Speech And Learning Difficulties

Voice training is done to find an appropriate source of sound production that can be articulated for communication purposes. Criteria for selecting sound source include: degree of tissue loss, esophageal stenosis, physical limitations of the patient; noise level of the patient’s environment; motivation level; and patient’s preference of sound source.

Types Of Sound Source

There are mainly three types of sound source a patient can choose from. These are: external man-made prosthesis or artificial larynx; sphincter like junction of the pharynx and esophagus or esophageal speech; and lastly, surgically implanted device or transesophageal puncture and silicon prosthesis.

Artificial Larynx

The principle of artificial larynx is to have an external mechanical sound source that is substituted for the larynx. Anatomic structures for articulation and resonance are most of the time unaltered.

There are two general types of electrolarynges that are available: neck type and intra oral type. The neck type is placed flush to the skin on the side of the neck, under the chin, or on the cheek. Sound is conducted via the oropharynx and is articulated normally.

The intraoral type is used for patients that can’t conduct sound through skin adequately. A small tube is placed toward the posterior oral cavity, and the produced sound is then articulated. The tube has little effect on articulatory accuracy if the patient is taught properly and learns to use it well.

The advantage of artificial larynx is that voice is restored after surgery immediately and the maintenance of the hardware is minimal. The disadvantage however, is that the quality of sound may seem mechanical.

Esophageal Speech

The principle behind esophageal speech is that air is of greater pressure in one chamber (oral cavity) will flow to a chamber containing less pressure (esophagus), if these chambers are connected.

Goals of esophageal speech include: to be able to phonate upon demand, use a rapid method of air intake, short latency between air intake and phonation, produce four to nine syllables per air charge, achieve a speaking rate of 85-129 words per minute, and attain good speech intelligibility.

There are mainly three methods of esophageal speech. Injection is a method where air in the mouth/nose is compressed by lingual or labial movement and is injected into the esophagus. Swallowing method uses air that enters during oral opening when swallowing. The air is used to produce voice.

Inhalation method maintains a patent airway between the nose, lips and esophagus. The stoma is used for inhalation. Air enters the esophagus when the pharyngo-esophageal muscle is relaxed during inhalation.

The advantage of this kind of speech includes: no external devices, natural sounding speech, and the possibility of pitch and loudness control. Disadvantages on the other hand are: there is reduced length of utterance, is hard to learn and requires good articulation.

Transesophageal Speech

This is another approach to voice restoration. It requires a surgical/prosthesis procedure that makes use of a man-made device inserted into a surgically created midline transesophageal fistula.

Air is conducted from the trachea to the esophagus through the prosthesis to excite the pharyngo-esophageal segment for voice production.

Advantages include: rapid restoration, natural sound, normal utterance length, hands-free, minimal maintenance and intelligible tonal language. Disadvantages are: the need for surgery, puncture stenosis, candida growth, aspiration of foreign objects, and troubleshooting.

There are two notable differences when teaching a hearing-impaired child compared to the traditional way of teaching language. First the choice of vocabulary taught is different. Second, the correctness of word order is different too.

Teaching at the Vocabulary or One Word Level

First, your choice of vocabulary is important. Customarily, words that are easy to say or lip read are usually taught first. Words like shoe, bow, tie, boot etc. are commonly taught with an emphasis on lip reading. On the other hand, children taught through auditory stimulation would likely say button first rather than bow. This is due to the inflectional pattern of button that is more stimulating to the child’s hearing.

Then there is the use for functional words. Auditory approach makes the early vocabulary of functional words possible. Words that a child uses to communicate everyday experiences but are very far off from the words said in the vocabulary lists devised for deaf children. Much of these words are not proper names or nouns.

Some of the first words are: Bye-bye, More, Oh, All gone, Off, Nice, Rough, Up, Uh-huh, Down, Hi, Ow, Hot, Cold, Light, No, Yummy, Yah, Pooie, Peeoo, Stop, Cut and Knock-knock.

While the first phrases include: open the door, I heard that, pick it up, bad girl, bye-bye in the car, daddy shop, I love you, come here, thank you, and peek-a-boo.

Developing First Nouns is the third critical point. When the child is already active in the communication process, it is recommended that the parents target a word that they perceive that the child would need. When the child is already able to recognize five to ten sounds associated to toys and a few functional words the development of symbolic language of the child should be accelerated.

The Circle Of Speech

The child’s vocabulary development could be illustrated in circles. The core skills comprise of basic listening experiences and pre-speech activities; and gestures. If the child possesses these skills, the therapist can proceed to the next level and teach him names like mommy, daddy, doggie, baby and a few verbs like listen and push, few adjectives like loud, hot and more and a few nouns like hat, cookie etc.

Fourth is the ability to developing language units. If the therapist would consider the child’s interests, it would be easy to plan language units. A few of these units are derived from the child’s everyday environment.

Body parts are one good example of language units. Words like eye, nose, and hair are words that a child can easily learn due to the association of his body. Family names are another example of language units. The child easily picks up words such as mama, Dada, and the names of his siblings since these are the people that he is exposed to most of the time.

Another language unit criteria can be food. Basic food related words like apple, candy and yummy can be taught. Verbs are also another kind of language unit. The therapist can teach words like cook, stir, drink, and jump. This can be done by doing the actions themselves so the child can easily pickup the concept.

School related words could also be a unit. Words like teacher, and his classmate’s names are a good start. Animal words, like dog, cat, kitty, can also be one separate unit, coupled with some sounds associated with animals.

There are six main types of fluency disorders namely: normal developmental disfluency, stuttering, neurogenic disfluency, psychogenic disfluency, language based disfluency, and mixed fluency failures. Due to the uniqueness and difference of each case, all of them require a different kind of management approach in speech therapy.

Management For Normal Developmental Disfluency

Developmental disfluency occurs during the critical period of speech and language development. A child is considered to have this condition if 5% or less of his overall speech-sample are repetitions and 1% or less are prolongations.

Etiologies of this condition could be: excitement while speaking, demands of Language Acquisition, Speech-Motor control is lagging, environmental factors like stress in the family (e.g. separation of parents) and the situations they are in, and daily pressures of competition.

Concerned parents still make their children with this kind of disfluency undergo therapy even if this could still possibly decline. These children are taught how to: decrease the rate of their speech, relieve other pressures that the therapist and parents mutually agree to change, and simplify their language.

Management For Stuttering

The onset of stuttering may occur between ages 1 ½- 11 years old but it mostly occurs during early childhood stage, which ranges from 2-6 years old. A condition is diagnosed to be stuttering when the speech has 5% or greater repetitions and 1% or greater prolongations. 

There are several approaches to therapeutic intervention for early stuttering namely: environmental manipulation, direct work with the child, psychological therapy, desensitization therapy, parent-child interaction therapy, fluency-shaping behavioral therapy, and parent and family counseling

Management For Neurogenic Disfluency

The onset of neurogenic disfluency is varied. It can occur at any age but it usually appears during adulthood or among the geriatric population. The neurological events that can trigger the onset of neurogenic disfluency are as follows: strokes, head trauma, extrapyramidal diseases, tumors, dementia, drug usage, anoxia, cryosurgery, viral meningitis, and vascular disease.

Self-monitoring program is one of the most suggested modes for the management of this kind of disfluency.

Management For Psychogenic Disfluency

The onset of psychogenic disfluency is also varied. A condition is said to be under this category when 90% of the patient’s utterances have become disfluent when the emotional stimuli is present. This condition originates in the mind. The etiology could be acute or chronic psychological disturbances. Stress is another factor that may also cause the disorder.

Psychologists, psychiatrist and counselors can only provide treatment of this kind of fluency disorder. Speech pathologists prioritize treatment only of the bad speech habits, which may still be present after resolving the emotional issues of the patient.

Management For Language Based Disfluency

This kind of fluency disorder may arise in a child as soon as any newly introduced language skill emerges, specifically during the toddler to preschool stage. The fluency failure may be due to linguistic or motor immaturity. It can also be a result of the child’s struggle to acquire newly introduced and more complex language rules.

The management of this kind of disfluency usually focuses on improving the child’s language skills to increase his/her linguistic and motor maturity.

Management For Mixed Fluency Failures

The onset of this condition cannot be exactly determined, since it is an overlap pf two or more causative factors. No specific age for identification since onset may be sudden. Therapists must prioritize the most debilitating and/or the most correctable aspect of the disfluency.