Communication Disorders 1

University of the Philippines Diliman, Quezon City

COMMUNICATION DISORDERS: A REVIEW OF RELATED LITERATURE

Submitted in partial fulfillment of the requirements for Psychology 145 Psychology of Language

By Calimutan, Yukiko Alyson M. 2011-25393

To Prof. Susana Corazon Cipres-Ortega

On March 28, 2014

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Speech and language impairments include a variety of conditions that interfere with communication. Speech impairments refer to the difficulty of producing and articulating speech sounds. On the other hand, language impairment is the deficit in the understanding and expressing language (Morales, 2013). Speech and language disorders fall under communication disorders in the DSM IV-TR. Communication disorders are often found in the developmental phase or childhood, wherein a child is at the early stage of language learning (Sadock & Sadock, 2007). Language disorders include expressive and mixed receptive-expressive language disorder. Conversely, speech disorders are further divided into two: phonological disorders and stuttering. There are a few revisions in the new DSM V with regard to the aforementioned disorders. Expressive and mixed receptive-expressive language disorders are combined and will be called as Language disorders. Phonological disorder will be renamed as Speech Sound disorder. Likewise, stuttering will be changed into childhood-onset fluency disorder (American Psychiatric Association, 2013). Speech and language disorders may be co morbid with each other, or these can occur independently (Morales, 2013). According to the National Dissemination Center for Children with Disabilities, 2013 in the United States, possible causes of speech and language disorders are hearing loss, brain injury, neurological disorders, drug abuse, and physical impairments such as having a cleft lip. In some cases, however, the causes are undetermined. In addition, language disorders are often interchanged with language delay, but some professionals insist on making a clear distinction. A delay refers to a much slower rate of learning the language in children. Nevertheless, children are able to talk normally. On the other hand, the usage of disorder refers to the abnormal development in language. At the early stage of

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language learning, it is difficult to determine if the problem is a delay or a disorder, since every child learns in his/her own pace (Afasic, 2004). This paper will focus on stuttering, phonological disorders and expressive language disorders. Cleft lip and palate will also be discussed.

SPEECH DISORDERS

STUTTERING
Stuttering affects the fluency of speech (American Speech-Language-Hearing Association, n.d.). It is a condition in which flow of speech is disrupted by involuntary speech motor events (Sadock & Sadock, 2007). The criteria of the DSM IV-TR for stuttering includes disturbance in the fluency of speech and time patterning of speech; disturbance of fluency interferes with academic or occupational achievement or with social communication; excess in speech difficulties if motor or sensory deficit is present. Manifestations of stuttering are pauses in speech, syllable repetitions, sound prolongations, dysrhythmic phonations and other speech hesitancies (Hunsaker, 2011). People who stutter may use interjections such as, um or like. These may be prolonged (uummm) or repeated (u-u-umm). In addition, their speech may be blocked or stopped. They may also appear and sound very tense and out of breath (American Speech-Language-Hearing Association, n.d.). Other behaviors can also be observed in between the disruptions, such as facial grimacing, head jerks, and eyeblinks (Sadock & Sadock, 2007). There are three types of stuttering: developmental stuttering, neurogenic stuttering and psychogenic stuttering. Developmental stuttering is the most common form, and it usually occurs in children. Neurogenic stuttering may occur when a person suffered stroke or brain injury.

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Lastly, psychogenic stuttering may happen when a person suffers a mental illness, or if he/she has undergone extreme psychological stress or anguish. This type of stuttering is the most uncommon among the three (University of Rochester Medical Center, n.d.). This condition begins in the early stage of the development of a childs communication skills (Hunsaker, 2011). It starts between ages of nine months and 9 years, with two peaks at ages of 2 to 3.5 years and 5 to 7 years (Sadock & Sadock, 2007). Stuttering is more prevalent in men than in women, with the incidence of stuttering of the former is four times greater than the latter. This is also evident cross culturally, regardless of other factors such as socioeconomic status and intelligence (Hunsaker, 2011). However, stuttering varies across individuals. Some children show the symptoms days or weeks onset, while for others it is more gradual (American Speech-Language-Hearing Association, n.d.). Approximately 80 percent of stuttering children are likely to have remission and eventually recover over time. Moreover, according to DSM IVTR, the percentage drops to o.8 by adolescence. Nonetheless, teenagers and adults stutterers are reported to have significant improvements with their speech (Sadock & Sadock, 2007). A study by Guitar, (2006) as cited in Hunsaker, (2011) suggests that genetic factors may be linked to the onset of stuttering among children. Moreover, according to DSM IV-TR, for males that stutter, there is 20% chance of their male offspring and 10% for their female offspring to develop the same condition (Sadock & Sadock, 2007). However, genetic links cannot explain all the incidences of stuttering. Hence, there may be other factors, such as the environment that may have contributed to the development of stuttering. These factors may include parents reactions to their childs dysfluencies, and the change from simple to complex grammars that should be learned during language development (Hunsaker, 2011). Furthermore, the severity of

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stuttering may increase due to some factors such as social pressure, frustration and anxiety (American Speech-Language-Hearing Association, n.d.). Treatments for stuttering vary depending on the persons age, communication goals, among others. Direct speech therapy focuses on modifying the stuttering responses by practicing the systematic rules of speech mechanics. Speech therapists uses different approaches this to meet the individual needs of clients. Distraction, selection and relaxation methods were also used as treatments. In using the distraction method, the patient is trained to talk along the rhythmic movements of the arm or fingers to avoid patterns such as repetition and prolongation of sounds. On the other hand, selection methods such as hypnosis were used to remove stuttering. These treatments, however, have only temporary effects. Relaxation exercises and techniques were also used, as tension and anxiety can also contribute to stuttering. Current interventions that are used were combinations of direct speech therapy, relaxation techniques, and distraction methods (Sadock & Sadock, 2007). These treatments are most effective during the early onset of stuttering. If it is not treated until the adolescent stage, there is a high risk of it continuing throughout adulthood (Van Riper, 1973 as cited in Hunsaker, 2011). Stuttering has made social impacts on the lives of people who have this kind of condition. In a survey conducted by Opp, (1997) as cited in Hunsaker, (2011), people who have this condition have reported higher rates of unemployment, discrimination in attaining employment, and denial of promotions. Moreover, a study by Parry (2009) as cited in Hunsaker, (2011), stutterers have been employed to undesirable, low salary jobs. Stuttering decreases a persons employability and opportunities for promotion (Hurst, 1983 as cited in Hunsaker, 2011). This condition may be stigmatized in the workplace as incompetent and less intelligent. In addition, stuttering can also be viewed as a negative attributes in finding and selecting a partner. However,

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in a study by Linn, (1998) as cited in Hunsaker, (2011), male stutters who disclosed their condition to their female date were perceived as good looking, intelligent and have good personalities. Hence, given these circumstances, stuttering may have a great effect on a persons self image. Stutterers are more self-conscious during conversations due to their stuttering behavior. Moreover, they reduce the time they spend speaking in public. This suggests that stuttering may decrease a persons self esteem. Further, other people may assume that stuttering is caused by the stutterer him/herself, rather than identifying other possible causes such as genetics (Blood, 2003 as cited in Hunsaker, 2011). Therefore, in order to lessen the stigma when it comes to this condition, its underlying causes must be clear.

PHONOLOGICAL DISORDERS
Phonological disorders refer to sound errors, such as omissions of sounds, distortions of sounds, or atypical pronunciation. Common errors are the omission of sounds and the substitution of one sound from another (Sadock & Sadock, 2007). The onset of these disorders is in early childhood. Moreover, Phonological problems are more prevalent in men than in women. Developmental phonological disorders, such as developmental articulation disorder and developmental phonological disorder, are more common than that of neurological that can be acquired when a person suffered/s from brain injury or stroke (Sadock & Sadock, 2007). The diagnosis of these disorders depends on the age of the patient. A 3 year old child must be able to articulate m, n, ng, b, p, h, t, k, q, and d sounds. A four year old must be able to articulate f, y, ch, sh, and z sounds. A 5 year old child must be able to correctly articulate th, s,

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and r sounds. The diagnostic criteria of phonological disorders from the DSM IV-TR are as follows: Failure to normally develop speech sounds that is appropriate for the age and dialect; the difficulty in speech sound production interferes with academic and occupational functionality; Excess speech difficulties when mental retardation, speech-motor sensory deficit, or environmental deprivation is present (Sadock & Sadock, 2007).. Dysarthria and dyspraxia are examples of phonological disorders with neurological causes (Sadock & Sadock, 2007). Dysarthria is the slurred speech caused by the weakness of the speech muscles. The speech production facets that are affected by this disorder are respiration, phonation, articulation and prosody. Its symptoms are slurred speech; slow rate of speech; rapid but incomprehensible speech; limited tongue, lip and jaw movement; abnormal intonation; hyper nasality; hoarseness of voice; poor control of saliva or drooling; chewing and swallowing difficulty. Some causes of dysarthria include stroke, celebral palsy, head injury and muscular dystrophy (American Speech-Language-Hearing Association, n.d.). This disorder can both occur in children and in adults. Moreover, it has four types: Dyskinetic, Spastic, Peripheral, and Mixed (UH Cogsci, n.d.). On the other hand, dyspraxia or apraxia of speech can be caused by brain damage, specifically to the area that is responsible for language production. It refers to difficulty planning and executing speech. A person with this condition knows what to say but his/her brain is unsuccessful in coordinating with the muscles that must take action in order to successfully perform speech. Its symptoms are the following: difficulty imitating speech sounds; difficulty imitating non-speech movements; inconsistent errors in articulating sound; slow rate of speech; and in severe cases, inability to produce sound. Usually, however, the sounds of rote/automatic words such as ouch can still be produced by the people with this condition Dyspraxia, just like

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dysarthria, can both occur in children and adults (American Speech-Language-Hearing Association, n. d.) Phonological disorders may lead to problems with learning, peers, and self-image. Children with these conditions are often teased and left out by peers, which may affect the self esteem of the child. Hence, receiving treatment is very essential. There are two possible interventions for these disorders: phonological approach and the traditional approach. Phonological approach is used for patients who have extensive patterns of speech sound errors. In this approach, the therapist gives the patient exercises on specific sounds, and when that is mastered, practice is extended in using meaningful words and sentences. On the other hand, the traditional approach is used for patients with only a few patterns of speech sound errors. This also includes practicing the articulation of the problem sounds, but in this approach, the therapist gives immediate feedback on the correct placing of the tongue to be able to produce the sound. In addition, speech therapy is also utilized as treatment for phonological disorders (Sadock & Sadock 2007).

LANGUAGE DISORDERS

EXPRESSIVE LANGUAGE DISORDER

Expressive language disorder refers to difficulties with either verbal or spoken expression. Most children have difficulties with the latter (Agt, 2011). People in this condition perform below the expected levels of the expected levels of vocabulary, tense usage, complex sentence constructions and word recall. To meet the criteria for this disorder, a childs score from a standardized verbal test must be significantly lower than his/her score in standardized non-

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verbal IQ test, as well as in standardized receptive language tests. The Wechsler Intelligence Scale for Children III (WISC-III) is used in identifying children with expressive language disorder. If a childs intellectual level on verbal speech is marked below his/her overall intelligence quotient, then theres a high risk of having expressive language disorder (Sadock & Sadock 2007). The criteria for diagnosis in the DSM IV-TR were as follows: the scores obtained from the standardized tests of expressive language development are substantially below than the individuals scores on standardized tests of non-verbal intellectual capacity and receptive language development; the difficulties interfere with academic and social achievement and social communication; criteria are not met for mixed receptive-expressive language disorder; Excess language difficulties if associated with mental retardation, speech-motor or sensory deficit, or environmental deprivation(Sadock & Sadock 2007). Children with this disorder have distinct characteristics, such as limited vocabulary, simple grammar, and variable articulation. Expressive language disorder is 2-3 times more common in males than females. Moreover, there is a high chance of developing this disorder if there are communication disorders in family history. Nonetheless, this disorder is not pervasive, and people who have this condition develop some non-verbal strategies to aid in socialization (Sadock & Sadock 2007). Treatments for this disorder are only initiated once it is observed that it persisted after the preschool years. Direct and mediated methods are used to improve use of different parts of speech such as tenses. Direct intervention uses a Speech-Language Pathologist (SLP) who directly guides the child. Mediated interventions, on the other hand, utilizes a speech and language professional that teaches the patients guardians (teacher or parent) some therapeutic

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language techniques. Language therapy improves communication strategies and social interactions by giving exercises on phonemes, vocabulary, and sentence construction. Psychotherapy is also used in patients who had problems with their self esteem due to their language impairment (Sadock & Sadock 2007). .

MIXED RECEPTIVE-EXPRESSIVE LANGUAGE DISORDER

People with receptive language impairment have difficulties with understanding spoken language (Agt, 2011). For a language to be adequately used, the speaker must be able to comprehend the language first. Hence, receptive language disorder simultaneously occurs with expressive language disorder. This condition is called mixed receptive-expressive language disorder in the DSM IV-TR. However, as mentioned above, expressive language disorder can occur alone (Sadock & Sadock 2007). Children with mixed receptive-expressive language disorder have impaired skills in reception and expression. The expression deficits are the same with those of expressive language disorder. On the other hand, receptive deficits include difficulties in auditory processing skills, such as association of sounds and symbols and the memory of sound sequences. These deficits my create communication barriers, hence affecting the individuals relationships with others (Sadock & Sadock 2007). The onset of this disorder is during early childhood. This condition is more common than expressive language disorder alone. Males also have a higher risk of having this disorder compared to women (Sadock & Sadock 2007). .

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The criteria for diagnosis for mixed receptive-expressive language disorder in the DSM IV-TR are the following: the scores obtained from the standardized tests of expressive language development and receptive language development are substantially below than the individuals scores on standardized tests of non-verbal intellectual capacity; the difficulties interfere with academic and occupational achievements, as well as social communication; criteria are not met for pervasive developmental disorder; Excess language difficulties if associated with mental retardation, speech-motor or sensory deficit, or environmental deprivation (Sadock & Sadock 2007). Before initiating on any treatment, children are recommended to undergo a comprehensive speech and language assessment. Interventions for this condition promote social communication, oral language, and literacy. Some speech and language instructions are integrated in various settings with other children who have learned several language structures. Children with this condition, however, learn more efficiently with small, specialized educational setting permits more individualized learning. Moreover, Psychotherapy and family counseling deals with the patients emotional, behavioral problems (Sadock & Sadock 2007). .

CLEFT LIP AND PALATE

Cleft lip/palate (CLP) is the most common craniofacial birth defect (practical plastic surgery for non surgeons) which happens during the fifth and eight week of neonatal development. It is a medical condition wherein the babys lip or mouth did not form properly, forming orofacial clefts. This condition can be classified into two: Cleft lip and Cleft lip with cleft palate (Centers for Disease Control and Prevention, 2013). According to a study by

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Zetinoglu and Davey 2012, this medical condition is prevalent in all races and ethnic groups and it is often diagnosed in Asian and Native Americans. In the Philippines, cleft lip is referred to as bingot, while cleft palate is called ngongo (Kalusugan.ph, n. d.). A cleft lip occurs when the tissue that forms the lip did not completely join before birth. This results to a slit-like formation or opening in the upper lip. The opening can be a small slit, but in some cases it is large enough that it reaches the nose. It can be unilateral, median and bilateral. In unilateral cleft palate, a slit is on one side of the lip, while the bilateral cleft palate has slits on both sides. In median cleft palate, the slit is right in the middle of the lip. This type is the most uncommon among the three. Cleft lips form between the fourth and seventh weeks of pregnancy (Center for disease control and prevention). On the other hand, a cleft palate happens when the tissue of the roof of the mouth did not form completely, leaving a split or an opening. The opening can be in the velar (soft palate) or in the hard palate. There are also cases when the opening is both in the front and back part of the mouth. This forms between the sixth and ninth week of pregnancy (Center for disease control and prevention). Several studies in these birth defects have focused on its possible causes. A study by Conrad, Richman, Nopoulos & Dailey, 2009 as cited in Zeytinoglu & Davey, 2012 stated that genes contribute to the formation of clefts. If a baby is born with either cleft lip or palate, there is a 4% chance that the sibling will have the same condition. Moreover, if two siblings have cleft lip palate, the chance of the third sibling having the same impediment will increase to between 710% (Suslak &Desposito, 1988 as cited in Zeytinoglu & Davey, 2012). In addition to genetic factors, environmental factors have also been considered. Exposure of the mother to medications during the first trimester of pregnancy, as well as drug intake and

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alcohol use can result to the formation of clefts in the offspring (Suslak &Desposito, 1988 as cited in Zeytinoglu & Davey, 2012). Likewise, cigarette smoking of the mother during pregnancy can also contribute to the developing of this medical condition (Khoury et al., 1987). Similarly, it has been found out that women who have diabetes have an increased risk of having a child with cleft lip with or without cleft palate (Center for Disease Control and Prevention). Children with CLP may have difficulty in feeding and talking. Moreover, they might also have hearing loss and dental problems, and they are also susceptible to ear infections (Center for Disease Control and Prevention). Cleft palate may cause abnormal speech development because of the position of the soft palate musculature. Hence, there is difficulty in articulating fricative (such as f and sh) and plosives (p, m, b), which is also called as velopharyngeal incompetence (VPI). This kind of speech pattern also includes hypernasality, nasal emission and nasal turbulence or resonance (Goldacre & Swan 2008). Cleft lip/palate may have an effect on the psychosocial health of an individual. Children with CLP might experience psychosocial distress because of their facial disfigurement. High incidence of teasing is reported among those who have CLP (Bernstein and Kapp, 1981; Heller et al., 1981; Noar,1991, 1992; Turner et al., 1997 as cited in Hunt et. al ,2005). Facial disfigurements may cause heightened levels of depression (Thompson & Kent, 2001 as cited in Hunt et. al, 2005), as well as behavioural inhibition (Richman & Eliason, 1982 as cited in Hunt et. al 2005). These studies somehow contradict the results of a study by Hunt et. al, 2005. Their research examined if people with CLP have higher risk of psychosocial problems compared to people who doesnt have CLP. Their result suggests that children and people with CLP do not

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exhibit major psychosocial problems. The authors, however, noted in the results that there are some specific problems that may arise. The findings show that there difficulties, though not significant enough, that are related to behavioural problems, satisfaction with facial appearance, depression, and anxiety. To treat CLP, surgery is required. Once a feeding pattern that suits the condition has been established, and the baby has regained weight, he/she can undergo the primary surgery. The lip and palate will undergo surgical repair within the first 2-3 months of the primary surgery duration. Then the soft palate closure will occur between the 4th and 12th month. Next to that would be the hard palate closure. Although the methods of the primary are sophisticated, there are cases when there are problems, such as speech difficulties, that can still be observed. Thus, a secondary surgery can be conducted (Goldacre & Swan 2008). The treatment of CLP does not end in surgery. Zeytinoglu & Davey (2012) suggested Engels Biopsychosocial model. According to this model, a medical condition cannot be fully treated if it is not viewed in a multi-disciplinarian approach. Hence, the treatments must also include support systems, like the family, and the patients relationship to them (Engel, 1977 as cited in Zeytinoglu & Davey, 2012). The findings of the study emphasized the importance of a family member in the treatment team. In addition to that, medical professionals must be knowledgeable on how to properly orient family members about the patients medical condition (Zeytinoglu & Davey, 2012). There is an international childrens medical charity called Operation Smile that gives free and safe surgery to children with CLP and other facial deformities. They also provide other medical needs through medical missions. Since 1982, this volunteer-based organization has given 200,000 free surgeries to children and young adults. Operation Smile currently has 60

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country offices (Operation smile, n. d.). Operation smile Philippines is the first in-country office. It is a non-stock, non-profit organization that supports the endeavours of Operation Smile International (Operation Smile Philippines, n. d.).

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REFERENCES __________________________________________________________
___________ (2013). Highlights of Changes from DSM-IV-TR to DSM-5. American Psychiatric Association, 1.

Agt, H. M. E. (2011). Language disorders in children: Impact and the Effects of Screening. Published Thesis Dissertation, Erasmus University Rotterdam, Netherlands.

Apraxia of Speech in Adults. (n.d.). American Speech-Language-Hearing Association. Retrieved March 27, 2014, from http://www.asha.org/public/speech/disorders/ApraxiaAdults/

Developmental language delay/ developmental language disorder. (n.d.). Afasic . Retrieved March 27, 2014, from http://www.afasic.org.uk/recognising-a-problem/speech-languageand-communication/delay-and-disorder/

Dysarthria. (n.d.). American Speech-Language-Hearing Association. Retrieved March 27, 2014, from http://www.asha.org/public/speech/disorders/dysarthria/

Facts about Cleft Lip and Cleft Palate. (2013, July 15). Centers for Disease Control and Prevention. Retrieved March 27, 2014, from http://www.cdc.gov/ncbddd/birthdefects//cleftlip.html.

Goodacre, T., & Swan, M. (2008). Cleft lip and palate: current management. Paediatrics and Child Health, 18(6), 285-89.

Hunsaker, Sadie A. (2011). "The Social Effects of Stuttering in Adolescents and Young Adults". Research Papers. Paper 70. http://opensiuc.lib.siu.edu/gs_rp/70

Hunt, O., Burden, D., Hepper, P., Johnston, C., (2005). The psychosocial effects of cleft lip and palate: a systematic Review. European journal of Orthodontics, 27, 274-85.

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Language Pathologies. (n.d.). UH Cogsci:Pathologies. Retrieved March 27, 2014, from http://www.class.uh.edu/cogsci/lang/pathologies.html

MGA KAALAMAN TUNGKOL SA NGONGO (CLEFT PALATE) AT BINGOT (CLEFT LIP). (n.d.). Kalusugan.ph. Retrieved March 18, 2014, from http://kalusugan.ph/mgakaalaman-tungkol-sa-ngongo-cleft-palate-at-bingot-cleft-lip/

Morales, S. (2013, September 12). Overview of Speech and Language Impairments. CHILD'S SPEECH CARE CENTER. Retrieved March 27, 2014, from http://www.childspeech.net/u_i.html

Operation Smile Philippines: About Us. (n.d.). Operation Smile Philippines. Retrieved March 27, 2014, from http://www.operationsmile.org.ph/about-us/

Sadock, B. J., & Sadock, V. A. (2007). Communication Disorders. Synopsis of Psychiatry Behavioral Sciences/Clinical Psychiatry (10 ed., pp. 1176-89). New York: Lippincott Williams & Wilkins.

Speech and Language Impairments. (n.d.). National Dissemination Center for Children with Disabilities. Retrieved March 25, 2014, from http://nichcy.org/disability/specific/speechlanguage

Stuttering. (n.d.). American Speech-Language-Hearing Association. Retrieved March 27, 2014, from http://www.asha.org/public/speech/disorders/stuttering.htm

Types of Stuttering. (n.d.). University of Rochester Medical Center. Retrieved March 27, 2014, from http://www.urmc.rochester.edu/speech-pathology/speech-languagedisorders/stuttering/types-stuttering.cfm

Who We Are: International Children's Medical Charity. (n.d.). Operation Smile. Retrieved March 27, 2014, from http://www.operationsmile.org/about_us/who-we-are/ Zeytinoglu, S. & Davey, M. (2012). Its a Privilege to Smile: Impact of Cleft Lip Palate on Families, American Psychological Review, 30(3) 265-66.

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