Why Can’t I Understand Her? – Disorders of Speech

By Daniel Miller, MS, MA, CCC-SLP

One of the most common reasons that children see speech therapists is because they are difficult to understand. This can lead to a lot of frustration when trying to communicate, on the part of both the child and the listener. This article intends to shed some light on the different types of speech disorders and their treatment.

In the field of speech-language pathology, the term “speech” is used to refer to articulation: how we shape sound and airflow to produce speech sounds. “Language” is used to refer to vocabulary, grammatical skills, and the content of talking. Children (and adults) may have disorders which impact speech only or language only, and often these co-occur as well. Here are the most well-known speech disorders:

• Phonological Disorder is a commonly observed speech sound disorder. A phonological disorder is a disorder of the organization of speech sounds. Children make pattern-based substitutions of one type of sound for another, such as always saying a sound that “stops” airflow such as “p” or “t” in place of a sound with continuous airflow such as “f” or “s” (for example, “tick” for “sick”). These patterns of substitutions are called “phonological processes.” If you know which processes apply to the child’s speech, you can actually “translate” that speech and figure out what he or she is intending to say (this is how we are able to understand children so well, even when they are simplifying words at young ages). Phonological processes are a normal part of speech development, but are expected to fade from a child’s speech by certain ages. When these persist past expected ages, speech therapy is warranted. Treatment often focuses on sound patterns rather than individual sounds: instead of working with the same sound until the child has mastered it, the therapist will target one sound in the pattern for a few weeks, then move on to another sound in the same pattern. This process aims to stimulate the child’s natural learning ability.
• Articulation Disorder is sometimes called simply a “speech sound” disorder. These terms often are used as umbrella terms to refer to any disorder that impacts speech sound skills (including any of the disorders on this list). However, therapists also use the term “articulation disorder” to refer to a disorder in acquiring just one or a few particular sounds, without evidence for disordered muscle control or widespread patterns of sound substitutions. Often, children will have mastered all of the sounds in the language, except for “r,” or except for “th,” or “s.” When you hear people use the term “lisp” or “speech impediment,” often this is what they have in mind. A child may place his or her tongue between their teeth for an “s,” making it sound more like “th,” or they may direct air around the sides of their tongue for “s” and “sh” instead of over the middle of the tongue. Speech therapists treat articulation disorders by first teaching the child to produce the sound all by itself, then giving them practice producing that sound in single words, in longer phrases and sentences, and finally in conversation.
• Childhood Apraxia of Speech or CAS is a rare speech disorder that impacts the child’s ability to plan movements of the muscles of the face, mouth, throat, and muscles of respiration for the purposes of speech production. The muscles themselves are not damaged or weak, but it is difficult for children to “program” movements of these muscles. Children with CAS may produce very little language early in life, making this disorder challenging to diagnose. Once upon a time CAS was a hot topic in communication disorder research (it is less so today). It was felt that CAS was being overdiagnosed, and much attention was given to its diagnosis and definition. The honest truth in the field today is that experts still disagree about some of the “core” characteristics of CAS, but it is generally agreed that children with CAS make variable errors (producing a word differently each time they are asked to imitate it), make errors with vowels (uncommon in other types of speech disorders), make errors with prosody (stress, speech rate, and intonation), and have a significantly harder time with longer words / phrases / sentences. Children with CAS benefit most from therapy sessions that are frequent, intensive, and shorter in duration, and children may need many hundreds of productions of a particular word or sound combination in order to successfully learn it. Therapy focuses on helping the child to produce a variety of consonant+vowel combinations (“ba, ma, tee, boo”) and syllable shapes (consonant-vowel-consonant such as “top,” or “consonant-consonant-vowel” such as “sky”), and to combine those syllables in a meaningful way (“pa” and “dee” can make “potty”). Because CAS affects muscle control, it is referred to as a “motor speech” disorder (where “motor” refers to muscles).
• Dysarthria, like CAS, is a disorder of motor speech skills. Dysarthria can result from injury to the brain, including traumatic injury (such as automobile accidents) and anoxic injury (such as nearly drowning). These are referred to as “acquired dysarthria,” because they were not present at birth. “Developmental dysarthria” is seen in children with cerebral palsy or other disorders affecting brain development. Children with dysarthria may have difficulty controlling and coordinating the tongue and other muscles needed for speech production. There may be instability or muscle weakness, or some degree of muscle paralysis, leading to characteristics such as weak or imprecise consonants, a breathy or raspy voice, difficulty with saliva management, and a quiet speaking volume (or overly loud also, if there is difficulty with respiratory control). Difficulty with muscle control in dysarthria is not limited to speech production, and children may also have difficulty with chewing and swallowing. Treatment may involve working on particular speech sounds, respiratory control, strategies to compensate (such as slowing down or pausing to check others’ understanding of your message), or use of assistive technology to supplement or, in severe cases, to replace verbal communication.

Closing Thoughts

Here is a helpful tip: take your child’s age and divide it by four. What is the resulting percentage? As a general rule, you can expect a child to be that understandable to adults other than his or her immediate caregivers (2 years old: 50% understandable, 3 years: 75% understandable, 4 and up: 100% or close to it). If you have concerns about your child’s speech skills, it is always a good idea to seek evaluation by a state and nationally certified speech-language pathologist.

This has been a summary of the major types of articulation disorders seen in children. If you have questions, please feel free to contact us here at Bothell Pediatric and Hand Therapy, or talk to your doctor. And as always, thanks for reading!