitude, etc.
for examples breathy vs normal quality, high vs low pitch, loud vs soft voice.
Conversion Aphonia: Involuntary whispering despite a normal larynx, Gradual or sudden onset,
can be triggered by an organic disorder, Psychotherapy often recommended. Approximately 80%
of patients with conversion aphonia are female
Conversion Mutism/Muteness: Most severe of conversion voice disorders. Patient makes no
attempt to phonate or articulate or may articulate without exhalation.
Common causes are patient history
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Wanting, but not allowing oneself, to express an emotion verbally (such as fear, anger, or
remorse)
•
A breakdown in communication with someone of importance to the patient
•
Shame or fear getting in the way of expressing feelings through normal speech and language
Mutational Falsetto/Puberphonia: Failure to change from higher-pitched voice of preadolescence to
lower-pitched voice of adolescence and adulthood. Male child or adolescent exhibits inappropriately
high voice. This disorder exists when there is some psychological reason for an individual to resist the
maturing and lowering pitch of the adult voice and maintains the higher pitch of a preadolescent. This
disorder is much more common in adolescent males but can also exist in females.
Juvenile Voice: Female companion to mutational falsetto, women maintains a child-like voice into
adulthood.
Spasmodic Dysphonia: Spasmodic dysphonia (SD), a focal form of dystonia, is a neurological voice
disorder that involves involuntary "spasms" of the vocal cords causing interruptions of speech and
affecting the voice quality.
Adductor Spasmodic Dysphonia: This is the most common type, and this affects the muscle that lies
within the vocal folds, the thyroarytenoid muscle, it contracts strongly, but then spasms. The vocal
folds squeeze together very tightly, causing a strained, strangled and harsh voice with voice arrests
(stopping of the voice). Spasmodic Dysphonia causes an intermittent excessive closing of the vocal
folds during vowel sounds in speech.
Abductor Spasmodic Dysphonia: This causes the muscle that brings the vocal folds together or the
cricoarytenoid muscle to contract suddenly. This produces a breathy voice and a lot of excess air
coming out of the vocal folds. This is the less common form of Spasmodic Dysphonia. While in
abductor Spasmodic Dysphonia, there is a prolonged vocal-fold opening during voiceless consonants.
Mixed Spasmodic Dysphonia: This is when both types of spasms appear during speech, adductor and
abductor in which an individual may demonstrate both types of spasms as he/she speaks. This is the
rarest form of these three types.
Disorder of Speech of Neurogenic Origin
Dyspraxia: Dyspraxia refers to trouble with movement. That includes difficulty in four key skills:
•
Fine motor skills
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Gross motor skills
•
Motor planning
•
Coordination
Dyspraxia is a brain-based motor disorder. It affects fine and gross motor skills, motor planning, and
coordination. It’s not related to intelligence, but it can sometimes affect cognitive skills. Dyspraxia is
sometimes used interchangeably with developmental coordination disorder. Children born with
dyspraxia may be late to reach developmental milestones. They also have trouble with balance and
coordination. Into adolescence and adulthood, symptoms of dyspraxia can lead to learning difficulties
and low self-esteem. Dyspraxia is a lifelong condition. There’s currently no cure, but there are
therapies that can help you effectively manage the disorder.
Dyspraxia Symptoms in Children: If your baby has dyspraxia, you might notice delayed milestones
such as lifting the head, rolling over, and sitting up, though children with this condition may eventually
reach early milestones on time.
Other signs and symptoms can include:
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Unusual body positions
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General irritability
•
Sensitivity to loud noises
•
Feeding and sleeping problems
•
A high level of movement of the arms and legs
As child grows, you might also observe delays in:
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Crawling
•
Walking
•
Potty training
•
Self-feeding
•
Self-dressing
Dyspraxia makes it hard to organize physical movements. For example, a child might want to walk
across the living room carrying their schoolbooks, but they can’t manage to do it without tripping,
bumping into something, or dropping the books.
Other signs and symptoms may include:
•
Unusual posture
•
Difficulty with fine motor skills that affect writing, artwork, and playing with blocks and
puzzles
•
Coordination problems that make it difficult to hop, skip, jump, or catch a ball
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Hand flapping, fidgeting, or being easily excitable
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Messy eating and drinking
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Temper tantrums
•
Becoming less physically fit because they shy away from physical activities
•
Although intelligence isn’t affected, dyspraxia can make it harder to learn and socialize due to:
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A short attention span for tasks that are difficult
•
Trouble following or remembering instructions
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A lack of organizational skills
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Difficulty learning new skills
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Low self-esteem
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Immature behavior
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Trouble making friends
Dyspraxia Symptoms in Adults: Dyspraxia is different for everyone. There are a variety of potential
symptoms and they can change over time. These may include:
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Abnormal posture
•
Balance and movement issues, or gait abnormalities
•
Poor hand-eye coordination
•
Fatigue
•
Trouble learning new skills
•
Organization and planning problems
•
Difficulty writing or using a keyboard
•
Having a hard time with grooming and household chores
•
Social awkwardness or lack of confidence
Dyspraxia has nothing to do with intelligence. If you have dyspraxia, you may be stronger in areas
such as creativity, motivation, and determination. Each person’s symptoms are different.
Dyspraxia Causes: The exact cause of dyspraxia isn’t known. It could have to do with variations
in the way neurons in the brain develop. This affects the way the brain sends messages to the rest of
the body. That could be why it’s hard to plan a series of movements and then carry them out
successfully.
Dyspraxia Risk Factors: Dyspraxia is more common in males than females. It also tends to run
in families.
Risk factors for developmental coordination disorders may include:
•
Premature birth
•
Low birth weight
•
Maternal drug or alcohol use during pregnancy
•
A family history of developmental coordination disorders
It’s not unusual for a child with dyspraxia to have other conditions with overlapping symptoms. Some
of these are:
•
Attention deficit hyperactivity disorder (ADHD), which causes hyperactive behaviors,
difficulty focusing, and trouble sitting still for long periods
•
Autism spectrum disorder, a neurodevelopmental disorder that interferes with social interaction
and communication
•
Childhood apraxia of speech, which makes it difficult to speak clearly
•
Dyscalculia, a disorder that makes it hard to understand numbers and grasp concepts of value
and quantity
•
Dyslexia, which affects reading and reading comprehension
Dysarthria: Speech is a unique, complex, dynamic motor activity through which human express
thoughts and emotions and respond to and control the environment. Speech is among the most
powerful tools possessed by human beings and it contributes enormously to the character and quality
of lives. Speech requires the integrity and integration of numerous neurocognitive, neuromotor,
neuromuscular, and musculoskeletal activities. The combined processes of speech motor planning,
programming, control and execution are referred to as motor speech processes.
Dysarthria can develop at any age, many of those who suffer from dysarthria are young children.
Because of this motor speech disorder, children with dysarthria have difficulty controlling the muscles
that control speech, such as the lips, jaws, tongue, larynx, and respiratory muscles. This prevents them
from speaking clearly and can result in an inability to raise the volume of speech, involuntary
mumbling, slurred speech, speech that is unusually fast or slow, or speech that lacks normal rhythm
and intonation.
Dysarthria is a collective name for a group of neurologic speech disorders that reflect abnormalities in
the strength, speed, range, steadiness, tone, or accuracy of movements required for the breathing,
phonatory, resonatory, articulatory, or prosodic aspects of speech production.
This definition explicitly recognizes the following:
•
Dysarthria is neurologic in origin.
•
It is a disorder of movement.
•
It can be categorized into different types, each type characterized by distinguishable perceptual
characteristics and different causes.
Classification of Dysarthria: The order of the distinctive sorts of dysarthria involves Ataxic
Dysarthria, Flaccid Dysarthria, Hyperkinetic Dysarthria, Hypokinetic Dysarthria, Mixed Dysarthria,
Spastic Dysarthria and Unilateral Upper Motor Neuron Dysarthria. Each one of these dysarthria’s has
its own pathogenesis.
Ataxic Dysarthria: Ataxic dysarthria a type of motor speech disorder; its neuropathology is associated
with cerebellar or cerebellar pathway lesions. The 10 abnormal language characteristics of ataxic
dysarthria can be separated into three bunches: articulatory mistake, portrayed by imprecision of
consonant creation, irregular articulatory breakdowns, and distorted vowels; prosodic abundance,
described by excess and equivalent stress, prolongation of phonemes, delayed interims, and slow rate;
and phonatory-prosodic deficiency, described by harshness, mono pitch, and mono loudness.
Flaccid Dysarthria: Flaccid dysarthria is a perceptually distinct gathering of MSDs created by
damage or sickness of one or more cranial or spinal nerves that supply speech muscles (lower motor
neuron involvement) or lower motor neuron (LMN) pathways. They might be show in any or the
greater part of the respiratory, phonatory, resonatory, and articulatory segments of language. The
speech qualities can be followed to muscle weakness and diminished muscle tone, and their
consequences for the speed, range and exactness of speech movements. Flaccidity (hypotonia) and
weak muscle contractions and hypotonia are predominant neurological indications.
Hyperkinetic Dysarthria: Hyperkinetic dysarthria a type of motor speech disorder; its
neuropathology is damage to basal ganglia (extrapyramidal system), resulting in rapid involuntary
movements and variable muscle tone; may affect all aspects of speech, but a dominant symptom is rate
and prosodic disturbances; specific problems include prolonged intervals, variable rate, mono pitch,
loudness variations, inappropriate silences, imprecise consonants, and distorted vowels; most effective
treatment is medical; various medications help control involuntary movements.
Hypokinetic Dysarthria: Hypokinetic dysarthria a type of motor speech disorder; its neuropathology
is damage to basal ganglia (extrapyramidal system) resulting in slow movement, limited range of
movement, and rigidity. Parkinsonism is the most frequent cause of this type of dysarthria; may affect
all aspects of speech, but especially voice, articulation, and prosody; specific problems include mono
pitch, mono loudness, reduced stress, imprecise consonants, variable rate of speech, increased speech
rate in some cases and a slower rate in a few, short rushes of speech, inappropriate silences, and harsh
and breathy voice. Is like the diminishments in the sufficiency of intentional movement (akinesia),
slowness of movement (bradykinesia), muscular rigidity, tremor at rest.
Mixed Dysarthria: Mixed dysarthria a type of motor speech disorder that is a combination of two or
more pure dysarthria. It is associated with lesions of multiple systems. The neuropathology is varied
depending on the types of dysarthria that are mixed; frequent causes include multiple strokes or
multiple neurological diseases; speech disorders are varied and dependent on the types of pure
dysarthria that are mixed.
Spastic Dysarthria: Spastic dysarthria a kind of motor speech issue brought about by respective harm
to the upper motor neuron (direct and indirect motor pathways). The symptoms of muscular
dysfunction due to interruption of the upper motor neuron supply to the speech musculature that reflect
in the speech output includes spasticity; weakness; restricted range of movement; and slowness of
movement. Spastic dysarthria is show by slow, dragging, labored speech which is delivered with some
difficulty. The most visible language deviations related to spastic dysarthria include: loose consonants,
mono pitch, reduced stress, harsh voice quality, mono loudness, low pitch, slow rate, hyper nasality,
strained, choked voice quality, short expressions, pitch breaks, constant hoarse voice and abundance
and equivalent stress.
Unilateral Upper Motor Neuron Dysarthria: Unilateral upper motor neuron dysarthria a type of
motor speech disorder caused by damage to the upper motor neurons that supply cranial and spinal
nerves involved in speech production; primarily a disorder of articulation in which the dominant
speech problem is imprecise production of consonants; less significant speech symptoms include harsh
voice quality, slow, imprecise, or irregular Alternating Motion Rates; generally slow rate of speech
with increased rate in segments; mild hyper nasality; excess and equal stress.
Causes of Dysarthria (Congenital, Acquired): Many neurologic illnesses, diseases, and
disorders both acquired and congenital can cause dysarthria.
Congenital or Developmental: The neurologic insult takes place at birth or prior to the development
of speech and language.
If a child has dysarthria at a very early age it may be due to birth injury, but it could also be caused by
a congenital disorder. Some baby’s brains develop improperly or incompletely while still in the womb,
and this can be caused by many different factors such as the mother’s diet, use of narcotics,
medications, and other substances that negatively affect the child’s development. A child who has
congenital dysarthria will already have the disorder even before they are born, but it may not be
diagnosable until the child reaches an age when he or she should begin speaking.
Acquired: Acquired: The individual may have developed some speech and language skills prior to
the neurologic insult.
Traumatic Brain Injury: One of the many childhood dysarthria causes is a traumatic brain injury. If a
child suffers blunt force trauma to their head, this can cause serious brain damage that affects their
ability to speak. This can occur at any age, but young children are very vulnerable because they have
less ability to protect themselves. Some traumatic brain injuries occur during birth. When a child is
being born, a large amount of pressure is put on the head by the vaginal walls or cervix. If there are
any complications with the delivery, if it takes an excessive amount of time, the head compression may
be severe enough to affect the brain. In addition, these same types of delivery complications can result
in the child’s brain not receiving enough oxygen, also known as hypoxia. Just a few minutes of oxygen
deprivation can result in lasting brain damage such as childhood dysarthria.
Neurological Conditions: There are numerous neurological conditions that have been identified as
childhood dysarthria causes. One of the leading causes of dysarthria is cerebral palsy. Though not
every child with cerebral palsy will suffer from childhood dysarthria, there is a strong link. Some other
neurological conditions that may cause dysarthria include:
•
Lou Gehrig’s disease
•
Muscular dystrophy
•
Guillain-Barre syndrome
•
Multiple sclerosis
•
Lyme disease
•
Huntington disease
•
Parkinson’s disease
•
Wilson’s disease
•
Myasthenia gravis
In addition to these neurological disorders, strokes and brain tumors are also proven childhood
dysarthria causes. Though strokes are more common in adults and especially those of advanced age,
neonatal strokes have a strong potential to affect the speech centers of the brain and can affect these
areas at a child’s most critical periods of cognitive development. When brain tumors are in the areas of
the brain that control speech and respiratory function, they also have the potential to cause childhood
dysarthria and severe respiratory problems.
Disorders of Language
Disorders of Language: A language disorder can cause issues with the comprehension and/or use
of spoken, written, and other forms of language. Students with a language disorder may struggle with
the form, content, or function of language.
Language disorder is a communication disorder in which a person has persistent difficulties in learning
and using various forms of language (i.e., spoken, written, sign language). Individuals with language
disorder have language abilities that are significantly below those expected for their age, which limits
the ability to communicate or effectively participate in many social, academic, or professional
environments.
Symptoms of language disorder first appear in the early developmental period when children begin to
learn and use language. Language learning and use relies on both expressive and receptive skills.
Expressive ability refers to the production of verbal or gestural signals, while receptive ability refers to
the process of receiving and understanding language. Individuals with language disorder may have
impairments in either their receptive or expressive abilities, or both. Overall, people with this condition
have deficits in understanding and producing vocabulary, sentence structure, and discourse. Because
people with language disorder typically have a limited understanding of vocabulary and grammar, they
also have a limited capacity for engaging in conversation.
Symptoms: Children with language disorder will typically be delayed in learning or speaking their
first words and phrases. When they do speak, their sentences are shorter and less complex than would
be expected for their age. Individuals with language disorder typically speak with grammatical errors,
have a small vocabulary, and may have trouble finding the right word at times. When engaging in
conversation, they may not be able to provide adequate information about the key events they’re
discussing or tell a coherent story. Because children with language disorder may have difficulty
understanding what other people say, they may have an unusually hard time following direction.
It is common for deficits in comprehension to be underestimated, because people with language
disorder may be good at finding strategies to cope with their language difficulties, such as using
context to infer meaning. They may also appear to be shy or reserved, and they may prefer to
communicate only with family members or other familiar people.
Language skills are highly variable in young children, and many children who are late in speaking their
first words or phrases do not develop language disorder. Delayed language acquisition is not predictive
of language disorder until age 4, when individual differences in language ability become more stable.
Language disorder that is diagnosed at age 4 or later is likely to be stable over time and often persists
into adulthood. Although language disorder is present from early childhood, it is possible that the
symptoms won’t become obvious until later in life, when the demands for more complex language use
increase.
There are three different types of language disorders, each with its own set of symptoms. An individual
may have more than one type of language disorder.
Forms of Language: Student struggles with
•
Phonology, or speech sounds and patterns
•
Morphology, or how words are formed
•
Syntax, or the formation of phrases and clauses
Content of Language
•
Student struggles with:
•
Semantics, or the meaning of words
Function of Language
•
Student struggles with:
•
Pragmatics, or how language is used in different contexts
Causes: Communication disorders have a strong genetic component, and individuals with language
disorder are more likely to have family members with a history of language impairment. Language
disorder is also strongly associated with other neurodevelopmental disorders, such as specific learning
disorder (literacy and numeracy), attention-deficit/hyperactivity disorder, autism spectrum disorder,
and developmental coordination disorder.
Language Delay: A language delay is language development that is significantly below the norm
for a child of a specified age.
Language delay is a communication disorder, a category that includes a wide variety of speech,
language, and hearing impairments. The milestones of language development, including the onset of
babbling and a child's first words and sentences, normally occur within approximate age ranges.
However, individual children vary enormously regarding the exact age at which each milestone is
reached. There also are different styles of language development. Most children have acquired good
verbal communication by the age of three. But one child may be wordless until the age of two and a
half and then immediately start talking in three-word sentences. Another child might have several
words at ten months but add very few additional words over the following year. Other children start
talking at about 12 months and progress steadily.
Language delay usually becomes apparent during infancy or early childhood. Any delay in general
development usually causes language delay. Children with language delay may acquire language skills
in the usual progression but at a much slower rate, so that their language development may be
equivalent to a normally developing child of a much younger chronological age. Maturation delay, also
called developmental language delay, is one of the most common types of language delay. Children
with a maturation delay may be referred to as "late talkers" or "late bloomers." Maturation delays
frequently run in families.
Causes and symptoms
Environmental causes: Common nonphysical causes of language delay include circumstances in
which the following are the case:
•
The child is concentrating on some other skill, such as walking perfectly, rather than on
language.
•
The child has a twin or sibling very close in age and thus may not receive as much individual
attention.
•
The child has older siblings who interpret so well that the child has no need to speak or whose
talk is so continuous that the child lacks the opportunity to speak.
•
The child is in a daycare situation with too few adults to provide individual attention.
•
The child is under the care of a non-English speaker.
•
The child is bilingual or multilingual, learning two or more languages simultaneously but at a
slower speed; the child's combined comprehension of the languages is normal for that age.
•
The child suffers from psychosocial deprivation such as poverty, malnutrition, poor housing,
neglect, inadequate linguistic stimulation, emotional stress.
•
The child is abused; abusive parents are more likely to neglect their children and less likely to
communicate with them verbally.
Physical causes: Language delay may result from a variety of underlying disorders, including the following:
•
mental retardation
•
maturation delay (This delay in the maturation of the central neurological processes required to
produce speech is often the cause of late talking.)
•
hearing impairment
•
dyslexia, a specific reading disorder which may cause language delay in preschoolers
•
a learning disability
•
cerebral palsy, in which numerous factors may contribute to language delay
•
autism, a developmental disorder in which, among other things, children do not use language or
use it abnormally
•
congenital blindness, even in the absence of other neurological impairment
•
brain damage
•
Klinefelter syndrome, a disorder in which males are born with an extra X chromosome
•
receptive aphasia or receptive language disorder, a deficit in spoken language comprehension
or in the ability to respond to spoken language, resulting from brain damage
•
expressive aphasia, an inability to speak or write, although comprehension is normal; caused by
malnutrition, brain damage, or hereditary factors
•
childhood apraxia of speech, a nervous system disorder
Mental retardation accounts for more than 50 percent of language delays. Language delay is usually
more severe than other developmental delays in retarded children, and it is often the first noticeable
symptom of mental retardation. Mental retardation causes global language delay, including delayed
auditory comprehension and use of gestures.
Impaired hearing is one of the most common causes of language delay. Any child who does not hear
speech in a clear and consistent manner will have language delay. Even a minor hearing impairment
can significantly affect language development. In general, the more severe the impairment, the more
serious the language delay. Children with congenital (present at birth) hearing impairment or hearing
loss that occurs within the first two years of life (known as prelingual hearing loss) experience serious
language delay, even when the impairment is diagnosed and treated at an early age. However, deaf
children born to parents who use sign language develop infant babble and a fully expressive sign
language at the same rate as hearing children.
Symptoms of language delay: Symptoms of language delay include the following
•
failure to meet the developmental milestones for language development
•
language development that lags behind other children of the same age by at least one year
•
inability to follow directions
•
slow or incomprehensible speech after three years of age
•
serious difficulties with syntax (placing words in a sentence in the correct order)
•
serious difficulties with articulation, including the substitution, omission, or distortion of
certain sounds
Language delays resulting from underlying conditions may have symptoms specific to the condition.
Nonetheless, specific symptoms of language delay may include the following:
•
not babbling by 12 to 15 months of age
•
not understanding simple commands by 18 months of age
•
not talking by two years of age
•
not using sentences by three years of age
•
not being able to tell a simple story by four or five years of age
Symptoms of language delay with mental retardation: Mentally impaired children usually babble
during their first year and may speak their first words within the normal age range. However, they
often cannot do the following:
•
put words together
•
speak in complete sentences
•
acquire a larger, more varied vocabulary
•
develop grammatically
Mentally impaired children in conversation may be repetitive and routine, exhibiting little creativity .
Nevertheless, vocabulary and grammatical development appear to proceed by very similar processes in
mentally retarded and developmentally normal children.
In general, the severity of language delay depends on the severity of the mental retardation. Levels of
retardation and language skill are ranked as follows:
•
mild retardation (intelligence quotient [IQ] range of 52–68): usually eventually develop
language skills
•
moderate retardation (IQ range of 36–51): usually learn to talk and communicate
•
severe retardation (IQ range of 20–35): have limited language but can speak a few words
Language delays among mentally retarded children vary greatly. Some severely mentally impaired
children
who
also
have hydrocephalus or Williams
syndrome may
acquire
exceptional
conversational language skills, sometimes called the "chatterbox syndrome." Some children (called
savants) test as mentally retarded but learn their native language, as well as foreign languages, very
easily. With Down syndrome and some other disorders, language delay is more severe than other
mental impairments. This factor may be due to the characteristic facial abnormalities and relatively
large tongues of Down-syndrome children. Children with Down syndrome also are at higher risk for
hearing impairment and ear infections that cause hearing loss.
Symptoms of language delay with other disorders: Symptoms of language delay in a hearingimpaired child include the following:
•
babbling at an older-than-normal age
•
babbling that is less varied and less sustained
•
first words at age two or older
•
only two-word sentences by age four or five in a profoundly deaf child
Dyslexic children have difficulty separating parts of words and single words within a group of words.
Symptoms of dyslexia may include:
•
poor articulation
•
difficulties identifying sounds within words, blending sounds, or rhyming
•
difficulty putting sounds in the correct order
•
hesitation in choosing words
A learning-disabled child usually exhibits an uneven pattern of language development. In addition,
about 50 percent of autistic children never learn to speak. Those who do speak often have severe
language delay and may use words in unusual ways. They rarely participate in interactive dialogue and
often speak with an unusual rhythm or pitch. The speech of some autistic children has an atonic or
sing-song quality.
Children with congenital blindness average about an eight-month delay in speaking words. Although
blind children develop language in much the same way as sighted children, they may rely more on
conversational formulas.
The speech of children with receptive aphasia is both delayed and sparse, ungrammatical, and poorly
articulated. Children with expressive aphasia fail to speak at the usual age although they have normal
speech comprehension and articulation. Children with defined lesions in language areas on either side
of the brain have initial but quite variable language delays. Usually their language catches up by the
age of two or three without noticeable deficits.
Apraxia affects the ability to sequence and vocalize sounds, syllables, and words. Children with
apraxia know what they want to say, but their brains do not send the correct signals to the lips, jaw,
and tongue to form the words. In addition to language delay, apraxia often causes other
expressive language disorders.
Specific Language Impairment: Specific language impairment (SLI) is a developmental
language disorder characterized by the inability to master spoken and written language expression and
comprehension, despite normal nonverbal intelligence, hearing acuity, and speech motor skills, and no
overt physical disability, recognized syndrome, or other medical factors known to cause language
disorders in children.
A variety of components of oral language may be affected by SLI, including grammatical and syntactic
development (e.g., correct verb tense, word order and sentence structure), semantic development (e.g.,
vocabulary knowledge) and phonological development (e.g., phonological awareness, or awareness of
sounds in spoken language). Children may manifest receptive difficulties, that is, problems
understanding language, or expressive difficulties, involving use of language.
Oral language difficulties are associated with a wide range of disabilities, including hearing
impairment, broad cognitive delays or disabilities, and autism spectrum disorders. Specific language
impairment differs from the preceding conditions. Although it is always important to rule out hearing
problems as a source of language difficulties including fluctuating hearing loss such as that associated
with repeated ear infections most children with SLI have normal hearing. Furthermore, specific
language impairment does not involve global developmental delays; children with SLI function within
the typical range in non-linguistic areas, such as nonverbal social interaction, play, and self-help skills
(e.g., feeding and dressing themselves). Children with autism spectrum disorders have core
impairments in social interaction and communication, including both nonverbal and verbal skills, as
well as certain characteristic behaviors (e.g., repetitive movements, lack of pretend play, and inflexible
adherence to routines) that are not found in youngsters with SLI.
Specific language impairment puts children at clear risk for later academic difficulties, in particular,
for reading disabilities. Children with SLI will have problems in learning to read, presumably because
reading depends upon a wide variety of underlying language skills, including grammar and syntax,
semantics, and phonological skills.
Disorders of Language of Neurogenic Origin
Aphasia:
Aphasia is an acquired disorder of spoken and written language (Greek: dys-, disordered; phasis,
utterance). Aphasia is a type of disorder where a person has difficulties comprehending language or
speaking due to some type of damage in the parts of the brain responsible for communication. The
symptoms of Aphasia vary based on the region of the brain that was damaged. There are different
regions responsible for understanding language, speaking, reading, and writing, though typically they
are found in the left side of the brain. Sometimes dysphasia is also referred to as aphasia, though
generally it's considered a less severe version of aphasia.
Aphasia is an acquired neurogenic language disorder resulting from an injury to the brain, most
typically, the left hemisphere. It involves varying degrees of impairment in four primary areas:
•
Spoken language expression
•
Spoken language comprehension
•
Written expression
•
Reading comprehension
Signs and Symptoms : Common signs and symptoms of aphasia include the following:
Impairments in Spoken Language Expression
•
Having difficulty finding words (anomia)
•
Speaking haltingly or with effort
•
Speaking in single words (e.g., names of objects)
•
Speaking in short, fragmented phrases
•
Omitting smaller words like the, of, and was (i.e., telegraphic speech)
•
Making grammatical errors
•
Putting words in the wrong order
•
Substituting sounds or words (e.g., “table” for bed; “wishdasher” for dishwasher)
•
Making up words (e.g., jargon)
•
Fluently stringing together nonsense words and real words, but leaving out or including an
insufficient amount of relevant content
Impairments in Spoken Language Comprehension
•
Having difficulty understanding spoken utterances
•
Requiring extra time to understand spoken messages
•
Providing unreliable answers to “yes/no” questions
•
Failing to understand complex grammar (e.g., “The dog was chased by the cat.”)
•
Finding it very hard to follow fast speech (e.g., radio or television news)
•
Misinterpreting subtleties of language (e.g., taking the literal meaning of figurative speech such
as “It's raining cats and dogs.”)
•
Lacking awareness of errors
Impairments in Written Expression (Agraphia)
•
Having difficulty writing or copying letters, words, and sentences
•
Writing single words only
•
Substituting incorrect letters or words
•
Spelling or writing nonsense syllables or words
•
Writing run-on sentences that don’t make sense
•
Writing sentences with incorrect grammar
Impairments in Reading Comprehension (Alexia)
•
Having difficulty comprehending written material
•
Having difficulty recognizing some words by sight
•
Having the inability to sound out words
•
Substituting associated words for a word (e.g., “chair” for couch)
•
Having difficulty reading non-content words (e.g., function words such as to, from, the)
Aphasia is often classified into
•
Nonfluent
•
Fluent
•
Subcortical
Fluent Aphasia (Receptive Aphasia)
Fluent aphasia is caused by lesions in the posterior brain structures. Word substitutions, neologisms,
and verbose verbal output. In this form of aphasia, the ability to grasp the meaning of spoken words
and sentences is impaired, while the ease of producing connected speech is not very affected.
•
Wernicke’s Aphasia: lesions in Wernicke’s area the posterior portion of the superior temporal gyrus
in the left hemisphere of the brain. Wernicke’s area is supplied by the posterior branch of the left
middle cerebral artery. Stroke of lower division of left middle cerebral artery cause Wernicke’s
Aphasia. Wernicke's area is the region of the brain that is important for language development.
Brodmann area 22 in human brain, is the area involve in auditory comprehension. The Wernicke's area
is responsible for the comprehension of speech. Wernicke’s aphasia is also referred to as ‘fluent
aphasia’ or ‘receptive aphasia’.
Individuals with Wernicke’s Aphasia have
o Fluent but often meaningless speech
o Jumbled content.
o Ability to grasp the meaning of spoken words and sentences is impaired
o Reading and writing are severely impaired
o Can produce many words
o Speak using grammatically correct sentences with normal rate and prosody
o What they say doesn’t make a lot of sense or use irrelevant words, Paraphasic, Neologism
o Not realize using the wrong words
o Not fully aware what they say
o Profound language comprehension deficits
• Anomic Aphasia: A variety of locations, often in posterior language regions, but some in frontal lobe.
lesion in the angular gyrus region. Anomic aphasia is one of the milder forms of aphasia.
Individuals with Anomic Aphasia have
o Word retrieval difficulties.
o Their speech is fluent and grammatically correct
o Significant word-finding difficulties
o Circumlocutions (attempts to describe the word they are trying to find).
o Understand speech well
o Can repeat words and sentences
o Can read adequately. Difficulty finding words is evident in writing as it is in speech.
•
Conduction Aphasia: A lesion in the arcuate fasciculus, deep supramarginal gyrus, or superior
temporal gyrus
Individuals with Conduction Aphasia have
o Speak Fluently
o Paraphasic output
o Good auditory comprehension
o Poor repetition
This condition is caused by damage to the arcuate fasciculus, which you can think of as a bundle of
nerves that connects two parts of your brain. These parts are Broca's area and Wernicke's area. Broca's
area is the part of your brain responsible for speech production, and Wernicke's area is the part of your
brain responsible for speech comprehension.
•
Transcortical Sensory Aphasia: Border zone regions of the territories of the middle cerebral and the
posterior cerebral arteries, sparing Wernicke’s area. Lesions in the inferior left temporal lobe of the
brain located near Wernicke's area.
Individuals with Transcortical Sensory Aphasia have
o Word errors, preservation
o Strong ability to repeat words and phrases. The patient may repeat questions rather than answer
them ("echolalia").
o Poor auditory comprehension
o Fluent speech with semantic paraphasia’s present.
Nonfluent Aphasia (Expressive Aphasia)
Non-fluent means that the patient has trouble getting words out, but usually has good understanding.
Generally caused leisions in the anterior brain structures. Slow, labored speech; word retrieval and
syntactic problems.
• Broca’s Aphasia: A large frontal lesion affecting Broca’s area and surrounding cortical regions as
well as white matter deep to Broca’s area. Stroke of upper division of left middle cerebral artery.
Broca's area is one of several language areas on the left hemisphere of the brain. Brodmann area 44
and 45 in human brain, is the area involve in production of language.
Individuals with Broca’s aphasia have
o Agrammatism
o Effortful articulation
o Short utterances
o Impaired prosody and intonation
o Good comprehension
o Word finding difficulties
o Poor repetition
This type of aphasia is also known as non-fluent or expressive aphasia.
•
Transcortical Motor Aphasia: A frontal lobe lesion often anterior and/or superior to Broca’s area,
sometimes in the territory of the anterior cerebral artery. Lesion in the border zone superior or anterior
to Broca’s area.
Individuals with Transcortical Motor Aphasia have
o Little to no initiation of spontaneous speech
o Excellent imitation (even of long utterances)
o Relatively intact comprehension
o Reading comprehension is good
o
Syntax not as bad as in Broca’s aphasia.
o Capable of naming and repeating words normally
•
Mixed Transcortical Aphasia: is milder form impairment in all modalities blend of fluent and nonfluent characteristics. This type of aphasia can also be referred to as "Isolation Aphasia". This type of
aphasia is a result of damage that isolates the language areas (Broca’s, Wernicke’s, and the arcuate
fasciculus) from other brain regions.
Broca’s, Wernicke’s, and the Arcuate Fasciculus are left intact; however, they are isolated from other
brain regions.
Individuals with Mixed Transcortical Aphasia have
o Severe speaking and comprehension impairment
o Preserved repetition.
o Difficulty to understand what is being said to them,
o Non-fluent
o Cannot name objects
o Cannot read or write
•
Global Aphasia: Global Aphasia is caused by injuries to multiple language-processing areas of the
brain, including those known as Wernicke’s and Broca’s areas. These brain areas are particularly
important for understanding spoken language, accessing vocabulary, using grammar, and producing
words and sentences. A large lesion affecting the frontal, parietal, and temporal lobes, or a smaller
deep lesion affecting pathways from both anterior and posterior language regions.
Global aphasia may often be seen immediately after the patient has suffered a stroke or a brain trauma.
Symptoms may rapidly improve in the first few months after stroke if the damage has not been too
extensive.
Individuals with Global Aphasia have
o Severe deficits in all areas of language comprehension and production
o Output may be limited to stereotypic utterances
o Can produce few recognizable words
o Understand little or no spoken language
o Neither read nor write
o Preserved intellectual and cognitive capabilities unrelated to language and speech.
Subcortical Aphasias:
Subcortical aphasia is a condition characterized by partial or total loss of the ability to communicate
verbally and it develops because of damage to subcortical brain areas without loss of cortical function in
Broca's or Wernicke's areas. A form of aphasia that results from damage to subcortical regions such as the
thalamus, internal capsule, and the basal ganglia.
o Little spontaneous speech
o Impaired executive language functions such as word fluency and sentence generation, but it largely
spares responsive language functions such as comprehension, repetition, and naming
o Thalamic aphasia may produce dysfunction at the prelinguistic level, such as impairments in
concept generation and dysfunction in the control of preformed speech patterns
o For aphasia related to white matter lesions, the primary language dysfunction is an impairment in
speech motor output.
Bilingual and Multilingual Aphasia:
With increased rates of “globalization”, the proportion of individuals who speak more than one
language is rapidly expanding. The term ‘‘Bilingual’’ or "Multilingual" refers to all those people who
use two or more languages or dialects in their everyday lives.
Bilingual people with aphasia who speak two or more languages may find each language is similarly
affected or that one language is more affected than the others. The best-recovered language may be the
first language (mother tongue) or can be the language most frequently used. For individuals who were
less proficient in their second language, aphasia may lead to apparent loss of the second language.
o Aphasia can cause alternating difficulties between languages or difficulty in translating
between languages
o Sometimes aphasia causes difficulty in selecting the appropriate language, and leads to use of
the non-target language e.g. speaking Italian with English speakers or switching between Italian
and English where normally only one language is spoken
o Bilingual individuals with aphasia who usually switch languages with other bilinguals may find
this harder to do or may do so incorrectly because of the aphasia.
o Often these patterns change over time and may be most acute in the early stages after a stroke
or trauma.
o For other bilinguals with aphasia there are difficulties in each language but selecting the right
language and switching between languages is unaffected.
Because of the differences that often occur after aphasia, it is important to have speech-language
assessment in each of the languages that are used, even if English is the language that has previously
been spoken the most.
Causes of Aphasia: Aphasia is caused by damage to the language centers of the brain. These
language centers are in the left hemisphere, but aphasia can also occur as a result of damage to the
right hemisphere.
Common causes of aphasia include the following:
•
Stroke
•
Traumatic brain injury
•
Brain tumors
•
Brain surgery
•
Brain infections
•
Progressive neurological diseases (e.g., dementia)
Stroke is the most common cause of aphasia.
Stroke: Aphasia is usually caused by a stroke or brain injury with damage to one or more parts of the
brain that deal with language. According to the National Aphasia Association, about 25% to 40% of
people who survive a stroke get aphasia. A stroke occurs when the blood supply to your brain is
interrupted or reduced. This deprives your brain of oxygen and nutrients, which can cause your brain cells
to die. A stroke may be caused by a blocked artery (ischemic stroke) or the leaking or bursting of a blood
vessel (hemorrhagic stroke). The signs of a stroke include a sudden severe headache, weakness, numbness,
vision problems, confusion, trouble walking or talking, dizziness and slurred speech.
Traumatic brain injury: TBI also known as craniocerebral trauma, is injury to the brain sustained by
physical trauma or external force. Brain injuries can be penetrating or nonpenetrating. Common Causes of
(TBI) are Falls, Automobile accidents, Crashing into objects, Assault of the head, Gunshot wounds and
Alcohol and drug abuse. Primary damage to the brain is caused by impact to the head. Secondary damage
to the brain is caused by Infection, Hypoxia, Edema or swelling, Elevated intracranial pressure, Infarction
or tissue death and Hematoma or focal bleeding.
Tumors: Tumors growing within the brain can be PRIMARY or SECONDARY (metastatic) onequarter of patients with primary brain tumors have language disturbances at the time of initial
presentation. The tissue around tumor swells, if tumor is in language area Aphasia can occur.
Hydrocephalus: Hydrocephalus refer to enlargement of the cerebral ventricles due to increase in
cerebrospinal fluid. It Can result in aphasia
Infections: Bacterial Meningitis: The pia matter, arachnoid and cerebrospinal fluid become infected,
causing inflammation/ swelling resulting in Aphasia and other symptoms.
Brain Abscess: It is caused by bacteria, fungus or parasites entry in brain tissues from some infection
which is present in other body part outside brain. Transmission can be through blood or tissues.
Toxemia: When nervous system encounter substance that poison nerve tissues, it can be due to Drug
overdose, Heavy metal poisoning (lead, mercury) and Chemical poisoning.
Dementia: Dementia is a general term for loss of memory and other mental abilities severe enough to
interfere with daily life. It is caused by physical changes in the brain. Alzheimer's is the most common
type of dementia.
Dementia: Dementia is an overall term for diseases and conditions characterized by a decline in
memory, language, problem-solving and other thinking skills that affect a person's ability to perform
everyday activities. Memory loss is an example. Alzheimer's is the most common cause of dementia.
Dementia is not a single disease; it’s an overall term that covers a wide range of specific medical
conditions, including Alzheimer’s disease. Disorders grouped under the general term “dementia” are
caused by abnormal brain changes. These changes trigger a decline in thinking skills, also known as
cognitive abilities, severe enough to impair daily life and independent function. They also affect
behavior, feelings and relationships.
Symptoms of Dementia: Symptoms of dementia can vary greatly. Examples include:
•
Problems with short-term memory.
•
Keeping track of a purse or wallet.
•
Paying bills.
•
Planning and preparing meals.
•
Remembering appointments.
•
Traveling out of the neighborhood.
Many dementias are progressive, meaning symptoms start out slowly and gradually get worse.
Causes: Dementia is caused by damage to brain cells. This damage interferes with the ability of brain
cells to communicate with each other. When brain cells cannot communicate normally, thinking,
behavior and feelings can be affected.
The brain has many distinct regions, each of which is responsible for different functions (for example,
memory, judgment and movement). When cells in a particular region are damaged, that region cannot
carry out its functions normally.
Different types of dementia are associated with particular types of brain cell damage in particular
regions of the brain. For example, in Alzheimer's disease, high levels of certain proteins inside and
outside brain cells make it hard for brain cells to stay healthy and to communicate with each other. The
brain region called the hippocampus is the center of learning and memory in the brain, and the brain
cells in this region are often the first to be damaged. That's why memory loss is often one of the
earliest symptoms of Alzheimer's.
Most changes in the brain that cause dementia are permanent and worsen over time, thinking and
memory problems caused by the following conditions may improve when the condition is treated or
addressed:
•
Depression.
•
Medication side effects.
•
Excess use of alcohol.
•
Thyroid problems.
•
Vitamin deficiencies.
Types of Dementia: Dementia is a general term for loss of memory and other mental abilities severe
enough to interfere with daily life. It is caused by physical changes in the brain. Alzheimer's is the
most common type of dementia, but there are many kinds.
•
Lewy Body Dementia
•
Down Syndrome and Alzheimer's Disease
•
Frontotemporal Dementia
•
Huntington's Disease
•
Mixed Dementia
•
Posterior Cortical Atrophy
•
Parkinson's Disease Dementia
•
Normal Pressure Hydrocephalus
Traumatic Brain Injury (TBI): TBI also known as craniocerebral trauma, is injury to the brain
sustained by physical trauma or external force. Brain injuries can be penetrating or nonpenetrating.
Common Causes of (TBI) are Falls, Automobile accidents, Crashing into objects, Assault of the head,
Gunshot wounds and Alcohol and drug abuse. Primary damage to the brain is caused by impact to the head.
Secondary damage to the brain is caused by Infection, Hypoxia, Edema or swelling, Elevated intracranial
pressure, Infarction or tissue death and Hematoma or focal bleeding.
Types of Traumatic Brain Injury (TBI)
1. Open Head Injury
2. Closed Head Injury
Open Head Injury: Result when the scalp and skull are penetrated caused by Bullets, Shell Fragments,
Knives and Blunt instruments. Primary damage is typically localized along the path of the object. Primary
damage may also result from bone fragments. Secondary Damage is Increased intracranial pressure,
Swelling, Bleeding and Infection. It rarely leads to coma. Risk of epilepsy is greater.
Closed Head Injury: The result of mechanical forces including the effects of both direct contact and
inertia. Damage results from the inward compression of the skull at the point of impact and the subsequent
rebound effects. Closed head injury literally causes the brain to bounce around against the rough and
sometime jagged inner surface of the skull. Coup/contra coup damage results in confusions and bruising.
Closed head injury results in decreased capacity to regulate Behavior, Emotions, Attention, Memory,
Mental processing speed, Attention and Executive functions.
Effects of a Traumatic Brain Injury
There is a. wide range of physical, cognitive, and behavioral effects which can result from brain injuries.
The injuries often cause diffuse damage and many interrelated brain functions can be affected. Each brain
injury differs from child to child as does the rate and degree of recovery. Children with TBI have great
potential for growth and development. They often make remarkable progress in many areas and
compensate for losses by developing new strengths.
Below are possible effects following traumatic brain injury, will assist the educator in determining student
needs and identifying appropriate services and strategies to facilitate the child's success in school.
Initial Effects: In the first few days following trauma, the child may experience a variety of medical
and physical complications, including swelling of the brain, edema (excess cerebral-spinal fluid),
respiratory difficulty, and seizures. Motor problems are often experienced early. Examples include
rigidity, spasticity, coordination difficulties, and tremors. As the child emerges from coma, he/she may
experience temporary neurologically based irritability, agitation, and aggression or may lack any
emotional expression. As the child improves, he/she may be able to follow simple 1·omines and
directions. The child may show memory for past events but remain confused with poor memory of
recent and current events.
These early, immediate problems usually din1inish very rapidly and the oven symptoms subside
considerably. This early, relatively rapid improvement is often interpreted as an indicali6n that
subsequent recovery will be as rapid and complete. However, children 'with severe, moderate, and
sometimes even mild injuries, may have persistent cognitive, behavioral. and sensory-motor
difficulties.
Cognitive Effects: Traumatic brain injuries in children can have delayed effects on cognitive functions.
Some difficulties become apparent only as the child continues through developmental stages and has
new and different educational demands. Effects of the brain injury occurring before the cognitive
functions fully develop may nor become apparent until a later age. For example, abilities in planning
and problem solving are usually quite undeveloped in early childhood. Cognitive difficulties in these
areas may not become apparent until the student is older and would be expected to have these skills
more developed. Long-term cognitive effects are typically experienced by children with TBI and can
affect memory, attention, concentration, and executive functions.
Memory: Memory deficits are among the more common and lasting effects following brain
injury. Children may have difficulty with encoding, storing, and retrieving new information.
This is particularly true when the information is presented quickly or in great amounts or in
detail. These difficulties can affect the child’s ability to learn new curriculum material, new
social and behavioral skills, and new spatial integrative tasks. Because prior memory can often
be well preserved, teachers may not initially realize the difficulty a student is having in learning
new academic material, in finding the way around a new school building, or in dealing with
new social demands. Early intervention to address memory difficulties is important to a child's
success after a traumatic brain injury.
Attention and Concentration: Brain injuries also often affect the child's ability to attend and
concentrate. The student is likely to experience problems focusing and sustaining attention for
long periods of time. A student may not fully comprehend a direction because he/she is unable
to filter out distractions in the classroom or may have difficulty functioning in situations where
there is a great deal of stimulation. Since the student cannot selectively attend to important
stimuli, he/she may "overload" quickly and can become quite agitated or confused. Attention
problems may also affect the student's ability to shift from one topic or activity to another.
After brain injury child may be able to process only small amount of information. When given
too much, he/she may stop processing completely and therefore miss information.
Executive Functions: Executive functions have major implication for the child's school
performance. Impaired executive functions are most commonly associated with damage to the
frontal lobes of the brain. This is an area commonly affected in closed head injury.
Executive function deficits may include the following:
▪
Setting realistic goals: The student often lacks the self-awareness necessary to establish
realistic goals.
▪
Planning and organizing behavior: The student is often unable to identify and organize the
sequence of steps to reach a goal.
▪
Initialing a task: The student may have the skill carry out a task but has difficulty initiating the
activity.
▪
Self-inhibiting: The student may be impulsive or unable to inhibit inappropriate statements,
emotions. or behaviors creating social and behavioral difficulties.
▪
Monito1ing and evaluating performance: The student mau be unable to adequately monitor
his/her behavior in learning or social situations. Often the student is unable to objectively
predict the outcome of the behavior, evaluate what he/she has done. or understand the effect of
this behavior on another person.
▪
Problem solving: The student may have difficulty in perceiving the nature of a problem and
considering a variety of possible solutions. It is common for students with TBI to consider only
one possible solution to problems and to fail to consider relevant information in weighing the
merits of possible solutions. Students may revert to methods of problem solving such as trial
and error which arc typical of younger children and less efficient than expected for their age
and academic level.
Executive system impairments also include difficulties in transferring newly acquired skills to
alternate settings. Transference of skills should be a planned process. This reinforces the need to
assess and teach skills to students with TBI in environments in which the skills will be used.
Speech and Language Effects: Speech problems evident early after brain injury, such as lack of
speech or extremely slow speech, often improve significantly in the early stages of recovery. If speech
problems persist, they may include speaking in monotone, slow rate of speech or imprecision in
articulation. Most d1ildren with brain injury recover motor speech functions.
While vocabula1y often recovers to preinjury levels, over time problems with new learning may have a
pronounced effect on vocabulary development. Students with TBI usually have ongoing higher-level
language and communication problems which can have consequences for academic and social success.
In expressive language, difficulties in confrontation naming (naming things or people upon visual
presentation) and word retrieval (coming up with the names for things or people in spontaneous speech)
are common, particularly under stress. There is usually a sharp deterioration in written and verbal
communication as the amount of information to be expressed increases. Short responses or sentences
may be adequately spoken or written whereas extended descriptions or narratives may be extremely
disorganized.
Comprehension of spoken language by children with TBI often deteriorates sharply with increases in
▪
the rate of speech
▪
the amount of information to be processed (beyond sentence length)
▪
the abstractness of the language spoken
▪
interference from the environment (such as a busy classroom or hallway or noisy, active
lunchroom).
Social communication may be greatly affected after a brain injury. The ability to participate
appropriately in conversation requires the use of cognitive, linguistic, and social skills, many of which
are affected following TBI. These include sustained attention to shifting topics, accurate perception
and interpretation of social cues, retention and integration of information already presented,
organization of ideas, retrieval of words to accurately express ideas, and application of rules of social
appropriateness. As a result, disorganized socially inappropriate conversation is common in students
with traumatic brain injury.
Students may produce language that is inappropriate to the setting (because of impulsiveness or
impaired social judgment), wander unpredictably in conversation, fail to initiate interaction, or have
difficulty inhibiting or terminating interaction. These common difficulties in the pragmatic domain of
language easily cause the child with a traumatic brain injury to seem "different"-socially awkward-and
to lose friends.
Behavioral Effects: Traumatic brain injury often has a pronounced effect on a student's behavior.
Many times, the changes reflect an exacerbation of challenging behaviors the child had prior to the
injury. There are other behaviors that may occur as a direct result of the injury and as such are new
responses for the child.
Behavior changes in children with TBI can result from:
▪
neurological damage to the brain
▪
cognitive-communicative problems
▪
feelings of failure and frustration that lead to acting-out or withdrawal
▪
situations that are overly demanding, confusing, or stimulating
▪
preinjury behavior problems.
Difficulties that can result from physical injury or resulting chemical imbalance in the brain include
agitation and irritability, mood swings. hyperactivity, and apathy. Emotional and behavioral outbursts
may seem to be unprecipitated by events in the environment and may not be under the child's direct
control. Disruptions in the brain following an injury can also cause changes in a child's activity level.
Some children may display a high degree of agitation with impaired concentration and attention.
Others have pronounced lethargy with great difficulty initiating activities.
Sensory Effects: Brain injury can cause complex visual disabilities such as double vision and impaired
coordination of both eyes. In some cases, the brain's visual processing areas are injured resulting in
visual field cuts or partial losses of vision. However, because the brain attempts to fill in the missing
areas, the individual may feel he/she is seeing completely. These students can have significant reading
problems (words or parts of words can be cut off). Students may also experience difficulty reading the
chalkboard or charts. Comprehensive assessments of visual functions are important to identify any
special problems experienced the children with TBI and the need for classroom accommodations or
visual aids. Young children in particular are not adept at identifying losses in their visual field, A
screening for visual ability is an important part of early assessment and should he have considered for
all students with TBI Consultation with a vision specialist is recommended if visual problems are
suspected.
Hearing loss ls also a common outcome of traumatic brain injury in children. An acceleration
dependent injury to the head can cause hearing problems due to damage to the external ear, the middle
ear, the inner ear, the auditory nerve, or the auditory center of the brain resulting in conductive
sensorineural, and/or cortical hearing impairment.
Motor and Physical Effects: Motor skills often recover to point where normal independent
functioning occurs following a brain injury. In some cases, motor recove1y can plateau, leaving some
long-term motor problems. Difficulties with balance, gait, strength, range of motion, and coordination
may continue.
Fatigue and lack of endurance are very frequent after TBI. Children often tire very quickly and may be
unable to persist on a task. Sharp reductions in the child's cognitive processing abilities such as
attention and concentration, at various times during the day are often indicative of neurologically based
fatigue. Simply recommending that the child go to bed earlier at night may not improve this type of
intermittent fatigue. Frequent changes to less demandi.ng activities and rest periods are usually
necessary.
Feeding and Swallowing Disorders
Mastication: Mastication refers to the processes involved in food preparation, including moving the
unchewed food onto the grinding surface of the teeth, chewing it, and mixing it with saliva in
preparation for swallowing.
Deglutition: Deglutition refers to swallowing.
These two biological processes require the integration of lingual, velar, pharyngeal, and facial muscle
movement with laryngeal adjustments and respiratory control. During the mastication and deglutition
process, all muscles inserting into the orbicularis oris may be called into action to open, close, purse,
and retract the lips as food is received. All intrinsic and extrinsic muscles of the tongue will be invoked
to move the food into position for chewing and preparation of the bolus (either liquid or a mass of food)
for swallowing. The velar elevators seal off the nasal cavity to prevent regurgitation, and the
pharyngeal constrictors must contract in a highly predictable fashion to move the bolus down the
pharynx and into the esophagus. With the addition of laryngeal elevation, more than 55 pairs of
muscles whose timing and innervation patterns must be coordinated through the accurate activation of
cranial and spinal nerves.
Swallowing: Swallowing, sometimes called deglutition is the process in the human or animal body
that allows for a substance to pass from the mouth, to the pharynx, and into the esophagus, while
shutting the epiglottis. Swallowing is an important part of eating and drinking. If the process fails and
the material (such as food, drink, or medicine) goes through the trachea, then choking or pulmonary
aspiration can occur. In the human body the automatic temporary closing of the epiglottis is controlled
by the swallowing reflex. The portion of food, drink, or other material that will move through the neck
in one swallow is called a bolus.
Dysphagia or Swallowing Disorders: Swallowing disorders, also called dysphagia is the medical
term for the symptom of difficulty in swallowing. It can occur at different stages in the swallowing
process, Oral phase, sucking, chewing, and moving food or liquid into the throat. Swallowing disorders
include many diseases and conditions that cause difficulty in passing food or liquid from the mouth
into the throat and esophagus, moving food down the esophagus, or having a sensation of pain during
swallowing.
Causes and Symptoms of Swallowing Problems: The causes and symptoms of swallowing problems
depend on the location of the difficulty. They are usually grouped into two categories, oropharyngeal
and esophageal.
Oropharyngeal Dysphagia: Oropharyngeal dysphagia is caused by diseases or disorders affecting the
mouth and throat. These may include:
•
Stroke. Stroke may affect the parts of the brain that control the voluntary phase of swallowing
in the mouth. Between 51 and 73 percent of stroke patients develop dysphagia.
•
Brain tumors, Parkinson's disease, and Alzheimer's disease. These disorders prevent impulses
from the brain and cranial nerves reaching the muscles of the mouth and throat.
•
Syphilis. Syphilis is a sexually transmitted disease that causes nerve cells in the spinal cord to
degenerate during its third or final stage. The loss of these cells can affect swallowing as well
as walking, hearing, and sight.
•
Abnormalities of the upper esophageal sphincter. Some people have a sphincter that does not
relax normally during swallowing. In others, the sphincter closes too quickly. This overly rapid
closure eventually results in the formation of a pouch in the upper esophageal wall.
•
Cancerous tumors of the throat and esophagus. These cause dysphagia by blocking the passage
of food.
•
Myasthenia gravis, polio, and muscular dystrophy. Diseases affecting skeletal muscles
elsewhere in the body also affect swallowing.
•
Esophageal rings and webs of tissue. These are noncancerous membranes along the walls of the
esophagus that some people are born with.
Symptoms Associated with Oropharyngeal Dysphagia Include:
•
Coughing or choking.
•
A nasal quality to the patient's voice.
•
Regurgitation. Regurgitation refers to food coming back up through the mouth or nose when
swallowing is not proceeding normally.
•
Aspiration. Aspiration occurs when the bolus enters the respiratory system (the windpipe and
lungs) rather than proceeding down the digestive tract.
•
Some seniors experience globus along with the dysphagia.
•
Chest pain. This symptom is often found in anxious or depressed patients with dysphagia.
•
Bad breath. This is a common symptom of Zenkel's diverticulum.
Esophageal Dysphagia: Causes of esophageal dysphagia include:
•
Achalasia. Achalasia is a disorder in which the sphincter at the lower end of the esophagus does
not relax normally and allow food to enter the stomach.
•
Scleroderma. This is a disease characterized by fibrous deposits of collagen in the skin and
internal organs. It can cause a narrowing of the esophagus near the point at which it joins the
stomach.
•
Spontaneous spasms of the muscles of the esophagus.
•
Narrowing of the lower portion of the esophagus by tumors.
•
Narrowing of the lower end of the esophagus caused by scarring from radiation treatments,
certain medications (most commonly antibiotics, NSAIDs, and potassium chloride), or peptic
ulcers.
Symptoms of Esophageal Dysphagia Include:
•
A sensation of food sticking in the back of the throat or further down the chest. The patient's
identification of the trouble spot, however, may not be the actual location of the blockage or
narrowing.
•
Pain or a feeling of heartburn underneath the breastbone.
•
Regurgitation.
•
Changing dietary habits, typically eating fewer solid foods and taking in more liquids and soft
foods.
Neurological Causes Affecting Swallowing
Neurologic disorders affecting swallowing can be categorized in many ways, including by the
anatomic site of the lesion such as the central or peripheral nervous system, by the pathologic process
such as ischemia and degeneration, by the underlying etiology, or by the clinical presentation such as
dementia and movement disorders. Disorders of the central nervous system (CNS) can be
nondegenerative or degenerative. Based on the clinical progression, degenerative disorders may be
subclassified into progressive and relapsing disorders. Progressive degenerative disorders may be
further subclassified based on their salient clinical characteristic into dementias and movement
disorders. In contrast to the CNS, most of the peripheral nervous system disorders that impact
swallowing is degenerative in nature.
Stroke: A stroke occurs when the blood supply to your brain is interrupted or reduced. This deprives
your brain of oxygen and nutrients, which can cause your brain cells to die. A stroke may be caused by
a blocked artery (ischemic stroke) or the leaking or bursting of a blood vessel (hemorrhagic stroke).
The signs of a stroke include a sudden severe headache, weakness, numbness, vision problems,
confusion, trouble walking or talking, dizziness and slurred speech. Swallowing abnormalities in stroke
are variable and may include oral lateral sulci retention, delayed oral transfer, delayed elicitation of a
pharyngeal swallow, decreased hyolaryngeal elevation, and aspiration.
Traumatic brain Injury: Traumatic brain injury can result in dysphagia depending on the brain
region involved. Brain injury resulting from trauma is generally more diffuse than that following
stroke, and cognitive impairments are often prominent depending on the site and severity of injury.
Amyotrophic Lateral sclerosis: Motor neurone disease (MND) causes a progressive weakness of
many of the muscles in the body. There are various types of MND. This leaflet is mainly about
amyotrophic lateral sclerosis (ALS), which is the most common type of MND. The cause is not known.
It is thought that certain chemicals or structures that only occur in motor nerves are damaged in some
way. The reason why the nerves become damaged is not clear. May experience some difficulties with
swallowing as the muscles which co-ordinate swallowing become affected. Eating and swallowing
become difficult when the tongue and the muscles around the mouth and throat become weak.
Parkinson’s Disease: The main symptoms of Parkinson's disease are usually stiffness, shaking
(tremor), and slowness of movement. A small part of the brain called the substantia nigra is mainly
affected. This area of the brain sends messages down nerves in the spinal cord to help control the
muscles of the body. Messages are passed between brain cells, nerves and muscles by chemicals called
neurotransmitters. Dopamine is the main neurotransmitter that is made by the brain cells in the
substantia nigra. Swallowing may become troublesome and saliva may pool in the mouth. Problems
with controlling impulses. For example, compulsive eating arises.
Progressive supranuclear palsy: Progressive supranuclear palsy (PSP) is a rare and progressive
condition that can cause problems with balance, movement, vision, speech and swallowing. It's caused
by increasing numbers of brain cells becoming damaged over time. PSP occurs when brain cells in
certain parts of the brain are damaged because of a build-up of a protein called tau. Tau occurs
naturally in the brain and is usually broken down before it reaches high levels. In people with PSP, it
isn't broken down properly and forms harmful clumps in brain cells. The amount of abnormal tau in the
brain can vary among people with PSP, as can the location of these clumps. This means the condition
can have a wide range of symptoms. As PSP progresses to an advanced stage, people with the
condition normally begin to experience increasing difficulties controlling the muscles of their mouth,
throat and tongue. The loss of control of the throat muscles can lead to severe swallowing problems,
which may mean a feeding tube is required at some point to prevent choking or chest infections caused
by fluid or small food particles passing into the lungs.
Myasthenic Gravis: Myasthenia gravis is a condition where muscles become easily tired and weak. It
is due to a problem with how the nerves stimulate the muscles to tighten (contract). The muscles
around the eyes are commonly affected first. This causes drooping of the eyelid and double vision.
People with myasthenia gravis have a fault in the way nerve messages are passed from the nerves to
the muscles. The muscles are not stimulated properly, so do not tighten (contract) well and become
easily tired and weak.
The fault is due to a problem with the immune system. Myasthenia gravis is an autoimmune disease.
This means that the immune system (which normally protects the body from infections) mistakenly
attacks itself. Muscles around the face and throat are also often affected. Difficulty in swallowing and
slurred speech may be the first signs of myasthenia gravis. Choking and accidentally inhaling bits of
food, which can lead to repeated chest infections.
Multiple sclerosis: Multiple sclerosis is a disorder of the brain and spinal cord. It can cause various
symptoms. Tremors or spasms of some of your muscles may occur. This is usually due to damage to
the nerves that supply these muscles. Some muscles may shorten (contract) tightly and can then
become stiff and harder to use. Swallowing becomes difficult.
Huntington’s disease: Huntington's disease is an inherited disease that causes the progressive breakdown
(degeneration) of nerve cells in the brain. Huntington's disease has a broad impact on a person's functional
abilities and usually results in movement, thinking (cognitive) and psychiatric disorders. The earliest
symptoms are often subtle problems with mood or mental abilities. A general lack of coordination and
an unsteady gait often follow. As the disease advances, uncoordinated, jerky body movements become
more apparent. Physical abilities gradually worsen until coordinated movement becomes difficult and
the person is unable to talk. Mental abilities generally decline into dementia.
Difficulties with eating and swallowing (dysphagia) and maintaining a constant body weight are
among the most troublesome complications of Huntington Disease (HD). There are many factors
involved and many reasons why these problems occur. These include: Most people with HD have
voracious appetites. They always seem to be hungry and tend to cram food into their mouths to try to
satisfy their hunger, causing problems with choking and loss of food by spillage. Feeding and eating
difficulties arise from the choreiform movements of the face and neck, incomplete lip closure and
irregular movements of the diaphragm. The loss of fine muscle control and co-ordination can make
eating a tiring and frustrating experience. Independent eating is also made difficult by the involuntary
movements of the upper body and difficulties with fine motor control and co-ordination, making
feeding oneself increasingly difficult. Swallowing problems are rarely a complaint at the time of
diagnosis of Huntington Disease, however, as the disease progresses, the co-ordination of the
swallowing mechanism becomes more and more impaired. Along with poor co-ordination, protection
of the airway is also compromised due to sudden unpredictable gulps of air during the inhalation cycle
of breathing. When inhalation occurs, the vocal cords are open and the airway is exposed, creating a
high risk for aspiration of food particles into the open airway. sometimes there is a too rapid or
immediate attempt to swallow which triggers coughing and choking.
Preparatory Phase: Getting food from plate to utensil to mouth includes correct bite size and pace of
eating. Chorea and impaired fine motor skills interfere with the mechanics of of food delivery, making
it harder to control bite size and the pace of eating so that "gulping" occurs. A care partner who cues or
assists in feeding is essential.
Oral phase: Main problems include chorea of the tongue, and uncoordinated movement of food to the
back of the throat. There is delay in starting the swallow, repeating of the swallow, or food left in the
mouth after the swallow. Food consistency in each bite is important; a bowl of cereal is a set up for
choking because the liquid may get to the back of the throat faster than the solid. Placing softer food in
the cheek by the molars helps overcome the slowness of propelling food to the back of the throat.
Starting the meal with something sour may help speed subsequent swallows. A "chin tuck" position of
the neck is probably preferred for protecting against aspiration.
Pharyngeal: Choking, coughing, aspiration: Small bites, thickened liquids, softer moist foods,
progressing to smashed, then pureed consistencies. Part of this is due to "respiratory" chorea, which
causes breathing during a swallow.
Esophageal: Regurgitation of food or vomiting. There is also evidence of muscle dysfunction in the
esophagus that may cause pain. It is important to stay upright for at least an hour after eating.
Dementia: Dementia is characterized by a decline in one or more major cognitive domains (i.e.,
language, visuospatial functions) accompanied by impairment in memory. There are multiple causes of
dementia. Patients with dementia not only have problems with swallowing but also with feeding in that
they may have limb apraxia affecting their ability to use eating utensils and agnosia affecting their
ability to recognize and accept food. Deficits in transfer of the bolus in the oral cavity are also
prominent.
Head and neck cancer: Speech and swallowing rehabilitation for people with head and neck cancer is a
complex. Treatment for oral cancer usually involves surgery with, or without, radiotherapy, and this
often impacts on speech and/or swallowing function. Surgery to the tongue can impact on the oral
stage of swallowing, as well as on speech. The degree of impairment is largely dependent on the extent
of lingual tissue resected and it has been stated by Lazarus that, “if less than 50% of the tongue is
resected and reconstruction is by primary closure, patients can regain functional swallowing”.5
Patients requiring total glossectomy are, unfortunately, usually limited to a diet of thin and/or thick
fluids, and use postural/ compensatory techniques to swallow orally. If a mandibulectomy occurs,
limitations to lip and jaw movements will reduce speech intelligibility and the oral stage of swallowing
will be slow. Resection of either the hard or soft palate can result in hypernasal speech and oral bolus
residue or nasal regurgitation of food/fluids may be observed, if the surgical repair is ineffective. Sites
of oropharyngeal cancer include the soft palate, retromolar trigone, tonsils, base of tongue and superior
and lateral pharynx. If the base of tongue or pharyngeal wall is affected, then speech may not
necessarily be grossly impaired, but swallowing almost certainly will be. The movement of the tongue
base is crucial to the efficiency of the swallow, as this area contributes, via its pressure generation
against the pharyngeal wall, to the propulsion of the bolus through the pharynx.
Laryngectomy: Laryngectomy is the removal of the larynx and separation of the airway from the
mouth, nose and esophagus. In a total laryngectomy, the entire larynx is removed (including the vocal
folds, hyoid bone, epiglottis, thyroid and cricoid cartilage and a few tracheal cartilage rings). In a
partial laryngectomy, only a portion of the larynx is removed. Following the procedure, the person
breathes through an opening in the neck known as a stoma. With an early cancer of the glottis (larynx)
on one, or both vocal folds, a patient’s initial complaint at presentation is often that of a hoarse/husky
voice. The laryngectomy surgery results in anatomical and physiological changes in the larynx and
surrounding structures. Consequently, swallowing function can undergo changes as well,
compromising the patient's oral feeding ability and nutrition. Patients may experience distress,
frustration, and reluctance to eat out due to swallowing difficulties. A total laryngectomy causes the
separation of the upper air respiratory tract (pharynx, nose, mouth) and lower air respiratory tract
(lungs, lower trachea).[24] Breathing is no longer done through the nose (nasal airflow), which causes
a loss/decrease of the sense of smell, leading to a decrease in the sense of taste.