Speech / Communication Disorders A speech disorder is an impairment of voice, articulation of speech sounds, and/or fluency.

These impairments are observed in the transmission and use of the oral symbol system. A language disorder is therefore the impairment or deviant development of comprehension and/or use of a spoken, written, and/or other symbol system. The disorder may involve: the form of language, the content of language, and/or the function of language in communication in any combination. A communication disorder is an inability to understand or use speech and language to relate to others in society. This can be divided into four areas: Language - this involves listening, speaking, reading and writing Articulation - the pronunciation of sounds and words Voice - the sound produced by vibration of the vocal cords Stuttering - a disruption in the normal flow or rhythm of speech Cause: The brain is extremely complex and our understanding of how it works is very limited. For the majority of communication disorders, we do not understand the cause. However, we do have an understanding of how to help many children maximize their speech and language development. Known causes of communication disorders include: Hearing Impairment: Full or partial hearing impairment may cause difficulty in speech and language development. An assessment of hearing ability is one of the first steps in the investigation of speech and language problems. Physical Disability: Cleft lip and palate, or malformations of the mouth or nose may cause communication disorders. More involved disabilities such as cerebral palsy may preclude any speech at all and for these non-verbal children, augmentative communication methods may be used. Developmental Disability: Some children,not all, with a developmental disability or Down Syndrome may be slower to learn to talk and may need extra assistance. Treatment: Treatment depends upon the actual disorder identified and therefore treatment runs the full gamit of medical and psychological therapies.

Communication Disorders
Author: Renee S Melfi, MD, Consulting Staff, Orthopaedic Associates of Central New York Coauthor(s): Susan J Garrison, MD, Medical Director of the Rehabilitation Center, Associate Professor, Department of Physical Medicine and Rehabilitation, Methodist Hospital, Baylor College of Medicine Contributor Information and Disclosures Updated: Apr 23, 2008

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The Normal Communication Process

Communication is a multidimensional dynamic process that allows human beings to interact with their environment. Through communication, people are able to express thoughts, needs, and emotions. Communication is an intricate process that involves cerebration, cognition, hearing, speech production, and motor coordination. Evaluation of a communication disorder includes consideration of all aspects of the normal communication process. Language is the transformation of thoughts into meaningful symbols communicated by speech, writing, or gestures. Thoughts are organized by the brain, specifically the left hemisphere, and encoded into a sequence according to learned grammatical and linguistic rules. These rules govern the way sounds are organized (phonology), the meaning of words (semantics), how words are formed (morphology), how words are combined into phrases (syntax), and the use of language in context (pragmatics). Speech involves the coordinated motor activity of muscles involved in respiration, phonation, resonance, and articulation. The entire system is modulated by central and peripheral innervation, including cranial nerves V, X, XI, and XII, as well as the phrenic and intercostal nerves. Respiratory muscles, specifically the muscles associated with expiration, must generate enough air pressure to provide adequate breath support to make speech audible. The diaphragm is the main muscle of expiration; however, the abdominal and intercostal muscles help to control the force and length of exhalation for speech. Phonatory muscles of the larynx generate vibratory energy during vocal cord approximation to produce sound.1 Vocal pitch and intensity are modified by subglottic air pressure, tension of the vocal cords, and position of the larynx. Articulatory muscles within the pharynx, mouth, and nose form the tone of the sound. The coordinated action of these muscles produces speech. By altering the shape of the vocal tract, we are capable of producing a tremendous range of sounds. Sound waves are transformed by the auditory system into neural input for the speaker and the listener. The outer ear detects sound pressure waves in the air and converts them into mechanical vibrations in the middle

and inner ear. The cochlea then transforms these mechanical vibrations into vibrations in fluid, which act on the nerve endings of the eighth cranial nerve. Thus, the process of communication begins and ends in the brain. Various disorders may impair a person's ability to communicate. These disorders may involve voice, speech, language, hearing, and/or cognition.2,3 Recognizing and addressing communication disorders is important; failure to do so may result in isolation, depression, and loss of independence.4,5 See also the following related eMedicine topic: Functional Voice Disorders

Voice Disorders (Dysphonia)

Voice is the audible sound produced by passage of air through the larynx. Voice typically is defined by the elements of pitch (frequency), loudness (intensity), and quality (complexity). By varying the pitch, loudness, rate, and rhythm of voice (prosody), the speaker can convey additional meaning and emotion to words. A voice disorder exists when the quality, pitch, or volume differs from that of other persons of similar age, culture, and geographic location. Dysphonia is classified as either an organic or a functional disorder of the larynx.6,7 Organic disorders cause an interruption in the smooth approximation of the vocal folds.1 Such disorders include the following:

Vocal nodules (callus formation on the vocal fold) Laryngitis (inflammation) Vocal polyps (fluid-filled sacs on the vocal fold) Laryngeal and esophageal tumors Contact ulcers Vocal cord paralysis (secondary to trauma, severing of the recurrent laryngeal nerve)8 Chronic obstructive pulmonary disease Surgery (eg, laryngectomy, tracheostomy)

Functional disorders affect the quality and volume of the voice. They include the following:

Vocal abuse/misuse o Screaming o Excessive throat clearing o Substance abuse (eg, smoking, alcohol) Normal aging Psychosocial disorders Hysterical conditions Conversion voice impairment

Rule out a treatable medical condition in all patients with voice disorders. For example, a voice disorder may be one of the first symptoms of laryngeal cancer. Patients should be referred to an otolaryngologist (ear, nose, and throat [ENT] specialist) for specialized examinations, which may include peripheral oral/nasal examination, voice analysis, and indirect or fiberoptic laryngoscopy. Once an organic disorder has been either treated or

excluded, the patient may be referred to a speech-language pathologist (SLP). The SLP helps the patient to produce the most functional voice possible.9,10 Laryngectomy rehabilitation Laryngectomy remains a common procedure for the treatment of laryngeal cancer. Total laryngectomy results in the complete loss of voice (aphonia). Speaking options for the patient following laryngectomy patient include the following:

External prosthetic devices o Electrolarynx - This device may be placed either into the oral cavity or through the neck tissue to introduce a vibratory tone into the mouth and pharynx. The muscles of articulation then produce words from this tone. Pneumatic reeds - This device is placed over a tracheostoma to allow air to pass across a reed, producing a tone that is carried into the mouth. Tracheo-esophageal shunt - This 1-way valve voice prosthesis shunts air from the lungs into

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the esophagus. The air is vibrated in the pharyngo-esophageal segment to produce an esophageal voice. Esophageal speech - This technique is accomplished by training the patient to suck air into the esophagus, hold the air, and then release it in a controlled manner through the oral cavity.

See also the following related eMedicine topics: Acute Laryngitis Spasmodic Dysphonia Vascular Lesions of the Vocal Fold Vocal Fold Cysts Voice Therapy

Motor Speech Disorders

The production of speech depends on motor coordination of the structures of the respiratory system, larynx, pharynx, and oral cavity. Disorders of motor speech are classified into dysarthrias and apraxias.

Dysarthria
Dysarthria refers to a group of motor speech disorders caused by a disturbance in the neuromuscular control of speech.4 It results from central or peripheral nervous system damage and is manifested as weakness, slowness, or incoordination of speech. Any or all of the normal motor structures may be involved. Unless a concomitant language disorder exists, a person with dysarthria has intact comprehension and is able to understand written, spoken, and read language. The most typical dysarthrias are summarized in Table 1.

Table 1. Summary of Dysarthrias

Open table in new window

Type

Characteristics

Neurologic Location

Neuromuscular Deficit

Examples Bulbar palsy, poliomyelitis, myasthenia gravis

Lower motor neuron Weakness, hypotonia, Strained/h Hypernasal, breathy voice quality; imprecise fasciculations arsh voice articulation quality, hypernasal , slow rate, monopitch Upper motor neuronHyp ertonia, weakness, reduced range and speed of movement Pseudobul bar palsy, stroke, encephalitis, spastic cerebral palsyAtaxicE xcess and equal stress, slow rateCerebellu mHypotonia, slow and inaccurate movementStr oke, tumor, alcohol abuse, infectionHypo kineticMonopi tch, reduced loudness, inappropriate silencesExtra pyramidalRigi dity, reduced range and

speed of movementPa rkinson disease, druginducedHyper kineticQuickS udden variations in loudness, harsh quality, hypernasalEx trapyramidal Quick, involuntary, random movementsC horea, myoclonus, Tourette syndromeSlo wUnsteady rate and loudnessExtr apyramidalSu stained, distorted, slow movementsAt hetosis, dyskinesiaTre morsRhythmi c alterations in pitch and loudnessExtr apyramidalIn voluntary, purposeless movementsO rganic voice tremor MixedHypern asality, harsh voice quality, monopitch, reduced stress, slow rate, variable

qualityVariabl e, upper and lower motor neurons, cerebellar, extrapyramid alVariable weakness, slow movement, limited range of motion, intention tremor, rigidity, spasticityAmy otrophic lateral sclerosis, Wilson disease, multiple sclerosisTyp eCharacteris ticsNeurolog ic LocationNeu romuscular DeficitExam plesFlaccid DefinitionBulbar Hypernasal, breathy voice quality; imprecise articulation palsy, poliomyelitis, myasthenia gravisSpasticStraine d/harsh voice quality, hypernasal, slow rate, monopitchUpper motor neuronHypertonia, weakness, reduced range and speed of movementPseudobu lbar palsy, stroke, encephalitis, spastic cerebral palsyAtaxicExcess and equal stress,

slow rateCerebellumHypo tonia, slow and inaccurate movementStroke, tumor, alcohol abuse, infectionHypokinetic Monopitch, reduced loudness, inappropriate silencesExtrapyrami dalRigidity, reduced range and speed of movementParkinson disease, druginducedHyperkinetic QuickSudden variations in loudness, harsh quality, hypernasalExtrapyra midalQuick, involuntary, random movementsChorea, myoclonus, Tourette syndromeSlowUnste ady rate and loudnessExtrapyram idalSustained, distorted, slow movementsAthetosi s, dyskinesiaTremorsR hythmic alterations in pitch and loudnessExtrapyram idalInvoluntary, purposeless movementsOrganic voice tremor MixedHypernasality, harsh voice quality, monopitch, reduced stress, slow rate, variable qualityVariable, upper and lower

motor neurons, cerebellar, extrapyramidalVaria ble weakness, slow movement, limited range of motion, intention tremor, rigidity, spasticityAmyotroph ic lateral sclerosis, Wilson disease, multiple sclerosisThe diagnosis of dysarthria is made clinically by assessing the pitch, nasality, articulation, rate, and intelligibility of the patient's speech. Additionally, each of the subsystems of speech (respiratory, laryngeal, pharyngeal, and oral structures) must be assessed. Bedside evaluation of dysarthria includes the following exercises:FlaccidSp astic Alternating motion rates (rapid repetition of "puh, tuh, kuh") Sequential motor rates (rapid repetition of "puh, puh, puh") Prolongation of "aah"

SLPs can administer formal speech intelligibility tests, such as the Tikofsky word list or the Assessment of the Intelligibility of Dysarthric Speech. The overall goal in the treatment of dysarthria is functional communicati on in which a patient can reliably communicat e basic needs of daily living. A generalized hierarchy of treatment moves through the following 3 stages, based on the severity of speech impairment: For severely involved speakers, establish a functional

means of communicati on using one of the following devices: o Com muni catio n board s o Com puter base d spee ch syste ms For moderately involved speakers, maximize speech intelligibility with one of the following tools: Palatal lift Teaching speakers to control and emphasize words For mildly involved speakers, increase the naturalness of speech in one of the following ways: o Pacin

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g board to contr ol rate Teac hing inton ation and appro priate phras ing Apra xia The seco nd categ ory of moto r spee ch disor ders, aprax ia, invol ves the capa city to progr am the positi oning of the spee ch musc ulatur

e and sequ ence the move ment s nece ssary for spee ch.4 Apra xia occur s in the prese nce of signif icant weak ness or incoo rdinat ion of the musc les of spee ch prod uctio n. The 2 recog nized types of aprax ia relate d to spee ch

disor ders are oral aprax ia and aprax ia of spee ch (AOS ). o Oral aprax ia is an aprax ia of nonv erbal oral move ment s. Patie nts have diffic ulty perfo rming move ment s such as sticki ng out their tongu e, lickin g their

lips, and protr uding their lips. Lesio ns of the prem otor corte x are a frequ ent findin g in patie nts with this disor der. o AOS is a disor der of articu lation that enco mpas ses the inton ation, rhyth m, and stres s of spee ch (pros ody).

Thes e patie nts find it diffic ult to accur ately plan, initiat e, and sequ ence spee ch move ment s. Typic ally, AOS occur s with left front al lesio ns adjac ent to the Broc a area. The follo wing chara cteris tics usual ly are prese

nt: Effortful, groping articulatory movements with attempts at selfcorrection11 Dysprosody that is unrelieved by extended periods of normal intonation, rhythm, and stress Articulatory inconsistenc y or repeated production of the same utterance Difficulty initiating an utterance Diagnosis is made clinically, based on the above characteristi cs. Additionally, AOS may be differentiated from dysarthria and aphasia, because in AOS, automatic speech, motor control, and

other language modalities (ie, listening, reading, writing) are spared. A number of extensive objective tests exist and may be administered by the SLP to provide additional qualitative and quantitative information. Treatment of apraxia is designed to teach effective communicati on strategies and improve volitional control of the oral musculature. Exercises are used to teach sound sequencing, program sound patterns, and improve rhythm in speech. Language disorders

(aphasia) Aphasia is a language disorder that results from damage to the areas of the brain responsible for language comprehensi on and expression.12 These injuries usually occur in the dominant side of the brain, which, for most people, is the left hemisphere. Depending on the site of the lesion, aphasia may involve spoken and written language expression, auditory comprehensi on, and reading and writing abilities.4 Aphasia may be described by a variety of abnormalitie s in speech

production. Table 2 summarizes the terminology used to describe expressive disorders of aphasia. Table 2. Terminology Describing Expressive Disorders of Aphasia Open table in new window

Term
Difficulty initiating speech

AdynamiaLower motor neuronWeakness, hypotonia, fasciculations Agrammatism Anomia Circumlocution Echolalia Jargon Logorrhea Neologism Paragrammatism

Absence of grammatical elements (verbs, articles, pronouns, prepositions) Difficulty producing nouns Utterance of associated words related to the word that cannot be retrieved Repetition of an utterance that does not require repetition Well-articulated but mostly incomprehensible language Excessively lengthy, often incomprehensible, but well-articulated language Substitution of contrived or invented words, well articulated Misuse of grammatical elements

Phonemic paraphasia Substitution of one sound for another (for example, "fable" for "table") Semantic paraphasia Word substitution belonging to the same semantic class (such as "table" for "chair") Stereotypes Telegraphic speech Repetition of nonsensical syllables for all communicative attempts ("dee, dee, dee") Utterance of mostly nouns and verbs

Term Adynamia Agrammatism Anomia Circumlocution Echolalia Jargon Logorrhea Neologism Paragrammatism Difficulty initiating speech

Definition

Absence of grammatical elements (verbs, articles, pronouns, prepositions) Difficulty producing nouns Utterance of associated words related to the word that cannot be retrieved Repetition of an utterance that does not require repetition Well-articulated but mostly incomprehensible language Excessively lengthy, often incomprehensible, but well-articulated language Substitution of contrived or invented words, well articulated Misuse of grammatical elements

Phonemic paraphasia Substitution of one sound for another (for example, "fable" for "table") Semantic paraphasia Word substitution belonging to the same semantic class (such as "table" for "chair") Stereotypes Telegraphic speech Repetition of nonsensical syllables for all communicative attempts ("dee, dee, dee")

Utterance of mostly nouns and verbsAphasias are classified in several ways. Traditionally, aphasia
syndromes were classified as expressive or receptive. Individuals with expressive, or motor, aphasia had difficulty producing words and were believed to have a lesion in the Broca area in the dominant frontal lobe. Patients with receptive, or sensory, aphasia have difficulty comprehending language and are thought to have a lesion in the Wernicke area of the dominant temporal lobe. In the 1960s, a popular modification of the classification system was proposed based on the fluency, or rate of speech. Fluent speech is produced at normal to rapid rates and is effortless and well articulated. Nonfluent speech is slow, labored, and poorly articulated. As a rule, lesions anterior to the fissure of Rolando produce nonfluent aphasias; lesions posterior to this fissure produce fluent aphasias. Newer brain imaging techniques, however, have shown that subcortical and right hemispheric structures also contribute to language functions. The traditional classification systems are limited in that they classify the types of disorders according to the site of the lesion only in the dominant cortical hemisphere. The currently accepted classification system evaluates fluency, comprehension, and repetition; it also divides the aphasias into cortical and subcortical forms. Classification of the cortical aphasias is summarized in Tables 3 and 4. Table 3. Summary of Cortical Aphasias Open table in new window

CharacteristicsOften
associated with apraxia, rare

GoodFluency

vocalizationPoorGlobalBorde r zone of frontal, temporal, parietal areasGoodNonfluentNeologism, wellarticulatedPoorTranscortical SensoryAdjacent to Broca area, left anterior cerebral arteryGoodNonfluentCircuml ocutions, word-finding difficultyAnomiaFluentGoodA rcuate fasciculus, left MCAPoorFluentNeologisms, paraphasias, well-articulated, paragrammatismEffortful, telegraphic, often associated with apraxia, agrammaticLeft middle cerebral artery (MCA), frontalBroca (Motor, expressive)NonfluentCharact eristicsLesion SiteBroca (Motor, expressive)NonfluentGoodPo orEffortful, telegraphic, often associated with apraxia, agrammaticLeft middle cerebral artery (MCA), frontalWernicke (Sensory, receptive)FluentPoorPoorNeo logisms, paraphasias, well-articulated, paragrammatismLeft MCA, temporalConductionFluentGo odPoorParaphasias, normal rateArcuate fasciculus, left MCAAnomiaFluentGoodGood Circumlocutions, wordfinding difficultyAngular gyrus, left MCATranscortical MotorNonfluentGoodGoodGr eater ease of articulation, intact naming, adynamiaAdjacent to Broca area, left anterior cerebral arteryTranscortical

SensoryFluentPoorGoodNeol ogism, well-articulatedAdjacent to Wernicke area, left posterior cerebral arteryMixed TranscorticalNonfluentPoorGoodEcholaliaBor der zone of frontal, temporal, parietal areasGlobalNonfluentPoorPo orOften associated with apraxia, rare vocalizationMultiple lobes, left MCAAphasia TypeFluencyComprehension RepetitionCharacteristicsAph asia Type Minnesota Test for Most comprehensive; can identify aphasia type; contains subtests in each Differential Diagnosis of major area of language; takes several hours to administer Aphasia (MTDDA)Table 4. See Image 1.Multiple lobes, left MCAPoorNonfluentEcholalia PoorMixed TranscorticalAdjacent to Wernicke area, left posterior cerebral arteryGoodFluentGreater ease of articulation, intact naming, adynamiaGoodTranscortical MotorAngular gyrus, left MCAParaphasias, normal rateGoodConductionLeft MCA, temporalWernicke (Sensory, receptive)FluentPoorPoorGo odPoorLesion SiteComprehensionRepetitio n The advent of computed tomography (CT) scanning and magnetic resonance imaging (MRI) has enhanced our ability to identify small subcortical lesions as causes of aphasia.13,14 The following 2 major forms of subcortical

aphasias are recognized: (1) thalamic and (2) those due to lesions in the caudate, putamen, and/or internal capsule. Thalamic aphasia generally consists of fluent speech, mild impairment in comprehension, and intact repetition. Paraphasias, neologism, perseveration, and fluctuating attention are also common in thalamic aphasia. Lesions involving the putamen and caudate with extension into the internal capsule may cause several aphasic syndromes. The core syndrome is one of relative intact fluency, comprehension, and repetition. Depending upon the extent and location of the lesion, the syndrome may include better or worse articulation and comprehension, apraxia, and paraphasias. Evaluation of aphasia should be performed by the SLP using a formal standardized assessment of the components of language. Tests are designed to evaluate the patient's receptive and expressive language capacities by sampling components, such as conversational speech, comprehension, repetition, naming, reading, and writing. Several of the most commonly used aphasia batteries are summarized in

Table 5.13,14 Table 5. Comprehensive Tests for Aphasia Open table in new window Test Boston Diagnostic Aphasia Examination (BDAE) Western Aphasia Battery (WAB) Porch Index of Communicative Ability (PICA) Communication Effectiveness Index (CETI) Test Commonly used; can identify aphasia type; quantitates strengths and weaknesses in various areas of language; takes several hours to administer Commonly used; based on BDAE but can be completed in 1 hour; classifies aphasia syndromes; assigns a severity of impairment Measures overall communication ability; takes 1 hours to complete; uses 10 common objects (eg, pen, comb) to elicit patient responses; may be used to predict and follow recovery Assesses communication for basic needs, life skills, and health threats; based on observation by patient's significant other in those skill areas Characteristics

Minnesota Test for Differential Most comprehensive; can identify aphasia type; contains subtests in each Diagnosis of Aphasia (MTDDA) major area of language; takes several hours to administer Boston Diagnostic Aphasia Examination (BDAE) Western Aphasia Battery (WAB) Porch Index of Communicative Ability (PICA) Communication Effectiveness Index (CETI) Commonly used; can identify aphasia type; quantitates strengths and weaknesses in various areas of language; takes several hours to administer Commonly used; based on BDAE but can be completed in 1 hour; classifies aphasia syndromes; assigns a severity of impairment Measures overall communication ability; takes 1 hours to complete; uses 10 common objects (eg, pen, comb) to elicit patient responses; may be used to predict and follow recovery Assesses communication for basic needs, life skills, and health threats; based on observation by patient's significant other in those skill areas

Successful treatment of aphasia is based on the detailed knowledge of a patient's cognitive and linguistic strengths and weaknesses obtained from the formal testing batteries. Traditional treatment strategies focused on syndrome-specific approaches, in which treatment is based on the diagnosed aphasia syndrome. More current strategies promote getting a message across by any means, that is, through language, gestures, drawing, or any other expressive method. Whatever strategy is employed, patients and families must be taught to maximize the individual's communicative strengths. Some treatment strategies are summarized in Table 6. Table 6. Methods of Treating Aphasia Open table in new window

Method Melodic Intonation Therapy (MIT) Amer-Ind Code Visual Communication Therapy Visual Action Therapy

Characteristics Undamaged right hemisphere is recruited for language recovery by using melody-based therapy

Ideal For Nonfluent aphasia

Use of gestures that are associated with verbal labels Nonfluent aphasia Use of symbols to express needs and respond to questions Use of pictures, drawings, and gestures to indicate objects Global aphasia Global aphasia Any

Promoting Aphasics Encourages patients to convey information through Communication Effectiveness any available modality (eg, speech, gestures, (PACE) drawings, expressions, mime) Method Melodic Intonation Therapy (MIT) Amer-Ind Code Visual Communication Therapy Visual Action Therapy Characteristics Undamaged right hemisphere is recruited for language recovery by using melody-based therapy

Ideal For Nonfluent aphasia

Use of gestures that are associated with verbal labels Nonfluent aphasia Use of symbols to express needs and respond to questions Use of pictures, drawings, and gestures to indicate objects Global aphasia Global aphasia

Media file 1: Classification of the Encourages patients to convey informationAny through any available modality (eg, aphasias.Promoting Aphasics Communication speech, gestures, drawings, expressions, mime) Effectiveness (PACE)

See also the following related eMedicine topics: Aphasia Apraxia and Related Syndromes

Keywords
communication disorders, voice disorders, dysphonia, motor speech disorders, language disorders, aphasia, selected cognitive-communication disorders, hearing impairmen

Communication disorder
A communication disorder - speech and language disorders which refer to problems in communication and in related areas such as oral motor function. The delays and disorders can range from simple sound substitution to the inability to understand or use language. [1]

[edit] Examples
Examples of communication disorders:

autism -- a developmental defect that affects understanding of emotional communication aphasia -- loss of the ability to produce or comprehend language Learning disability - Both speaking and listening components of the definition Dysnomia - Deficit involving word retrieval Asperger syndrome - Areas of social and pragmatic language Semantic Pragmatic Disorder - Challenges with the semantic and pragmatic aspects of language blindness -- a defect of the eye or visual system deafness -- a defect of the ear or auditory system dyslexia -- a defect of the systems used in reading dyscalculia -- a defect of the systems used in communicating numbers expressive language disorder -- affects speaking and understanding where there is no delay in non-verbal intelligence. mixed receptive-expressive language disorder -- affects speaking, understanding, reading and writing where there is no delay in non-verbal intelligence. speech disorders such as o cluttering, a speech organization disorder o stuttering o oesophageal voice o speech sound disorder o specific language impairment o dysarthria

See also:

Glossary of medical terms related to communications disorders Voice disorders

[edit] External links

Voice and Speech Disorder Online Community (VoiceMatters.net) List of communication disorder related links Speech and Language Disorder Facts and Resources Child Language Disorders

Adult Language Disorders

[edit] References
1. ^ The Development of Language;Jean Berko Gleason:2001,Allyn&Bacon

Selected Cognitive-Communicative Disorders

Cognitive-communicative disorders affect the ability to communicate by impairing the pragmatics, or social rules, of language. Cognitive processes involved include the following

Orientation Attention Perception Memory Organization Impulsivity Reasoning Recall Planning and sequencing Social behavior Cognitive-communicative impairments occur primarily with the following 3 conditions: Right hemispheric dysfunction Traumatic brain injury (TBI) Dementia Patients with right hemispheric lesions have relatively intact language but demonstrate impaired overall communication abilities. Common deficits seen in right hemispheric lesions are visuospatial processing, insensitivity to context (missing subtleties), impulsivity, difficulty with expression and reception of emotions, lack of affective aspects (vocal inflection, facial expressions), impaired conversational rules (turn taking), left-sided neglect, poor topic maintenance (tangential), unawareness of deficits, and failure to recognize humor. These impairments often cause patients to be considered difficult to get along with, rude, indifferent, or depressed. Formal testing batteries for evaluating right hemispheric deficits can be administered by the SLP, including the RIC Evaluation of Communication Problems in Right Hemisphere Dysfunction (RICE) and the Mini Inventory of Right Brain Injury (MIRBI). Such batteries include analysis of the above deficits and assist the practitioner in deciding what treatment approaches to use. Treatment of right hemispheric dysfunction tends to focus on behavior modification. The goal of treatment is to improve a patient's understanding of the context and pragmatics of communication. Importantly, family training to allow adjustments to and understanding of the patient's new personality is paramount to rehabilitation success. Patients with TBI may experience a variety of communication disorders, including aphasia, dysarthria,

apraxia, and stuttering. Most typical are disturbances of perception, behavior, information retrieval, memory, and executive functioning. Social difficulties are common due to impairment in social perceptiveness, self-regulation, emotional lability, and perseveration. Expressive language deficits often include confabulation, circumlocution, and verbosity.

Patients with TBI often show deficits in perception, language, and memory; therefore, all of these modalities should be evaluated. As patients recover, they generally demonstrate progressive improvement in cognitive functioning. Because recovery is a dynamic process, patients with TBI should be tracked serially by a neuropsychologist to help guide the treatment plan. Treatment of the cognitive-communicative deficits in patients with TBI requires special considerations. Most patients with TBI are aged younger than 30 years and have the potential to return to the workforce. Although initially the patient benefits from traditional rehabilitative techniques, he/she requires additional focus on areas of orientation, memory, attention, and self-regulation. Additionally, the patient's environment should be structured so that predictability reinforces memory. Lastly, generalization to real world settings is necessary during therapy if re-entry into the community is to be successful. Dementia results in generalized intellectual impairment that compromises communication ability. A result of diffuse, bilateral damage, dementia may be cortical and/or subcortical. The severity of language impairment is associated with impairment in other mental functions. Patients with dementia often are classified into the following stages: Early stage o The person is least affected. o Some difficulties with pragmatics, orientation, and word finding occur. Middle stage o There is further deterioration from the above description. o Additionally, disruption of grammar is present. Late stage o There is a progression to global impairment, with all components of language affected o Speech becomes mainly neologistic and echolalic and eventually disappears. o The patient becomes mute.

Assessment of the demented patient should include a full history and physical examination, as well as formal testing. The Mini Mental Status examination can be administered quickly and easily. The SLP can administer the Arizona Battery for Communication Disorders of Dementia to assess communicative deficits. Assessment should be performed at regular intervals to follow the patient's progression.

Dementia is progressive and diffuse; therefore, treatment is supportive. Treatment goals should include environmental controls, capitalization on any preserved memory, and family training.

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Hearing Impairment
As mentioned earlier, the ability to hear is an integral part of the normal communication process. Impaired ability to relate to sounds can result in social isolation, depression, avoidance, and diminished quality of life.

Frequencies used in the measurement of clinical hearing range from 250-8000 Hz. The most critical part of this spectrum is the range of frequencies used for the reception and understanding of speech, 400-4000 Hz.

Conductive hearing loss results from dysfunction of the outer and/or middle ear. Patients with conductive hearing loss usually can understand (discriminate) speech correctly but require louder volumes of speech. Possible causes of conductive hearing impairment include cerumen impaction, presence of a foreign body, tympanic membrane perforation, otitis media, and otosclerosis.

Sensorineural hearing loss results from dysfunction of the inner ear (cochlea) or neural fibers of the eighth cranial nerve. Patients with sensorineural hearing loss usually have decreased speech discrimination. Conditions causing sensorineural impairment include excess noise, advanced age (presbycusis), ototoxic drugs, viral or bacterial illness, tumors, and cortical lesions.

A mixed hearing disorder involves components of conductive and sensorineural hearing loss. Central hearing impairment results from dysfunction of the central auditory pathways (eg, tumors, demyelinating disease, vascular damage).

In general, conductive hearing is assessed by measuring sensitivity to sound waves vibrating through the air and moving from the external auditory canal and middle ear. Bone conduction is assessed by placing a vibrating tuning fork over the mastoid process. This maneuver bypasses the outer and middle ear and conducts sound vibrations directly to the cochlea. Therefore, it reflects the sensitivity of the sensorineural system. The type and extent of hearing loss should be quantified further by audiometric screening by an otolaryngologist. Assessment includes measurements of air and bone conduction, as well as tests of speech discrimination. In many cases of conductive or mixed hearing loss, the disease process can be reversed through proper treatment (eg, cerumen removal, tympanoplasty, myringotomy).

The most common rehabilitative therapy for hearing impairment is the hearing aid. Any person with hearing difficulties that limit daily activities should be considered a prospective candidate for a hearing aid. A hearing aid evaluation should be performed by a certified clinical audiologist. The use of a hearing aid does not cure the impairment, but it does improve the ability to communicate effectively. Successful hearing aid use is dependent on the patient's self-perceived impairment, acceptance of the device, and desire to use hearing amplification.

Cochlear implants are auditory prostheses that provide hearing for the profoundly deaf. The implant converts sound into electrical signals that are delivered directly to any viable eighthnerve neurons in the cochlea. Sounds perceived with a cochlear implant are entirely different from the amplified sound heard with a hearing aid.

Assistive listening devices are used in selected listening environments. They employ a microphone placed close to the specific sound source, that transmits to the hearing-impaired listener. Assistive listening devices are effective in that they enhance the desired sound and diminish background noise. Other devices, such as closed-captioned television decoders, flashing alarms, telephone equipment, and tactile/vibration devices, are available.

Auditory training teaches the patient to be an assertive listener. Patients are instructed to inform others as to their most effective means of communication. The hearing-impaired person also is trained to use speech reading (recognizing facial expressions, gestures) to improve understanding of speech.

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