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Types of Speech Impediments

Phynart Studio / Getty Images

Articulation Errors

Ankyloglossia, treating speech disorders.

A speech impediment, also known as a speech disorder , is a condition that can affect a person’s ability to form sounds and words, making their speech difficult to understand.

Speech disorders generally become evident in early childhood, as children start speaking and learning language. While many children initially have trouble with certain sounds and words, most are able to speak easily by the time they are five years old. However, some speech disorders persist. Approximately 5% of children aged three to 17 in the United States experience speech disorders.

There are many different types of speech impediments, including:

• Articulation errors

This article explores the causes, symptoms, and treatment of the different types of speech disorders.

Speech impediments that break the flow of speech are known as disfluencies. Stuttering is the most common form of disfluency, however there are other types as well.

Symptoms and Characteristics of Disfluencies

These are some of the characteristics of disfluencies:

• Repeating certain phrases, words, or sounds after the age of 4 (For example: “O…orange,” “I like…like orange juice,” “I want…I want orange juice”)
• Adding in extra sounds or words into sentences (For example: “We…uh…went to buy…um…orange juice”)
• Elongating words (For example: Saying “orange joooose” instead of "orange juice")
• Replacing words (For example: “What…Where is the orange juice?”)
• Hesitating while speaking (For example: A long pause while thinking)
• Pausing mid-speech (For example: Stopping abruptly mid-speech, due to lack of airflow, causing no sounds to come out, leading to a tense pause)

In addition, someone with disfluencies may also experience the following symptoms while speaking:

• Vocal tension and strain
• Head jerking
• Eye blinking
• Lip trembling

Causes of Disfluencies

People with disfluencies tend to have neurological differences in areas of the brain that control language processing and coordinate speech, which may be caused by:

• Genetic factors
• Trauma or infection to the brain
• Environmental stressors that cause anxiety or emotional distress
• Neurodevelopmental conditions like attention-deficit hyperactivity disorder (ADHD)

Articulation disorders occur when a person has trouble placing their tongue in the correct position to form certain speech sounds. Lisping is the most common type of articulation disorder.

Symptoms and Characteristics of Articulation Errors

These are some of the characteristics of articulation disorders:

• Substituting one sound for another . People typically have trouble with ‘r’ and ‘l’ sounds. (For example: Being unable to say “rabbit” and saying “wabbit” instead)
• Lisping , which refers specifically to difficulty with ‘s’ and ‘z’ sounds. (For example: Saying “thugar” instead of “sugar” or producing a whistling sound while trying to pronounce these letters)
• Omitting sounds (For example: Saying “coo” instead of “school”)
• Adding sounds (For example: Saying “pinanio” instead of “piano”)
• Making other speech errors that can make it difficult to decipher what the person is saying. For instance, only family members may be able to understand what they’re trying to say.

Causes of Articulation Errors

Articulation errors may be caused by:

• Genetic factors, as it can run in families
• Hearing loss , as mishearing sounds can affect the person’s ability to reproduce the sound
• Changes in the bones or muscles that are needed for speech, including a cleft palate (a hole in the roof of the mouth) and tooth problems
• Damage to the nerves or parts of the brain that coordinate speech, caused by conditions such as cerebral palsy , for instance

Ankyloglossia, also known as tongue-tie, is a condition where the person’s tongue is attached to the bottom of their mouth. This can restrict the tongue’s movement and make it hard for the person to move their tongue.

Symptoms and Characteristics of Ankyloglossia

Ankyloglossia is characterized by difficulty pronouncing ‘d,’ ‘n,’ ‘s,’ ‘t,’ ‘th,’ and ‘z’ sounds that require the person’s tongue to touch the roof of their mouth or their upper teeth, as their tongue may not be able to reach there.

Apart from speech impediments, people with ankyloglossia may also experience other symptoms as a result of their tongue-tie. These symptoms include:

• Difficulty breastfeeding in newborns
• Trouble swallowing
• Limited ability to move the tongue from side to side or stick it out
• Difficulty with activities like playing wind instruments, licking ice cream, or kissing
• Mouth breathing

Causes of Ankyloglossia

Ankyloglossia is a congenital condition, which means it is present from birth. A tissue known as the lingual frenulum attaches the tongue to the base of the mouth. People with ankyloglossia have a shorter lingual frenulum, or it is attached further along their tongue than most people’s.

Dysarthria is a condition where people slur their words because they cannot control the muscles that are required for speech, due to brain, nerve, or organ damage.

Symptoms and Characteristics of Dysarthria

Dysarthria is characterized by:

• Slurred, choppy, or robotic speech
• Rapid, slow, or soft speech
• Breathy, hoarse, or nasal voice

Additionally, someone with dysarthria may also have other symptoms such as difficulty swallowing and inability to move their tongue, lips, or jaw easily.

Causes of Dysarthria

Dysarthria is caused by paralysis or weakness of the speech muscles. The causes of the weakness can vary depending on the type of dysarthria the person has:

• Central dysarthria is caused by brain damage. It may be the result of neuromuscular diseases, such as cerebral palsy, Huntington’s disease, multiple sclerosis, muscular dystrophy, Huntington’s disease, Parkinson’s disease, or Lou Gehrig’s disease. Central dysarthria may also be caused by injuries or illnesses that damage the brain, such as dementia, stroke, brain tumor, or traumatic brain injury .
• Peripheral dysarthria is caused by damage to the organs involved in speech. It may be caused by congenital structural problems, trauma to the mouth or face, or surgery to the tongue, mouth, head, neck, or voice box.

Apraxia, also known as dyspraxia, verbal apraxia, or apraxia of speech, is a neurological condition that can cause a person to have trouble moving the muscles they need to create sounds or words. The person’s brain knows what they want to say, but is unable to plan and sequence the words accordingly.

Symptoms and Characteristics of Apraxia

These are some of the characteristics of apraxia:

• Distorting sounds: The person may have trouble pronouncing certain sounds, particularly vowels, because they may be unable to move their tongue or jaw in the manner required to produce the right sound. Longer or more complex words may be especially harder to manage.
• Being inconsistent in their speech: For instance, the person may be able to pronounce a word correctly once, but may not be able to repeat it. Or, they may pronounce it correctly today and differently on another day.
• Grasping for words: The person may appear to be searching for the right word or sound, or attempt the pronunciation several times before getting it right.
• Making errors with the rhythm or tone of speech: The person may struggle with using tone and inflection to communicate meaning. For instance, they may not stress any of the words in a sentence, have trouble going from one syllable in a word to another, or pause at an inappropriate part of a sentence.

Causes of Apraxia

Apraxia occurs when nerve pathways in the brain are interrupted, which can make it difficult for the brain to send messages to the organs involved in speaking. The causes of these neurological disturbances can vary depending on the type of apraxia the person has:

• Childhood apraxia of speech (CAS): This condition is present from birth and is often hereditary. A person may be more likely to have it if a biological relative has a learning disability or communication disorder.
• Acquired apraxia of speech (AOS): This condition can occur in adults, due to brain damage as a result of a tumor, head injury , stroke, or other illness that affects the parts of the brain involved in speech.

If you have a speech impediment, or suspect your child might have one, it can be helpful to visit your healthcare provider. Your primary care physician can refer you to a speech-language pathologist, who can evaluate speech, diagnose speech disorders, and recommend treatment options.

The diagnostic process may involve a physical examination as well as psychological, neurological, or hearing tests, in order to confirm the diagnosis and rule out other causes.

Treatment for speech disorders often involves speech therapy, which can help you learn how to move your muscles and position your tongue correctly in order to create specific sounds. It can be quite effective in improving your speech.

Children often grow out of milder speech disorders; however, special education and speech therapy can help with more serious ones.

For ankyloglossia, or tongue-tie, a minor surgery known as a frenectomy can help detach the tongue from the bottom of the mouth.

A Word From Verywell

A speech impediment can make it difficult to pronounce certain sounds, speak clearly, or communicate fluently. 

Living with a speech disorder can be frustrating because people may cut you off while you’re speaking, try to finish your sentences, or treat you differently. It can be helpful to talk to your healthcare providers about how to cope with these situations.

You may also benefit from joining a support group, where you can connect with others living with speech disorders.

National Library of Medicine. Speech disorders . Medline Plus.

Centers for Disease Control and Prevention. Language and speech disorders .

Cincinnati Children's Hospital. Stuttering .

National Institute on Deafness and Other Communication Disorders. Quick statistics about voice, speech, and language .

Cleveland Clinic. Speech impediment .

Lee H, Sim H, Lee E, Choi D. Disfluency characteristics of children with attention-deficit/hyperactivity disorder symptoms . J Commun Disord . 2017;65:54-64. doi:10.1016/j.jcomdis.2016.12.001

Nemours Foundation. Speech problems .

Penn Medicine. Speech and language disorders .

Cleveland Clinic. Tongue-tie .

University of Rochester Medical Center. Ankyloglossia .

Cleveland Clinic. Dysarthria .

National Institute on Deafness and Other Communication Disorders. Apraxia of speech .

Cleveland Clinic. Childhood apraxia of speech .

Stanford Children’s Hospital. Speech sound disorders in children .

Abbastabar H, Alizadeh A, Darparesh M, Mohseni S, Roozbeh N. Spatial distribution and the prevalence of speech disorders in the provinces of Iran . J Med Life . 2015;8(Spec Iss 2):99-104.

By Sanjana Gupta Sanjana is a health writer and editor. Her work spans various health-related topics, including mental health, fitness, nutrition, and wellness.

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• The Effects of Stress and Trauma on Language Development

Joy D. Osofsky, PhD

• Early Intervention
• Language Disorder(s)
• Social, Emotional, Behavioral

Learning Outcomes

After this course, participants will be able to:

• Describe ways exposure to trauma affects cognitive and language development.
• Describe how abuse and neglect play an important role in language development.
• List at least 3 prevention strategies that can help avert more serious developmental outcomes over time.

Introduction and Overview

I am going to talk with you about trauma and its effects on language development. I recently attended an all-day summit about adverse childhood experiences (ACEs) sponsored by a division within the American Psychological Association. It’s a very important topic and we need to learn more about ways to integrate it within our thinking, as well as how it relates to policy, which is also very important. I am sure that many of you are familiar with trauma, and how it impacts development in different ways. Today, we are focusing on language. Here is our roadmap for today’s course: I will first do a general review of the impact of trauma on development, and then look specifically at how trauma exposure can affect language development. Finally, we will look at the clinical implications related to language development, and the kinds of things that we can do to help parents and teachers help children in this area.

If young children (ages 0-6) are exposed to trauma, there are a number of different ways that can affect their development. It is very important to realize when working with very young children, problems with speech and language delay start very early and if the family goes somewhere for help – for example to a clinic or a primary care doctor - in general, they will be told that nothing can be done for those very young children. Nothing is done, and then they get into school, and there are more problems.

So, I want to raise awareness about the fact that we can do something early.

Effects of Trauma on Young Children

Here are some symptoms that very young children exposed to trauma may exhibit. You can find poor verbal skills, with delayed language or reduced intelligibility. When we talk about trauma - maltreatment, abuse, and neglect - it is important to recognize that the majority of trauma we see with young children is due to neglect. Neglect, of course, plays a very important role in the lack of language skills in these children.

If there is speech or language delay with trauma exposure, there are many things we need to look at. Obviously, we need to look at hearing. But we also see learning disabilities, which I am sure many of you are familiar with. With trauma, children have much more difficulty focusing on learning in school. They have much more difficulty being still and paying attention. And if they experience neglect or maltreatment, they often do not feel very good about themselves. That comes into play in the first four years of life. I know that other speakers in this virtual conference have talked about brain development, which plays an important role. So, how a young child feels about himself is incorporated into cognitive development and language development.

How does trauma impact a child's development in general? You have heard already, in this conference, about the neuroscience and the neurobiological effects on the brain. One of the references listed at the end of the course is from the Harvard Center for the Developing Child. They have taken on translating the complex science of early childhood development into very understandable material related to stress, trauma, and toxic stress. I am not a neuroscientist, and I depend on their translation of that material, which is really useful for those of us who are not neuroscience specialists.

Trauma obviously impacts the early attachment relationships, and early relationships have an impact on all later relationships; therefore, how attachments develop early on is very important. One of the effects of trauma exposure in a child is dysregulation, both in emotions and in behaviors.

I like to think about trauma impacting young children using the following analogy. I am sure all of you are familiar with the book, The Little Engine That Could, where the train is trying to make it up the track. If you conceptualize trauma as an event that can push that train off the track, then our role as clinicians is to help that child get back on track. Essentially, trauma derails the normal developmental trajectory, and can contribute to developmental delays, which is obviously what we are talking about today. It can also contribute to a negative sense of self, and difficulty in forming attachments in both early and later years of life.

It is important to be aware of the red flags that may indicate the emotional needs of a baby or very young child are not being met. A child in the first year of life should have a whole range of emotions, from clear attention, to sadness, to smiling. With the baby who has been exposed to trauma, you often see bland affect. You look at the baby and think, "Is this baby depressed?" My colleagues in the field of mental health do not like us to use the word “depression” in relation to a young baby, but you can think of it as withdrawn behavior. For example, the baby who lacks responsiveness and does not show eye contact, particularly with the primary caregiver. There is a problem with attachment to the caregiver, though the child may be friendly to strangers. We know that some young children are friendlier than others, but they really should not show preference for a stranger over a familiar caregiver. Another red flag is a baby who really does not want to be held close and cuddled in any way.

When children get a little older, to toddler or preschool age, that is when you start to see the aggressive behavior, dysregulation, difficulty sitting still and paying attention. There is no question that while a young child may be hesitant to be with you at first, over time, they become more comfortable with you because you pay a lot of attention to them. But if you get indiscriminate attachment where the child really prefers a stranger to the primary caregiver, that is of great concern.

You can also see feeding problems or sleep problems. There are many behaviors that are part of toddlers’ normal development that are not pleasant for parents or teachers. Toddlers will hit, they will bite, and they will throw tantrums. The question is whether these behaviors occur beyond what seems to be normal in terms of development. Those are things that we need to look at.

The Impact of Trauma on Adults

We also need to consider that trauma exposure not only impacts the child, but also affects parents, caregivers, and teachers. All of the people who are caring for the child may also be impacted by the trauma. When you are impacted by trauma as an adult, it may be difficult for you to be what we call “emotionally available” to the child. You may be there physically, but not really emotionally available to them.

Also, if a young child or toddler has been traumatized, we see the child play out their trauma. Here is a quick example: After Hurricane Katrina, I played a role in the mental health response. We housed first responders who had lost their homes on cruise ships that were in the harbor because they had nowhere to live and had to work in the city. We felt it was important to get all the children to come back, and we got a lot of children onto the cruise ship. We had to set up childcare centers for them. The first thing many of these children did when they went into the childcare center was to play “hurricane.” Playing hurricane was very traumatic for the parents. They did not want the children to do that. We suggested the parents go walk around the boat, take a brief break, and have a bit of respite while the children were with us. Children who are traumatized replay whatever trauma they experienced. We also see that frequently with domestic violence, and that can be very traumatizing for the parent. The parents need to protect themselves because they feel vulnerable. So it is very, very important to pay attention to the adults if trauma has occurred as well. Of course, sometimes, we know that the adults are the perpetrators; we will talk a little bit about that later on.

Factors that Influence How Children Experience Trauma

What determines how much children are influenced by trauma, if they go through these experiences? The factors that seem to affect this are how many times they have been exposed to trauma, how severe it was, and how close they are to the event. What seems to be most important in terms of how much they will be impacted is the child’s relationship with either the victim or the perpetrator.

I have an example of children separated from parents during the London blitz. When they were concerned about the bombing, they would have the children go out to the country with relatives so they would be safe, while the parents stayed in London. But actually, when researchers followed the children over time, the children who stayed with their parents in London had fewer symptoms later on than the children who were separated.  That speaks to the importance of the attachment relationship.

Other factors that influence children's exposure and the extent to which trauma will impact them are their age and developmental stage at time of the trauma, and how dangerous the situation is. I already mentioned that their relationship to the victim or perpetrator is also important. Is there someone there who can support them? There is no question about relationships being a critical factor for children who are impacted by trauma. Genetics can play a role as well.

Any previous history of trauma, as well as subsequent traumatic experiences, are very important in terms of how a child will be impacted by trauma. Our experience shows children who had a previous history of trauma and then were impacted by a disaster and had to evacuate and ended up losing their homes, or experienced a disaster and then had subsequent trauma, showed many more mental health symptoms than those who are more protected. So we need to look at chronicity of trauma and the numbers of traumatic experiences.

Additional Risk Factors for Speech and Language Delays

What are additional risk factors that relate to speech and language delays? This is the area that we are focusing on in this course. Children who grow up in poverty are more likely to have speech and language delays for a whole variety of reasons. They may not have as many resources available to them. They may be more stressed. Depending on how they were raised, the parents may not talk to the children that much because there are so many things in their lives that create stress. Other risk factors include not having social support, having parents with limited education, and having young parents. Having parents who are depressed is also a risk factor because parents who are depressed do not talk to their children and probably do not read to their children.  You all know that talking and reading to a child is very important for language development.

If children are exposed to drugs prenatally - particularly fetal alcohol, but also other drugs - that can impact their development generally and language development specifically. Other risk factors during pregnancy, such as poor nutrition, and then low birth weight can play a role.

Abuse and neglect are very important risk factors related to language development. Children who are in foster care, especially those with multiple placements who do not have a steady attachment relationship and a stable environment, are also going to be at risk for not only speech delay, but other kinds of behavior problems as well. In doing research for this course, a number of other risk factors came up.

As we know, boys tend to develop a little bit slower, particularly in the area of language and speech, than girls, and are therefore more likely to have speech delays. Ongoing hearing problems are an obvious risk factor, but may not be picked up. Often, when a child is in preschool, either they are doing a hearing exam there or a teacher asks the parents to get the child a hearing exam if the child is three years old and is not putting together the numbers of words that is typical. So, hearing problems obviously play a role.

A child with a difficult temperament has additional risk factors because they have trouble sitting still and paying attention. They may not listen to other people. They may not be able to sit still and have books read to them. Those are additional risk factors.

Children with disabilities are at higher risk for language delays as well. Children with disabilities experience a higher rate of maltreatment. Almost three times the number of children with disabilities are maltreated as compared with normally developing children. If children are deaf or hard of hearing, they have a much greater risk for neglect and abuse than non-disabled children. Children with communication delays have five times the risk for neglect and abuse, and that is probably related to the fact that parents or caregivers do not have patience with them. These children do not have the receptive language to be able to follow directions, and that is probably much more frustrating for the parents trying to care for them. There are a whole variety of reasons that can lead to an increased rate of abuse for children with disabilities, but unfortunately, it does occur, and it does impact language.

Effects of Trauma and Maltreatment on Infants and Toddlers

What happens when an infant or toddler is maltreated? We know that lack of stimulation interferes with growth and development of the brain, and certainly the part of the brain that controls cognitive development. With maltreatment, there is also difficulty with attachment, and the attachment relationship is a protective factor related to trauma. So if there are difficulties with attachment, it can be very problematic for children’s language development. We often see that maltreated infants do not use speech and language.

Very often, maltreated infants and young children will exhibit aggressive behaviors. They will bring attention to themselves in ways that are negative because they cannot do it with language. One feeds into the other. It is always very important to know if the children are getting attention in ways that are negative as a result of not having language. Obviously, abuse and neglect co-occur with domestic violence, substance use, and other risk factors.  

Effects of Trauma, Maltreatment, and Neglect on Speech/Language Development

There are some data related to the effects of exposure to trauma on speech and language.  Thirty-five percent of children with speech and language delays have experienced maltreatment. Many children who are referred for speech therapy have experienced abuse and neglect. So, there would be a great benefit to having speech-language professionals be more educated and informed about the effects of trauma, abuse, and neglect on development.

Joy D. Osofsky, PhD, is a clinical and developmental psychologist, Paul J. Ramsey Endowed Chair of Psychiatry and Barbara Lemann Professor of Child Welfare at Louisiana State University Health Sciences Center (LSUHSC) in New Orleans.  Dr. Osofsky has published widely and authored or edited six books related to trauma in the lives of children including in 2017, Treating Infants and Young Children Impacted by Trauma: Interventions that Promote Healthy Development (American Psychological Association) and in 2018, Violence and Trauma in the Lives of Children - Two Volume Handbook (Praeger Publishers). She is past president of Zero to Three: National Center for Infants, Toddlers and Families and the World Association for Infant Mental Health. She serves as the Clinical Consultant and on the Leadership Team for the Zero to Three Safe Babies Court Team Program. 

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Overcoming Speech Impediment: Symptoms to Treatment

There are many causes and solutions for impaired speech

• Types and Symptoms
• Speech Therapy
• Building Confidence

Speech impediments are conditions that can cause a variety of symptoms, such as an inability to understand language or speak with a stable sense of tone, speed, or fluidity. There are many different types of speech impediments, and they can begin during childhood or develop during adulthood.

Common causes include physical trauma, neurological disorders, or anxiety. If you or your child is experiencing signs of a speech impediment, you need to know that these conditions can be diagnosed and treated with professional speech therapy.

This article will discuss what you can do if you are concerned about a speech impediment and what you can expect during your diagnostic process and therapy.

FG Trade / Getty Images

Types and Symptoms of Speech Impediment

People can have speech problems due to developmental conditions that begin to show symptoms during early childhood or as a result of conditions that may occur during adulthood. 

The main classifications of speech impairment are aphasia (difficulty understanding or producing the correct words or phrases) or dysarthria (difficulty enunciating words).

Often, speech problems can be part of neurological or neurodevelopmental disorders that also cause other symptoms, such as multiple sclerosis (MS) or autism spectrum disorder .

There are several different symptoms of speech impediments, and you may experience one or more.

Can Symptoms Worsen?

Most speech disorders cause persistent symptoms and can temporarily get worse when you are tired, anxious, or sick.

Symptoms of dysarthria can include:

• Slurred speech
• Slow speech
• Choppy speech
• Hesitant speech
• Inability to control the volume of your speech
• Shaking or tremulous speech pattern
• Inability to pronounce certain sounds

Symptoms of aphasia may involve:

• Speech apraxia (difficulty coordinating speech)
• Difficulty understanding the meaning of what other people are saying
• Inability to use the correct words
• Inability to repeat words or phases
• Speech that has an irregular rhythm

You can have one or more of these speech patterns as part of your speech impediment, and their combination and frequency will help determine the type and cause of your speech problem.

Causes of Speech Impediment

The conditions that cause speech impediments can include developmental problems that are present from birth, neurological diseases such as Parkinson’s disease , or sudden neurological events, such as a stroke .

Some people can also experience temporary speech impairment due to anxiety, intoxication, medication side effects, postictal state (the time immediately after a seizure), or a change of consciousness.

Speech Impairment in Children

Children can have speech disorders associated with neurodevelopmental problems, which can interfere with speech development. Some childhood neurological or neurodevelopmental disorders may cause a regression (backsliding) of speech skills.

Common causes of childhood speech impediments include:

• Autism spectrum disorder : A neurodevelopmental disorder that affects social and interactive development
• Cerebral palsy :  A congenital (from birth) disorder that affects learning and control of physical movement
• Hearing loss : Can affect the way children hear and imitate speech
• Rett syndrome : A genetic neurodevelopmental condition that causes regression of physical and social skills beginning during the early school-age years.
• Adrenoleukodystrophy : A genetic disorder that causes a decline in motor and cognitive skills beginning during early childhood
• Childhood metabolic disorders : A group of conditions that affects the way children break down nutrients, often resulting in toxic damage to organs
• Brain tumor : A growth that may damage areas of the brain, including those that control speech or language
• Encephalitis : Brain inflammation or infection that may affect the way regions in the brain function
• Hydrocephalus : Excess fluid within the skull, which may develop after brain surgery and can cause brain damage

Do Childhood Speech Disorders Persist?

Speech disorders during childhood can have persistent effects throughout life. Therapy can often help improve speech skills.

Speech Impairment in Adulthood

Adult speech disorders develop due to conditions that damage the speech areas of the brain.

Common causes of adult speech impairment include:

• Head trauma 
• Nerve injury
• Throat tumor
• Stroke 
• Parkinson’s disease 
• Essential tremor
• Brain tumor
• Brain infection

Additionally, people may develop changes in speech with advancing age, even without a specific neurological cause. This can happen due to presbyphonia , which is a change in the volume and control of speech due to declining hormone levels and reduced elasticity and movement of the vocal cords.

Do Speech Disorders Resolve on Their Own?

Children and adults who have persistent speech disorders are unlikely to experience spontaneous improvement without therapy and should seek professional attention.

Steps to Treating Speech Impediment 

If you or your child has a speech impediment, your healthcare providers will work to diagnose the type of speech impediment as well as the underlying condition that caused it. Defining the cause and type of speech impediment will help determine your prognosis and treatment plan.

Sometimes the cause is known before symptoms begin, as is the case with trauma or MS. Impaired speech may first be a symptom of a condition, such as a stroke that causes aphasia as the primary symptom.

The diagnosis will include a comprehensive medical history, physical examination, and a thorough evaluation of speech and language. Diagnostic testing is directed by the medical history and clinical evaluation.

Diagnostic testing may include:

• Brain imaging , such as brain computerized tomography (CT) or magnetic residence imaging (MRI), if there’s concern about a disease process in the brain
• Swallowing evaluation if there’s concern about dysfunction of the muscles in the throat
• Electromyography (EMG) and nerve conduction studies (aka nerve conduction velocity, or NCV) if there’s concern about nerve and muscle damage
• Blood tests, which can help in diagnosing inflammatory disorders or infections

Your diagnostic tests will help pinpoint the cause of your speech problem. Your treatment will include specific therapy to help improve your speech, as well as medication or other interventions to treat the underlying disorder.

For example, if you are diagnosed with MS, you would likely receive disease-modifying therapy to help prevent MS progression. And if you are diagnosed with a brain tumor, you may need surgery, chemotherapy, or radiation to treat the tumor.

Therapy to Address Speech Impediment

Therapy for speech impairment is interactive and directed by a specialist who is experienced in treating speech problems . Sometimes, children receive speech therapy as part of a specialized learning program at school.

The duration and frequency of your speech therapy program depend on the underlying cause of your impediment, your improvement, and approval from your health insurance.

If you or your child has a serious speech problem, you may qualify for speech therapy. Working with your therapist can help you build confidence, particularly as you begin to see improvement.

Exercises during speech therapy may include:

• Pronouncing individual sounds, such as la la la or da da da
• Practicing pronunciation of words that you have trouble pronouncing
• Adjusting the rate or volume of your speech
• Mouth exercises
• Practicing language skills by naming objects or repeating what the therapist is saying

These therapies are meant to help achieve more fluent and understandable speech as well as an increased comfort level with speech and language.

Building Confidence With Speech Problems 

Some types of speech impairment might not qualify for therapy. If you have speech difficulties due to anxiety or a social phobia or if you don’t have access to therapy, you might benefit from activities that can help you practice your speech. 

You might consider one or more of the following for you or your child:

• Joining a local theater group
• Volunteering in a school or community activity that involves interaction with the public
• Signing up for a class that requires a significant amount of class participation
• Joining a support group for people who have problems with speech

Activities that you do on your own to improve your confidence with speaking can be most beneficial when you are in a non-judgmental and safe space.

Many different types of speech problems can affect children and adults. Some of these are congenital (present from birth), while others are acquired due to health conditions, medication side effects, substances, or mood and anxiety disorders. Because there are so many different types of speech problems, seeking a medical diagnosis so you can get the right therapy for your specific disorder is crucial.

Centers for Disease Control and Prevention. Language and speech disorders in children .

Han C, Tang J, Tang B, et al. The effectiveness and safety of noninvasive brain stimulation technology combined with speech training on aphasia after stroke: a systematic review and meta-analysis . Medicine (Baltimore). 2024;103(2):e36880. doi:10.1097/MD.0000000000036880

National Institute on Deafness and Other Communication Disorders. Quick statistics about voice, speech, language .

Mackey J, McCulloch H, Scheiner G, et al. Speech pathologists' perspectives on the use of augmentative and alternative communication devices with people with acquired brain injury and reflections from lived experience . Brain Impair. 2023;24(2):168-184. doi:10.1017/BrImp.2023.9

Allison KM, Doherty KM. Relation of speech-language profile and communication modality to participation of children with cerebral palsy . Am J Speech Lang Pathol . 2024:1-11. doi:10.1044/2023_AJSLP-23-00267

Saccente-Kennedy B, Gillies F, Desjardins M, et al. A systematic review of speech-language pathology interventions for presbyphonia using the rehabilitation treatment specification system . J Voice. 2024:S0892-1997(23)00396-X. doi:10.1016/j.jvoice.2023.12.010

By Heidi Moawad, MD Dr. Moawad is a neurologist and expert in brain health. She regularly writes and edits health content for medical books and publications.

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• Diseases & Conditions

Stuttering is a speech condition that disrupts the normal flow of speech. Fluency means having an easy and smooth flow and rhythm when speaking. With stuttering, the interruptions in flow happen often and cause problems for the speaker. Other names for stuttering are stammering and childhood-onset fluency disorder.

People who stutter know what they want to say, but they have a hard time saying it. For example, they may repeat or stretch out a word, a syllable, or a consonant or vowel sound. Or they may pause during speech because they've reached a word or sound that's hard to get out.

Stuttering is common among young children as a usual part of learning to speak. Some young children may stutter when their speech and language abilities aren't developed enough to keep up with what they want to say. Most children outgrow this type of stuttering, called developmental stuttering.

But sometimes stuttering is a long-term condition that remains into adulthood. This type of stuttering can affect self-esteem and communicating with other people.

Children and adults who stutter may be helped by treatments such as speech therapy, electronic devices to improve speech fluency or a form of mental health therapy called cognitive behavioral therapy.

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Stuttering symptoms may include:

• Having a hard time starting a word, phrase or sentence.
• Stretching out a word or sounds within a word.
• Repeating a sound, syllable or word.
• Brief silence for certain syllables or words, or pausing before or within a word.
• Adding extra words such as "um" if expecting to have problems moving to the next word.
• A lot of tension, tightness or movement of the face or upper body when saying a word.
• Anxiety about talking.
• Not being able to communicate well with others.

These actions may happen when stuttering:

• Rapid eye blinks.
• Trembling of the lips or jaw.
• Unusual face movements, sometimes called facial tics.
• Head nodding.
• Tightening of fists.

Stuttering may be worse when the person is excited, tired or under stress, or when feeling self-conscious, hurried or pressured. Situations such as speaking in front of a group or talking on the phone can be especially hard for people who stutter.

But most people who stutter can speak without stuttering when they talk to themselves and when they sing or speak along with someone else.

When to see a doctor or speech-language pathologist

It's common for children between the ages of 2 and 5 years to go through periods when they may stutter. For most children, this is part of learning to speak, and it gets better on its own. But stuttering that continues may need treatment to improve speech fluency.

Call your healthcare professional for a referral to a specialist in speech and language called a speech-language pathologist. Or you can contact the speech-language pathologist directly for an appointment. Ask for help if stuttering:

• Lasts more than six months.
• Happens along with other speech or language problems.
• Happens more often or continues as the child grows older.
• Includes muscle tightening or physically struggling when trying to speak.
• Affects the ability to effectively communicate at school or work or in social situations.
• Causes anxiety or emotional problems, such as fear of or not taking part in situations that require speaking.
• Begins as an adult.

Researchers continue to study the underlying causes of developmental stuttering. A combination of factors may be involved.

Developmental stuttering

Stuttering that happens in children while they're learning to speak is called developmental stuttering. Possible causes of developmental stuttering include:

• Problems with speech motor control. Some evidence shows that problems in speech motor control, such as timing, sensory and motor coordination, may be involved.
• Genetics. Stuttering tends to run in families. It appears that stuttering can happen from changes in genes passed down from parents to children.

Stuttering that happens from other causes

Speech fluency can be disrupted from causes other than developmental stuttering.

• Neurogenic stuttering. A stroke, traumatic brain injury or other brain disorders can cause speech that is slow or has pauses or repeated sounds.
• Emotional distress. Speech fluency can be disrupted during times of emotional distress. Speakers who usually do not stutter may experience problems with fluency when they are nervous or feel pressured. These situations also may cause speakers who stutter to have greater problems with fluency.
• Psychogenic stuttering. Speech difficulties that appear after an emotional trauma are uncommon and not the same as developmental stuttering.

Risk factors

Males are much more likely to stutter than females are. Things that raise the risk of stuttering include:

• Having a childhood developmental condition. Children who have developmental conditions, such as attention-deficit/hyperactivity disorder, autism or developmental delays, may be more likely to stutter. This is true for children with other speech problems too.
• Having relatives who stutter. Stuttering tends to run in families.
• Stress. Stress in the family and other types of stress or pressure can worsen existing stuttering.

Complications

Stuttering can lead to:

• Problems communicating with others.
• Not speaking or staying away from situations that require speaking.
• Not taking part in social, school or work activities and opportunities for success.
• Being bullied or teased.
• Low self-esteem.
• Stuttering. American Speech-Language-Hearing Association. https://www.asha.org/public/speech/disorders/stuttering/. Accessed Feb. 2, 2024.
• Fluency disorders. American Speech-Language-Hearing Association. https://www.asha.org/practice-portal/clinical-topics/fluency-disorders/. Accessed Feb. 2, 2024.
• Childhood-onset fluency disorder (stuttering). In: Diagnostic and Statistical Manual of Mental Disorders DSM-5-TR. 5th ed. American Psychiatric Association; 2022. https://dsm.psychiatryonline.org. Accessed Feb. 2, 2024.
• Stuttering. National Institute on Deafness and Other Communication Disorders. https://www.nidcd.nih.gov/health/stuttering. Accessed Feb. 2, 2024.
• Sander RW, et al. Stuttering: Understanding and treating a common disability. American Family Physician. 2019;100:556.
• Laiho A, et al. Stuttering interventions for children, adolescents and adults: A systematic review as part of the clinical guidelines. Journal of Communication Disorders. 2022; doi:10.1016/j.jcomdis.2022.106242.
• 6 tips for speaking with someone who stutters. The Stuttering Foundation. https://www.stutteringhelp.org/6-tips-speaking-someone-who-stutters-0. Accessed Feb. 2, 2024.
• 7 tips for talking with your child. The Stuttering Foundation. https://www.stutteringhelp.org/7-tips-talking-your-child-0. Accessed Feb. 2, 2024.
• Clark HM (expert opinion). Mayo Clinic. Feb. 11, 2024.

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Traumatic Brain Injury: Cognitive and Communication Disorders

What are the cognitive and communication problems that result from traumatic brain injury?

Cognitive and communication problems that result from traumatic brain injury vary from person to person. These problems depend on many factors which include an individual's personality, preinjury abilities, and the severity of the brain damage.

The effects of the brain damage are generally greatest immediately following the injury. However, some effects from traumatic brain injury may be misleading. The newly injured brain often suffers temporary damage from swelling and a form of "bruising" called contusions. These types of damage are usually not permanent and the functions of those areas of the brain return once the swelling or bruising goes away. Therefore, it is difficult to predict accurately the extent of long-term problems in the first weeks following traumatic brain injury.

Focal damage, however, may result in long-term, permanent difficulties. Improvements can occur as other areas of the brain learn to take over the function of the damaged areas. Children's brains are much more capable of this flexibility than are the brains of adults. For this reason, children who suffer brain trauma might progress better than adults with similar damage.

In moderate to severe injuries, the swelling may cause pressure on a lower part of the brain called the brainstem, which controls consciousness or wakefulness. Many individuals who suffer these types of injuries are in an unconscious state called a coma. A person in a coma may be completely unresponsive to any type of stimulation such as loud noises, pain, or smells. Others may move, make noise, or respond to pain but be unaware of their surroundings. These people are unable to communicate. Some people recover from a coma, becoming alert and able to communicate.

In conscious individuals, cognitive impairments often include having problems concentrating for varying periods of time, having trouble organizing thoughts, and becoming easily confused or forgetful. Some individuals will experience difficulty learning new information. Still others will be unable to interpret the actions of others and therefore have great problems in social situations. For these individuals, what they say or what they do is often inappropriate for the situation. Many will experience difficulty solving problems, making decisions, and planning. Judgment is often affected.

Language problems also vary. Problems often include word-finding difficulty, poor sentence formation, and lengthy and often faulty descriptions or explanations. These are to cover for a lack of understanding or inability to think of a word. For example, when asking for help finding a belt while dressing, an individual may ask for "the circular cow thing that I used yesterday and before." Many have difficulty understanding multiple meanings in jokes, sarcasm, and adages or figurative expressions such as, "A rolling stone gathers no moss" or "Take a flying leap." Individuals with traumatic brain injuries are often unaware of their errors and can become frustrated or angry and place the blame for communication difficulties on the person to whom they are speaking. Reading and writing abilities are often worse than those for speaking and understanding spoken words. Simple and complex mathematical abilities are often affected.

The speech produced by a person who has traumatic brain injury may be slow, slurred, and difficult or impossible to understand if the areas of the brain that control the muscles of the speech mechanism are damaged. This type of speech problem is called dysarthria. These individuals may also experience problems swallowing. This is called dysphagia. Others may have what is called apraxia of speech, a condition in which strength and coordination of the speech muscles are unimpaired but the individual experiences difficulty saying words correctly in a consistent way. For example, someone may repeatedly stumble on the word "tomorrow" when asked to repeat it, but then be able to say it in a statement such as, "I'll try to say it again tomorrow."

How are the cognitive and communication problems assessed?

The assessment of cognitive and communication problems is a continual, ongoing process that involves a number of professionals. Immediately following the injury, a neurologist (a physician who specializes in nervous system disorders) or another physician may conduct an informal, bedside evaluation of attention, memory, and the ability to understand and speak. Once the person's physical condition has stabilized, a speech-language pathologist may evaluate cognitive and communication skills, and a neuropsychologist may evaluate other cognitive and behavioral abilities. Occupational therapists also assess cognitive skills related to the individual's ability to perform "activities of daily living" (ADL) such as dressing or preparing meals. An audiologist should assess hearing. All assessments continue at frequent intervals during the rehabilitative process so that progress can be documented and treatment plans updated. The rehabilitative process may last for several months to a year.

How are the cognitive and communication problems treated?

The cognitive and communication problems of traumatic brain injury are best treated early, often beginning while the individual is still in the hospital. This early therapy will frequently center on increasing skills of alertness and attention. They will focus on improving orientation to person, place, time, and situation, and stimulating speech understanding. The therapist will provide oral-motor exercises in cases where the individual has speech and swallowing problems.

Longer term rehabilitation may be performed individually, in groups, or both, depending upon the needs of the individual. This therapy often occurs in a rehabilitation facility designed specifically for the treatment of individuals with traumatic brain injury. This type of setting allows for intensive therapy by speech-language pathologists, physical therapists, occupational therapists, and neuropsychologists at a time when the individual can best benefit from such intensive therapy. Other individuals may receive therapy at home by visiting therapists or on an outpatient basis at a hospital, medical center, or rehabilitation facility.

The goal of rehabilitation is to help the individual progress to the most independent level of functioning possible. For some, ability to express needs verbally in simple terms may be a goal. For others, the goal may be to express needs by pointing to pictures. For still others, the goal of therapy may be to improve the ability to define words or describe consequences of actions or events.

Therapy will focus on regaining lost skills as well as learning ways to compensate for abilities that have been permanently changed because of the brain injury. Most individuals respond best to programs tailored to their backgrounds and interests. The most effective therapy programs involve family members who can best provide this information. Computer-assisted programs have been successful with some individuals.

What research is being done for the cognitive and communication problems caused by traumatic brain injury?

Researchers are studying many issues related to the special cognitive and communication problems experienced by individuals who have traumatic brain injuries. Scientists are designing new evaluation tools to assess the special problems that children who have suffered traumatic brain injuries encounter. Because the brain of a child is vastly different from the brain of an adult, scientists are also examining the effects of various treatment methods that have been developed specifically for children. These new strategies include the use of computer programs. In addition, research is examining the effects of some medications on the recovery of speech, language, and cognitive abilities following traumatic brain injury.

Where can I get more information?

NIDCD maintains a directory of organizations that can answer questions and provide printed or electronic information on traumatic brain injury. Please see the list of organizations at www.nidcd.nih.gov/directory .

NIH Pub. No. 98-4315 July 1998 Contact information updated February 2002

National Institute on Deafness and Other Communication Disorders. www.nidcd.nih.gov .

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What to Know About Speech Impairment

A speech impairment affects people who have problems speaking in a regular tone of voice or tempo. Speech impairments make it hard for people to communicate properly, and they can happen in both children and adults. ‌

These disorders can cause frustration and embarrassment to the person suffering from them.

What is Speech Impairment?

People who have speech impairments have a hard time pronouncing different speech sounds. They might distort the sounds of some words and leave other sounds out completely.

There are three general categories of speech impairment:

• Fluency disorder. This type can be described as continuity, smoothness, rate, and effort in speech production.
• Voice disorder. A voice disorder means you have an atypical tone of voice. It could be an unusual pitch, quality, resonance, or volume.
• Articulation disorder. If you have an articulation disorder, you might distort certain sounds. You could also fully omit sounds.

Stuttering , or stammering, is a common fluency disorder that affects about 3 million Americans. It usually affects young children who are just learning to speak, but it can continue on into adulthood.

Speech and language impairments are two words that are often used interchangeably, but they are two very different types of problems.

Speech means talking. It uses the jaw muscles, tongue, lips, and vocal chords. Language is a set of words and symbols made to communicate a message. Language and speech disorders can affect you separately, or both can happen at the same time.

Types of Speech Impairments

Speech impairments can begin in childhood and carry on through your adult years. Others can happen due to trauma, or after a medical event like a stroke.

The types of speech impairments are:

• Childhood apraxia of speech. This can happen to children when it’s time for them to start talking. The brain’s signals don’t communicate with the mouth, so the child can’t move their lips and tongue in the way they’re mean to.
• Dysarthria. This type of speech impairment happens when the muscles you use to talk are too weak, and can’t form words properly.
• Orofacial myofunctional disorders (OMD). OMDs are characterized by an abnormal pattern of facial muscle use. OMD interferes with how the facial muscles, including the tongue, are used. People who suffer from OMD might also struggle to breathe through their nose.
• Speech sound disorders. It’s normal for children to struggle to pronounce certain sounds as they learn to talk. But after ages four or five, constant mispronunciation might signal a problem. It can continue into adulthood, or some people get it after a stroke.
• Stuttering. Stuttering can mean repeating words or sounds like “uh” and “um” (disfluencies) involuntarily. Stuttering can be intensified by strong emotions or stress.
• Voice. A voice disorder can mean you “lost” your voice because you stressed it too much. It can also mean a chronic cough or paralysis of the vocal cords, among others.

Health Issues That Affect Speech Impairment

Other than childhood speech impairments, there are a range of reasons you could get one in your adult years. They can happen due to a traumatic event, illness, or surgery.

Dysarthria , aphasia, and voice disturbances can happen in adulthood, and are usually due to these medical events.

Aphasia. Aphasia is the loss of ability to understand words, spoken or written. There are many types of aphasia . It can happen after a stroke or if a tumor reaches the part of the brain where language is processed.

Medical issues that can cause aphasia:

• Head trauma
• Transient ischemic attack (TIA)
• Brain tumor
• Alzheimer’s disease

Dysarthria. Dysarthria is usually caused by a nerve problem. The person suffering from it loses the ability to make certain sounds or might have poor pronunciation. It can also affect your ability to control the tongue, larynx, lips, and vocal chords.

Medical issues that can cause dysarthria:

• Facial trauma
• Diseases that affect your nervous system
• Side effects of certain medication
• Alcoholic intoxication
• Dentures that don’t fit properly
• Transient ischemic attack (TIA) ‌

Voice disturbances. Traumatic events or extreme stress placed on the vocal cords can cause you to “lose” your voice or have a vocal disturbance. Disease can also affect the way your voice sounds.

Cancerous or noncancerous growths or nodules on the vocal cords can make your voice sound different.

Understanding Speech Impairments

Having a speech impairment can be a very frustrating and embarrassing experience for the person experiencing it. It’s important to be patient and understanding when communicating.

Try the following tips to improve communication and foster an accepting environment with someone who has a speech impairment:

• Speak slowly and use hand gestures
• Keep a pen and paper handy in case it’s needed to communicate
• Maintain a calm environment free of stimulating sounds
• Use simple phrases when you speak
• Use your normal tone of voice

Consulting with a mental health care provider can help with feelings of anger and depression that can accompany speech impairments.

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Committee on the Evaluation of the Supplemental Security Income (SSI) Disability Program for Children with Speech Disorders and Language Disorders; Board on the Health of Select Populations; Board on Children, Youth, and Families; Institute of Medicine; Division of Behavioral and Social Sciences and Education; National Academies of Sciences, Engineering, and Medicine; Rosenbaum S, Simon P, editors. Speech and Language Disorders in Children: Implications for the Social Security Administration's Supplemental Security Income Program. Washington (DC): National Academies Press (US); 2016 Apr 6.

Speech and Language Disorders in Children: Implications for the Social Security Administration's Supplemental Security Income Program.

• Hardcopy Version at National Academies Press

2 Childhood Speech and Language Disorders in the General U.S. Population

Speech and language disorders in children include a variety of conditions that disrupt children's ability to communicate. Severe speech and language disorders are particularly serious, preventing or impeding children's participation in family and community, school achievement, and eventual employment. This chapter begins by providing an overview of speech and language development and disorders. It then addresses the following topics within the committee's charge: (1) current standards of care for assessing and diagnosing speech and language disorders; (2) causes of and risk factors for these disorders; (3) their prevalence and its relationship to age, development, and gender; and (4) common comorbidities (i.e., other co-occurring conditions).

• OVERVIEW OF CHILDHOOD SPEECH AND LANGUAGE DISORDERS

Differentiating Language from Speech

The words “language” and “speech” are often used interchangeably in casual conversation, but in the context of communication disorders, it is important to understand the differences between them. Language refers to the code, or symbol system, for transforming unobservable mental events, such as thoughts and memories, into events that can be perceived by other people. Being a competent language user requires two essential capabilities. One, known as expressive language or language production , is the ability to encode one's ideas into language forms and symbols. The other, known as receptive language or language comprehension , is the ability to understand the meanings that others have expressed using language. People commonly express themselves by speaking and understand others' meanings by listening. However, language also can be expressed and understood in other ways—for example, by reading, writing, and signing ( Crystal, 2009 ).

Speech has a narrower meaning than language because it refers specifically to sounds produced by the oral mechanism, including the lips, tongue, vocal cords, and related structures ( Caruso and Strand, 1999 ). Speech is the most common way to transmit language and, unlike language, can be observed directly. Speech disorders are sometimes mistakenly equated with language disorders, and conversely, normal speech is sometimes assumed to reflect normal language. In fact, speech disorders and language disorders can occur separately or together. For example, a child might have a speech disorder, such as extremely poor articulation, yet have intact language skills. Another child might have a language disorder, such as extremely poor comprehension, yet be able to produce speech sounds normally. Finally, some children have both language disorders and speech disorders. In young children who are producing little if any speech, it can be difficult to determine whether a speech disorder, a language disorder, or both are present. As noted in Chapter 3 on treatment, early intervention for such children generally is designed to facilitate both language and speech skills. When children reach an age that allows each area to be assessed separately, it becomes possible to narrow the focus of treatment according to whether deficits are found only in speech, only in language, or in both.

In this report, the terms “speech disorders,” “language disorders,” and “speech and language disorders” are used (see Box 1-2 ). The terms “speech disorders” and “language disorders” are used only to refer to these disorders as defined in this chapter, while the term “speech and language disorders” denotes all of the disorders encompassed by these two categories.

Overview of Speech and Language Development and Disorders

The foundations for the development of speech and language begin in utero, with the growth of the anatomical structures and physiological processes that will eventually support sensory, motor, attention, memory, and learning skills. As discussed in the later section of this chapter on causes and risk factors, virtually every factor that threatens prenatal development of the fetus—from genetic abnormalities, to nutritional deficiencies, to exposure to environmental toxins—is associated with an increased risk of developing speech and/or language disorders. Before the end of the prenatal period, fetuses are able to hear, albeit imperfectly, speech and other environmental sounds, and within a few minutes after birth they show special attention to human faces and voices. This early interest in other people appears to set the stage for forming relationships with caregivers, who scaffold the child's growing ability to anticipate, initiate, and participate in social routines (e.g., Locke, 2011 ). The social experiences and skills that occur during the infant's first months of life are important precursors to pragmatic language skills: the infant first learns to engage in reciprocal interactions and to convey communicative intentions through nonlinguistic means such as gestures, and begins to accomplish these same goals through language forms such as early words. In the first few months of life, infants show improvement in their ability to recognize increasingly detailed patterns of speech, a precursor to linking spoken words with their meanings. Also in the first months of life, infants begin to use their oral mechanisms to produce nonspeech sounds, such as cooing and squealing, as they develop control of their muscles and movements. Thus, they are able to produce increasingly consistent combinations of speech-like sounds and syllables (babbling), a precursor to articulating recognizable words (e.g., Kent, 1999 ).

Evidence from neurophysiological habituation, neuroimaging, and preferential looking studies shows that children begin to recognize speech patterns that recur in their environments early in the first year of life ( Friedrich et al, 2015 ; Pelucchi et al., 2009 ; Werker et al., 2012 ). When tested using behavioral measures, most 12- to 18-month-old children show that they can understand at least a few words in the absence of gestural or other cues to their meaning (e.g., Miller and Paul, 1995 ). They also can produce at least a few intelligible words during this period (e.g., Squires et al., 2009 ), showing that they are acquiring both expressive language and speech skills. Their speech skills progress in a systematic fashion over the next few years, as they learn first to say relatively simpler consonants (e.g., “m,” “d,” “n”) and later to say more challenging consonants (e.g., “s,” “th,” “sh”) and consonant clusters (e.g., “bl,” “tr,” “st”) ( Shriberg, 1993 ). Receptive language, expressive language, and speech all develop at a rapid pace through the preschool period as children learn to understand and say thousands of individual words, as well as learn the grammatical (or morpho-syntactic) rules that enable them to understand and produce increasingly lengthy, sophisticated, intelligible, and socially acceptable combinations of words in phrases and sentences (e.g., Fenson et al., 2007 ). These speech and language skills enable children to achieve communication goals as diverse as understanding a simple story, taking a turn in a game, expressing an emotion, sharing a personal experience, and asking for help (e.g., Boudreau, 2008 ). By the end of the preschool period, children's ability to understand the language spoken by others and to speak well enough for others to understand them provides the scaffolding for their growing independence.

The end of the preschool period is also when most children show signs that they can think consciously about sounds and words, an ability known as metalinguistic awareness ( Kim et al., 2013 ). Awareness of the phonological (sound) characteristics of words, for example, enables children to identify words that rhyme or words that begin or end with the same speech sound. Such phonological awareness skills have been linked to children's ability to learn that speech sounds can be represented by printed letters—one of the skills necessary for learning to read words ( Troia, 2013 ). Reading requires more than recognizing individual words, however. Competent readers also must understand how words combine to express meanings in connected text, such as phrases, sentences, and paragraphs. Strong evidence shows that children's receptive language skills—such as their knowledge of vocabulary and grammar—are important contributors as well to this aspect of reading comprehension ( Catts and Kamhi, 2012 ; Duke et al., 2013 ).

In short, by the time children enter elementary school, the speech and language skills they have acquired through listening and speaking provide the foundation for reading and writing. These new literacy skills are critical for learning and social development through the school years and beyond. At the same time, ongoing growth in spoken language skills contributes to building personal and professional relationships and participating independently in society.

It is worth noting that children's speech and language experiences may vary substantially depending on the values and expectations of their culture, community, and family. This point is most obvious for children being raised in multilingual environments, who acquire more than one language. Although the majority of people in the world speak two languages, bilingualism currently is not the norm in the United States, and bilingualism has sometimes been assumed to increase the risk of speech and language disorders. However, there is no evidence that speech or language disorders are more prevalent in bilingual than in monolingual children with similar biological and sociodemographic profiles ( Gillam et al., 2013 ; Goldstein and Gildersleeve-Neumann, 2012 ; Kohnert and Derr, 2012 ).

Similarly, some investigators have reported differences in the amounts and kinds of language experienced by children according to their socioeconomic circumstances, and some of these differences have been associated with scores on later tests that emphasize language skills, including tests of vocabulary and verbal intelligence ( Hart and Risley, 1995 ; Hurtado et al., 2014 ). The language spoken to children certainly influences their language skills, and some aspects of language have been linked to parents' socioeconomic and educational backgrounds (e.g., Hoff, 2013 ). However, the range of language variations observed to date has not been found to increase the risk of speech or language disorders independent of other factors associated with low socioeconomic status, including inadequate or poor-quality health care, hunger, reduced educational and social resources, and increased exposure to environmental hazards ( Harrison and McLeod, 2010 ; Parish et al., 2010 ; Pentimonti et al., 2014 ).

Speech Disorders

As described above, speech refers to the production of meaningful sounds (words and phrases) from the complex coordinated movements of the oral mechanism. Speech requires coordinating breathing (respiration) with movements that produce voice (phonation) and sounds (articulation). Respiration yields a stream of breath, which is set into vibration by laryngeal mechanisms (voice box, vocal cords) to yield audible phonation or voicing. Exquisitely timed and coordinated movements by the articulatory mechanisms, including the jaw, lips, tongue, soft palate, teeth, and upper airway (pharynx), then modify this voiced stream to yield the speech sounds, or phonemes, of the speaker's native language ( Caruso and Strand, 1999 ). Speech disorders are deficits that may prevent speech from being produced at all, or result in speech that cannot be understood or is abnormal in some other way. This broad category includes three main subtypes: speech sound disorders, voice disorders, and stuttering. Speech sound disorders can be further classified into articulation disorders, dysarthria, and childhood apraxia of speech. The speech variations produced by speakers of different dialects and non-native speakers of English are not defined as speech disorders unless they significantly impede communication or educational achievement.

Speech sound disorders , often termed articulation or phonological disorders, are deficits in the production of individual speech sounds, or sequences of speech sounds, caused by inadequate planning, control, or coordination of the structures of the oral mechanism. Dysarthria is a speech sound disorder caused by medical conditions that impair the muscles or nerves that activate the oral mechanism ( Caruso and Strand, 1999 ). Dysarthric speech may be difficult to understand as a result of speech movements that are weak, imprecise, or produced at abnormally slow or rapid rates ( Morgan and Vogel, 2008 ; Pennington et al., 2009 ). Neuromuscular conditions, including stroke, infections (e.g., polio, meningitis), cerebral palsy, and trauma, can cause dysarthria. Another rare speech sound disorder, childhood apraxia of speech , is caused by difficulty with planning and programming speech movements ( ASHA, 2007 ). Children with this disorder may be delayed in learning the speech sounds expected for their age, or they may be physically capable of producing speech sounds but fail to produce the same sounds correctly when attempting to use them in words, phrases, or sentences.

Voice disorders (also known as dysphonias ) occur when the laryngeal structures, including the vocal cords, do not function correctly ( Carding et al., 2006 ). For example, a voice that sounds hoarse or breathy may be due to growths on the vocal cords, allergies, paralysis, infection, or excessive vocal abuse when speaking. A complete inability to produce any sound, called aphonia , may be caused by inflammation, infection, or injury to the vocal cords.

Stuttering (also known as fluency disorder or dysfluency ) is a speech disorder that disrupts the ability to speak as smoothly as desired. Dysfluent speech contains an excessive amount of repetitions of sounds, words, and phrases, and involuntary breaks, or “blocks.” Severe stuttering can effectively prevent a speaker from speaking at all; it may also lead to other abnormal physical and emotional behaviors as the speaker struggles to end a particular block or avoid blocks in the future ( Conture, 2001 ).

Language Disorders

As described above, language refers to the code, or system of symbols, for representing ideas in various modalities, including hearing and speaking, reading, and writing. Language may also refer to the ability to interpret and produce manual communication, such as American Sign Language. Language disorders interfere with a child's ability to understand the code, to produce the code, or both ( American Psychiatric Association, 2013 ; WHO, 1992 ). Children with expressive language disorders have difficulty in formulating their ideas and messages using language. Children with receptive language disorders have difficulty understanding messages encoded in language. Children with expressive-receptive language disorders have difficulty both understanding and producing messages coded in language.

Language disorders may also be classified according to whether they affect pragmatics, semantics, or grammar. Pragmatic language disorders may be seen in children who generally lack social reciprocity, a contributor to the dynamic turn-taking exchanges that typify the earliest communicative interactions (e.g., Sameroff, 2009 ). A child with a receptive pragmatic language disorder may have difficulty understanding messages that involve abstract ideas, such as idioms, metaphors, and irony. A child with an expressive pragmatic disorder may have difficulty producing messages that are socially appropriate for a given listener or context. A child with a receptive semantic disorder may not understand as many vocabulary words as expected for his or her age, while a child with an expressive semantic disorder may find it difficult to produce the right word to convey the intended meaning accurately. A child with a receptive grammatical deficit may not understand the differences between word endings that indicate concepts such as past ( walked ) or present ( walking ), or may not understand complex sentences (e.g., The man that the boy saw was running away ). Similarly, a child with an expressive grammatical disorder may produce short, incomplete sentences that lack the grammatical endings or structures necessary to express ideas clearly or completely.

Language disorders can interfere with any of these subsystems, singly or in combination. For example, children with severe pragmatic deficits may appear uninterested in communicating with others. Other children may try to communicate, but suffer from semantic disorders that prevent them from acquiring the words they need to express their messages. Still other children have normal pragmatic skills and vocabularies, but produce grammatical errors when they attempt to combine words into phrases and sentences. Finally, children with phonological disorders may be delayed in learning which sounds belong in words.

As mentioned earlier, language disorders first identified in the preschool period have been linked to learning disabilities when children enter school ( Sun and Wallach, 2014 ). In fact, the Individuals with Disabilities Education Act (IDEA) (Section 300.8) defines a specific learning disability as “a disorder in one or more of the basic psychological processes involved in understanding or in using language, spoken or written, that may manifest itself in the imperfect ability to listen, think, speak, read, write, spell, or to do mathematical calculations.” Strong evidence suggests that early language disorders increase the risk of poor literacy, mental health, and employment outcomes well into adulthood (e.g., Atkinson et al., 2015 ; Clegg et al., 2015 ; Law et al., 2009 ). For this reason, children with a history of language disorders as preschoolers are monitored closely when they enter elementary school, so that services can be provided to those whose language disorders adversely affect literacy, learning, and academic achievement.

Box 2-1 summarizes the major types of speech and language disorders in children.

Types of Speech and Language Disorders in Children.

Co-occurring Speech and Language Disorders

Speech and language disorders may co-occur in children, and in children with severe disorders it is plausible that less obvious deficits in other aspects of development, such as cognitive and sensorimotor processing, may also be implicated. In the first few years of life it may be particularly difficult to determine whether a child's failure to speak is the result of a speech disorder, of a language disorder, or of both. For one thing, many speech and language abilities emerge during the early years of development, and disorders cannot be identified until children have reached the ages at which various speech and language abilities are expected. This difficulty is compounded by the fact that children under the age of approximately 30 months are often difficult to evaluate because they may be reluctant or unable to engage in formal standardized tests of their speech and language skills.

Fortunately, effective treatments for very young nonspeaking children exist that do not depend on differentiating speech from language disorders, and a child's rate of progress in treatment may provide important evidence on the nature and severity of the disorders.

• DIAGNOSING SPEECH AND LANGUAGE DISORDERS

Speech and language disorders can accompany or result from any of the conditions that interfere with the development of perceptual, motor, cognitive, or socioemotional function. Accordingly, conditions as varied as Down syndrome, fragile X syndrome, autism spectrum disorder, traumatic brain injury, and being deaf or hard of hearing are known to increase the potential for childhood speech and/or language disorders, and many children with such conditions will also have speech and language disorders. In addition, studies of children with primary speech and language disorders often reveal that they have abnormalities in other areas of development. For example, studies by Brumbach and Goffman (2014) suggest that children with primary language impairment show general deficits in gross and fine motor performance, and such children also show deficits in working memory and procedural learning ( Lum et al., 2014 ). Conversely, some children who have primary speech sound disorders as preschoolers have deficits in reading and spelling during their elementary school years ( Lewis et al., 2011 ). In short, considerable evidence suggests that spoken language skills, including speech sound production, constitute an integrated system and that clear deficits in one area may coexist with deficits in other areas that can compromise future development in language-related domains such as literacy. Intensive monitoring of speech and language development in such children is important for early detection and intervention to lessen the effects of speech and language disorders.

In many children, however, speech and language disorders occur for unknown reasons. In such children, diagnosing speech and language disorders is a complex process that requires assessing not only speech and language skills but also cognitive, perceptual, motor, and socioemotional development; biological, medical, and socioeconomic circumstances; and cultural and linguistic environments. Best-practice guidelines recommend evaluating across multiple domains and obtaining information from multiple sources, including a combination of formal, standardized, or norm-referenced tests; criterion-referenced observations by speech-language pathologists and other professionals; and judgments of familiar caregivers about the child's speech and language competence relative to community expectations for children of the same age ( ASHA, 2004 ; Nelson et al., 2006 , 2008 ; Royal College of Speech & Language Therapists, 2005 ; Shevell et al., 2003 ; Wilkinson et al., 2013 ).

On norm-referenced tests, children's scores are compared with average scores from large, representative samples of children of the same age. Children scoring below a cutoff value are defined as having a deficit, and severity is defined according to how far below average their scores fall. Deficits can range from mild to severe. In clinical practice, scores that fall more than two but less than three standard deviations below the mean are described as severely or extremely low; only 2.14 percent of children would be expected to score this poorly. Scores that fall three or more standard deviations below the mean are extraordinarily low; only 0.13 percent of children would be expected to score this poorly ( Urbina, 2014 ). Figure 2-1 represents these numbers in graphic terms. It shows that only 1 child in 1,000 would be expected to score three or more standard deviations below the mean, and only about 22 children in 1,000 would score more than two but less than three standard deviations below the mean.

In a normative sample of 1,000 children, only 1 child (shown in orange) is expected to score three or more standard deviations below the mean. Another 22 children (shown in light green) are expected to score more than two but less than three standard (more...)

In practice, few norm-referenced speech and language tests include a separate severity category for scores that are three or more standard deviations below the mean; all scores two or more standard deviations below the mean are classified together as “severe” or “very low” ( Spaulding et al., 2012 ). As noted in Chapter 1 , these clinical criteria for defining severity are not identical to the legal standards for severity specified in the regulations for the Supplemental Security Income (SSI) program, which also considers functional limitations (that are the result of the interactive and cumulative effects of all impairments) to determine the severity. Chapter 4 includes an in-depth review of how children are evaluated for disability in the SSI eligibility determination process.

Norm-referenced testing is not always possible because children may be too young or too disabled to participate in formal standardized testing procedures. In children younger than 3 years and others incapable of formal testing, behaviors and skills are compared with those of typically developing children using criterion-referenced measures or observational checklists ( Salvia et al., 2012 ). Some criterion-referenced measures involve detailed observations of specific skills, such as parent checklists of the number of words that children say. For example, 3-year-old children are expected to say 50 or more different words; those who fail to reach this criterion may be identified as having a significant vocabulary delay. Similarly, by 9-10 months of age, children are expected to communicate with their caregivers using nonlinguistic signals such as pointing and clapping; a 12-month-old who appears uninterested in others and fails to produce such basic communicative precursors to language may be identified as having a significant delay in the pragmatic domain of language. Still other criterion-referenced measures involve more global judgments of whether the child's language abilities are generally commensurate with those of peers, such as asking parents whether they are concerned about their child's ability to talk or understand as well as other children of the same age. In many cases, children are diagnosed as having language delays when their level of performance on some criterion-referenced skill is inconsistent with age to a significant degree, usually defined as a “percentage of delay” relative to chronological age. For example, a 24-month-old with the skills of children half her age (i.e., 12-month-old children) can be described as having a 50 percent delay; if her skills are comparable to those of 18-month-olds, she is described as having a 25 percent delay. In many states, delays of more than 20-25 percent are used to identify children under age 3 years for early intervention under Part C of the 2004 IDEA ( Ringwalt, 2015 ).

Validated norm-referenced tests may not be available for children who are members of cultural and linguistic communities that are not represented adequately in normative samples (e.g., AERA et al., 2014 ; Roseberry-McKibbin, 2014 ). In addition, norm-referenced test scores may be influenced by such extraneous factors as additional or confounding deficits (e.g., poor vision, inability to respond actively to test items), fatigue, and emotional state on a given day ( Urbina, 2014 ). Finally, norm-referenced testing may not adequately reflect the functional limitations that speech and language deficits impose on the child's ability to participate in some demanding, real-world contexts. For example, a child with a speech sound disorder may be able to articulate a single word reasonably clearly on a norm-referenced speech test, but be incapable of coordinating the many events necessary to produce an intelligible sentence in fast-paced, dynamic conversation. Similarly, a child with an expressive language disorder may be able to produce single words and short phrases successfully elicited by a norm-referenced test, but be incapable of producing grammatical sentences, much less stories that include them. And a child with a receptive language disorder may understand words presented individually and point to a picture on a norm-referenced test, but be unable to comprehend sentences, especially if the sentences are lengthy, complex, spoken at the normal rate of two to four words per second, or spoken in noisy or distracting environments. For all of these reasons, best diagnostic practices require that evidence from norm- and criterion-referenced testing by professionals be considered in conjunction with judgments made by people who are familiar with the child's usual functioning in his or her daily environment (e.g., Paul and Norbury, 2012 ).

• CAUSES AND RISK FACTORS

This chapter now turns to an overview of known underlying causes of speech and language disorders, followed by a summary of factors that have been associated with an increased risk of speech and language disorders having no known cause. Although prevalence estimates are available for some of the causes described below, and speech and language disorders are frequently mentioned among their sequelae, evidence on the percentage of speech and language disorders attributable solely to the underlying condition is not available. For example, Down syndrome, a chromosomal disorder with a prevalence of 1:700 live births, causes deficits spanning multiple areas of development, including not only speech and language but also cognition and sensorimotor skills, making it difficult to quantify the syndrome's causal role specifically in speech and language disorders.

Speech and Language Disorders with Known Causes

Determining the underlying etiology of a speech or language disorder is essential to providing the child with an appropriate set of interventions and the parents with an understanding of the cause and natural history of their child's disability. A variety of congenital and acquired conditions may result in abnormal speech and/or language development. These conditions include primary disorders of hearing, as well as specific genetic diseases, brain malformation syndromes, inborn errors of metabolism, toxic exposures, nutritional deficiencies, injuries, and epilepsy.

Children who are deaf or hard of hearing provide an especially clear example of the interrelationships among the many causes and consequences of speech and language disorders in childhood ( Fitzpatrick, 2015 ). Because adequate hearing is critically important for developing and using receptive language, expressive language, and speech, being deaf or hard of hearing can lead to speech and language disorders, which in turn contribute to socioemotional and academic disabilities. This is particularly the case when the onset of hearing problems is either congenital or acquired during the first several years of life. Therefore, it is essential that hearing be assessed in children being evaluated for speech and language disorders.

Childhood hearing loss may result from or be associated with a wide variety of causes, which are categorized in Box 2-2 . Hearing may be affected by disorders of either the sensory component of the auditory system (i.e., peripheral) or the processing of auditory information within the brain (i.e., central). Peripheral causes may be either unilateral or bilateral and are subdivided into conductive types, which are due to developmental or acquired abnormalities of the structures of the outer or middle ear, and sensorineural types, which are due to a variety of disorders affecting the sound-sensing organ—the cochlea—and its nerve that goes to the brain—the cochlear nerve.

Examples of Conditions Affecting Hearing Early in Life That May Affect the Development of Speech and Language.

Conductive-related causes of reduced hearing levels include congenital structural malformations of the outer and inner ear, consequences of acute or recurrent middle-ear infections, eustachian tube dysfunction, tumors, and trauma. Sensorineural types are even more diverse. A variety of genetic disorders have been identified that affect the function of the cochlea or cochlear nerve, and the disorder may be sporadic or inherited in an autosomal dominant, autosomal recessive, or X-linked manner, depending on the specific gene. Sensorineural types may be secondary to medical illness or even treatments for babies who must be placed in neonatal intensive care units because of either prematurity or a variety of perinatal disorders, such as hypoxia (oxygen deficiency), disturbances of blood flow, infections, or hyperbilirubinemia (excessive bilirubin levels that lead to jaundice and brain dysfunction known as kernicterus). Prenatal infections due to maternal cytomegalovirus, toxoplasmosis, or rubella (TORCH infections) can have a significant congenital impact on the sensorineural hearing mechanism, as can postnatal infectious illnesses such as meningitis (inflammation of membranes around the brain and spinal cord). Ironically, the treatment of meningitis or other bacterial infections with certain antibiotics can result in decreased hearing levels, as some of these life-saving drugs are ototoxic (i.e., harmful to structures of the ear). The impact of antibiotics on central hearing function is much less common in childhood and generally does not lead to total deafness.

The best-recognized cause affecting central hearing is Landau-Kleffner syndrome, or acquired epileptic aphasia, a rare condition that typically presents in early childhood with either minimal speech and language development or loss of previously acquired speech and language due to cortical deafness secondary to persistent epileptiform activity in the electroencephalogram, even in the absence of clinical seizures. Lastly, neonatal hyperbilirubinemia (kernicterus) can impact both sensorineural and central hearing, the latter as a result of dysfunction at the level of the brainstem. Importantly, in addition to the causes described above, many factors that impact hearing are themselves caused by, or co-occur with, underlying conditions that affect other aspects of children's development.

Apart from being deaf or hard of hearing, there are a diverse set of conditions that should be considered as other potential causes of speech and language disorders, as summarized in Box 2-2 . As is the case with hearing, abnormal development of anatomic structures critical to the proper generation of speech may lead to speech sound disorders or voice disorders. For example, articulation and phonological disorders may result from cleft palate. A wide variety of genetic syndromes are known to be associated with disordered speech and language development. These include well-characterized conditions that are due to an abnormal number of a specific chromosome, such as Down syndrome (associated with three rather than two copies of chromosome 21) ( Tedeschi et al., 2015 ) or Klinefelter syndrome (which occurs in boys who have a normal Y chromosome together with two or more X chromosomes, rather than one X chromosome).

Well-recognized genetic syndromes due to a mutation in a single gene (such as fragile X syndrome, neurofibromatosis type I, Williams syndrome, and tuberous sclerosis) are associated with speech or language disorders, and current research has demonstrated that alterations in small groups of genes (copy number variations such as 16p11.2 deletion) may increase the risk of a speech or language disability. In general, when indicated by history and clinical examination, these genetic conditions can be detected with clinically available blood-based laboratory tests. Primary malformations of the central nervous system—such as hydrocephalus (an expansion of the fluid-filled cavities within the brain), agenesis of the corpus callosum (the absence of the main structure that connects the right and left hemispheres of the brain), and both gross and microscopic abnormalities of cortical development (cortical dysplasia, an abnormal layering or location of neurons)—also may be associated with speech and language disorders. In general, these primary disruptions in brain anatomy may be diagnosed by magnetic resonance imaging (MRI) and in some cases discovered via an in utero maternal-fetal ultrasound examination.

A variety of prenatal and postnatal toxic exposures may result in abnormal brain development with resultant neurodevelopmental consequences. Maternal alcohol and other substance use are well recognized in this regard, as is postnatal exposure to lead. Similarly, abnormal prenatal growth, postnatal nutritional deprivation, and hypothyroidism (underactive thyroid) have developmental consequences. Injuries to the developing brain, such as perinatal stroke from brain hemorrhages or ischemia (inadequate blood supply), accidental trauma, and nonaccidental trauma (child abuse), must also be considered, as must such neoplastic conditions as primary brain tumors, metastatic disease, and the consequences of oncological therapies (e.g., chemotherapy and radiation). Some children with cerebral palsy (a condition that results in abnormal motor development and that has numerous causes) may also have an associated speech or language disorder. In addition, speech and language disorders may be secondary to poorly controlled epilepsy associated with a variety of causes, including structural abnormalities in cortical development, genetic disorders (e.g., mutations in ion channel genes), and complex epileptic encephalopathies (e.g., West, Lennox-Gastault, or Landau-Kleffner syndromes) ( Campbell et al., 2003 ; Feldman and Messick, 2009 ).

Box 2-3 presents a listing of examples of speech and language disorders with known causes.

Examples of Speech and Language Disorders with Known Causes.

Risk Factors Associated with Speech and Language Disorders with No Known Cause

In addition to the etiologies described above, a number of variables have been associated with an increased risk of childhood speech and/or language disorders with no known cause. Findings in this literature are somewhat inconsistent ( Harrison and McLeod, 2010 ; Nelson et al., 2006 ), varying with characteristics of the children examined (e.g., age, phenotype, severity, comorbidity) and with research design features (e.g., sample size, control for confounding, statistical analyses).

Studies of speech and language disorders in children, such as speech sound disorders ( Lewis et al., 2006 , 2007 ) and specific language impairment ( Barry et al., 2007 ; Bishop, 2006 ; Bishop and Hayiou-Thomas, 2008 ; Rice, 2012 ; Tomblin and Buckwalter, 1998 ), show that these conditions are familial (i.e., risk for these disorders is elevated for family members of affected individuals) and that this familiality is partially heritable (i.e., genetic factors shared among biological family members contribute to family aggregation). However, heritability estimates (i.e., the proportion of phenotypic variance that can be attributed to genetic variance) for some speech and language disorders, such as specific language impairment, have been inconsistent ( Bishop and Hayiou-Thomas, 2008 ). For example, twin studies on heritability of language disorders have shown a range of estimates of heritability, from 45 percent for deficient language achievement ( Tomblin and Buckwalter, 1998 ) to 25 percent for specific language impairment ( DeThorne et al., 2005 ). One study of 579 4-year-old twins with low language performance and their co-twins found heritability was greater for more severe language impairment, suggesting a stronger influence of genes at the lower end of language ability ( Viding et al., 2004 ). Finally, a review of twin data found that the environment shared by the twins was “relatively unimportant” in causing specific language impairment compared with genetic factors ( Bishop, 2006 ). Overall, the evidence suggests that susceptibility to speech and language disorders results from interactions between genetic and environmental factors ( Newbury and Monaco, 2010 ).

To date, the evidence best supports a cumulative risk model in which increases in risk are larger for combinations of risk factors than for individual factors ( Harrison and McLeod, 2010 ; Lewis et al., 2015 ; Pennington and Bishop, 2009 ; Reilly et al., 2010 ; Whitehouse et al., 2014 ). In a study of speech sound disorders, for example, Campbell and colleagues (2003) found that three variables—male sex, low maternal education, and positive family history of developmental communication disorders—were individually associated with increased odds of speech sound disorder, but the odds of such a disorder were nearly eight times larger in a child with all three risk factors than in a child with none of them. Based on a national database in the United Kingdom, Dockrell and colleagues (2014) report higher odds (2.5) of speech, language, and communication needs in boys than in girls, and they document a strong social gradient for childhood speech, language, and communication disorders in which the odds were 2.3 times greater for children entitled to free school lunches and living in more deprived neighborhoods than for children without these factors. It is important to note that risk indices such as odds ratios cannot provide evidence on the proportion of cases of the disorder that are caused by the factor in question, both because they could reflect the influence of some other, unknown causal factor and because they are influenced by the composition of the samples (e.g., base rate, severity) in which they are calculated.

Research has shown a strong association between poverty and developmental delays, such as language delays. For example, in a study of 513 3-year-olds who had been exposed to risk factors that included inadequate income, lack of social supports, poor maternal prenatal care, and high family stress, King and colleagues (2005) found that 10 percent of children—four times the expected 2.5 percent—had severe delays, scoring two or more standard deviations below the mean on a norm-referenced language test. Walker and colleagues (2011) showed that experiences in early life affect the structure and functioning of the brain. For example, a malnourished expectant mother who faces barriers in accessing prenatal care is at risk of having a child who is premature, is small for his or her gestational age, or experiences perinatal complications ( Adams et al., 1994 ; Walker et al., 2011 ). Children exposed to such factors in the womb are at increased risk for developing a disability such as specific language impairment ( Spitz et al., 1997 ; Stanton-Chapman et al., 2004 ). Lastly, a variety of other psychosocial factors—including deprivation of appropriate stimuli from parents and caretakers ( Akca et al., 2012 ; Fernald et al., 2013 ; Hart and Risley, 1995 ), excess media (television and screen time) exposure ( Christakis et al., 2009 ; Zimmerman et al., 2007 ), and poor sleep hygiene ( Earle and Myers, 2014 )—need to be considered as potential risk factors for speech and language disorders.

Law and colleagues (2000) found that there existed no systematic synthesis of the evidence concerning the prevalence of pediatric speech and language disorders with primary causes; their observation remains true in 2015 ( Wallace et al., 2015 ). Estimating the prevalence of these disorders with confidence is difficult for several reasons. First, because the characteristics of these disorders differ with age, the diagnostic tools by which they are identified necessarily vary in format, ranging from simple parental reports at the earliest ages to formal standardized testing at later ages. Second, because these disorders can vary in scope—from problems with relatively discrete skills (e.g., producing individual speech sounds) to problems with broader and less observable sets of abilities (e.g., drawing inferences from or comprehending language that is ambiguous, indirect, or nonliteral)—there exists no single diagnostic tool capable of addressing the full range of pediatric speech and language skills. Third, as with many pediatric psychological and behavioral disorders, diagnostic criteria involve integrating observations from multiple sources and time points.

As a result, there currently is no single reference standard for identifying pediatric speech and language disorders of primary origin in children of all ages. Instead, prevalence estimates come from studies that focused on different ages and used different diagnostic tools and criteria. Law and colleagues (2000) found a median prevalence of 5.95 percent in the four studies they reviewed; they observe that this value is consistent with several other estimates, but emphasize the need for caution pending additional evidence from well-designed population studies.

The following subsections describe prevalence estimates from studies that have attempted to distinguish speech disorders from language disorders. However, these estimates also must be viewed with caution, given differences among studies in sample composition and diagnostic criteria.

Consistent with the varying expectations for speech skills in children of different ages, estimates of the incidence (i.e., the risk of acquiring a disorder for an individual in a specified population) and prevalence (i.e., the percentage of individuals affected by a disorder in a specified population at a specific point in time) of speech disorders vary according to age, the presence of other neurodevelopmental disorders, and the diagnostic criteria employed.

Most of the literature on the prevalence of speech disorders has focused on children with articulation or phonological disorders due to unknown causes. Shriberg and colleagues (1999 , cited in Pennington and Bishop, 2009 ) report a mean prevalence of 8.2 percent for such disorders; Bishop (2010) estimates prevalence at 10 percent. The prevalence of these disorders varies with age, however, decreasing from 15-16 percent at age 3 ( Campbell et al., 2003 ) to approximately 4 percent at age 6 ( Shriberg et al., 1999 ). Evidence suggests that speech sound disorders affect more boys than girls ( Eadie et al., 2015 ), particularly in early life. In preschoolers, the ratio of affected boys to girls is 2 or 3:1, declining by age 6 to 1.2:1 ( Pennington and Bishop, 2009 ; Shriberg et al., 1999 ). Although many children with speech sound disorders as preschoolers will progress into the normal range by the time of school entry, the close ties between spoken and written language have motivated many studies of the extent to which speech sound disorders are associated with an increased risk of reading, writing, or spelling disorders. To date, evidence from several studies (e.g., Lewis et al., 2015 ; Pennington and Bishop, 2009 ; Skebo et al., 2013 ) suggests that in comparison with their unaffected peers, children with speech sound disorders but normal-range language skills may have somewhat lower reading scores than their peers, but they rarely meet eligibility criteria for a reading disability ( Skebo et al., 2013 ). However, severity has not been considered to date in studies of the relationship between speech sound disorders and reading skills ( Skebo et al., 2013 ).

Little evidence is available concerning the epidemiology of voice disorders in children (dysphonias) not attributable to other developmental disorders. In a prospective population-based cohort of 7,389 8-year-old British children, 6-11 percent were identified as dysphonic; male sex, number of siblings, asthma, and frequent upper respiratory infections were among the factors associated with an increased risk of voice disorders ( Carding et al., 2006 ).

Stuttering is estimated to have a lifetime incidence of 5 percent but a population prevalence of just under 1 percent ( Bloodstein and Ratner, 2008 ). The prevalence of stuttering before the age of 6 years is much higher than that at later ages; evidence from several sources suggests that rates of natural recovery from stuttering in children before age 6 may be as high as 85 percent ( Yairi and Ambrose, 2013 ). Evidence indicates that stuttering affects only slightly more boys than girls during the preschool period, although higher ratios of affected males to females have been observed at later ages. Finally, approximately 60 percent of cases of developmental stuttering co-occur with other speech and language disorders ( Kent and Vorperian, 2013 ).

As with speech disorders, estimates of the prevalence of language disorders vary across studies by age, the presence of other neurodevelopmental disorders, and the diagnostic criteria employed. Language disorders with no known cause, sometimes referred to as “specific” (or “primary”) language impairments (e.g., Reilly et al., 2014 ), are highly prevalent, affecting 6-15 percent of children when identified through formal norm-referenced testing in population-based samples ( Law et al., 2000 ). This is consistent with the cutoff values of 1.0-1.5 standard deviations below the mean employed in several investigations (e.g., Tomblin et al., 1997b ). By contrast, prevalence estimates are generally higher when based on parent or teacher reports. For example, in a survey of parents and teachers conducted in a nationally representative sample of 4,983 4- to 5-year-old children in Australia, McLeod and Harrison (2009) found that prevalence estimates based on parent and teacher reports were somewhat higher than those based on norm-referenced testing, with 22-25 percent of children perceived as having deficits in talking (expressive language) and 10-17 percent as having deficits in understanding (receptive language). As noted by Law and colleagues (2000) , the discrepancy between prevalence rates defined according to norm- and criterion-referenced methods could be due to a number of factors, including the inability of norm-referenced tests to capture or reflect the child's language functioning in relatively more challenging situations, such as classrooms and conversations.

Language disorders that have no known cause have been reported to affect more boys than girls, but it appears that the gender imbalance is greater in clinical than in population-based samples (e.g., Pennington and Bishop, 2009 ). For example, the ratio of affected males to females has ranged from 2:1 to 6:1 across several clinical samples, but boys were only slightly more likely to be affected than girls (1.3:1) in a large population-based sample of U.S. kindergarten children ( Tomblin et al., 1997b ).

As noted earlier, many aspects of literacy depend heavily on the language knowledge and skills that children acquire before they enter school ( Catts and Kamhi, 2012 ), and children with severe language disorders have a substantially increased risk of deficits in reading and academic achievement. Estimates vary, but children diagnosed with language disorders with no known cause as preschoolers are at least four times more likely to have reading disabilities than their unaffected peers ( Pennington and Bishop, 2009 ). Similarly, evidence from a large-scale, prospective methodologically sound cohort study of kindergarteners followed longitudinally showed that the majority of those with language disorders with no known cause continued to exhibit language and/or academic difficulties through adolescence ( Tomblin and Nippold, 2014 ).

One study that helped frame the committee's understanding of prevalence estimates of speech and language disorders was a study of specific language impairment conducted by Tomblin and colleagues (1997b) . This study selected a geographic region in the upper Midwest of the United States and sampled rural, suburban, and urban schools within that region. All eligible 5- to 6-year-old children were systematically screened and followed up with diagnostic testing for specific language impairment. Children were not included if they spoke a language other than English, failed a hearing test, or demonstrated low functioning in nonverbal intelligence (suggesting overall lower intellectual functioning). When a cutoff 1.25 standard deviations below the mean (i.e., approximately the 10th percentile, or the lowest 10 percent of the normative sample) on at least two language scores was used, the prevalence rate of specific language impairment was estimated at 7.4 percent of kindergarten children. The prevalence of specific language impairment for boys was 8 percent and for girls was 6 percent.

When the cutoff was set at two standard deviations below the mean (i.e., approximately the 2nd percentile), the prevalence estimate dropped to 1.12 percent. Using 1.25 standard deviations below the mean as the criterion, there were slightly higher rates of specific language impairment among African American and Native American children relative to white and Hispanic children. Only 29 percent of the parents of the kindergarteners diagnosed with specific language impairment reported having been informed that their children had speech or language problems. It is important to note that large-scale epidemiological studies on autism spectrum disorder, learning disorders, and attention deficit hyperactivity disorder have clearly demonstrated that active case-finding strategies lead to higher and more accurate rates of identification of children with neurodevelopmental disorders ( Barbaresi et al., 2002 , 2005 , 2009 ; CDC, 2014 ; Katusic et al., 2001 ) relative to studies depending only on parent reports. Studies that followed this sample of children with specific language impairment into their school years demonstrated that as a group, they also experienced lower academic achievement.

The Tomblin et al. (1997a) study underscores several methodological issues relevant for the current report: differences in severity level for case identification, comorbidity with other disorders considered primary disabilities, and differences in prevalence related to gender and racial or ethnic identity. Subsequent studies with the children included in this study identified low maternal and paternal education and paternal history of speech, learning, or intellectual difficulties as risk factors for specific language impairment ( Tomblin et al., 1997a ).

Table 2-1 provides a summary of prevalence estimates from the studies of U.S. children that the committee also reviewed. This list is not the result of a meta-analysis, nor is it exhaustive; rather, the table includes a number of well-designed studies that employed clear and consistent definitions. The committee reviewed numerous well-designed studies and meta-analyses from other countries (e.g., Beitchman et al., 1996a , b , c [Canada]; Law et al., 2000 [United Kingdom, others]; McLeod and Harrison, 2009 [Australia]). For the purposes of this study, however, the committee limited the summary of prevalence estimates to U.S. children. Table 2-1 includes the populations and conditions studied, the diagnostic criteria used to identify the conditions, and the prevalence of the conditions (or percent positive). Confidence intervals are included when available. As noted earlier, and as is evident from the table, the studies reviewed vary greatly in terms of ages, diagnostic tools or criteria, and methods used. The estimates presented in the table (in addition to estimates based on national survey data presented in Chapter 5 ) indicate that speech and language disorders affect between 3 and 16 percent of U.S. children.

Estimates of the Prevalence of Speech and Language Disorders from Studies of U.S. Children.

• COMMON COMORBIDITIES

An examination of comorbidities (i.e., other co-occurring conditions) of speech and language disorders is complicated by the central role of language and communication in the development and behavior of children and adolescents. Speech and language disorders are a definitional component of certain conditions, most prominently autism spectrum disorder ( American Psychiatric Association, 2013 ). Other neurodevelopmental disorders, including cognitive impairment, are universally associated with varying degrees of delays and deficits in language and communication skills ( American Psychiatric Association, 2013 ). In addition to their co-occurrence with a wide range of neurodevelopmental disorders, speech and language delays in toddlers and preschool-age children are associated with a significantly increased risk for long-term developmental challenges, such as language-based learning disorders ( Beitchman et al., 1996a , b , c , 1999 , 2001 , 2014 ; Brownlie et al., 2004 ; Stoeckel et al., 2013 ; Voci et al., 2006 ; Young et al., 2002 ). While specific language impairments (i.e., those not associated with other diagnosable neurodevelopmental disorders) are relatively common, it is likely that substantially greater numbers of children and adolescents experience significant speech and/or language impairment associated with other diagnosable disorders. Finally, speech and language delays and deficits may lead to impairments in other aspects of a child's functional skills (e.g., social interaction, behavior, academic achievement) even when not associated with other diagnosable disorders ( Beitchman et al., 1996c , 2001 , 2014 ; Brownlie et al., 2004 ; Voci et al., 2006 ; Young et al., 2002 ). This section, therefore, examines the association of speech and language disorders from the following perspectives: (1) speech and language disorders that are comorbid with other diagnosable disorders, and (2) speech and language disorders in early childhood that confer a quantifiable risk for the later development of comorbid conditions. Together, these two perspectives create a comprehensive picture of the association of speech and language disorders with other neurodevelopmental disorders.

Autism spectrum disorder is a highly prevalent neurodevelopmental disorder, affecting an estimated 1 in 68 8-year-old children in the United States ( CDC, 2014 ). By definition, all children with autism spectrum disorder have deficits in communication, ranging from a complete absence of verbal and nonverbal communication skills, to atypical language (e.g., echolalia or “scripted” language), to more subtle deficits in pragmatic (i.e., social) communication ( American Psychiatric Association, 2013 ). The formal diagnostic criteria for autism spectrum disorder require documentation of deficits in the social-communication domain ( American Psychiatric Association, 2013 ). In clinical practice, when children present with significant delays in the development of communication skills, autism spectrum disorder is one of the primary diagnostic considerations ( Myers and Johnson, 2007 ).

All children and adolescents with intellectual disability have varying degrees of impairment in communication skills ( American Psychiatric Association, 2013 ). Among those with mild intellectual disability, deficits in communication may be relatively subtle, including inability to understand or employ highly abstract language or impairment in social communication. In contrast, children and adolescents with severe or profound levels of intellectual disability may be able only to communicate basic requests, understand concrete instructions, and communicate with simple phrases or single words; others may be unable to employ or understand spoken language. A number of specific genetic disorders are directly associated with varying degrees of intellectual disability together with abnormalities of speech and language (see Box 2-3 ). Some of these genetic conditions often are also associated with specific profiles of speech and language impairment ( Feldman and Messick, 2009 ). Examples include dysfluent speech in children with Down syndrome, echolalia in boys with fragile X syndrome, and fluent but superficial social language in children with Williams syndrome ( Feldman and Messick, 2009 ).

Language-based learning disorders, including reading and written language disorders, are often associated with speech and language disorders. The association between language impairment and reading disorders has been demonstrated in studies examining the likelihood that family members of subjects with language impairment are at increased risk for reading disorder ( Flax et al., 2003 ). Both epidemiologic and clinic-based studies have demonstrated that children with speech sound disorders and language disorders are at increased risk for reading disorder ( Pennington and Bishop, 2009 ). Similarly, multiple studies have demonstrated a strong association between attention deficit hyperactivity disorder and speech and language disorders ( Pennington and Bishop, 2009 ; Tomblin, 2014 ).

The comorbidity of speech and language disorders and other neurodevelopmental disorders may not be apparent in pre-school-age children, since these very young children may not yet manifest the developmental lags or symptoms required to make comorbid diagnoses of such conditions as learning disorders and attention deficit hyperactivity disorder. In their prospective community-based study, for example, Beitchman and colleagues (1989) found significant differences in measures of “reading readiness” among 5-year-old children with poor language comprehension compared with children with either high overall speech and language ability or isolated articulation difficulties ( Beitchman et al., 1989 ). Similarly, there was a tendency for 5-year-olds with a combination of low articulation and poor language comprehension to have higher teacher ratings of hyperactivity and inattention and lower maternal ratings of social competence ( Beitchman et al., 1989 ). By age 12, the children who earlier had shown combined deficits in speech and language had significantly lower levels of reading achievement and higher rates of diagnosed psychiatric disorders (57.1 percent versus 23.7 percent for children with normal speech and language at age 5) ( Beitchman et al., 1994 ). By age 19, children with documented language impairment at age 5 had significantly higher rates of reading disorder (36.8 percent versus 6.4 percent), math disorder (53.9 percent versus 12.2 percent), and psychiatric disorders (40 percent versus 21 percent) compared with their peers with normal language ability at age 5 ( Young et al., 2002 ).

In summary, speech and language disorders are frequently identified in association with (i.e., comorbid with) a wide range of other neurodevelopmental disorders. Children with comorbid conditions can be expected to be more severely impaired and to experience greater functional limitations (due to the interactive and cumulative effects of multiple conditions) than children who do not have comorbid conditions. Furthermore, young children with language impairments are at high risk for later manifestation of learning and psychiatric disorders. It is therefore important both to carefully examine the speech and language skills of children with other developmental disorders and to identify other neurodevelopmental disorders among children presenting with speech and language impairment. Among populations of children with conditions as diverse as autism spectrum disorder, attention deficit hyperactivity disorder, traumatic brain injury, and genetic disorders, speech and language disorders may be the most easily identified impairments because of the central role of language and communication in the functional capacity of children and adolescents.

• FINDINGS AND CONCLUSIONS

2-1. Speech and language disorders are prevalent, affecting between 3 and 16 percent of U.S. children. Prevalence estimates vary according to age and the diagnostic criteria employed, but best evidence suggests that approximately 2 percent of children have speech and/or language disorders that are severe according to clinical standards. 2-2. Some speech and language disorders result from known biological causes. 2-3. In many cases, these disorders have no identifiable cause, but factors including male sex and reduced socioeconomic and educational resources have been associated with an increased risk of the disorders. 2-4. Diagnosing speech and language disorders in children is a complex process that requires integrating information on speech and language with information on biological and medical factors, environmental circumstances, and other areas of development. 2-5. Speech and language disorders frequently co-occur with other neurodevelopmental disorders and may be among the earliest symptoms of serious neurodevelopmental conditions. 2-6. Children with severe speech and language disorders have an increased risk of a variety of adverse outcomes, including mental health and behavior disorders, learning disabilities, poor academic achievement, and limited employment and social participation.

Conclusions

2-1. Severe speech and language disorders represent serious threats to children's social, emotional, educational, and employment outcomes. 2-2. Severe speech and language disorders are debilitating at any age, but their impacts on children are particularly serious because of their widespread adverse effects on development and the fact that these negative consequences cascade and build on one another over time. 2-3. Severe speech and language disorders may be one of the earliest detectable symptoms of other serious neurodevelopmental conditions; for this reason, they represent an important point of entry to early intervention and other services. 2-4. It is critically important to identify such disorders for two reasons: first, because they may be an early symptom of other serious neurodevelopmental disorders, and second, so that interventions aimed at forestalling or minimizing their adverse consequences can be undertaken.

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The Impact Of Trauma On Speech Development In Children: Exploring The Link Between Adversity And Speech Impediments

• Last updated Apr 24, 2024
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Traumatic experiences can have a profound impact on a child's development, and in some cases, it may even lead to the development of a speech impediment. While this may seem surprising, it is not uncommon for children who have experienced trauma to struggle with speech and communication. Understanding the connection between trauma and speech impediments is essential for providing the right support and intervention for these children, enabling them to overcome the challenges they face and regain their ability to express themselves effectively.

What You'll Learn

Introduction: potential effects of trauma on speech development in children, understanding speech impediments: types, causes, and symptoms, trauma-related speech impediments: how adverse experiences can impact communication, early intervention and support: strategies for helping kids overcome speech impediments.

Traumatic experiences can have profound effects on a child's development, including their speech. While every child may respond differently to trauma, it is important to be aware of the potential impact it can have on their speech development. This blog post will explore the potential effects of trauma on speech development in children, including the signs to look out for and strategies to support their communication skills.

Children who have experienced trauma may exhibit a range of speech-related difficulties, including speech delays, stuttering, and speech sound disorders. These difficulties can manifest as a direct result of the trauma itself or as a secondary effect of emotional and psychological distress.

One of the most common speech-related difficulties that can arise from trauma is speech delays. Traumatic experiences can disrupt a child's cognitive, emotional, and social development, which can in turn affect their language and speech skills. Delayed speech development may be characterized by a child being slower to meet typical speech milestones, such as babbling, first words, and simple sentences.

Stuttering, a speech disorder characterized by disruptions in the flow of speech, can also be a result of trauma. The emotional stress and anxiety caused by traumatic experiences can lead to an increase in stuttering symptoms or the development of stuttering in children who previously did not exhibit this difficulty. Stuttering can further compound the emotional distress of a child who has experienced trauma, as it may hinder their ability to effectively communicate their needs and experiences.

In addition to speech delays and stuttering, trauma can also contribute to the development of speech sound disorders. Speech sound disorders involve difficulties with the production of certain sounds or sound patterns in spoken language. Trauma can affect a child's ability to hear and discriminate between different sounds, which can make it challenging for them to accurately produce these sounds themselves. This can result in difficulties with articulation and phonological processes, affecting the overall clarity and intelligibility of their speech.

If you suspect that a child may be experiencing speech difficulties as a result of trauma, it is important to seek professional help from a speech-language pathologist (SLP). An SLP can assess the child's speech and language skills, identify any areas of difficulty, and provide targeted interventions to support their communication development.

In addition to professional intervention, there are also strategies that parents, caregivers, and educators can employ to help support a child's speech development in the aftermath of trauma. These strategies may include creating a safe and supportive environment, providing opportunities for expressive language through play and storytelling, and engaging in activities that promote relaxation and reduce stress.

It is important to remember that every child is unique, and their response to trauma will vary. While some children may show immediate signs of speech difficulties following a traumatic event, others may not display any noticeable difficulties until months or even years later. Regular monitoring of a child's speech development is crucial to identify any potential difficulties and provide necessary support as early as possible.

In conclusion, trauma can have a significant impact on a child's speech development. Understanding the potential effects of trauma and being attuned to signs of speech difficulties can help parents, educators, and professionals provide appropriate support and intervention. By working together, we can help children navigate the challenges of trauma and foster their communication skills for a brighter future.

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Speech impediments can have a significant impact on a person's ability to communicate effectively. These impediments can manifest in various forms and can have different causes. While some speech impediments are present from birth, others can develop after trauma or injury, including in children.

In this article, we will explore different types of speech impediments, their causes, and symptoms to help you better understand and identify them.

Types of Speech Impediments:

Articulation Disorders:

This type of speech impediment involves difficulties in producing sounds or groups of sounds. These difficulties can include substituting one sound for another, omitting sounds, or distorting sounds. Examples include lisps or difficulty pronouncing certain consonant sounds.

Phonological Disorders:

Phonological disorders manifest as difficulties understanding and using the rules for organizing sounds in language. Children with this impediment may have challenges distinguishing between similar sounds or have trouble using complete words.

Stuttering:

Stuttering is a speech impediment characterized by interruptions in the flow of speech. These interruptions can manifest as repetitions of sounds, syllables, or words, prolongation of sounds, or complete blocks during speech.

Voice Disorders:

Voice disorders occur when a person's pitch, loudness, or quality of voice differs significantly from that of others within their age and gender group. Examples include hoarseness, breathiness, or a voice that is too high or low in pitch.

Apraxia of Speech:

Apraxia of speech is a neurological disorder that affects voluntary muscle movements necessary for speech. Children with apraxia may have difficulty coordinating muscle movements, resulting in inconsistent speech errors or difficulty producing sounds in a coordinated manner.

Causes of Speech Impediments:

Developmental Factors:

Some speech impediments may be the result of a child's difficulty in developing the necessary skills for clear speech. These may include delays in oral-motor development, hearing loss, or difficulties with language development.

Trauma or Injury:

Trauma or injury to the brain or oral structures can result in speech impediments. This can occur due to accidents, head injuries, or other traumatic events that affect the brain's areas responsible for speech production or the structures involved in articulation.

Neurological Conditions:

Certain neurological conditions, such as cerebral palsy, Down syndrome, or autism spectrum disorders, can also cause speech impediments. These conditions can affect muscle control, coordination, or cognitive abilities, leading to difficulties in speech production.

Symptoms of Speech Impediments:

• Difficulty producing certain sounds or groups of sounds.
• Repeating sounds, syllables, or words.
• Prolonging sounds or hesitating during speech.
• Omitting or distorting sounds.
• Stumbling over words or having difficulty finding the right words.
• Inconsistent speech errors.
• Hoarse or breathy voice quality.
• Abnormal pitch or volume of voice.
• Difficulty coordinating muscle movements for speech.

It is important to note that children may exhibit temporary speech difficulties during their development, which can be considered normal. However, if these difficulties persist or significantly affect their ability to communicate, it is advisable to seek professional evaluation and intervention.

Speech therapy is a common intervention for individuals with speech impediments. A licensed speech-language pathologist can provide targeted therapy to improve speech production, language skills, and overall communication abilities. If trauma or injury is suspected as the cause of a speech impediment, a medical evaluation may be necessary to diagnose and address any underlying issues.

Understanding the different types, causes, and symptoms of speech impediments can help parents, caregivers, and educators recognize the need for intervention and support. Early identification and intervention are often key to helping children overcome speech impediments and improve their communication skills, leading to enhanced overall well-being and quality of life.

The Link Between Emotional Trauma and Tics: Unraveling the Connection

Traumatic events can have long-lasting effects on a person's mental, emotional, and physical well-being. One potential consequence of trauma that is often overlooked is its impact on speech and communication. Children, in particular, can develop speech impediments as a result of significant trauma.

It is important to understand that trauma-related speech impediments are not purely physical in nature. They are rooted in the psychological and emotional distress that a child experiences during and after a traumatic event. These impediments can manifest in various forms, such as stuttering, mumbling, or difficulty articulating words.

So, how does trauma lead to speech impediments in children? Here are a few key factors to consider:

• Impact on the Brain: Trauma can disrupt the normal functioning of the brain, affecting areas responsible for speech production and comprehension. This can result in difficulties with forming coherent sentences, finding appropriate words, or understanding others' speech.
• Emotional Distress: Traumatic experiences can create intense emotions like fear, anxiety, and shame. These emotions can greatly influence a child's ability to communicate effectively. For example, a child may struggle to express their thoughts and feelings due to a fear of being judged or misunderstood.
• Post-Traumatic Stress Disorder (PTSD): Children who have been through trauma may develop PTSD, which can further impact their speech and communication abilities. Symptoms of PTSD, such as hyperarousal or avoidance, can make it challenging for a child to engage in verbal expression.
• Social Isolation: Children who have experienced trauma might withdraw from social interactions, leading to decreased opportunities for practicing and developing their communication skills. This isolation can exacerbate existing speech difficulties or contribute to the development of new ones.

Identifying trauma-related speech impediments in children is crucial for their overall well-being. Here are a few signs to look out for:

• Inconsistent speech patterns (e.g., fluency may vary significantly from one day to another)
• Avoidance of certain words or sounds
• Difficulty initiating or maintaining conversations
• Limited vocabulary or trouble finding the right words
• Tendency to mumble or speak softly
• Repetitions, prolongations, or blocks in speech

If you suspect that a child may have a trauma-related speech impediment, it is essential to seek professional help. Speech-language pathologists (SLPs) are trained specialists who can assess and treat communication disorders. They will work closely with the child to develop a tailored treatment plan that addresses their specific challenges and needs.

Treatment for trauma-related speech impediments typically involves a combination of therapy techniques, including:

• Articulation and Pronunciation Exercises: SLPs help children focus on specific speech sounds and provide exercises to improve their articulation and pronunciation skills.
• Fluency Techniques: If a child experiences stuttering or other fluency difficulties, SLPs can teach strategies to increase fluency and reduce disruptions in speech.
• Expressive Language Development: SLPs assist children in expanding their vocabulary, improving sentence structure, and enhancing their overall expressive language abilities.
• Social Skills Training: Communication is not just about verbal expression. SLPs may also incorporate social skills training to help children develop effective communication strategies in various social situations.
• Counseling: Addressing the emotional aspects of trauma is crucial for children with speech impediments. SLPs may collaborate with mental health professionals to provide counseling or refer the child to appropriate therapy services.

It is important to keep in mind that recovery from trauma-related speech impediments takes time and patience. With the right support and intervention, children can overcome these challenges and improve their communication skills, leading to better overall well-being and quality of life.

If you suspect that a child you know is struggling with a trauma-related speech impediment, it is essential to reach out to a speech-language pathologist or other qualified professionals who can provide the necessary assessment and treatment. Together, we can help children heal and find their voices again.

How the Brain Can Heal from Trauma: Understanding the Healing Process

Speech impediments can affect a child's ability to communicate effectively and may arise due to various factors, including trauma. When a child experiences a traumatic event, it can have a profound impact on their overall development, including speech and language skills. Early intervention and support play a crucial role in helping children overcome speech impediments caused by trauma. In this article, we will explore effective strategies that can assist professionals, parents, and caregivers in supporting children in their journey toward better speech and language skills.

Recognize the Signs:

When a child experiences trauma, it is essential to be aware of potential speech impediments that may develop as a result. Signs of speech impediments may include difficulty producing certain sounds, overall speech delay, stuttering, or increased frustration when attempting to communicate. Identifying these signs early can help professionals and parents address the issue promptly.

Create a Safe and Supportive Environment:

Children who have experienced trauma may struggle with feelings of anxiety or isolation, making it challenging for them to communicate effectively. Creating a safe and supportive environment is crucial to help the child feel comfortable and encourage their willingness to try different communication techniques. Provide a patient and understanding atmosphere that allows the child to express themselves without fear of judgment.

Encourage Communication:

Encourage the child to communicate by actively listening and responding to their attempts, regardless of any speech errors or difficulties they may have. Maintain eye contact, provide visual cues, and use gestures, depending on the child's needs and preferences. These strategies can help the child develop confidence in their ability to express themselves, fostering better communication skills.

Engage in Play-Based Communication Activities:

Children often learn best through play. Incorporate play-based communication activities, such as using puppets, toys, or storybooks, to make speech therapy more engaging and enjoyable for the child. Encourage them to imitate sounds, practice pronunciation, and engage in turn-taking conversations. These activities can make learning fun and help the child associate positive experiences with communication.

Seek Professional Help:

Consulting a speech-language pathologist (SLP) who specializes in communication disorders and trauma-related speech impediments is crucial. An SLP can evaluate the child's speech and language skills, provide a tailored therapy plan, and guide parents and caregivers in implementing effective techniques at home. Early intervention by a professional can significantly improve a child's chances of overcoming speech impediments caused by trauma.

Implement Speech Therapy Techniques:

Speech therapy techniques specific to trauma-related speech impediments can involve a combination of exercises and strategies. These may include speech sounds production exercises, breathing exercises to control speaking pace, relaxation techniques, and mindfulness exercises to reduce anxiety. A multidimensional approach helps address the underlying causes and build the child's overall communication skills.

Maintain Consistency and Patience:

Overcoming speech impediments takes time and practice. Consistency is crucial in reinforcing new speech patterns and building resilience. Encourage regular practice sessions, both during therapy sessions and at home. Celebrate small milestones and achievements along the way to boost the child's confidence and motivation.

Early intervention and support are vital for helping children overcome speech impediments caused by trauma. By recognizing the signs, creating a safe environment, encouraging communication, engaging in play-based activities, seeking professional help, and implementing effective techniques, parents and caregivers can foster the child's development and enhance their speech and language skills. With patience, consistency, and unwavering support, children can thrive and overcome their speech impediments to lead fulfilling lives filled with effective communication.

How Brain Scans Detect Signs of Trauma

Frequently asked questions.

Yes, it is possible for a child to develop a speech impediment after experiencing trauma.

Traumatic events such as witnessing violence, physical abuse, or experiencing a severe accident can potentially lead to speech impediments in children.

Trauma can disrupt the normal development of a child's speech and language skills. It may cause difficulty in articulating words, stuttering, or other speech impairments.

Signs of speech impediments related to trauma may include difficulty pronouncing certain sounds, struggling to express thoughts or feelings verbally, or sudden changes in speech patterns.

It is important to seek a professional evaluation from a speech-language pathologist (SLP) who specializes in trauma-related speech issues. SLPs can provide therapy and support to help improve a child's speech and language skills.

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The King's True Trauma

It's nice to see trauma therapy depicted well on the big screen..

Posted February 28, 2011

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Hollywood isn't always kind to my profession, so as a Manhattan psychotherapist it was with trepidation that I saw The King's Speech , a movie depicting the therapeutic relationship that helped King George VI overcome a crippling speech impediment. The winner of four Academy Awards, including best picture, generated good will among critics and viewers of all ages. I too came away delighted, yet I was curious. How could a gentle, feel-good film get something so right that so many of my colleagues get so wrong?

The movie is, indeed, enormously controversial- not for its depiction of the sympathies of Winston Churchill (another stutterer, by the way), or whether the speech therapist, played by Geoffrey Rush, really insisted on calling the future King of England by his family nickname, Bertie. Without realizing it, the movie takes a bold, saber-rattling stand on a topic the recalcitrant medical community barely acknowledges: that most speech defects are actually outward manifestations of childhood trauma.

In The King's Speech , Bertie (at that time the Duke of York, second in line to the throne after a brother who later abdicated), played by Colin Firth, tries every remedy of the day to cope with his debilitating affliction. The future Queen Elizabeth (Helena Bonham Carter) drags her husband to one last resource: Lionel Logue (Rush), an Australian actor and self-styled speech therapist. Logue has no medical credentials - relying instead on empathy, intuition , and his work with traumatized and speechless victims of WWI. He sees that his royal patient's stammer is not rooted in mechanical breakdown, and proves it by having Bertie read aloud from Shakespeare while headphones blast music into his ears. When the future king finally listens to the resulting recording, he hears only the sound of his own voice mellifluously reciting from the Bard.

Logue is more of a psychotherapist than a speech therapist, which is how he knows the future King has more than a speech defect.

It did not surprise me to learn that the screenwriter, David Seidler, also stuttered in childhood. In interviews, Seidler ascribes his early condition to the trauma he experienced as a toddler during WWII, including his family's displacement . Through Seidler's own childhood trauma, he has managed to articulate treatment details for stuttering that few in the psychology and psychiatry field understand.

I, too, suffered from a "speech defect" that began in childhood. When I was called upon to speak in class, all I managed were unintelligible, grunted syllables-or nothing at all, just as we see in The King's Speech. Years later, I learned to teach, speak and lecture with fluency. I didn't get there by trying Demosthenes' marbles in the mouth. Nor did King George VI, for a reason the movie makes clear: It's pointless to work on the symptom when the underlying cause goes unrecognized.

In the case of King George VI and many patients with speech impediments worldwide, the problem is Developmental Trauma Disorder. The traumatic triggers refer to an experience that is emotionally painful, distressing or shocking, and often results in lasting mental and physical effects. We usually think of trauma as a single, explosive isolated event such as 9/11, but it can also be a series of related events, such as being on the frontlines in wartime, or - in my case - growing up with an abusive, alcoholic parent.

Unfortunately Developmental Trauma Disorder isn't in the forthcoming edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Dr. Bessel A. van der Kolk, M.D., of the Trauma Center at the Justice Resource Institute in Boston, petitioned last year for inclusion of this new diagnostic terminology, based on his research into the neurology of trauma, and was rejected.

But if you want to know more about this prevalent problem, it's right there in The King's Speech . People with this kind of trauma are controlled by their own tortured psychology. They feel unsafe, bad, defective, wrong and inadequate. It strikes regardless of vocation, social standing, education , success, race or gender and might inflict a screenwriter, a psychotherapist, or a future King of England.

Traditionally, the theory behind trauma treatment is that you relieve the pressure of haunting memories when the individual talks about it. Yet research shows that Developmental Trauma Disorder affects a part of the brain words can't reach-the limbic system, specifically the amygdala and hypothalamus, all lower in the brain and far from the cortex, the seat of thinking, logic and reason. This is why the understanding and insight produced by "talk" and behavioral therapy doesn't fix trauma. The patient doesn't hear it. The traumatized brain cannot process the words.

Consider Logue's methods: singsong, guttural utterances and curse words, physical movements such as rolling on the floor. The patient's intellectual grasp of his condition is irrelevant. Although Bertie eventually opens up about the childhood abuses he endured: humiliation and criticism, harsh disapproval of his father, King George V, the leg braces he was forced to wear and sexual abuse by a nanny. Yet healing is the product of the developing trust between him and his therapist. Since trauma involves a psychological injury resulting from multiple, chronic, prolonged, developmentally adverse events, treatment requires the establishment of intimacy . Logue knows he has to create a "safe place" for his patient: "I will call you Bertie, and you will call me Lionel."

Many therapists today have difficulty endorsing a strategy of healing intimacy. Yet there is a revolution in the works, and The King's Speech fires the first salvo: You cannot treat trauma with words alone. Treating the king's halting speech as a matter of faulty mechanics is like telling an alcoholic to "just stop drinking"; would that it were so simple! The King's Speech is a wakeup call for the professional psychological community that continues to use talk therapy in situations where it doesn't work. With speech "defects," successful treatment cannot target symptoms at the expense of treating the trauma that caused them.

In the movie's last scene, Hitler's shadow looms, and an entire country awaits reassurance. "Speak to me," Logue commands his patient in a calm, firm voice that breaches the canyon and places this momentous speech in the safe place of intimacy. The red light flashes. Bertie begins to speak. The trauma has been overcome- by the trust and security of his friendship with the man who understands his problems and treats his deep, underlying issues. The King has entered the safety of a world that makes room for the goodness that was inside him, waiting for a chance to emerge. I work every day to establish this kind of trust with my patients. If only the outcome of trauma therapy were always as beautiful as the end of this poignant Hollywood movie. -- Frederick Woolverton, Ph.D., is director of The Village Institute for Psychotherapy in Manhattan and the co-author of the forthcoming book "Unhooked."

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