Recognizing and treating speech and language disabilities.

Human communication: a message sent by one person and understood by another. It is enhanced by shared beliefs, behaviors, values, customs, and experiences. Sometimes it is confusing because the message conveyed by the words is different from the message sent by the voice and by the body (e.g., "I'm so excited," said in a monotone with a completely blank expression on the face). Sometimes it is incomplete because a speaker does not want to reveal personal information or because a listener is distracted by thoughts of everything else that needs to be done that day.

Communication is difficult, even under the best of circumstances. But, for at least 3 million people with a speech or language disability, communication may be so difficult that personal, educational, and vocational growth is stifled. The purpose of this article is to describe speech and language disabilities, their impact, and how they are diagnosed and treated. The article concludes with ways to enhance your communication with people who have speech and language disabilities.

Impact of Speech or Language Disability

In the words of one young woman who learned to communicate with an electronic system, the inability to communicate is:

" ... very frustrating. It's very lonely. It hurts.

"Think about it. You feel, you think, you know and understand the words, yet you cannot speak them. You hear everyone around you in an interesting conversation, but you cannot join in.

"You cannot express any of the feelings or emotions that are just as deep inside of you as anyone else. You are furiously angry and you have to hold it in; or you are extremely happy and you can't show it. Your heart is so full of love you could just burst, but you can't share it....

"I know what it is like to be fed potatoes all my life. I hate potatoes! But then, who knew that but me?

"I know what it is like to be dressed in reds and blues when my favorite colors are mint greens, lemon yellows, and pinks...

"Mama found me one night curled up in a ball in my bed crying, doubled over in pain...she thought I had a bad stomachache due to constipation. Naturally a quick cure for that was an enema. It didn't help my earache at all!" (From Keyhole Communique, 3(3), May 1989.)

Without adequate communication, people often feel disconnected from others. They may question their selfworth and they may develop inappropriate emotional reactions to the problem that further impede commumication with others.

Speech and language skills are essential not only for communication but also for educational achievement. Even early elementary school students must be able to follow directions, make associations between sounds and letters, analyze words, make oral presentations, and learn the meaning of abstract words and concepts for mathematics such as few, many, some, all-except. The need for these skills increases rapidly as learning becomes more dependent on the teacher's oral presentations and on understanding the more complex language of textbooks. These demands increase at the same time as the academic curriculum deemphasizes skill building in phonics, vocabulary, number concepts, and language.

By the upper grades, understanding and using sophisticated language concepts--for example, metaphors, jokes, negotiation, and persuasions--is expected across a broad range of subject areas. Consequently, academic achievement will suffer for anyone who has significant speech or language difficulty.

Problems may extend into the workplace when a new job or a promotion places different demands on speaking, writing, and general communication skills. And, of course, others often meet the disability before the person. Ratings of the speech, intelligence, education, and friendliness of two attorneys with normal speech decreased significantly when they were taught to lisp (Mowrer, Wahl, & Doolan, 1978). Businessmen rated talkers whose voice boxes were removed and who were using an alternative, effective method of communication as more limited in the number of jobs they could handle and in the amount of public contact that was appropriate (Gilmore, 1974). Personality traits of shyness, anxiousness, lack of self-control, and social withdrawal were attributed more to men who stuttered than to a control group with normal fluency, despite the fact that research has failed to document a common personality type, a consistent neurosis, or a pattern of significant maladjustment in people who stutter (Woods & Williams, 1976). Recently, a government employee who routinely received "Outstanding" work evaluations but was passed up for promotion for 10 years reached an out-of-court settlement with his employer and dropped his lawsuit that alleged discrimination because of his stuttering and his age.

People with speech or language disabilities not only must acquire the communication skills required for a job but then must often convince employers that they can do the job. The Americans with Disabilities Act, which prohibits discrimination in employment and requires reasonable accommodations for applicants and employees with disabilities, will expand opportunities for people with speech or language disabilities but may not instantaneously eliminate prejudicial attitudes.

Speech or Language?

What are these disabilities that can have such far-reaching consequences? Speech problems affect how the communication message sounds. When so many speech sounds are distorted that the speaker cannot be understood, when there is no source of sound because the vocal cords have been surgically removed, or when stuttering disrupts the natural thythm of the oral message, there is a speech problem.

Language refers to a code made up of a group of rules that cover what words mean, how to make new words (friend, friendly, unfriendly), how to combine words ("Peg walked to the new store," not "Peg walk store new"), and what word combinations are best in what situations ("Would you mind moving your foot?" could change quickly to "Get off my foot, please!" if the first request got no results).

A person who cannot understand the language code has a receptive language problem. A person who is not using enough language rules to share thoughts, ideas, and feelings completely and appropriately has an expressive language problem. One type of problem can exist without the other, but often they occur together in children and adults. Language problems often accompany mental retardation, hearing loss, learning disabilities, stroke, trauma, and degenerative brain disease, but may also exist without any known cause.

Speech and language problems can exist together or independently. The problems can be mild, severe, or somewhere in between. They should be evaluated by a speech-language pathologist so that appropriate treatment can be carried out and negative consequences reduced or avoided.

Speech Disabilities

For speech, disabilities may occur in articulation, voice, or rhythm. Articulation disorders refer to difficulties in producing correct speech sounds. One sound may be substituted for another (wabbit for rabbit), a sound may be omitted (ba for ball), a sound may be distorted (shad for sad), or errors may be a combination of the above types. Articulation disorders are most common in children and usually are due to a problem in learning one or more speech sounds or classes of sounds. However, articulation disorders can also result from hearing loss; paralysis, weakness, or incoordination of speech muscles caused by neurological disease; or structural damage to the tongue, palate, or other parts of the body used for making speech sounds.

When the number of misarticulated sounds is low, speech remains quite intelligible. However, listeners may pay more attention to how the speech sounds than to what is being said, or they may form stereotypical impressions of the speaker (cf. Mowrer et al., 1978). There are people whose articulation problems are so severe, usually because of physical limitations, that their speech is unintelligible.

Voice refers to the production of sound by the vocal cords and the enrichment of this basic tone by different shapes of the oral and nasal cavities. Disorders can occur from inappropriate pitch (too high, too low, never changing, or pitch breaks); loudness (too loud or not loud enough); or quality (harsh, hoarse, breathy, or nasal). Mild disorders may not be noticed because society tolerates quite a broad range of vocal behaviors within the limits of normalcy. However, problems like spasmodic dysphonia, which produces a severely strained, strangled-sounding voice, and laryngectomy (surgical removal of the voice box), which requires patients to have a new source of sound for voice, are disruptive to all aspects of living (cf. Gilmore, 1974).

The primary disorder of speech rhythm is stuttering. It is marked by hesitations, repetitions, and prolongations of sounds, syllables, words, or phrases (e.g., cow...boy, tuh-tuh-tuh-table, sssssssun). In an attempt to escape the stuttering moment, people who stutter may avoid words or certain speaking situations; use facial grimaces, head jerks, eye blinks, tongue protrusion, and other bodily contortions; change pitch and vocal inflections arbitrarily; start all speaking attempts with interjections like um, er, well; or use many other techniques that further impede the flow of speech and call attention to the speaker.

People with chronic stuttering can be disfluent on almost every word and take minutes to say one word. Listeners may become impatient, ignore people who stutter, and form negative impressions (cf. Woods & Williams, 1976). People who stutter are likewise frustrated by the inability to communicate and to control their own speech. They may have momentary feelings of rejection and non-acceptance, but their feelings can also be intense, frequent, and can lead to depression.

More and more scientific evidence is suggesting a physiological cause of stuttering and de-emphasizing psychological/emotional problems and learning factors, such as parentlal overreaction to normal hesitancies in speech. The cause of stuttering may be neurological, muscular, or something else; but the effect is that millions of people struggle to communicate their ideas and to maximize their personal and vocational potential.

Disorders of articulation, voice, and rhythm can occur together. Neurologic insult and diseases (cerebral palsy, amyotrophic lateral sclerosis, Parkinson's disease, etc.) can affect several components of the speech production system so that sounds are distorted, voice quality is unacceptable, and rhythm is disturbed. In some cases, no usable speech remains.

Multiple speech problems also occur from clefts of the palate and other craniofacial anomalies (Pierre-Robin and Treacher-Collins syndromes, for example). Not only is speech nasal in this situation, but it also contains severe articulatory omissions and substitutions.

Language Disabilities

Language disabilities may occur in the form, content, or use of language, alone or in any combination. A person with a language disability may have difficulty understanding or expressing language in any mode--spoken, written, or gestural.

Expressive problems with language form refer to difficulties using and combining correct words. For example, past tense or plural forms may be used incorrectly (goed for went; fishes for fish), or words may be combined ungrammatically in sentences ("I'm is gonna go to there"). Receptive problems with language form may result from difficulty in understanding long or complex sentences ("Before you pick up any additional forms, make sure to deliver the original forms to the correct department in your area"). A person who has problems with language form may find that others question his or her social and intellectual abilities.

Problems with language content refer to difficulties with the meaning of words or sentences. People with disabilities affecting language content have limited vocabulary and rely on concrete expressions. For instance, they would be more likely to say, "I like that thing" than "I thought that novel provided an exceptional picture of the privileged class of the Victorian ear." Dependence on concrete language affects the understanding of words, including idioms ("He reached a brick wall"), metaphors ("wide as a house"), sarcasm ("I sure believe that"), and jokes, especially those based on words with multiple meanings ("The best way to talk to a monster is long distance"). People with a language content problem may be perceived as unintelligent. Also, if they miss the sarcasm or humor in a conversation, they may be considered insensitive or "too serious."

Consistently using language that is inappropriate with a specific person (using a person's first name without permission) or in a particular setting (yelling an instruction across desks in a quiet office) is a problem with language use. Language can be used for many different purposes (to question, promise, inform, persuade, hint, compare). A person with language use problems may use language for only a few reasons (demand, argue, insist). Difficulty with conversation--changing a topic, rephrasing, making small talk--may also be obvious. Nonverbal language behavior, such as standing too close when speaking or avoiding eye contact during conversation, may also signal a language use disability.

It is important to know that all language differences are not language disabilities. Language use may vary, depending on cultural norms and expectations. In some cultures, for example, it is considered rude to make direct eye contact with authority figures.

Difficulties in language use can lead to interpersonal problems. A boss may regard an employee as disrespectful when the employee demands action ("Get me some paper!") rather than making a more subtle, polite request ("Would you mind ordering some pads of paper?"). Co-workers may think a colleague is confused when he or she introduces an unrelated topic during a conversation.

The causes and severity of language disabilities vary. Typically, a person who has mental retardation, stroke, head injury, dementia, or a learning disability has associated language problems.

Mental Retardation

Individuals who are mentally retarded have below average intellectual and adaptive abilities. However, most can be self-sufficient and productive employees. Characteristic language behaviors in form, content, and use include those in Table 1.

Table 1 Mental Retardation: Typical Speech and LanguageProblems

Language Form

* Simple sentence structure

* Use of incorrect word forms --Plurals--"Two book" --Past tense--"He ranned" --Possessives--"Mine book" --Subject-verb agreement "They runs"

* False starts--"I want... I'm gonna... I..."

Language Content

* Limited vocabulary

* Talking excessively with little meaning

* Frequent repetition of the comments of self or others

* Overuse of cliches

* Difficulty with time concepts (before and after; yesterday or tomorrow)

Language Use

* Language is too casual or familiar with a superior

* Difficulty starting or ending a conversation smoothly

Aphasia 

Aphasia is a loss of language ability due to focal brain damage. The brain injury is generally caused by stroke, although it may also result from head injury, tumor, or infectious disease such as meningitis. Thinking ability typically is not affected. A person with aphasia loses some or all ability to talk, understand, read, and write. Even gestures may lack meaning when brain damage is severe.

Damage to the left side of the brain, where the language center is located in the majority of people, usually results in some form of aphasia. There are different types of aphasia, depending on the site of the brain injury. Fluent aphasia is marked by problems understanding language. Nonfluent aphasia is characterized by difficulty producing language despite good comprehension skills. Compbinations of fluent and nonfluent aphasia also occur. Table 2 summarizes the typical language problems associated with fluent and nonfluent aphasia. [TABULAR DATA OMITTED]

Some of the language problems common in aphasia, such as difficulty thinking of the right word, are known to us all. "Aphasic symptoms are not bizarre or mysterious--they are extreme variants of everyday occurrences. For example, all of us have misspelled a word we know well; all of us have experienced difficulty in remembering a name or a word or have heard or read something, even in our own language, that we couldn't understand. It is quite useful to keep these experiences in mind" (Holland, Swindell, & Reinmuth, 1990).

Because aphasia is caused by injury to the brain, it is often accompanied by other symptoms. For example, people with aphasia often display emotional lability (i.e., display of emotion that is inappropriate to the context, such as laughing uncontrollably for no reason), or they may be depressed because their life has been so drastically altered. Some degree of paralysis on the right side of the body is also usually evident.

Head Injury

Head injuries, which are caused by trauma to the head, result in damage to the brain. Primary damage is the direct result of bruises and lacerations; secondary damage is the result of swelling, increased pressure, and lack of oxygen. Head injuries usually cause disorders of language and cognition (thinking). Cognition includes attention, recognition, discrimination of similarities and differences, memory, organization, reasoning, and problem-solving.

Typical problems of language and cognition following head injury include those in Table 3.

Table 3 Head Injury: Typical Language and CognitionProblems

Language Content

* Reduced understanding of language content

* Difficulty understanding abstract information

* Word-finding problems

Language Use

* Swearing and laughing inappropriately

* Excessive talking

* Interrupting

* Difficulty maintaining topic

Cognition

* Difficulty learning new information, rules, and procedures

* Ineffective problem-solving and judgment (e.g., inflexibility, impulsivity, disorganized thinking)

* Attention, perception, and memory problems

* Impaired executive functions (self-awareness of strengths/weaknesses, goal setting, planning, self-initiating, self-inhibiting, self-monitoring, self-evaluating)

Dementia

Dementia is a form of cognitive disorder accompanied by language problems. Alzheimer's disease is the most common form of dementia. Many of the problems characteristic of dementia are a result of memory loss.

Language and cognition problems that are characteristic of dementia include those in Table 4.

Table 4 Dementia: Typical Language and Cognition Problems

Language Form

* Total lack of speech (late-stage dementia)

* Inappropriate constant repetition

Language Content

* Word-finding problems

* Vague and empty speech

Language Use

* Poor topic maintenance and turn-taking skills

CognitiFon

* Delusions and hallucinations 

* Agitation, hostility, and emotional lability

* Impaired thinking and reasoning ability

Learning Disabilities

Individuals with school problems or learning disabilities may continue to have speaking, reading, and writing problems as adults.

Characteristic spoken and written language problems include those in Table 5

Table 5 Learning Disabilities: Typical Speech and LanguageProblems

Language Form

* Difficulty producing multisyllabic words

Language Content

* Word-finding problems

* Concrete, limited vocabulary

Language Use

* Lack of organization in language

* Difficulty starting and ending conversations

* Literal interpretation of language (e.g., cannot understand a joke)

Speech and Language Evaluation

When a speech or language disability is suspected, the first step is a thorough evaluation to determine the strengths, areas of concern, and impact of any disability, and then plan an appropriate and effective treatment program. The evaluation process involves collecting data from several sources. The major components of a speech and language evaluation are presented in Table 6. Evaluations are conducted periodically throughout the treatment to assess progress.

Table 6 Elements of a Speech and Language Evaluation

Client History:

* Conditions related to onset and development of problem

* Previous diagnostic findings

* Previous rehabilitation services

* General developmental status (particularly for hearing, speech, and language)

* Current health status

* Educational/vocational status

* Emotional/social development

* Pertinent family concerns

Method of Collection:

* Direct statements from individuals and family members

* Pre-interview questionnaires

* Referring professionals

* Client and/or family interview

Direct Observation and Examination:

* Physical examination of organs and systems used to support speech, voice, and language production

* Production of speech sounds in spontaneous speech and imitative tasks

* Language comprehension at different linguistic levels (from, content, use)

* Complexity of language expression in different settings

* Production of voice in several contexts (coughing, vowel prolongation, counting, singing, producing different pitch levels)

* Fluency of speech during different speaking conditions

* Hearing screening

Method of Collection:

* Instrumental assessment as required (video analysis of swallowing)

* Standardized/nonstandardized tests (formal and informal observations)

* Spontaneous speech

* Often done as part of an inter- or multidisciplinary diagnostic team

* May be audio/video recorded for further analysis

What Happens Following an Evaluation?

Results of the evaluation are organized, compared to normative data, and evaluated in terms of a person's age, sex, culture, and overall development. From these analyses, management plans are made and then carried out.

Because cultural background affects the use of speech and language, language disabilities can be defined or treated only in a cultural context. Sensitivity to cultural differences is imperative when conducting a speech and language evaluation and implementing a treatment plan. A language difference is not a language disorder.

Who conducts speech and language evaluations? Speech-language pathologists--professionals trained to assess and treat individuals with communication disabilities--help people develop their communication abilities and treat disorders of speech, language, and voice. Their services include prevention, identification, evaluation, treatment, and rehabilitation of communication disorders. Audiologists--hearing healthcare professionals who specialize in prevention, identification, and assessment of hearing disabilities--provide treatment and rehabilitative services.

Speech and Language Treatment

Treatment for speech and language disabilities is based on the principle that communication is used to fulfill social purposes: to get attention, make requests, state facts, express feelings and opinions, report events, and change the actions of others. Treatment is most effective when it is conducted within such a natural context.

Setting. The goal of speech-language treatment is to help an individual achieve the highest possible level of functional communication. Speech and language is not a rote exercise to be practiced only in an isolated clinic. Rather, treatment should involve meaningful, intentional, and practical activities applied in the natural environment (work, home, and community).

Participants. Speech and language skills cannot be taught in a vacuum. Treatment should involve family members, co-workers, and peers.

Content. Treatment plans must be individualized and based on specific speech and language problems identified during the evaluation. Treatment is a dynamic process based on ongoing evaluations. Treatment plans are modified according to the individual's progress.

Techniques. There are several approaches to speech and language treatment. Some or all approaches may be appropriate during the course of an individual's treatment, depending on the particular disability. During treatment, a speech-language pathologist may provide direct instruction about speech production (e.g., giving a tongue placement cue or encouraging air flow prior to voice production), or may model correct speech or language behavior and ask for an imitation. Prompting and cuing are other techniques used. The speech-language pathologist may prompt with the first letter or a related word for an individual experiencing word-finding problems. Such cues can be used by nonprofessionals or by the individuals themselves.

The speech-language pathologist may effect treatment entirely thorugh verbal direction and client self-monitoring, or specialized equipment and computers may be used to facilitate the desired behavior, provide extended practice, and increase motivation.

To the casual observer, it may seem that the speech-language pathologist is not doing anything special. Closer scrutiny, however, will reveal that complexity of the task is carefully controlled, that responses are systematically stimulated or modeled, that ineffective strategies are quickly replaced by alternatives, and that the entire treatment plan has been carefully crafted so that appropriate output is rewarded by the intrinsic value of communication itself.

The speech-language pathologist can also choose other approaches to rehabilitation as the nature and severity of the disability and individual needs dictate:

* Use of augmentative and alternative communication devices. Individuals with severe speech or language problems may need a nonspoken mode of communication. Augmentative or alternative communication (AAC) embodies a wide range of simple and complex methods that help people communicate (e.g., pointing to letters, words, or pictures on a communication board or using sophisticated technology such as a computer that produces synthesized speech). Advanced technology can help individuals write, use a computer, and converse. As a result, a broader range of job opportunities is now available to people with severe communication disabilities.

* Teaching compensatory strategies. Individuals may be taught to use their least blocked modality to trigger use of other modalities (e.g., from singing to speaking). They may also be helped to use on-the-job compensatory language systems and strategies (e.g., asking people to speak slowly and clearly).

* Use of prosthetics. People with certain medical conditions may need to use prosthetic devices to facilitate their ability to communicate orally. For instance, individuals who have Parkinson's disease or a similar neurogenic disability may use a voice amplifier. An artificial larynx may be used by individuals whose medical conditions have necessitated the removal of their larynx (voice box).

Importance of Counseling

Counseling by the speech-language pathologist is a critical treatment element with a major impact on outcome. Counseling may be viewed as a three-pronged process, in which the speech-language pathologist provides:

* information about resources, such as support groups, advocacy networks, and avenues for financial aid;

* education, explaining the speech and language disability and its impact, rehabilitation alternatives, realistic goals, and prognosis; and

* support, allowing clients to share their feelings about the speech and language problems, discussing ways to cope, and making referrals to other professionals as appropriate.

Ways to Improve Communication

The following suggestions can help you become an effective communication partner with someone with a speech and language disability:

* Be patient; allow time for an answer.

* Give your undivided attention.

* Minimize distraction.

* Be friendly; start up a conversation.

* Ask how you can help to improve communication (e.g., by reading instructions that accompany communication aids or devices).

* Speak slowly, clearly, and in your regular tone of voice.

* Talk as you would talk to any person around the same age.

* Indicate when you do not understand. Ask for a repetition.

* Ask short questions that require brief answers or a head nod if you want to obtain information quickly.

* If someone uses a special augmentative aid or technique, learn how it is used to help you converse.

Following these suggestions will help you and the person with a speech and language problem communicate more effectively. You may also gain an increased appreciation of individual differences and styles of communication.

And, lastly--perhaps where it counts the most--there are many ways to ease communication for persons with speech or language disabilities in the workplace. Employers can make low-cost accommodations as needed, such as obtaining an amplified telephone mouthpiece or encouraging use of a personal voice amplifier. Also, jobs can be restructured. For example, if employees have difficulty using telephones, employers can provide access to computers and fax machines as alternatives.

If you have concerns or want more information, call or write the American Speech-Language-Hearing Association, 10801 Rockville Pike, Rockville, MD 20852; [phone]. Or use the toll-free consumer HELPLINE--[phone] for names of speech-language pathologists and audiologists in your area or for additional information about speech, language, or hearing development and disabilities.

The authors gratefully acknowledge the contribution of Cheryl B. Wohl in the development and final preparation of this article.

Bibliography

1. Gilmore, S.I. (1974). Social and vocational acceptability of esophageal speakers compared to normal speakers. Journal of Speech and Hearing Research, 17, 599-607.

2. Holland, A.L., Swindell, C.S., & Reinmuth, O.M. (1990). Aphasia and related adult disorders. In G.H. Shames & E.H. Wiig (Eds.), Human communication disorders (3rd ed., pp. 424-461). Columbus, OH: Merrill.

3. Mowrer, D.E., Wahl, P., & Doolan, S.J. (1978). Effects of lisping on audience evaluation of male speakers. Journal of Speech and Hearing Disorders, 43, 140-148.

4. Woods, C.L., & Williams, D.E. (1976). Traits attributed to stuttering and normally fluent males. Journal of Speech and Hearing Research, 19, 267-278.