Speech and language disorders (2008) Bishop & Norbury

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  • 1.9781405145923_4_047.qxd 11/7/07 1:59 PMPage 781Speech and Language Disorders 47 Dorothy V. M. Bishop and Courtenay Frazier Norbury Speech, Language and Communication are represented by words that are composed of a small set ofspeech sounds, or phonemes). Where learning of oral language The distinction between speech, language and communica-is compromised because a child is deaf, manual (sign) languages tion may be illustrated by three child cases. Emma is a lively have evolved, showing similar structural characteristics to and engaging 9-year-old who has difculty making herself spoken languages. In addition, oral language can be expressed understood because her production of speech sounds is very in written form. Language involves more than speech, and com- unclear. However, she demonstrates normal language skills: munication involves more than language. However, it is she understands what others say to her, and can express her- possible for someone to speak without producing language self in writing using long and complex sentences. Her ability(e.g., when a person utters meaningless gobbledegook), and to communicate is hampered by her speech difculties, but sheit is possible for someone to produce utterances that obey the enjoys interacting with others, and when people fail to under- formal rules of language, yet communication is not achieved, stand her, she supplements her utterances with gesture and facialas in the case of Jack. In evaluating children with impairments, expression to get her message across.it is important to keep these three levels in mind, and to recog-Thomas is a 6-year-old who has no difculty in producingnize that a problem at one level does not necessarily entail a speech sounds clearly, but his language skills are limited, as problem at another. evidenced by his use of simple and immature sentence con- In this chapter we make a broad division between disorders struction. Instead of saying Id like a drink he says Meaffecting speech, and those affecting language and communica- want drink. However, although his language is far moretion. This distinction has some similarity with the distinction simple than that of other 6-year-olds, he does use it to com-made in DSM-IV-TR (American Psychiatric Association, 2000) municate with other children and adults. In contrast, 4-year-between phonological disorder (315.39) and language disorder old Jack produces a great deal of complex, uent and clearly (315.31), but the coverage is broader. Among speech disorders, articulated language, but he does not use it to communicatewe cover disorders affecting uency, voice and prosody as effectively. Thus, his opening gambit to a stranger might be well as problems of speech sound production that may have to say: In Deep Space Nine you cant get to level 6 until you a neurological basis. For language and communication dis- have killed all the foot soldiers, but if you get to level 6, youorders, we focus heavily on specic language impairment (SLI), have to rst destroy the klingons before you can enter the palacewhich is analogous to the DSM language disorder category, of death. but we also consider other conditions required for a differentialOne way of depicting the relationship between speech, language and communication is shown in Fig. 47.1, where language is a subset of communication and speech is a subset of language. Communication is dened by McArthur (1992, p. 238) as the transmission of information (a message) between a source and a receiver, using a signaling system. The primary means of communication between humans isSpeech through language, but communication also encompasses other means of signaling meaning, such as facial expression, bodily gesture and non-verbal sounds. Language differs from these other communicative modes; it is a complex formal system inLanguage which a small number of elements are combined in a rule-based manner to generate an innite number of possible meanings. Most human language is expressed in speech (i.e., meanings Communication Rutters Child and Adolescent Psychiatry, 5th edition. Edited by M. Rutter, D. Bishop, D. Pine, S. Scott, J. Stevenson, E. Taylor and A. Fig. 47.1 Relationship between speech, language and Thapar. 2008 Blackwell Publishing, ISBN: 978-1-4051-4592-3.communication.781

2. 9781405145923_4_047.qxd11/7/071:59 PMPage 782CHAPTER 47diagnosis, including acquired epileptic aphasia, autistic disorderDuring these informal tasks, the practitioner can make a num-and selective mutism.ber of important observations. The rst concerns the childs expressive language output. How long and grammatically complex are the childs utterances? How rich is the childsGeneral Principles of Assessment vocabulary? Does he or she struggle to nd the words for com- mon objects? Does he or she use gestures and facial expres-In most instances, detailed assessment of the speech and sion? Is the speech uent, or is the childs speech pepperedlanguage system will be carried out by a specialist speech-with hesitations and repetitions? What is the childs voicelanguage therapist, who will have extensive knowledge of quality like? Is he or she shouting and hoarse, or whisperinglinguistics and language development, the anatomy and physio-inappropriately? Is the child intelligible, or are there numer-logy that supports the language system, and access to a varietyous speech errors that impede understanding? Does the childof assessment and intervention techniques. With regard totell a story as a coherent sequence of events, or does he orcommunication, the primary decisions for the practitioner to she get muddled and leave important events out?make at initial assessment are: The next set of observations concerns the childs under-1 Is the childs communication development delayed orstanding, which may be more difcult to gauge in this setting.disordered?Nevertheless, it can be revealing to observe how the child2 What aspects of communication are causing the most concern?responds to the questions and comments of others. Are the3 Is referral to speech-language therapy warranted?answers appropriate to the questions? Does the child follow The rst port of call in the assessment process is the case adult directions? Does the child understand the premise of ahistory. This will give the practitioner an opportunity to story or does he or she misinterpret key events? Does the childexplore with the childs parents who is concerned about com- appear to understand the gestures and facial expressions ofmunication, and precisely what they are concerned about. others? Can the child listen while engaged with something else,Although many parents will be concerned about the childsor must the adult focus his or her attention before speaking?language development, others may not be aware of difcul- Finally, these informal interactions enable the practitionerties with communication. These parents may not see languageto observe other important behaviors. How and why does theas the central problem, but will voice concerns about behavior,child engage with the other people in the room? Does he orsocial skills and learning that may be related to underlying she look up when called? Is the childs play creative and imag-language difculties.inative, or destructive and repetitive? Can the child stick with As part of the case history, it is essential to obtain from an activity, or is his or her attention span unduly short? Is theparents clear examples of what motivates the child to com- child frustrated when he or she is not understood? Does hemunicate and how the child achieves communication. For or she try again? Does the child recognize when he or she hasexample, does the child communicate only to get his or her not understood something and ask for clarication? Is the childbasic needs met? Does the child communicate to show others anxious, or does he or she quickly adjust to the new situation?things that interest him or her? Does the child use words orIn combination with the case history, this set of observationsphrases? If not, does the child gesture, vocalize and/or point should provide the practitioner with a working hypothesis ofin an effort to get the message across? In addition to concretethe childs strengths and weaknesses which will guide the assess-examples of the types of communication the child produces,it is also important to ascertain the types of communication ment process (see chapter 19). !the child can understand. Does the child follow an adults pointor eye gaze? Can he or she follow simple verbal instructions Speech Disordersout of context? For more able children this may not pose aproblem, but they may have difculty following a story orSpeech refers to the production of oral language, which isgetting the point of a joke. achieved by modications to the vocal tract while a stream Once the practitioner has gained an impression of the child of air is breathed out from the lungs. Speech difculties infrom the parents, it will be necessary to determine directly the children are not difcult to detect, but accurate diagnosischilds current level of functioning. Throughout the rest of thisrequires specialist assessment by a speech and language ther-chapter, we give specic signposts to impairment in speech,apist. The main types of difculty that are encountered arelanguage and broader communication, and suggest standard-those affecting the distinctive production of speech sounds,ized assessments in each of these domains that can assist in uency of connected speech, voice, and prosody (i.e., speechthe diagnostic process (Table 47.1). However, it is usuallymelody and intonation).preferable to start by observing the childs communication ina less structured setting. This can be achieved by videoing theDifferential Diagnosis of Speech Sound Disorderschild playing with his or her parents or siblings in the clinic. All spoken languages encode meaning in terms of a small setIf the child has some verbal language, this pl