Speech and Language Impairments
According to the U.S. Department of Education, in 2006 there were 1,486,960 children with diagnoses of speech and language impairments in U.S. public schools. Even greater numbers of children had speech and language impairments associated with other diagnoses such as learning disabilities, autism spectrum disorders, or hearing impairment. The school-based speech and language pathologist (SLP) works to promote the functional skills of children affected by speech and language impairments and “to provide support in the general educational environment for students with communication handicaps to facilitate their successful participation, socialization, and learning” (American Speech-Language-Hearing Association, ASHA, 2000, p. 11). The impact of the impairment on the child's educational functioning is the paramount consideration.
Speech and language impairments may be classified by symptomology, the particular aspects of speech or language that are affected; specificity, whether or not the impairment is part of a broader deficit; and etiology, whether the impairment is developmental or acquired. In the following sections, these classifications are defined.
Speech. Children affected by speech impairment most often have deficits in producing the sounds of the language as compared to their same-age peers. They may leave out sounds (e.g., tar for star) or substitute one sound for another (e.g., cawot for carrot). In some cases the child does not understand the rules that govern the production and combination of speech sounds, which is commonly referred to as phonological impairment. In other cases, the root of the problem is motoric, which is commonly referred to as articulation impairment. Often, because the roots are not completely understood, the terms are used interchangeably. Articulation/phonological impairment is the single most frequent diagnostic category represented on the caseload of the school SLP (ASHA, 2006).
Speech impairments broadly defined also include abnormal voice, nasal resonance, and fluency (ASHA, 1993). Children with voice problems present with deviations in pitch, quality, or loudness of their speech as compared to other children of their same sex and age. Nasal resonance problems involve either hypo- or hyper-nasality. The former results when a blockage (e.g., swollen adenoids) prevents air from resonating within the nasal cavity during speech. The latter results when the soft palate does not make adequate closure with the pharyngeal wall during production of the oral sounds of the language. The speech of children who stutter is characterized by disruptions in rate and rhythm as well as repetitions of sounds, syllables, words or phrases. Affected children may struggle or tense when they stutter.
Language. Children affected by language impairments have deficits in understanding or expressing words, sentences, or extended discourse in either spoken or written modalities. This deficit may involve problems with semantics, the meaning of language (e.g., understanding the meaningful relationship between the words animal, cat, and Tabby); morphology and syntax, the grammar of language (e.g., inflecting verbs with –ed to indicate past tense); or pragmatics, the social use of language (e.g., judging the right amount of information to convey to a listener). Childhood language impairments may be referred to as language delays or language disorders. The term delay implies slow but typical development whereas disorder implies atypical development.
Primary or Secondary Impairment. Developmental speech and language impairments may be primary or secondary diagnoses. Children with primary impairments are otherwise normally developing. The cause of the impairment is usually unknown though central nervous dysfunction is presumed (ASHA, 1997) and, according to Bruce Tomblin and colleagues (1997), such impairments run in families. Children with primary language impairments affecting the oral modality are often said to have specific language impairment; those with primary impairments affecting the written modality are often said to have language learning disabilities, but either diagnostic category can encompass impairments in both modalities. Other children have speech and language impairments that are secondary to another deficit. For example, children with attention deficit hyperactivity disorder may have difficulty planning and organizing discourse as well as problems using language in a pragmatically appropriate manner, whereas children with cerebral palsy may have difficulty pronouncing speech sounds.
Developmental or Acquired Impairment. Most speech and language impairments exhibited by school children are developmental, that is, roots of the problem exist from birth and manifestations of the problem emerge as the child develops and it becomes obvious that the child is slower or atypical compared to peers. In a minority of cases, speech and language impairments are acquired when a child suffers an illness or accident that affects brain function. In these cases, the impairment may be referred to as aphasia. Rhea Paul (2001) summarizes these aphasias as follows. In cases of stroke and traumatic brain injury, children tend to be initially mute but have generally good recovery over time. A stroke, especially one that results in focal damage to the left hemisphere, typically results in long-term but subtle deficits in verbal memory, grammatical complexity, word finding, and reading. Traumatic brain injuries, such as those sustained from falls or car accidents, may result in long-term problems with word finding, discourse, and pragmatics. Speech motor control may also be compromised. A seizure disorder known as Landau-Kleffner syndrome has its onset in childhood and usually results in permanent impairments in the comprehension and expression of language.
In school settings, diagnosis and assessment are typically accomplished by teams of professionals who collaborate to make decisions regarding a given child's strengths and weaknesses. When speech and language development is a potential area of weakness, the SLP will be part of that team. The diagnosis of speech and language impairments is, in general, a two-pronged process. First, the child is referred for diagnostic testing, usually because a family member or teacher is concerned about his or her ability to function successfully in situations that demand verbal performance. Such situations include expressing basic needs, making friends, communicating in the classroom, taking tests, and learning to read and write. The SLP explores these concerns as well as the child's developmental and educational history via parent and teacher interviews.
Second, via standardized norm-referenced testing, observations in natural settings, and descriptive criterion-referenced assessments (e.g., review of classroom work portfolios, probes of response to intervention) the SLP determines whether the child is functioning more poorly than peers of the same chronological age in one or more domains (e.g., speech, semantics, morpho-syntax, pragmatics) and whether the child is apt to improve functioning in response to various supports. There is no universally agreed upon cut-off score on standardized tests for identifying speech and language impairments. Instead, the decision varies with the extent of the real-life impact, the number of domains affected, and the resources available for intervening on the child's behalf. State codes may establish eligibility criteria as well as recommended amounts of service and service delivery options in school settings (ASHA, 2000).
In cases of secondary impairments, speech and language problems may be one symptom leading to the diagnosis of the primary impairment. For example, late talking may be the first sign that a child is affected by a hearing impairment. In other cases, the primary impairment is diagnosed first and speech and language is monitored because the child is known to be at risk. This situation is illustrated in Down syndrome, an impairment typically diagnosed in utero. Children with Down syndrome are known to have particular difficulties with speech-motor control and expressive language development; therefore, they are frequently placed in speech and language intervention programs as babies. In cases in which speech and language problems are secondary to a deficit that involves mental retardation, the extent of the speech and language problem may be determined relative to mental-age peers (i.e., younger normally developing children) rather than chronological-age peers. In cases of acquired language impairments, the child may also be compared to his or her own previous level of functioning, if that is known.
Implicit in the above definitions is the enormous variability between children with speech and language impairments. One child may have a very mild deficit affecting only a few speech sounds whereas another may have a very severe deficit that prevents oral language altogether. In between are numerous other profiles, some of which are predictable if the roots of the impairment are known. For example, Laurence Leonard (1998) notes that children with specific language impairment are typically late to acquire first words. Their acquisition of grammar lags even further behind (in English this is often manifested as omission of inflections on verbs across an extended developmental period). Abbeduto and Hagerman (1997) note that children with fragile X syndrome, especially boys, often present with variability in rate of speech, delays in the development of words and word inflections, and perseverations of words during discourse. Finally, Krista Wilkinson (1998) notes that children with autism spectrum disorders have difficulty establishing and maintaining joint attention with communicative partners. Their speech may sound monotonous and the information that they convey via speech may strike the listener as odd or tangential. Although researchers can make generalizations like these for almost any diagnostic category, the value of the exercise is questionable. Two children who share a diagnosis may be less similar than two children with different diagnoses. Moreover, knowing the child's diagnostic category is of limited help in designing an intervention. Instead, the SLP typically meets with more success by selecting goals and strategies based on what is known about the child rather than the diagnosis.
In school settings, interventions for children with speech and language impairments are specified by an Individual Family Service Plan (IFSP) for children younger than three or an Individual Educational Program (IEP) for children who are three or more years of age. These plans are mandated by the Individuals with Disabilities Education Act of 1997 (IDEA). In the case of a child with or at risk for speech and language impairments, either plan will specify goals for speech and language development and the services and program accommodations necessary to reach those goals. Typically the SLP will set both long-term and short-term goals. If, for example, a long-term goal for the child is to master new grammatical forms, a more intermediate goal might be to learn to use helping verbs and the short-term targets of focus might be will, can, and does.
According to Rebecca McCauley and Marc Fey (2006), to approach these goals, the SLP must determine the context for the intervention (e.g., classroom-based, pull-out group, pull-out individual, self-contained classroom), the intervention agent (e.g., SLP, teacher, peer, parent), and the dosage (e.g., minutes per week). These decisions are made with consideration of the needs of the child, the wishes of the parents, and state codes. The SLP then determines the activities and strategies that will work best for a given child. Activities may include picture naming drills, joint book reading, dramatic play, computerized language comprehension exercises, and writing assignments, to name a few. During those activities, the SLP employs strategies that may include asking the child to listen to or imitate models of correct target productions, to correct mistakes when given feedback, or to respond when given scaffolds such as cues and simplifications of the task. The SLP chooses materials that will provide focused stimulation, that is, those which will allow many opportunities for the child to experience and to practice the target. The SLP may recast, revise, or expand the child's spontaneous utterances as a way to further model targets. When the SLP is not the primary agent of intervention, she serves as a collaborative consultant to teachers, parents, or peers by explaining the goals, activities, and strategies to be used with the child. An additional important component of intervention is on-going reassessment to ensure that the child is making progress; if not, program modification is necessary.
Best practice requires that decisions made about the intervention program are guided by the expertise of the SLP in light of the needs and values of the child and family and the research evidence that demonstrates the utility of various program options. Learning about the child and family is an on-going process that begins with the case-history interviews and observations, continues during the IFSP or IEP process, and grows as the SLP manages the child's intervention. SLPs who adhere to evidence-based practice seek independent confirmation and converging evidence for clinical decisions from the research literature. They evaluate research evidence to ensure that it is characterized by adequate experimental control and that it is free from bias. They determine whether the effects of any reported clinical procedure are sizeable, relevant to the child in question, and feasible in the school setting (ASHA, 2004).
As in any profession, the state-of-the-art in speech and language pathology is dynamic. A number of issues have prompted important changes in service delivery to children with speech and language impairments. Three issues are highlighted below.
Inclusion. The IDEA amendments of 1997 encouraged the participation of children with special needs in the general education curriculum. As a result, children with speech and language impairments are now often assessed and treated, at least in part, within the regular classroom. According to Rhea Paul (2001) and Carol Westby (2006), during curriculum-based assessment, the SLP analyzes the spoken or written features of the student's school work (homework, tests, projects), observes the child's successes and failures during school activities, and tests the utility of various scaffolds for the child's verbal performance during such activities. Curriculum-based intervention requires the SLP to move away from contrived exercises outside the classroom and towards consultant or collaborative roles within the classroom. As consultants to classroom teachers, SLPs suggest modified verbal instructions that enhance comprehension and verbal responding in the moment as well as strategies, materials, and activities that promote improvements in speech and language development over time. As collaborators, SLPs plan and implement lessons along with teachers. In either role, the SLP is concerned with supporting the child's communication in the classroom as well as his or her performance on language-related academic tasks whether they are taking a spelling test or comprehending a social studies text. Curriculum-based practice in schools is highly compatible with a broader emphasis in the field of speech pathology on intervening via purposeful and functional activities in naturalistic settings.
Diversity. According to a 1994 report from the U.S. General Accounting Office, bilingual students learning English as a second language were common in nearly every state. SLPs recognize that differences between communities in dialect or language are to be cherished, not pathologized or stigmatized (ASHA, 1983). Therefore, one of the key roles played by the SLP in increasingly diverse school settings is to help assessment teams distinguish speech and language patterns that reflect the learning of English as a second language from those indicative of true impairments. To make this distinction effectively, IDEA mandates that the child's native language development be assessed. Such assessment is complicated by a lack of professionals who are familiar with more than a mere handful of the 311 languages reported by the National Virtual Translation Center to be spoken in the United States as well as a lack of standardized tests that are normed for students who are bilingual. The limited availability of appropriate standardized tests represents yet another impetus in the movement towards curriculum-based assessments in naturalistic classroom settings. In cases in which true impairments have been discerned in the bilingual child, intervention is also complicated. For example, as noted by Celeste Roseberry-McKibben (2007), cultural and linguistic differences between the parents and the SLP may impede effective involvement of the family in the intervention. Such challenges may increase as the diversity of the U.S. population continues to grow; however, that growth will surely motivate useful changes in the design of tests and the education of SLPs and other professionals.
Evidence-based Practice. SLPs have long been aware that collecting data from individual children is important for planning interventions and monitoring their success. They have known that keeping current with research in the field is important. What changed with the advent of the evidence-based practice movement in the early 2000s was the emphasis on finding high levels of evidence, evaluating the quality of that evidence, and applying that evidence in decision making for individual children. Various guidelines exist for determining levels of evidence and evaluating quality (ASHA 2004). The SLP can also make use of published systematic reviews and meta-analyses and searchable online databases that summarize findings over multiple studies and include quality appraisals for each. Evidence-based practice is the joint responsibility of clinicians and scientists. As school-based SLPs retool to master evidence-based decision making; scientists must continue to fill gaps in the quantity and quality of available evidence. These joint efforts stand to further enhance the assessment and intervention services provided to school children with speech and language impairments.
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