Assessment and Treatment of SpeechZLanguage Disorders
Speech-language pathologists provide diagnostic, treatment, and educational services to children who are experiencing impairments of speech, language, voice, fluency, communicative-cognitive, memory, and swallowing skills.
The primary disorders are outlined in Table 4.11 (35), divided into developmental versus acquired.Assessment
In assessing language disorders in children, it is crucial to understand the normal developmental level associated with the chronological age of the child to determine premorbid developmental levels and to assess the impact of the neurologic event or other interruption in typical developmental maturation on that development.
It is equally important to identify children at risk, as we know that speech and language delays/disorders in infancy and toddlerhood can result in difficulties in academic learning, social interaction, and development of appropriate peer relationships throughout childhood (36,37).
Areas of assessment in pediatric communication disorders include pragmatics, cognition, orientation, attachment/interaction, prelinguistic behaviors, phonological development/intelligibility, oral motor function, language comprehension (auditory and reading), language production (verbal and written), fluency, voice, hearing, and feeding and swallowing. These areas are assessed formally through test batteries, objective procedures, and parent interview questionnaires, as well as informally through direct observation of and interaction with children in naturalistic contexts. Detailed description of specific assessment materials and procedures in each of these areas is beyond the scope of this chapter. It should be noted that assessment is often done as part of a multidisciplinary evaluation, and input from other disciplines is often vital in providing the most comprehensive diagnosis and treatment plan.
One area of common need for multidisciplinary input is augmentative and alternative communication. For children who are nonverbal or who have significant motor impairment, a reliable means of access to augmentative communication devices and to computers must be identified, and this process may require input from speech pathology, occupational therapy, rehabilitation engineering, and sometimes physical therapy. Once a child has undergone a thorough evaluation, results are carefully| Primary Disorders of Speech, Language, and Swallowing | ||
| DEVELOPMENTAL | ACQUIRED | |
| Motor speech disorders | Phonologic disorder Verbal apraxia Articulation disorder | Dysarthria Verbal araxia Articulation dsorder |
| Language disorders | Language delay Language disorder | Aphasia |
| Voice disorders | Aphonia Dysphonia | Aphonia Dysphonia |
| Fluency disorders | Nonfluency Dysfluency/stuttering | Dysfluency/stuttering |
| Communicative-cognitive disorders Learning dsabilities Autism Memory disorders | Traumatic Brain Injury Aphasia Short-term memory deficit Long-term memory deficit Verbal learning deficit | |
| Swallowing disorders Source: From Ref. 35. | Oral aversion Discoordination of suck-swallow-breathe | Oral dysphagia Pharyngeal dysphagia Oropharyngeal dysphagia |
reviewed, a diagnosis is made, and treatment recommendations are formulated. A child's parents or caregivers are included as much as possible in the assessment process, as well as in the development of the treatment program.
With regard to the diagnosis, it is important to have a clear understanding of a child's medical history and any contribution that medical status may have made to the child's communication disorder. This will determine whether the deficit is considered developmental or acquired, and the diagnosis will then drive the treatment recommendations, including specific goals and objectives, treatment timeframe, and projected outcome (prognosis). A clear understanding of a child's cognitive level is also crucial in making appropriate diagnoses as well as treatment recommendations. If a child's cognitive level is commensurate with level of language ability, expectations for improvement and prognosis are different than for a child exhibiting a significant discrepancy between language and cognition.
Assessment tools and strategies that are accessible and appropriate for individuals with speech and other impairments are critical. Typical standardized tests specify the modality in which information is presented to the child and the modality in which the child must respond. Most procedures require clear speech for full participation. For example, most tests of phonological awareness require the participant to verbally present words or sounds to demonstrate skills. For an individual with significant apraxia, it is difficult to determine whether errors are due to underlying deficits in phonological awareness, effects of apraxia, or other reasons. For individuals who use alternative or augmentative communication, most communication requires the individual to make selections from preprogrammed arrays. This presents a further confound in that the ability to make choices of preference may be more developed than the ability to answer a factual question on demand if there are impairments in pragmatics (38).
Given the dearth of accessible speech, language, and cognitive assessment tools for individuals with communication impairments, especially if there are concurrent motor impairments, efforts to develop such instruments is a priority to optimize educational and medical interventions, as well as to provide accurate and meaningful diagnoses.
In addition to developing treatment recommendations, it is important to make any other referrals as appropriate. For example, if a child's history includes language regression, a referral to pediatric neurology may be indicated. If a child with documented speech and language delay has not had a formal hearing assessment, a referral to audiology is warranted. Finally, if a child is exhibiting characteristics consistent with a disorder on the autism spectrum, a referral to pediatric psychology may be necessary to obtain a formal diagnosis.
Treatment
Once a child has been evaluated, recommendations for treatment are made. These include specific goals and objectives in the identified deficit areas. Treatment for children with developmental speech and language delay or disorder differs in a number of important aspects from treatment for children with an acquired speech and language disorder. First, we distinguish between developmental delay and disorder in that delay implies typical but slowed or late development of communication skills. Disorder implies aberrant development of communication skills. For example, most typically developing children overgeneralize certain semantic concepts in the course of acquiring expressive vocabulary. At some point, they may use the word dog to refer to all four-legged animals, or juice to refer to all drinks. For children with developmental delay, they would be expected to persist in these overgeneralizations beyond predicted ages. In contrast, children with developmental disorders may exhibit atypical language patterns, such as reversing word order or leaving out certain parts of speech (eg, verbs) completely in their development of expressive language. These errors are not part of the typical pattern of language acquisition, and thus would be considered a disorder.
Treatment for children with developmental speech and language delay will typically focus on general language stimulation within the specific areas of delay.
For example, for a child with delay in expressive language, a general goal might be for a child to use language successfully to get daily needs and wants met. Objectives within that goal might be to increase expressive vocabulary, increase utterance length, ask and answer questions, or improve speech intelligibility. Treatment for children with developmental disorders will need to be more tailored to the specific errors exhibited, which will not necessarily fall within the typical acquisition of speech/language milestones. Children with the diagnosis of autism would fall under the category of developmental disorder, in that their language development does not follow the typical developmental progression. There are a number of treatment programs for children with autism, ranging from applied behavioral analysis (ABA) (39,40) to the “floor-time” (DIR) approach (41). The decision regarding which treatment approach to use in part is determined by the severity of the communication disorder; children with more severe disorders are often referred to ABA programs due to the increased amount of structure. Children with milder disorders may benefit more from a play-based approach such as DIR.Treatment for children with acquired communication disorders can be somewhat more complex, as it requires a detailed understanding of the specific deficits as well as how they related to the child's development of communication as a whole. In addition, it requires the ability to distinguish between gains due to spontaneous recovery from injury, gains due to typical expected development, and gains due to treatment. One of the most common areas of treatment in acquired communication disorders is traumatic brain injury.
Janet Lees proposes three stages of recovery in pediatric brain injury: acute period, lasting from emergency admission to reestablishment of stable conscious state; consistent recovery, lasting from reestablishment of stable conscious state to the point where progress begins to slow, or plateau; and the slowed recovery, or plateau stage (42).
The period during which a child makes the greatest progress is the second stage, in which intensive therapy and educational input can maximize recovery. The period where long-term residual deficits become apparent occurs during the third stage. The length of each stage varies, depending on the severity of the head injury. When treating children with acquired traumatic brain injury, it is important to keep in mind the unique characteristics and needs specific to pediatric brain injury. For example, pediatric brain injury occurs on a moving baseline of normal development upon which further development is expected. For this reason, assessment tools need to be appropriate for the developmental age of the child; in young children, this means some functions will not be accessible. Plasticity in the developing nervous system may allow the preservation of certain functions, particularly those related to language. In addition, plasticity could theoretically involve relocation of function to the opposite hemisphere or elsewhere in the same hemisphere. Normal recovery may occur, can be a most dramatic and unexplained phenomenon, and should not be confused with plasticity. Finally, critical periods for the development of a particular function may exist, which, at most, cannot be retrieved. This may, for example, apply to the development of social communication in young children at relatively high risk of the development of autistic features (43).When it is not possible to promote or maintain verbal communication in children, regardless of whether they have a developmental or acquired disorder, it may be necessary to provide augmentative or alternative options for communication. Numerous options are available for nonverbal children, ranging from sign language to high-tech augmentative communication devices. Common low-tech solutions include signing, pictures (eg, Picture Exchange Communication System, or PECS) (44), and recordable devices with finite selections, such as the Cheap Talk Device. (see article by Elizabeth Libby Rush at http://enablingdevices.com/ ask-Steve/assistive_technology_devices_used_in_ education_1). Children in need of augmentative or alternative communication typically are evaluated by speech pathology first, and if a more comprehensive assessment is indicated, a second evaluation may be done as part of a multidisciplinary assessment, including occupational therapy and rehabilitation engineering. Children who have significant motoric impairments often need input from occupational therapy regarding access solutions. Children who have complex needs requiring more custom solutions often benefit from input from rehabilitation engineering.