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 is a disorder that results from damage to language centers of the brain. As a result, individuals who were previously able to communicate through speaking, listening, reading and writing become more limited in their ability to do so. The most common cause of aphasia is stroke , but gunshot wounds, blows to the head, other traumatic brain injury, brain tumor, and other sources of brain damage can also cause aphasia.

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.

Apraxia in adults (also referred to as apraxia of speech, verbal apraxia, or dyspraxia) is a motor speech disorder caused by damage to the parts of the nervous system related to speaking. It is characterized by problems sequencing the sounds in syllables and words and varies in severity depending on the nature of the nervous system damage. People with apraxia know what words they want to say, but their brains have difficulty coordinating the muscle movements necessary to say those words and they may say something completely different, even nonsensical. Some characteristics of Apraxia include: difficulty imitating speech sounds; difficulty imitating non-speech movements, such as sticking out their tongue (oral apraxia); groping for sounds; inconsistent errors; and slow rate of speech. In severe cases, it can cause an inability to produce sound at all. In these cases a preserved ability to produce “automatic speech”, such as greetings like “How are you?” is present. Apraxia can occur in conjunction with dysarthria (muscle weakness affecting speech production) or aphasia (language difficulties related to neurological damage)

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.

Childhood apraxia of speech is a disorder of the nervous system that affects the ability to sequence and produce sounds, syllables, and words. It is not due to muscular weakness or paralysis. The problem is in the brain’s planning to move the body parts needed for speech (e.g., lips, jaw, tongue). The child knows what he or she wants to say, but the brain is not sending the correct instructions to move the body parts of speech the way they need to be moved.

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.

Attention Deficit Hyperactivity Disorder (ADHD) is a neurobiological condition seen primarily in the school-aged population that affects one’ s ability to maintain attention. The disorder and its symptoms are chronic, meaning they affect an individual throughout life. The symptoms are also pervasive , meaning they are a continuous problem and not just a response to a temporary situation. The behaviors occur in multiple settings, rather than just one. Current research supports the idea of two distinct characteristics of ADHD, inattention and/or hyperactivity-impulsivity .

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 Dementias : The term “dementia” describes a cluster of symptoms related to memory loss and overall cognitive impairment that is progressive in nature and often irreversible. Dementia has many causes, including: Alzheimer’s Disease; Multiple Small Strokes (Multi-Infarct Dementia); Parkinson’s Disease; Huntington’s Disease; Drug use or interactions; Depression; Brain tumors; Other cerebrovascular disease; Head Trauma; and Alcoholism.

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 – After a stroke or other brain injury, the muscles of the mouth, face, and respiratory system may become weak, move slowly, or not move at all. The resulting speech condition is called dysarthria. The type and severity of dysarthria depends on which area of the nervous system is affected. Symptoms include “slurred” speech ; speaking softly or barely able to whisper; slow rate of speech; rapid rate of speech with a “mumbling” quality; limited tongue, lip, and jaw movement; abnormal intonation (rhythm) when speaking; changes in vocal quality (“nasal” speech or sounding “stuffy”); hoarseness; breathiness; drooling or poor control of saliva; chewing and swallowing difficulty.

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.

Swallowing disorders , also called dysphagia (dis FAY juh), can occur at different stages in the swallowing process:

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.

Laryngeal Cancer – Laryngectomy is the removal of the voice box (larynx) from the neck, usually due to cancer. The larynx protects the airway to the lungs during swallowing and also contains the vocal cords that act as the sound source for speech. Therefore, after a total laryngectomy, a person must use a new way of breathing and a new sound source for speech.

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.

Oral CancerA malignant growth that affects any part of the oral cavity, including the lips, upper or lower jaw, tongue, gums, cheeks, and throat. These types of cancers represent 2%-5% of all forms of cancer, and approximately 30,000 new cases are diagnosed every year.

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.

Late Blooming or Language Problem?

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:

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.

Right Hemisphere Brain Damage

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.

Speech for Patients With Tracheostomies or Ventilators

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.



Blockage of blood vessels in the brain

Bleeding into or around the brain

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:

Stuttering : Stuttering is a disorder of speech fluency that interrupts the forward flow of speech. All individuals are disfluent at times, but what differentiates the person who stutters from someone with normal speech disfluencies is the kind and amount of the disfluencies.


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:

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:

Fluency strategies may include:

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.

Traumatic Brain Injury

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:

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.

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

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.

What is voice?

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

What Is Autism?

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.

Who Is Affected by Autism?

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.

How Do Speech and Language Normally Develop?

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).

What Causes Speech and Language Problems in Autism?

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.

What Are the Communication Problems of Autism?

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.

How Are the Speech and Language Problems of Autism Treated?

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.

How Are the Speech and Language Problems of Autism Treated?

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.

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.

What can be done about speech problems?

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.

What is the role of the speech-language pathologist on a cleft palate team?

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.


to teach, to love, to guide to encourage