Speech-Language Disorders

Speech-Language Pathologists are professionals that specialize in the evaluation and treatment of communication and swallowing disorders. They work with every age population, starting from birth to geriatrics. A speech-language pathologist must hold a masters degree or doctorate in order to practice speech-pathology. They work in various settings including hospitals, private practices, and schools.

Communication is one of the most essential elements of life. Any kind of breakdown in communication can have a detrimental effect on a person’s quality of life. It is extremely important for a child or adult with any kind of communication or swallowing problem to receive help from a speech-language pathologist immediately.

About the Profession:
Speech-language pathology is the study, prevention, assessment, and treatment of disorders of speech, language, and swallowing.

Areas of specialization include disorders of developmental language, neurogenic speech and language, fluency, voice, articulation/phonology, and swallowing, and alternative and augmentative communication. Assessment of an individual with a communication disorder may involve the use of a wide variety of diagnostic procedures by the speech-language pathologist as well as by medical and/or related professionals. Treatment procedures also vary and may involve individual or group approaches, use of instrumentation for biofeedback or for alternative/augmentative communication, education of family members and or caregivers, and consultation with other professionals.

Speech-language pathologists who are involved in research activities seek to increase knowledge of: the normal processes of speech and language production; the etiology, symptomatology, and prognosis of various disorders; and efficacious methods for evaluation and treatment of disorders.

Aphasia,
Apraxia in adults,
Childhood apraxia,
Attention Deficit Hyperactivity Disorder (ADHD),
The Dementias,
Dysarthria,
Swallowing disorders,
Laryngeal Cancer,
Oral Cancer,
Late Blooming or Language Problem,
Right Hemisphere Brain Damage,
Speech for Patients With Tracheostomies or Ventilators,
Stroke,
Stuttering,
Traumatic Brain Injury,
What Is voice?
What Is Autism?
Who Is Affected by Autism?
How Do Speech and Language Normally Develop?
What Causes Speech and Language Problems in Autism?
What Research Is Being Conducted to Improve the Communication of Individuals with Autism?
What speech problems might children with clefts have?
What can be done about speech problems?
What is the role of the speech-language pathologist on a cleft palate team?

Some people with aphasia have problems primarily with expressive language (what is said) while others have their major problems with receptive language (what is understood). In some cases, both receptive and expressive language are impaired. Language is affected not only in its oral form of talking and understanding but also in its written form of reading and writing . The nature of the problems varies from person to person depending on many factors but most importantly on the amount and location of the damage to the brain.

Persons with severe aphasia may understand almost nothing of what is said to them and say little or nothing. At best, their oral communication may be only approximations of "yes" and "no" and maybe common social phrases like "hi" and "thanks." Persons with mild aphasia may be able to carry on normal conversations in many communication settings. They may have trouble understanding language only when it is long or complex, or they may have some trouble finding the words they need to express an idea or to explain themselves, orally or in written form. Word finding problems ( anomia ) are common in people with aphasia and is like the common experience of having a word "on the tip of our tongues" but not being able to remember it.

The speech-language pathologist works collaboratively with other rehabilitation and medical professionals (doctors, nurses, neuropsychologists, occupational therapists, physical therapists, social workers), and families to provide a comprehensive evaluation and treatment plan for the person with aphasia.

The speech-language pathologist completes an assessment of speech and language skills through both structured observations and formal tests. Therapy consists of exercises to improve specific language skills affected by damage to the brain. For example, the person may practice naming objects, following directions, answering questions about stories, etc. These exercises vary depending on individual needs, and become more complex and challenging as skills improve. The speech-language pathologist helps the person learn ways to make use of stronger language skills to compensate for weaker language skills.

According to the American Academy of Neurology, 700,000 people incur strokes each year resulting in 80,000 new cases of aphasia annually. The National Aphasia Association estimates that there are over one million Americans who have aphasia.

Stroke can occur at any age, but risk of stroke increases with age, doubling every decade after age 55. Approximately 72 percent of stroke occurs after 65 years of age.

A speech-language pathologist works with people with apraxia to improve speech abilities and overall communication skills. The muscles of speech often need to be "retrained" to produce sounds correctly and sequence sounds into words. This occurs through exercises designed to allow the person to repeat sounds, words, and sentences over and over and practice correct mouth movements for sounds.

Signs of Childhood Apraxia of Speech In Very Young Children include:The child does not coo or babble as an infant; produces first words after some delay, but these words are missing sounds; produces only a few different consonant sounds; is unsuccessful at combining sounds; simplifies words by replacing difficult sounds with easier ones or by deleting difficult sounds. Although all children do this, the child with developmental apraxia of speech does so more often. Feeding problems may also be present.

Apraxia In Older Children: The child makes inconsistent sound errors that are not the result of immaturity; can understand language much better than he or she can produce it; has difficulty imitating speech; may appear to be groping when attempting to produce sounds or to coordinate the lips, tongue, and jaw for purposeful movement; has more difficulty saying longer phrases than shorter ones; appears to be worse when he or she is anxious; is hard for listeners to understand.

A speech-language pathologist assesses the muscle development of the patient’s lips, jaw, and tongue, checking for signs of weakness. An evaluation of the coordination of the speech mechanism for purposeful movement is conducted by having the patient imitate non-speech actions (e.g., moving the tongue from side to side, smiling, frowning, puckering the lips, etc.). The speech-language pathologist will also evaluate the coordination and sequencing of muscle movements for speaking by having the child repeat strings of sounds (e.g., puh-tuh-kuh) as fast as possible. The coordination of breathing with speaking, another skill that requires planning and sequencing of muscle movements, is evaluated too.

The speech-language pathologist checks to see whether or not the child uses breathing efficiently to change the intonation of speech. For example, when asking a question, does the child have enough air to raise the pitch of the voice at the end of the question?

Speech articulation (pronunciation of sounds in words) is evaluated. Along with pronunciation of individual sounds and combined sounds, overall intelligibility of the child's speech is assessed, in single words as well as in conversation.

Intervention for the child diagnosed with apraxia of speech often focuses on improving the planning, sequencing, and coordination of motor movements for speech production.

The client and his family are provided with home assignments to accelerate progress and to facilitate carryover of newly learned strategies outside of the treatment room.

One of the most important things for the family to remember is that treatment of apraxia of speech takes time, commitment, and a supportive environment that helps the child feel successful with communication. Research has shown that progress occurs when treatment is rendered daily. Without this, the disorder can persist into adulthood with years of speech-related anxiety and frustration.

Inattention is characterized by difficulty concentrating. Irrelevant thoughts, sights, and sounds seem to get in the way of focusing and sustaining attention. As a result, the child often appears as if he or she is not listening. Individuals who are hyperactive seem unable to sit still. They squirm in their seats, roam around the room, tap their pencil, wiggle their feet, and touch everything. They are restless and fidgety. They may bounce from one activity to the next, trying to do more than one thing at once. Impulsive individuals have difficulty thinking before they act, e.g., hitting a classmate when they are upset or frustrated. They may have difficulty waiting their turn, e.g., when playing a game. Inattention, hyperactivity, and impulsivity have their effects on speech and language.

ADHD affects 3 to 5 percent of all children, perhaps as many as 2 million American children. Intelligence is normal or even gifted. Boys are 2 to 3 times more likely to be affected by the disorder than girls. ADHD often continues into adolescence, and sometimes into adulthood. The specific cause of ADHD is still unknown.

The symptoms of dementia vary slightly depending on the diagnosis, but, in general, are quite similar. Alzheimer's Disease is the most common and well-studied cause of dementia, affecting up to 70% of those diagnosed with dementia. It is characterized by gradually worsening cognitive functioning that begins as subtle and occasional memory loss. As the disease progresses, an individual may experience: Episodes of confusion; difficulty on the job; getting lost in familiar areas; problems handling personal affairs (finances, housekeeping, grooming, etc.); personality changes; depression (as the person recognizes their deficits); significant memory loss; difficulty following simple directions; decreasing communication skills; and swallowing difficulty.

By the final stages, the person with Alzheimer's Disease may be unable to feed themselves, walk independently, or even speak intelligibly.

Diagnosing Alzheimer's Disease

A complete medical workup is necessary to rule out other causes of cognitive impairment. For example, drug interactions or frequent small strokes can cause dementia, but are not indicative of Alzheimer's Disease. In the absence of other possible causes, Alzheimer's may be diagnosed; however, a definitive diagnosis can only be made at autopsy ,with a complete examination of brain tissue.

Treating Alzheimer's Disease:

• Several medications exist that seem to slow down the progression of symptoms, but do not reverse the disease. More often, behavioral interventions are utilized to assist the person in recalling important information or performing daily activities. A speech-language pathologist (SLP) can assist the person with Alzheimer's use various strategies to preserve communication and cognitive functioning for as long as possible. Examples of strategies include using written cues for completing tasks or to assist memory recall, developing "memory books" to assist in recalling personal information, and training family members or caregivers in how to facilitate improved communication with the person with Alzheimer's. If the individual presents with swallowing problems, the SLP can work with the person to ensure safe swallowing. After thoroughly evaluating the patient (e.g., clinical exam, videofluoroscopy, or flexible endoscopy), therapy is provided. This may include training compensatory strategies or altering the person's diet so that they can eat without risk of choking or illness. The ultimate goal of any intervention is to preserve the person's quality of life for as long as possible.

Dysarthria is caused by many different conditions that involve the nervous system, including: Stroke; Brain Injury; Tumors; Cerebral Palsy; Parkinson's disease; Lou Gehrig's disease (ALS); Huntington's disease; and Multiple Sclerosis.

• oral phase-- sucking, chewing, and moving food or liquid into the throat
• pharyngeal phase-- triggering the swallowing reflex, squeezing food down the throat, and closing off the airway to prevent food or liquid from entering the airway ( aspiration ) or to prevent choking
• esophageal phase-- relaxing and tightening the openings at the top and bottom of the feeding tube in the throat ( esophagus ) and squeezing food through the esophagus into the stomach

Some causes of feeding and swallowing problems in children include: nervous system disorders (cerebral palsy, meningitis, encephalopathy); gastrointestinal conditions; prematurity/low birth weight; heart disease; cleft lip or palate; and conditions affecting the airway.

Signs and symptoms of feeding and swallowing problems in very young children may include: arching or stiffening of the body during feeding; irritability or lack of alertness during feeding; failure to accept different textures of food; and prolonged feeding times (more than 30 minutes).

General signs may include: excessive drooling or leaking food/liquid from the mouth; gurgly, hoarse, or breathy voice quality during and/or after a meal; coughing or gagging during meals; recurring pneumonia or respiratory infections; difficulty coordinating breathing with eating or drinking; frequent spitting up; less than normal weight gain or growth.

As a result, children may have : dehydration; malnutrition (including weight loss); risk of aspiration (food or liquid entering the airway); pneumonia or repeated upper respiratory infections that can lead to chronic lung disease; and embarrassment or isolation in social situations involving eating.

A speech-language pathologist will take a careful history of a child' s medical history, development, and symptoms, will look at the strength and movement of the muscles involved in swallowing, will observe feeding to see your child' s posture, behavior, and oral movements during eating and drinking, may perform special tests (such as a videofluroscopic exam, and/or flexible endoscopy) to evaluate swallowing.

Treatment varies greatly depending on the cause and symptoms of the swallowing problem, but may include: exercises for strength, sensation, and coordination of muscles involved in feeding and swallowing, recommendations for special foods, equipment, or techniques (such a head positions/postures) to improve feeding and swallowing

Some causes of feeding and swallowing problems in adults include damage to the nervous system, such as: Stroke, Brain injury, Spinal cord injury, Parkinson' s disease, Multiple sclerosis, Amyotrophic lateral sclerosis (ALS or Lou Gehrig's disease), Muscular dystrophy, Cerebral palsy, and Alzheimer's disease.

Problems affecting the head and neck, including: cancer in the mouth, throat, or esophagus; and injury or surgery involving the head and neck. Decayed or missing teeth, or poorly fitting dentures can affect swallowing.

Many other diseases, conditions, or surgical interventions can result in swallowing problems. General signs may include: coughing during or right after eating or drinking; wet or gurgly sounding voice during or after eating or drinking; extra effort or time needed to chew or swallow; food or liquid leaking from the mouth or getting stuck in the mouth; recurring pneumonia or chest congestion after eating; low grade fevers; weight loss or dehydration from not being able to eat enough

As a result, adults may have: poor nutrition or dehydration; risk of aspiration (food or liquid entering the airway) which can lead to pneumonia and chronic lung disease; less enjoyment of eating or drinking; and embarrassment or isolation in social situations involving eating.

Diagnosis of laryngeal cancer does not always mean surgical removal of the entire larynx. Depending on the size, location, and time of cancer detection, one or more of the following approaches may be used: radiation therapy, chemotherapy, partial laryngectomy. In these cases, voice may be preserved although its quality may not be normal because of removing parts of the larynx, changes to laryngeal tissue from radiation or chemotherapy, or removal of nearby neck muscles (to prevent or stop the spread of the cancer).

In other cases, total laryngectomy, with or without radiation therapy or chemotherapy, may be the only life-saving solution. During this operation, a new route for breathing is surgically created. The larynx-end of the windpipe (trachea) is connected to a hole (stoma ) that is made in the neck. Rather than using the mouth and the nose, the person with the laryngectomy will breathe through this stoma.

The speech-language pathologist will meet with the patient and family before surgery. He or she will evaluate factors like vocal quality, pitch range, and presence or absence of accent or regional speech variations. This evaluation allows the speech-language pathologist to understand the person's speech and voice capabilities. This understanding helps to plan treatment after surgery.

The speech-language pathologist will also explain the anatomy and physiology of the larynx, describe how surgery will change this, and provide information on what will happen in the intensive care unit immediately following the surgery.

After surgery, the speech-language pathologist's primary goal is to provide the patient with a new sound source for speech. There are three primary options:

Esophageal Speech : Following a laryngectomy, a person is unable to speak by exhaling air from the lungs through the mouth. Using esophageal speech, a person takes air in through the mouth, traps it in the throat, and then releases it. As the air is released, it makes the upper parts of the throat/esophagus vibrate and produces sound. This sound is shaped into words in the same way it was before surgery: with the lips, tongue, teeth, and other mouth parts. This type of alaryngeal speech is difficult to learn and use effectively, especially in rushed or stressful communication situations.

Artificial Larynx : The person uses an electronic or mechanical instrument that provides the sound source for speech. Some of these devices are held against the neck, and others have a tube that the patient inserts in his mouth. The mouth shapes the sound into words, as occurred before surgery. Many people use an artificial larynx as their first means of alaryngeal speech. Esophageal talkers may still keep an artificial larynx for use in certain situations, e.g., in noisy places where their esophageal speech is not loud enough to be heard.

Tracheoesophageal Puncture (TEP): This surgical procedure, one of the more popular methods of alaryngeal speech production, can be performed at the time of the laryngectomy surgery or afterwards. The surgeon creates a connection between the trachea and the esophagus with a small puncture. A small, one-way shunt valve is then inserted into this puncture. To speak, the person inhales air through the stoma and into the lungs. Then, he or she covers the stoma with a finger. Air from the lungs is then directed from the trachea, through the shunt valve, and into the esophagus. The esophagus vibrates, creating a sound source for speech. This sound is then shaped into speech sounds in the mouth in the same way it was done before laryngectomy. The SLP will assist the individual in selecting and fitting the prothesis and can teach proper prothesis care and use.

Cancers of the larynx account for approximately 2-5% of diagnosed cancers. More than twice as many men as women are diagnosed. Most cases occur between the ages of 50 and 70.

Cigarette, cigar, or pipe smoking; smokeless tobacco; or excessive use of alcohol can cause oral cancer. More than twice as many men as women are diagnosed with oral cancers and most cases occur between 50 and 70 years of age.

A red or white patch or a lump anywhere in the mouth that lasts for more than a month, or a sore that bleeds easily or doesn't heal. Difficulty in chewing, swallowing or moving the tongue and jaw are later symptoms.

Coordinated movement of all structures in the mouth and throat is essential for the production of intelligible speech. These same abilities are also necessary for a persons to swallow normally.

The effects of a cancer on speech and swallowing depend on the location and size of the growth. For example, a sore or lump on the lips may restrict movement. This could result in unclear production of speech sounds made with the lips (labial sounds) such as /p/, /b/, and /m/. Restricted movement of the lips might also reduce people' s ability to hold food in their mouth when eating. A lesion on the tongue may affect the intelligibility of some lingual sounds, such as /l/ and /r/, and limit the ability to move food around the mouth or push food back toward the throat during swallowing. A growth on the roof of the mouth (soft palate) or in the throat may change the nasal quality of the voice.

Postsurgical outcomes on speech and swallowing abilities also depend on the location and size of the cancerous growth. However, other important factors include the amount of tissue removed in surgery, the availability and frequency of speech/swallowing treatment, and the motivation of the patient.

In some cases, reconstructive plastic surgery or the use of prosthetic devices can restore oral functioning to near normal levels.

Evaluation and treatment by a speech-language pathologist is essential to restore speech intelligibility and swallowing skills. Speech-language pathologists are integral parts of the hospital-based cancer team and perform both pre- and postsurgical assessments in addition to treatment.

Treatment often includes helping patients adapt to the differences in the size, shape, and feel of their mouth. The speech-language pathologist will also train a patient on how to make specific modifications in oral movement to produce the most intelligible speech sounds. Treatment for swallowing problems varies from simple changes in food consistency to exercises for weak oral muscles to learning totally new ways to swallow. In many cases, improvement is evident within several months.

If parents think that development is slow, they may check out their impression with other parents, relatives, or their pediatrician. They may get an answer such as "My son was slow too. Now he won't shut up" or "Don't worry, she'll outgrow it." But suppose she doesn' t?

You won' t know for sure. Although the stages that children pass through in the development of speech and language are very consistent, the exact age when they hit these milestones varies a lot. Factors such as the child' s inborn ability to learn language, other skills the child is learning, the amount and kind of language the child hears, and how people respond to communication attempts can slow down or accelerate the speed of speech and language development. This makes it difficult to say with certainty where any young child' s speech and language development will be in 3 months, or 1 year.

There are, however, certain factors that may increase the risk that a late-talking child in the 18- to 30-month-old age range, and with normal intelligence, will have continuing language problems. These factors include:

• Receptive language: Understanding language generally precedes expression and use. Some studies that have followed-up late-talking children in this age range have found, after a year, that age-appropriate receptive language discriminated late bloomers from children who had true language delays. Other researchers doing follow-up studies included only children whose receptive language was within normal limits because they believed that delay in this area was likely to produce worse outcomes.
• Use of gestures: One study has found that the number of gestures used by late-talking children with comparably low expressive language can indicate later language abilities. Children with a greater number of gestures used for different communication purposes are more likely to catch up with peers. Such a result is supported by findings that some older children who are taught non-verbal communication systems show a spontaneous increase in oral communication.
• Age of diagnosis: More than one study has indicated that the older the child at time of diagnosis, the less positive the outcome. Obviously, older children in a study have had a longer time to bloom than younger children but have not done so, indicating that the language delay may be more serious. Also, if a child is only developing slowly during an age range when other children are rapidly progressing (e.g. 24-30 months) that child will be falling farther behind.
• Progress in language development: Although a child may be slow in language development, he or she should still be doing new things with language at least every month. New words may be added. The same words may be used for different purposes. For example, "bottle" may one day mean "That is my bottle," the next, "I want my bottle," and the next week, "Where is my bottle? I don' t see it." Words may be combined into longer utterances ("want bottle" "no bottle"), or such longer utterances may occur more often.

Parents don' t have to rely on the predictions of others or to guess that their child will be just like a friend' s and eventually catch up in language development. If parents are concerned about their child' s speech and language development, they should see a speech-language pathologist certified by the American Speech-Language-Hearing Association for a professional evaluation. The speech-language pathologist can administer tests of receptive and expressive language, analyze a child' s utterances in various situations, determine factors that may be slowing down language development, and counsel parents on the next steps to take.

The speech-language pathologist may give suggestions on stimulating language development, and ask that the parent and child return if parental concern continues. Or, the speech-language pathologist may want to schedule a re-evaluation right then. In more severe cases, the speech-language pathologist may want the parent and child to become involved in an early intervention program. The programs typically consist of demonstrating language stimulation techniques for home use, and more frequent monitoring of the child' s progress. In the most severe cases, a more formal treatment program may be recommended.

Waiting to find out if your child will catch up will still be hard, but you won't feel guilty that you did not do everything you could.

Damage to the right hemisphere of the brain can lead to cognitive-communication problems, such as impaired memory, attention problems and poor reasoning. In many cases, the individual with right brain damage is not aware of the cognitive difficulties or communication problems that they are experiencing. The causes of right hemisphere damage include: Stroke;Traumatic Brain Injury; Surgery Infection/Illness; Tumor.

People with right hemisphere damage experience communication problems that are more subtle in nature than those that occur from left hemisphere damage. This is due in part to the fact that, in most of the population, the language centers are in the left hemisphere, while cognitive functioning is often housed in the right hemisphere. Cognitive-communication problems that can occur from right hemisphere damage include difficulty with: Attention ,Memory ,Organization ,Reasoning ,Problem-solving ,Orientation Left-side neglect, Social judgment/pragmatics.

When a person experiences right hemisphere brain damage with resulting cognitive-communication problems, a referral to a speech-language pathologist may be warranted. The SLP will work with the individual and develop a treatment plan designed to improve the individual's cognitive-communication abilities.

You have to breathe to live. But what happens when a progressive disease like muscular dystrophy or amyotrophic lateral sclerosis (Lou Gherig's disease) moves from attacking arms and legs to attacking breathing (respiratory) muscles? Or what happens when a car accident survivor is left with a head injury and swelling that slows down the response of the brain's respiratory center? And what about children born with lung disease or deformities of the chest wall and spine that interfere with breathing? These patients will have to breathe. How do they do it?

A surgical opening is made in the windpipe (trachea) by cutting the neck below the Adam's apple, below the vocal cords. A tube is placed in the opening, and air is inhaled and exhaled through the tube rather than through the mouth and nose. For some, a tracheostomy is a short-term measure. For others, it is long-lasting or permanent.

Such life support does have a price. As a result of tracheostomy and the new route of air travel, structures of the upper airway that warm and moisten air, filter air-borne debris, and facilitate coughing, sneezing, smelling, tasting, and swallowing play a reduced or non-existent role. The extra debris, without the normal means of clearing it, can cause a buildup of fluids and secretions in the lungs that need to be cleared by suctioning through the tracheostomy tube. Reduced smell, taste, and swallowing can reduce appetite and food intake to the point, in the most severe cases, of threatening life once again. Food and secretions can be misdirected (aspirated) into the lungs and potentially cause pneumonia and even asphyxiation.

If these were not enough potential problems, air flow as a result of the tracheostomy by-passes the vocal cords that allow for the production of sound and speech. Air takes the path of least resistance, with most of it going out the tracheostomy tube. Some air may leak up to the vocal cords, but it may not be forceful enough to drive the vocal cords into vibration, or it may only allow enough force for very short utterances.

Caretakers and family members become frustrated because they do not know the needs and wants of the patient. The patient feels isolated and alone at a time when his or her life is undergoing dramatic change.

Young children are deprived of the vocal explorations and social interactions that are critical to the development of language skills. The situation is made worse because caretakers tend to talk less to children who cannot communicate. These children are then robbed of the rich models they need to hear so they can figure out what language is all about. What can be done?

There are a number of options for speaking with a tracheostomy. Tracheostomy tubes can consist of plain tubes or can come with inflatable cuffs that, when pumped up, provide a greater seal against the neck than plain tubes. This increased seal can provide greater air supply to the lungs, but may not allow enough air leakage to power the vocal cords.

Patients with a cuffless tube or patients who may only need the cuff inflated at certain times, for example during eating or sleeping, may get enough air leakage for speech, or they may be able to produce speech by blocking or occluding the tube with their fingers or hand. Then the patient will breathe through the mouth and nose and vibrate the vocal cords as they did before surgery.

These methods do not work for all patients for a variety of reasons. Covering the tube may cause an increased resistance to breathing that is intolerable to some patients. Contaminants from the hand or fingers may introduce infection into the body, a particularly critical situation for patients with aspiration problems. Some patients may not get enough air for speech without blocking the tube, but may not have the awareness, muscle movement, or muscle tone to make a good occlusion.

As an alternative, a variety of valves are available that can be attached to the tracheostomy tube. These valves allow air to enter via the tube, but leave by way of the mouth and nose. Use of certain valves is also reported to have secondary benefits of reducing secretions, increasing the sense of smell, reducing aspiration, facilitating tube removal in patients for whom tracheostomy is not permanent, and perhaps even increasing oxygenation of blood in the arteries. Because all valves do not produce the same quality of speech or the same secondary benefits, a valve for a specific patient should be selected based on the scientific and clinical results.

For some patients, a tracheostomy tube alone may not be enough. The tube may need to be connected to a breathing machine (ventilator) that provides a mixture of gases for life support. Patients on ventilators can speak as long as the tracheostomy tube allows flow through the larynx and vocal cords. However, the speech patterns of ventilator users present particular problems.

Because of the design of the ventilator, speech occurs during the expiratory cycle of the ventilator. Then there is a long silence until the next cycle of the ventilator. During this silence, the patient may lose his or her turn to talk as conversation partners fill the silence with their own speech. Listeners may also find it hard to follow the patient's communication message because the normal rhythm of conversational give-and-take is disrupted.

Spoken phrases may have sudden bursts of loudness, reduced loudness at the end of phrases, and changes in voice quality because pressure in the trachea from the ventilator gases is not as stable as this pressure is in typical speech production. Recent research has indicated that the speech of patients on ventilators may be improved by making simple adjustments to ventilator settings, particularly if no other problems exist besides breathing insufficiency. There is also at least one speaking valve available that can be used with a ventilator.

The multiple and interrelated decisions that need to be made for patients with tracheostomies or ventilators cannot be made by one professional. Physicians, nurses, respiratory therapists, dietitians, speech-language pathologists, and others must all work together to choose the options that best meet the patient's total health needs. The speech-language pathologist assesses the patient's cognitive and language abilities to determine communication potential, evaluates oral-motor and swallowing functions, and assesses the patient's ability to produce voice in different situations that may include using a speaking valve. Whatever mode of communication is recommended for the patient in the context of his or her other needs, the speech-language pathologist plays a central role in ensuring that patients and caretakers know how maximum communication can be achieved. Speech-language pathologists also treat problems of swallowing when indicated.

Tracheostomy and ventilator use is life sustaining. Speech for patients with tracheostomies or ventilators is life enriching.

Stroke occurs when a clogged or burst artery interrupts blood flow to the brain. This interruption of blood flow deprives the brain of needed oxygen and causes the affected brain cells to die. When brain cells die, function of the body parts they control is impaired or lost. A stroke can cause paralysis or muscle weakness, loss of feeling, speech and language problems, memory and reasoning problems, swallowing difficulties, problems of vision and visual perception, coma, and even death.

Symptoms

• Sudden numbness or weakness of the face, an arm and/or a leg
• Sudden confusion, trouble speaking, or difficulty understanding speech
• Sudden difficulty seeing in one or both eyes
• Sudden trouble walking, dizziness, loss of balance, or loss of coordination
• Sudden severe headache with no known cause

Causes

Blockage of blood vessels in the brain

• Clots can travel from the blood vessels of the heart or neck and lodge in the brain.
• Small vessels in the brain can become blocked, often due to high blood pressure or damage from diabetes.
• Clots can form in the blood vessels of the brain due to arteriosclerosis (hardening of the arteries).

Bleeding into or around the brain

• Weak spots on brain arteries (aneurysms) burst, covering the brain with blood.
• Blood vessels in the brain break because they have been weakened by damage due to high blood pressure, diabetes, or aging.

Because of the organization of our nervous systems, an injury to one side of the brain affects the opposite side of the body. Often the person loses movement and/or feeling in the arm and/or leg opposite the side of the brain affected by the stroke. This makes it difficult for him or her to perform activities of daily living (e.g., dressing, feeding, bathing, tying shoes, etc.). It is also common for survivors of stroke to tire easily.

Communication is the ability to understand and convey a message orally, in writing, and with gestures, facial expressions and body language. After a stroke, some people experience language deficits (aphasia) that significantly impair their ability to communicate. These deficits vary depending on the extent and location of the damage.

Cognition refers to thinking skills. Cognitive processes include an awareness of one's surroundings, sustained attention to tasks, memory, reasoning, problem solving, and executive functioning (e.g., goal setting, planning, initiating, self-awareness, self-inhibiting, self-monitoring and evaluation, flexibility of thinking). Cognitive difficulties are common in people with a stroke on the right side of the brain, and they vary in seriousness depending on the location and severity of the damage.

Some stroke patients have trouble concentrating when there are internal and external distractions (e.g., carrying on a conversation in a noisy restaurant, dividing attention among multiple tasks/demands). Their processing of new information is generally slower. Longer messages may have to be "chunked," or broken down into smaller pieces. The stroke survivor may have to repeat/rehearse incoming messages to make sure crucial information has been processed. Communication partners may have to slow down their rate of speech to accommodate these processing needs.

Recent memory is affected in some people, making new learning difficult. For example, some people may have trouble learning the new things they are being taught, such as how to get in and out of their wheelchair safely.

Impairments in executive functioning may diminish the ability to set long- and short-term goals. Planning and organizing tasks may be effortful, and it may be difficult to self-evaluate work. Consequently, these individuals may seem disorganized and unable to negotiate their lives without the assistance of families and friends.

The person's use of language may reflect this disorganization. He or she may have difficulty chaining a sequence of thoughts together to tell a story. He or she may switch topics without warning, or seem to "go off on tangents" without informing the listener.

Deficits in social communication skills may alter the ability to take turns in conversation, maintain a topic of conversation, use an appropriate tone of voice, interpret the subtleties of conversation, "keep up" with others in a fast-paced interaction. Persons after stroke may seem over-emotional (overreacting), impulsive, or "flat" (without emotional affect). They may say or do inappropriate things in conversation. Most frustrating to families and friends, there may be little to no self-awareness of just how inappropriate actions are.

Oral motor functioning is sometimes affected by a stroke. Muscles of the lips and tongue may be weaker or less coordinated ( dysarthria ). Speech may not be clear. Breathing muscles may be weaker, affecting the patient' s ability to speak loud enough to be heard in conversation. Muscles may be so weak that the person is unable to speak; consequently, he or she may need augmentative or alternative communication aids to help express ideas (e.g., communication board).

The speech-language pathologist completes an assessment of speech and language skills. [link to appropriate section in aphasia file].

Social communication skills ( pragmatic language ) are evaluated with formal tests and the role-playing of various communication scenarios. The person may be asked to interpret/explain jokes, sarcastic comments, absurdities in stories/pictures (e.g., What is strange about a person using an umbrella on a sunny day?). During informal conversation, the speech-language pathologist will observe proficiency with initiating conversation and conversational topics, taking turns during a discussion, expressing thoughts clearly using a variety of words and grammatical constructions, maintaining a topic of conversation, and alerting the listener when topics are changed. The speech-language pathologist will assess the ability to clarify communication intentions if the conversational partner does not understand.

If problems are observed, the speech-language pathologist will evaluate swallowing , and work with a dietitian and doctor to make recommendations regarding food consistency (e.g., pureed versus chopped food). The focus of this evaluation will be to ensure that the person is able to swallow safely, without accidentally inhaling food into the lungs ( aspiration ).

If necessary, the speech-language pathologist may evaluate the ability to use an augmentative/alternative communication device to help express basic needs and ideas.

The treatment program focuses on improving the skills that have been affected by the stroke:

• If language skills are affected, the speech-language pathologist will work on specific drills and strategies to improve them.
• The person may participate in group therapy sessions to practice conversational skills with other stroke survivors. The speech-language pathologist may lead the group through structured discussions, focusing on improving initiation of conversation, turn-taking, clarification of ideas, and repairing of conversational breakdowns. Group members may role-play common communication situations that take place in the community and at home, such as talking on the telephone, ordering a meal in a restaurant, and talking to a salesperson at a store.
• If cognitive skills are affected, the person will learn to compensate for difficulties remembering (e.g., using a memory log to keep track of daily happenings) and organizing (e.g., using an organizer to plan tasks, using checklists). Treatment always focuses on increasing awareness of deficits in order to help self-monitoring in the hospital, home, and community.
• Eventually persons are taken on individual and group community outings to practice their use of compensatory strategies outside of the hospital. They are asked to plan, organize, and carry out these trips using the compensatory strategies they have learned. For example, persons may practice using daily planners and checklists to plan the outing. They may practice functional reading and writing skills by using a telephone book to find the phone number of a restaurant and to write it down. They may practice telephone skills by calling the restaurant and making a reservation. They may practice reading maps, taking public transportation to the restaurant, and counting the change needed to purchase a ticket. They may practice their functional conversational skills by ordering their food in the restaurant.
• Later on in the recovery, the speech-language pathologist may work with a vocational specialist to help transition back into work or school, if applicable. The speech-language pathologist may also work with employers and/or educational specialists to implement the use of compensatory strategies in these settings. The speech-language pathologist may work with them to modify the patient' s work/school environment to meet language and/or cognitive needs.
• If speech muscles are weak, the speech-language pathologist may teach exercises to strengthen these muscles. The person practices the exercises at home and in therapy. The person may also be taught strategies to make speech more intelligible and to compensate for the muscle weakness.
• If swallowing is a problem, the speech-language pathologist may teach exercises to strengthen or improve the coordination of swallowing muscles, or may teach strategies to compensate for muscle weakness and improve the safety of swallowing. The speech-language pathologist works closely with doctors, nurses, and the dietitian to recommend the food consistencies that are safest and most appropriate for the patient' s needs. As the person gains more strength and coordination in swallowing muscles, the speech-language pathologist works with these professionals to "upgrade" diet. For example, he or she may recommend upgrading diet from a pureed/blended consistency to a chunky consistency.
• If the person is learning how to use an augmentative or alternative communication aid, treatment will focus on teaching use of the aid in structured conversation, with other stroke survivors, with family, and eventually in the community.

Characteristics

• Repetition of sounds (e.g., b-b-b-ball), syllables (e.g., mo-mo-mommy), parts of words (e.g., basket-basket-basketball), whole words, and phrases
• Prolongation , or stretching, of sounds or syllables (e.g., r-----abbit)
• Tense pauses, hesitations, and/or no sound between words
• Speech that occurs in spurts, as the client tries to initiate or maintain voice
• Related behaviors: reactions that accompany stuttering such as tense muscles in the lips, jaw, and/or neck; tremor of the lips, jaw, and/or tongue during attempts to speak; foot tapping. eye blinks, head turns, etc. [to try to escape from the stuttering]; etc. There are many related behaviors that can occur and vary from person to person.
• Variability in stuttering behavior, depending on the speaking situation, the communication partner(s), and the speaking task. A person who stutters may experience more fluency in the speech-language pathologist' s office than in a classroom or workplace. There may be no difficulty making a special dinner request at home, but extreme difficulty ordering a meal in a restaurant. Conversation with a spouse may be easier, and more fluent, than that with a boss. A person may be completely fluent when singing, but experience significant stuttering when talking on the telephone.
• The person who stutters may experience sound and word fears, situational fears, anticipation of stuttering, embarrassment, and a sense of shame. Certain sounds or words may be avoided. One word may be substituted for another that is thought to be harder to say. Or, certain speaking situations may be avoided altogether. For example, a person who stutters may always wait for someone else to answer the phone. Or, he or she may walk around a store for an hour rather than ask sales staff where an item can be found. These reactions to stuttering occur in more advanced stages.

Repetitions and prolongations are essential features of stuttering. The presence of the other listed behaviors varies from person to person.

Every one is disfluent at times and may sometimes have repetitions and prolongations. However, the disfluencies of people who do not stutter are not as frequent as those who do. The kind of disfluencies are also generally different. Normal disfluencies tend to be a repetition of whole words or the interjection of syllables like um and er. while stuttering tends to be repetition and prolongation of sounds and syllables.

Almost all children go through a stage of frequent disfluency in early speech development, usually between the ages of 2 and 5. Speech is produced easily in spite of the disfluencies. As children mature and sharpen their communication skills, these disfluencies typically disappear, but not always.

Stuttering usually starts during this same time period, but may occasionally appear for the first time in a school-age child and, more rarely, in an adult. As a parent, seek the advice of an ASHA-certified speech-language pathologist if:

• you or your child are concerned about his or her speech
• disfluencies begin to occur more often
• disfluencies begin to sound effortful or strained.

Early treatment of stuttering is generally more effective than waiting until a child is in school .

The goals of speech-language pathology treatment are improved fluency and success in communication. There are a variety of successful approaches for accomplishing these goals. There are no published scientific data that indicate the general superiority of any one approach.

Prior to treatment, the speech-language pathologist will conduct a detailed evaluation . This assessment may include:

• a developmental and behavioral history of speech and language by interviewing family members and/or the person who stutters
• a structured speech sample (e.g., a recording of the person describing a picture, reading a passage aloud, or describing a job or favorite activity)
• speech samples in different everyday communication situations
• determination of variables that may affect speech fluency through interviews and review of video- and/or audiotapes
• experimentation with different fluency strategies to assess how they may improve speech
• observation of articulation, expressive and receptive language skills, cognitive skills, voice, hearing and vision
• information from other professionals, as necessary, to help plan treatment.

Fluency strategies may include:

• reducing the rate of speech and using slow, smooth speech movements
• easing into voicing of speech sounds
• voicing continuously during utterances
• articulating lightly
• starting air flow for speech before any other muscle movement
• other techniques

Special equipment or a computer may be used to teach these strategies or give immediate feedback on how well these strategies are being used.

The person who stutters may also be taught different things to do when he or she has a stuttering block or feels that one is about to occur. Reducing tension in specific muscle groups and substituting a bouncing kind of speech are examples of this kind of strategy.

The speech-language pathologist may also provide suggestions and counseling on modifying the speaking situation. Parents and other communication partners may be asked to modify their behaviors by talking more slowly or not interrupting. The person who stutters may want to tell a stranger, "I stutter. It may take me longer to say a sentence than what you are used to." Such a statement reduces the time pressure to speak and makes it easier to use slower, more relaxed speech. In general, the speech-language pathologist and the person who stutters will discuss different speaking situations and determine together the best way to handle them, even those that are feared or have been avoided by the person who stutters.

We still do not know what causes stuttering. It may be caused by different factors for different people, or it may occur when a combination of elements comes together. Furthermore, what causes stuttering may be very different from what makes the behavior continue or get worse. Possible conditions that may cause stuttering are incoordination of the speech muscles, the way people talk to a child, the rate of language development, and life stresses.

We do know that children who stutter are no more likely to have psychological problems than children who do not stutter. In general, there is no reason to believe that emotional trauma causes stuttering.

• Try not to finish sentences or fill in words. No one likes words put in his or her mouth. Problems can also multiply if you guess wrong.
• Avoid suggestions such as "Slow down," "Relax," of "Take a Breath." If these suggestions worked, the person wouldn't stutter.
• Wait patiently until your conversational partner is finished speaking. Maintain eye contact and try not to look embarrassed or alarmed.
• Talk about stuttering openly. It should not be a taboo subject. Your friend or family member will appreciate your interest in the subject.
• Do not be afraid to say, "I' m sorry, I didn' t understand what you said." No matter how much of a struggle your communication partner had with stating a point or idea, it is preferable to say something rather than to guess what you think was being said.
• Talk in a relaxed, slower than normal manner.
• Try not to interrupt.
• Do not criticize or correct the speech.

Injury to the head (traumatic brain injury, or TBI ) may cause interference with normal brain functions. There are two broad categories used to describe TBIs:

Penetrating Injuries: In these injuries, a foreign object, e.g., a bullet, enters the brain and causes damage to specific brain parts. This focal , or localized, damage occurs along the route the object has traveled in the brain. Symptoms vary depending on the part of the brain that is damaged.

Closed Head Injuries: Closed head injuries result from a blow to the head as occurs, for example, when the head strikes the windshield or dashboard of a car. These injuries cause two types of brain damage:

primary brain damage, damage that is said to be complete at the time of impact, and secondary brain damage , damage that evolves over a period of hours to days after the trauma.

Primary injuries may include some or all of the following:

• Skull fracture : Breaking of the bony skull
• Contusions/bruises : Often occur right under the location of impact or at points where the force of the blow has driven the brain against the bony ridges inside the skull
• Hematomas/blood clots: Occur between the skull and the brain or inside the brain itself
• Lacerations: Tearing of the frontal (front) and temporal (on the side) lobes or blood vessels of the brain (The force of the blow causes the brain to rotate across the hard ridges of the skull causing the tears).
• Diffuse axonal injury: Arises from a cutting, or shearing, force from the blow that damages nerve cells in the brain's connecting nerve fibers.

Secondary injuries may include brain swelling ( edema ), increased pressure inside of the skull ( intracranial pressure ), epilepsy, intracranial infection, fever, hematoma, low or high blood pressure, low sodium, anemia, too much or too little carbon dioxide, abnormal blood coagulation, cardiac changes, lung changes, and nutritional changes.

Physical problems may include hearing loss, tinnitus (ringing or buzzing in the ears), headaches, seizures, dizziness, nausea, vomiting, blurred vision, decreased smell or taste, reduced strength and coordination in the body, arms, and legs.

Individuals with a brain injury often have cognitive and communication deficits that significantly impair their ability to live independently. These deficits vary depending on how widespread brain damage is and the location of the injury.

Brain injury survivors may have trouble finding the words or grammatical constructions they need to express an idea or explain themselves through speaking and/or writing, as if the words they need are "on the tip of their tongues." It may be an effort for them to understand both written and spoken messages, as if they were trying to comprehend a foreign language. They may have newfound difficulties with spelling, writing, and reading, skills that presented no problem prior to their injury.

Deficits in social communication skills may alter the individual's ability to take turns in conversation, maintain a topic of conversation, use an appropriate tone of voice, interpret the subtleties of conversation (e.g., the difference between sarcasm and a serious statement), respond to facial expressions and body language, or keep up with others in a fast-paced conversation. Individuals may seem overemotional (overreacting) or "flat" (without emotional affect). Most frustrating to families and friends, a person may have little to no awareness of just how inappropriate he or she is acting. In general, communication can be very frustrating and unsuccessful.

In addition to all of the above, functioning of speech muscles may also be affected. Muscles of the lips and tongue may be weaker or less coordinated affecting the ability to speak clearly. Breathing muscles may be weaker, affecting the ability to speak loud enough to be heard in conversation. Muscles may be so weak that the person is unable to speak at all. Weak muscles may also limit the ability to chew and swallow effectively.

Cognition refers to thinking skills. Cognition includes an awareness of one's surroundings, sustained attention to tasks, memory, reasoning, problem solving, and executive functioning (e.g., goal setting, planning, initiating, self-awareness, self-inhibiting, self-monitoring and evaluation, flexibility of thinking). Cognitive difficulties are highly common in persons who are traumatically brain injured, and problems again vary depending on the location and severity of the injury to the brain.

• Patients frequently have trouble concentrating when there are internal and external distractions, e.g., carrying on a conversation in a noisy restaurant or dividing attention among multiple tasks/demands.
• The processing or "taking in" of new information is generally slower. Longer messages may have to be "chunked," or broken down into smaller pieces. The patient may have to repeat/rehearse incoming messages to make sure he or she has processed the crucial information. Communication partners may have to slow down their rate of speech to accommodate the patient's processing needs.
• Recent memory is affected, making new learning difficult, e.g., students may have trouble learning and retaining new concepts taught in class. Long-term memory for events and things that occurred pre-injury, however, is generally unaffected, e.g., the patient will remember names of friends and family.
• Impairments in executive functioning diminish the ability to initiate tasks and set long-term and short-term goals for task completion. Planning and organizing the job at hand is an effort, and it is difficult to self-evaluate work. Consequently, these individuals seem disorganized and unable to negotiate their lives without the assistance of families and friends. They also may have difficulty solving problems, and they may react impulsively (without thinking first) to situations.
• The speech-language pathologist completes a formal evaluation of speech and language skills . An oral motor evaluation checks the strength and coordination of the muscles that control speech. Understanding and use of grammar ( syntax ), understanding and use of vocabulary ( semantics ), reading and writing are evaluated. The SLP will evaluate the person's ability to relate an extended narrative ( language sample ). Can he or she explain something or retell a story, centering on a topic and chaining a sequence of events together in a logical order? Is narrative coherent or is it difficult to follow?
• Social communication skills ( pragmatic language ) are evaluated with formal tests and the role-playing of various communication scenarios. The person may be asked to discuss stories and the points of view of various characters. Does he or she understand how the characters are feeling, and why they are reacting a certain way? Can he or she explain how different characters' actions affect what happens in the story? The person may be asked to interpret/explain jokes, sarcastic comments, or absurdities in stories/pictures (e.g., what is strange about a person using an umbrella on a sunny day?).
  * The speech-language pathologist will assess cognitive-communication skills. Is the person aware of surroundings? Does he or she turn towards a voice? Does the person know his or her name, the date, where he or she is, what happened to him or her ( orientation)? Recent memory skills are assessed, e.g., whether the main details in a short story are retained. Executive functioning is evaluated. The speech-language pathologist assesses the patient's ability to plan, organize, and attend to details (e.g., completing all of the steps for brushing teeth). The SLP may read an incomplete story and ask for a logical beginning, middle or conclusion. The person may be asked to provide solutions to problems ( reasoning and problem solving ). For example, what would you do if you locked your keys in your car? How can this problem be avoided in the future?.
  * If there is difficulty swallowing , the speech-language pathologist will evaluate this function, and work with a dietician and physician to make recommendations regarding food consistency (e.g., pureed versus chopped food). The focus of this evaluation will be to insure that the individual is able to swallow safely, without accidentally inhaling food into his or her lungs ( aspiration ).
• If necessary, the speech-language pathologist may also evaluate the benefit of a communication aid or device to express basic needs and ideas.

The treatment program will vary depending on the stage of recovery, but it will always focus on increasing independence in everyday life.

• In the early stages of recovery, e.g., during coma), treatment focuses on getting general responses to sensory stimulation. The family is given information about the best techniques for interacting with the loved one.
• As an individual becomes increasingly aware of surroundings, treatment will focus on helping to sustain attention for basic activities. The speech-language pathologist will also work to decrease the patient's confusion by orienting him or her to the date, to where he or she is, and what has happened.
• Later on in recovery, treatment will focus on helping the person compensate for difficulties remembering (e.g., using a memory log to keep track of daily happenings). The person will work with the clinician individually and in small groups to learn strategies to help problem solving, reasoning, and organizational skills. He or she may work in social skills groups to help with conversational skills. Treatment will always focus on increasing awareness of deficits in order to help self-monitoring in the hospital, home, and community.
• Eventually, individuals may be taken on community outings to practice outside the hospital what they have learned. They are asked to plan, organize and carry out these trips using memory logs, organizers, checklists, and other helpful aids. Later on in recovery, the speech-language pathologist may work with a vocational rehabilitation specialist to help with transition back into work or school or with employers and/or educational specialists to implement strategies in these settings. The SLP may work on modifying the work/school environment to meet the person's cognitive needs.
• Individual therapy may focus on improving language skills as needed. If weak musculature is an issue for speaking and swallowing, treatment will focus on strengthening affected muscles for talking and eating. If the person is learning how to use an augmentative or alternative communication device, treatment will focus on increasing efficiency and effectiveness with the device.

Approximately 500,000 individuals sustain traumatic brain injuries in the United States each year (200 per 100,000 population). Within this group, approximately 200,000 individuals die; 50,000 to 100,000 of them survive with significant impairments to prevent them from living independently. More than 200,000 of them have continuing problems that interfere with daily living. Males, especially those between the ages of 15 and 24, are nearly twice as likely to sustain a traumatic brain injury as females. There is also an increased risk of traumatic brain injury among those older than 75 and younger than 5.

Voice is the sound produced by the larynx (LAR-inks), commonly called the voice box

The larynx is located in the neck. The "Adam's apple," seen most prominently on men, forms the front of the larynx. The vocal folds extend back from the Adam's apple.

Air passes from the lungs through the larynx when you exhale. Generally there is no sound made by this simple act of breathing. By closing the vocal folds like a valve, the air passes gently between them, vibrating the folds and producing voice.

A normal voice is judged according to whether the pitch, loudness, and quality are adequate for communication and suit a particular person. A person may use a pitch which is too high or too deep, intensity that is too loud or too soft, or voice quality may be too hoarse, breathy, or nasal. Sometimes a voice may seem inappropriate for an individual, such as a high-pitched voice in an adult male.

Voice is a problem when the pitch, loudness, or quality calls attention to itself rather than to what the speaker is saying. It is also a problem if the speaker experiences pain or discomfort when speaking or singing.

There are a variety of causes of voice problems. People can become hoarse temporarily by cheering at a baseball game or can sustain an injury that causes a paralysis of the vocal folds. Misuse of the voice, such as talking too loudly or using a pitch level that is too high or too low, results in a voice problem. So can an improper breathing pattern or excessive smoking. The most common voice problems from vocal abuse are vocal fold nodules and polyps. Other voice disorders occur without apparent cause. These include spasmodic dysphonia and paradoxical vocal fold movement.

If you have hoarseness, voice change, or discomfort that lasts for more than ten days in the absence of an allergy or cold, you should have an examination by a medical doctor. This examination will help you decide whether your problem will require professional assistance.

Many problems improve dramatically with the help of a speech-language pathologist. Some problems can profit by a combination of medical or surgical treatment and speech-language pathology services. When faulty use of the voice has caused a condition requiring surgery, the help of a speech-language pathologist will be necessary to avoid a recurrence of the problem. With some conditions, such as cancer of the larynx, a laryngologist (ENT) may recommend surgery and presurgical counseling with a speech-language pathologist.
Autism and Communication

This disorder begins in early childhood and persists throughout adulthood affecting three crucial areas of development: verbal and nonverbal communication, social interaction, and creative or imaginative play.

Autism is the most common of a group of conditions called pervasive developmental disorders (PDDs). It involves delays in many areas of childhood development. The first signs of autism are usually noticed by the age of three. Many individuals who are autistic also develop epilepsy, a brain disorder that causes convulsive seizures, as they approach adulthood. Other characteristics may include repetitive and ritualistic behaviors, hand flapping, spinning or running in circles, excessive fears, self-injury such as head banging or biting, aggression, insensitivity to pain, temper tantrums, and sleeping and eating disturbances. Autistic individuals live a normal life span, but most require lifelong care and supervision.

Autism is one of the most common developmental disabilities. Individuals are of all races and ethnic and socioeconomic backgrounds. Current estimates suggest that approximately 400,000 individuals in the United States have autism. Autism is three to four times more likely to affect boys than girls. Autism occurs in individuals of all levels of intelligence. Approximately 75 percent are of low intelligence while 10 percent may demonstrate high intelligence in specific areas such as math.

The most intensive period of speech and language development is during the first three years of life, a period when the brain is developing and maturing. These skills appear to develop best in a world that is rich with sounds, sights, and consistent exposure to the speech and language of others. At the root of this development is the desire to communicate or interact with the world.

The beginning signs of communication occur in the first few days of life when an infant learns that a cry will bring food, comfort, and companionship. Newborns also begin to recognize important sounds such as the sound of their mother's voice. They begin to sort out the speech sounds (phonemes) or building blocks that compose the words of their language. Research has shown that by 6 months of age, most children recognize the basic sounds of their native language.

As the speech mechanism (jaw, lips, tongue, and throat) and voice mature, an infant is able to make controlled sound. This begins in the first few months of life with "cooing," a quiet, pleasant, repetitive vocalization. Usually by 6 months of age an infant babbles or produces repetitive syllables such as "ba, ba, ba" or "da, da, da." Babbling soon turns into a type of nonsense speech called jargon that often has the tone and cadence of human speech but does not contain real words. By the end of their first year, most children have mastered the ability to say a few simple words. Children are most likely unaware of the meaning of their first words, but soon learn the power of those words as others respond to them.

By 18 months of age most children can say 8 to 10 words and, by age 2, are putting words together in crude sentences such as "more milk." During this period children rapidly learn that words symbolize or represent objects, actions, and thoughts. At this age they also engage in representational or pretend play. At ages three, four, and five a child's vocabulary rapidly increases, and he or she begins to master the rules of language. These rules include the rules of phonology (speech sounds), morphology (word formation), syntax (sentence formation), semantics (word and sentence meaning), prosody (intonation and rhythm of speech), and pragmatics (effective use of language).

Although the cause of speech and language problems in autism is unknown, many experts believe that the difficulties are caused by a variety of conditions that occur either before, during, or after birth affecting brain development. This interferes with an individual's ability to interpret and interact with the world. Some scientists tie the communication problems to a "theory of mind" or impaired ability to think about thoughts or imagine another individual's state of mind. Along with this is an impaired ability to symbolize, both when trying to communicate and in play.

The communication problems of autism vary, depending upon the intellectual and social development of the individual. Some may be unable to speak, whereas others may have rich vocabularies and are able to talk about topics of interest in great depth. Despite this variation, the majority of autistic individuals have little or no problem with pronunciation. Most have difficulty effectively using language. Many also have problems with word and sentence meaning, intonation, and rhythm.

Those who can speak often say things that have no content or information. For example, an autistic individual may repeatedly count from one to five. Others use echolalia, a repetition of something previously heard. One form, immediate echolalia, may occur when the individual repeats the question, "Do you want something to drink?" instead of replying with a "yes" or "no." In another form called delayed echolalia, an individual may say, "Do you want something to drink?" whenever he or she is asking for a drink.

Others may use stock phrases such as, "My name is Tom," to start a conversation, even when speaking with friends or family. Still others may repeat learned scripts such as those heard during television commercials. Some individuals with higher intelligence may be able to speak in depth about topics they are interested in such as dinosaurs or railroads but are unable to engage in an interactive conversation on those topics.

Most autistic individuals do not make eye contact and have poor attention duration. They are often unable to use gestures either as a primary means of communication, as in sign language, or to assist verbal communication, such as pointing to an object they want. Some autistic individuals speak in a high-pitched voice or use robot-like speech. They are often unresponsive to the speech of others and may not respond to their own names. As a result, some are mistakenly thought to have a hearing problem. The correct use of pronouns is also a problem for autistic individuals. For example, if asked, "Are you wearing a red shirt today?" the individual may respond with, "You are wearing a red shirt today," instead of "Yes, I am wearing a red shirt today."

For many, speech and language develop, to some degree, but not to a normal ability level. This development is usually uneven. For example, vocabulary development in areas of interest may be accelerated. Many have good memories for information just heard or seen. Some may be able to read words well before the age of five but may not be able to demonstrate understanding of what is read. Others have musical talents or advanced ability to count and perform mathematical calculations. Approximately 10 percent show "savant" skills or detailed abilities in specific areas such as calendar calculation, musical ability, or math.

If autism or some other developmental disability is suspected, the child's physician will usually refer the child to a variety of specialists, including a speech-language pathologist, who performs a comprehensive evaluation of his or her ability to communicate and designs and administers treatment.

No one treatment method has been found to successfully improve communication in all individuals who have autism. The best treatment begins early, during the preschool years, is individually tailored, targets both behavior and communication, and involves parents or primary caregivers. The goal of therapy should be to improve useful communication. For some, verbal communication is a realistic goal. For others, the goal may be gestured communication. Still others may have the goal of communicating by means of a symbol system such as picture boards. Treatment should include periodic in-depth evaluations provided by an individual with special training in the evaluation and treatment of speech and language disorders, such as a speech pathologist. Occupational and physical therapists may also work with the individual to reduce unwanted behaviors that may interfere with the development of communication skills.

Some individuals respond well to highly structured behavior modification programs; others respond better to in-home therapy that uses real situations as the basis for training. Other approaches such as music therapy and sensory integration therapy, which strives to improve the child's ability to respond to information from the senses, appear to have helped some autistic children, although research on the efficacy of these approaches is largely lacking.

Medications may improve an individual's attention span or reduce unwanted behaviors such as hand-flapping, but long-term use of these kinds of medications is often difficult or undesirable because of their side effects. No medications have been found to specifically help communication in autistic individuals. Mineral and vitamin supplements, special diets, and psychotherapy have also been used, but research has not documented their effectiveness.

In addition to ongoing research on other aspects of autism across the National Institutes of Health (NIH), researchers at the National Institute on Deafness and Other Communication Disorders (NIDCD) are also investigating the communication difficulties or differences of people who have autism. At the heart of the research effort is a five-year collaborative NIH effort between the NIDCD and the National Institute of Child Health and Human Development (NICHD) which was launched in May 1997. The effort involves more than 65 scientists at 24 universities from around the world, including the United States, Canada, Britain, France, and Germany, who are examining how autism develops. In addition, scientists are also exploring the speech and language features in autism, evaluating current treatment practices, and designing new treatments. Additional studies include investigations of brain development and functioning in autism and the use and effects of certain drugs on communication behavior.

What speech problems might children with clefts have?

Before the palate is repaired, there is no separation between the nasal cavity and the mouth. This means that a) the child cannot build up air pressure in the mouth because air escapes out of the nose, and b) there is less tissue on the roof of the mouth for the tongue to touch. Both of these problems can make it difficult for the child to learn how to make some sounds.

It is not unusual for a child who is born with a cleft palate to show a delay in both the onset of speech and the development of speech sounds during the first 9-24 months of age. Once the palate has been repaired, your child may be able to learn more consonant sounds and say more words, but speech may still be delayed during the early years. Articulation problems (difficulties in making certain sounds) may persist in some children throughout early childhood for a variety of reasons. If your child's teeth do not "line up" correctly, speech may be understandable, but some sounds (like "s" or "sh") may sound distorted or "mushy." It is also important to remember that some children, with or without a cleft palate, may simply develop speech more slowly than others.

When speech is produced correctly, the soft palate lifts and moves toward the back of the throat, separating the nasal cavity from the mouth so that air and sound can be directed out of the mouth. The inability to close off the nasal cavity from the mouth is called velopharyngeal inadequacy. Children who have velopharyngeal inadequacy may sound like they are "talking through their noses." This problem occurs because when the soft palate cannot close off the nose from the mouth, air and sound can escape through the nose during speech, possibly resulting in hypernasality and nasal emission of air. (It is normal for air and sound to come out of the nose when saying the "m," "n," or "ing" sounds.) Approximately 25% of children with repaired cleft palates still show signs of velopharyngeal inadequacy.

You may notice that your child produces "grunt" or "growl" sounds. These sounds represent a behavior that some children learn in an attempt to compensate for velopharyngeal inadequacy. This behavior usually begins before the palate is repaired, but it may continue even after the palate is closed.

Children with velopharyngeal inadequacy may also have a voice disorder. In this case, your child's voice may sound hoarse or "breathy" and may fatigue easily. This problem is usually caused by the strain that he or she puts on the vocal cords while trying to build the pressure necessary for normal speech.

Speech therapy alone may be able to correct your child's speech disorder. Therapy can be extremely effective for children with mild hypernasality, an articulation disorder, or speech delay. The goal of speech therapy will be to develop good speech habits as well as to learn how to produce sounds correctly. Speech therapy alone will generally not correct hypernasality that is caused by moderate to severe velopharyngeal inadequacy.

The type of therapy your child receives will be determined by the type of problem your child has. Furthermore, the amount of therapy your child needs will depend on the severity of the speech problem. If your child's articulation difficulties are related to a dental abnormality, the combination of articulation therapy and dental treatment can help to minimize the problem.

If your cleft palate team decides that speech therapy alone will not correct your child's speech problem, there are some other options. Your child may require another palate surgery to help with speech. The two most common speech surgeries are 1) pharyngeal flap and 2) sphincter pharyngoplasty. (The surgeon may also choose to redo the original repair.) Your child's speech-language pathologist and surgeon will work together to determine the most appropriate type of surgery for your child. Talk to your surgeon about which procedure he or she intends to perform. It is important to remember that surgery is not a "quick fix." It is almost always necessary for a child to participate in speech therapy after surgery to practice correct articulation and good speech habits.

Although surgery is the most frequently-chosen approach for improving velopharyngeal function, a prosthetic device may be an option for some patients. These speech aids are placed in the mouth, much like an orthodontic retainer. The two most common types are 1) the speech bulb and 2) the palatal lift. The speech bulb is designed to partially close off the space between the soft palate and the throat. The palatal lift appliance serves to lift the soft palate to a position that makes closure possible. Many professionals feel that prosthetic appliances work best in children who are at least five years of age. However, each patient should be evaluated on an individual basis to determine if one of these devices is appropriate for him or her.

The speech-language pathologist on the cleft palate team has many responsibilities and should see your child regularly. The speech-language pathologist should consistently assess your child's speech and language development, as well as screen for hearing problems (with the help of an audiologist). In addition to evaluating speech, the speech-language pathologist can help you and your child minimize feeding difficulties, possibly offering guidance on adapted feeding techniques.