Speech and language pathology in school settings

Speech-language pathology, also known as communication sciences and disorders in the United States, is a fast-growing profession that, according to the Bureau of Labor Statistics, offers about 120,000 jobs in the United States alone. The American Speech-Language-Hearing Association (ASHA) has 166,000 members, who are audiologists, speech-language pathologists, speech, language, and hearing scientists, and speech language pathology assistants. To begin practice in most areas of the United States, a prospective therapist must have an undergraduate degree (preferably in some area of communications) and a graduate degree (with two externships; usually about 2 to 2 1/2 years) in speech pathology. A 9-month, supervised clinical fellowship year is then completed, after which the Certificate of Clinical Competence (CCC) in speech pathology from the American Speech-Language-Hearing Association (ASHA) is granted. In order to be certified clinically competent the Praxis exam must be passed. In some areas the master's degree is not required. In some areas additional requirements must be met: an additional certification from ASHA in school speech pathology and audiology, certification in special education instruction, and/or and must have passed any other federal or state examinations for licensure and certification. To retain the ASHA license a minimum amount of continuing education must be completed. A doctorate is not currently required (as of June 2011), but that may change, as it has for many other areas of therapy. Speech-language pathology overlaps with many educational disciplines, such as communication sciences, linguistics, special education, and health care. This article will explore some of the fundamental elements of speech-language pathology, looking at the career in an educational setting.

Speech and language pathology

Speech-Language Pathologists (SLP) are professionals who assess and diagnose individuals with speech, language, cognitive, and swallowing disorders. SLPs are informally referred to as speech therapists. SLPs may also conduct research in the field, run a private practice, or work with large companies to improve employee-customer communication (American Speech-Language-Hearing Association). This article will focus on the aspects of speech-language pathology as practiced with young children in a school setting.

For most people, the terms speech, language, and communication have nearly the same definition. However, in the realm of speech-language pathology, there are important distinctions to be made.

Speech is the spoken production of language and the process through which sounds are produced. Several parts of the body work together to produce sound waves, and this motor production of speech is called articulation. The parts of the vocal tract involved with speech include the lips, tongue, teeth, throat, vocal folds, and lungs. Speech disorders affect the physical mechanisms of communication and cause problems with articulation or phonology. Examples of speech disorders include stuttering, lisping, and voice disorders.

Language is a system used to represent thoughts and ideas. Language is made up of several rules that explain what words mean, how to make new words, and how to put words together to form sentences. A community must share the same language in order to attach meaning to utterances. The method of delivery of language may be visual (e.g., American Sign Language), auditory (e.g., English), and/or written. Humans are the only creatures innately capable of using language to discuss an endless number of topics. Language disorders can be developmental or acquired (e.g., specific language impairment and aphasia, respectively).

Communication is the exchange of information and ideas through the use of speech and language. The transfer of information is often spoken, but may also be implied through body language or contextual cues such as intonation or hesitation. Usually, communication is a four-step process:

Encoding: the speaker creates the message in his mind
Transmittal: the speaker sends the message
Reception: the listener receives the message
Decoding: the listener breaks down the message in his mind

If a problem occurs at any step of the process, the message might not be communicated. Without the ability to communicate through speech and language, we would not be able to tell a doctor that we have a stomach ache, choose food from a menu, or say "I love you" to our children. Communication is a most basic component of human nature and it develops before we are even conscious of it.

PHAGIA & SWALLOWING The process of grasping, biting, sucking, mucose making, swallowing and routine eating ability. Dysphagia can effect in many aspect of life. Dysphagia accurs in developments disorder and acquired brain and buccofacial anomalies or disease.

Speech and Language Pathology Jobs

Speech-Language Pathologists (SLPs) have several options when seeking employment. One of the most popular is to secure a school-based position through an agency that specializes in this area. One of the largest and most respected agencies is Therapy Source, a nationwide organization founded in 2001, and based out of Plymouth Meeting, PA.

Development of speech and language

Every child develops at a different rate, but most go through the same stages. Listed below are the average ages of some important language and comprehension milestones as developed by the American Speech-Language-Hearing Association. Please note that like with any developmental timeline, these stages may be quite varied and perhaps met in a different order. A child who accomplishes these milestones differently may not necessarily have a developmental delay or speech disorder (and a child who hits these stages early is not necessarily a prodigy!).

birth to 3 months
- startles to loud sounds
- smiles when spoken to
- responds to pleasure with 'cooing' noises
4 months to 6 months
- notices and pays attention to sounds and music
- shifts eyes in direction of sounds
- makes babbling noises that resemble speech
7 months to 1 year
- recognizes basic familiar words such as cup or ball
- imitates different speech sounds
- produces first words such as bye-bye or mama
1 year to 2 years
- listens to simple stories
- identifies pictures by name when directed (point to the cow, e.g.)
- speaks two-word sentences such as more juice or where daddy?
2 years to 3 years
- understands differences in meaning for basic words (up-down or in-out)
- produces three-word sentences
- can name most objects
3 years to 4 years
- understands questions
- talks about events
- speech is understood by most people
4 years to 5 years
- pays attention and responds to stories and questions
- speaks clearly
- tells detailed, ordered stories

Problems can arise at any stage of development, as well as much later in life. They can be the result of a congenital defect, a developmental disorder, or an injury. If a problem is suspected, an assessment should be made by an SLP who can diagnose and treat communication disorders.

Diagnosis of communication disorders

In a school setting, children are often screened when they start kindergarten. This process involves a rapid assessment to determine which children need further testing, diagnosis, or treatment. Often, a screening is a sort of informal interview between an SLP and a child or group of children. The child may be asked to give their name, count, pronounce the names of pictured objects, and answer open-ended questions. The purpose of these tasks is to elicit a brief language sample from the child which the SLP will use to evaluate articulation, fluency, and other aspects of speech. Screenings usually last about five minutes (Oyer 10).

After a screening is done, an individual diagnosis must be made. This involves a one-on-one evaluation which may last two hours or more. If an individual has been referred for testing, either by a doctor, teacher, or other professional, the screening process is skipped and testing starts here. This session allows the SLP to gather information that will help in the diagnosis of a speech or language problem, as well as provide insight to possible causes, goals and objectives for therapy, and which techniques will work best for that individual. Individual evaluations often include the following components:

A visual examination of the oral cavity and throat (typically with a flashlight and tongue depressor) to determine whether the physical structures appear to be capable of speech production
Tests of articulation of speech sounds in words and sentences as well as alone
A measure of the ability to hear the difference between correct speech sounds and sounds actually produced
Tests of expressive language and spontaneous speech
Evaluations of fluency and voice
A hearing test
A case history

After this evaluation, the SLP will review the results and information gathered and determine whether the individual would benefit from speech therapy. Goals and objectives of therapy are outlined and a specific treatment plan is created, drawing on the strengths and weaknesses and unique situation of that individual (Oyer 11).

Common communication and language disorders

Disorders that affect children may affect adults differently, or even not at all. As the body grows and develops, the types of disorders that affect an individual change. Children typically exhibit developmental language disorders, but may also experience problems due to illness or injury.

In developing children, language disorders are often related to congenital disabilities or neurological or physiological results of childhood illness. These seemingly unrelated problems can seriously affect speech and language development. Children that have cognitive impairments are often delayed in development of communication skills. Different genetic syndromes that often cause cognitive impairment, such as Down syndrome or Williams syndrome, often affect different areas of speech. Children with autism tend to have difficulty communicating and expressing their emotions or desires. Sometimes this is due to specific problems with articulation or semantics, but often it is an issue of neurological development directly related to autism. Brain injuries, tumors, or seizures in children can also cause loss of language skills. Children with attention deficit hyperactivity disorder (ADHD) commonly have learning difficulties which also affect their language development. Emotional disturbances early in childhood can also affect the growth of basic communicative skills. Perhaps more obvious are the developmental and communicative consequences of childhood hearing loss (Boone 200-05).

Some disorders commonly diagnosed in children:

Specific language impairment/ Developmental Language Disorder (#DevLangDis)

Some children have language development deficits that cannot be linked to neurological, intellectual, social, or motor causes. The child's language skills grow much more slowly than those of typically developing children. While other children are speaking in complete sentences, using conjugated verb forms, the SLI child's speech sounds telegraphic- lacking grammatical and functional morphemes (e.g., He go store. rather than He goes to the store.) Their vocabulary remains relatively small while other children are adding new words every day. The SLI child often produces short sentences in order to avoid embarrassment and may have problems understanding complex or figurative structures (such as metaphors or multi-clausal sentences). Problems due to SLI can also lead to learning disabilities as the child fails to understand information being presented in science, language arts, or math classes. Studies suggest that the cause of SLI is a biological difference in brain anatomy and development (Boone 204). Treatment objectives generally focus on vocabulary development, verb morphology, memory and recall, and narrative skills (Goffman 154).

Articulation disorders

An articulation disorder may be diagnosed when a child has difficulty producing phonemes, or speech sounds, correctly. When classifying a sound, speech pathologists refer to the manner of articulation, the place of articulation, and voicing. A speech sound disorder may include one or more errors of place, manner, or voicing of the phoneme.

Different types of articulation disorders include:

omissions: certain sounds are deleted, often at the ends of words; entire syllables or classes of sounds may be deleted; e.g., fi' for fish
substitutions: one sound is substituted for another, often with similar places or manners or articulation; e.g., fith for fish
distortions: sounds are changed slightly by what may seem like the addition of noise, or a change in voicing; e.g., filsh for fish
additions: an extra sound is added to one already produced correctly; often occurs at the ends of words; may include changes in voicing; e.g., fisha for fish (Boone 256-58)

The phonemes that present the greatest challenge for children include /l/ as in pull, /r/ as in mirror, /ʃ/ ("sh") as in shut, /tʃ/ ("ch") as in church, /dʒ/ ("j") as in fudge, /z/ as in zoo, /ʒ/ ("zh") as in measure, /θ/ ("th") as in math and /ð/ ("th") as in this (Boone 112).

Articulation disorders may be attributed to a variety of causes. A child with hearing loss may not be able to hear certain phonemes pronounced at certain frequencies, or hear the error in their own production of sounds. Oral-motor problems may also be at fault, such as developmental verbal dyspraxia (a problem with coordination of speech muscles) or dysarthria (abnormal facial muscle tone, often due to neurological problems such as cerebral palsy). Abnormalities in the structure of the mouth and other speech muscles can cause problems with articulation; cleft palate, tongue thrust, and dental-orthodontia abnormalities are some common examples. Finally, it is difficult for children to hear and produce all of the different phonemes of a given language. Development is slow, and may take up to seven years. Sometimes, as children grow, articulation problems fade and disappear without treatment. Often, however, therapy is necessary. Treatment therapies may target semantic differences related to phonemic differences (e.g., teaching a child the difference between toe and toad, underlining the importance of the final consonant), physical-motor differences (e.g., using a mirror to show a child the correct tongue placement for a particular sound), or behavior-modification techniques (e.g., repetitive production through prompts and fun learning games). Support and reinforcement of therapy practices, both in the classroom and at home, are crucial to the success of articulation disorder treatment (Boone 122-24, 259–62, 274–76).

It is necessary to note the difference between articulation disorders and dialectical variations. There are several dialects of English spoken in the United States, influenced by socioeconomic status, geographic isolation, and other languages either brought to the U.S. by settlers or indigenous languages of the Native Americans. These social dialects are rule-governed and are not to be considered lesser than, but simply different from standard English. Examples of dialectical features that may be mistaken for articulation disorders include the 'r-lessness' of New York City speech in words like floor, here, and paper as well as the reduction of consonant clusters in African-American Vernacular English (AAVE). If a word ends with two or more consonants such as in cold, and is followed by another word that begins with a consonant such as cuts, cold is shortened to col, producing col cuts. These features alone should not be treated as articulation disorders to be 'cured' by speech therapy. However, it is possible for a child with a dialectal variation to also have a communication disorder. It is important for a speech pathologist to be able to tell the difference (Oyer 170).

Voice disorders

Children may experience problems with their voice due to misuse or abnormalities in the vocal mechanisms. There are two types of voice disorders: those of phonation, and those of resonance. Both types can be the result of either abuse or physical structure. Voice disorders are among the most successfully treated speech and language problems because they can be solved with surgery or reconditioning of the voice (Boone 286).

A phonation disorder is a problem with pitch, loudness, or intensity that originates in the vocal folds of the larynx. Phonation disorders may be functional, caused by continuous yelling or throat clearing, excessive smoking, or speaking at an abnormally low frequency or pitch. The results may be an increased size or thickening of the vocal folds, lesions or polyps on the vocal folds, or problems with elasticity of the larynx. In these cases, the treatment involves resting the voice and learning to speak at optimal pitches and volumes, as well as eliminating external causes such as smoking. Phonation disorders may also be organic, due to viral growths, cancer, paralysis of laryngeal nerves, surgical intubation, or external traumas such as being hit in the throat with a baseball. These problems may require surgical removal of growths or reconstruction of the larynx, accompanied by voice therapy (Boone 287-96).

A resonance disorder occurs when any part of the vocal tract is altered or dysfunctional.

In the case of an oral resonance disorder, the tongue sits too high in the front or back of the mouth. When the tongue is too far forward in the mouth, a type of 'baby voice' occurs, and a lisp may also result. Treatment involves practicing back vowels such as /a/ in father, /o/ in boat, and /u/ in spoon, accompanied by back consonants like /k/ in broke and /g/ in bog. When the tongue sits toward the back of the mouth, the voice sounds dull, and problems with articulation at the front of the mouth may also occur. Treatment focuses on front consonants such as /w/ in where or work, /p/ in pink, /b/ in ball, /f/ in laugh, /v/ in leave, /l/ in mail, and /th/ in with or bath coupled with high-front vowels like /i/ in wheat, /I/ in fit, /e/ in pay, /E/ in bet, and /ae/ in slat. This type of resonance disorder is commonly seen in children with severe hearing impairment.

Nasal resonance disorders occur when the space between the oral and nasal cavities remains open or closed, producing a hypernasal or denasal resonance. Causes of hypernasality include paralysis of the velum, a short velum, or a cleft palate which allows air to escape to the nasal cavity. The speech of actor James Stewart is a recognizable example of hypernasality (although in this case, there was no structural problem; rather, he employed the highly nasal voice as part of his character). Denasality is often caused by a structural blockage which doesn't allow air to pass between the oral and nasal cavities. A child experiencing denasality may sound like they have a bad cold. If a structural problem is to blame, surgery is the most common treatment. After surgery, or if there is no structural cause, voice therapy is often given, involving massive amounts of practice (Boone 305-12).

Fluency disorders

As a child's language and vocabulary grows, they may struggle to locate a particular word or sound. Normal dysfluency occurs in developing children as a repetition of whole words or phrases while the child searches for a particular thought or word. Around age three-and-a-half, children may compulsively repeat words or phrases. This tends to fade by the time the child is five. Stuttering, in contrast, results in repeated or prolonged speech sounds or syllables. Often, involuntary blocks in fluency will be accompanied by muscle tension due to frustration. The mouth may tighten up or the eyes may blink rapidly. A child may become so embarrassed by stuttering that they talk as little as possible to avoid the struggle. This may have serious academic and social implications. The cause of stuttering is unknown, yet widely debated. Most theories suggest emotional, psychological, or neurological origins. Psychological treatment aims at improving the self-image of the child and the child's attitude toward the problem, while other therapies attempt to increase fluency by modifying the rhythm and rate of speech (Boone 316-29, 335–38).

How many people are affected by communication disorders?

According to the National Institutes of Health, it is estimated that, in the United States,

between 8 and 10 percent of people have a communication disorder
7.5 million people have voice disorders
cleft palate affects 1 in 700 live births
5 percent of children have noticeable communication disorders
stuttering affects more than 3 million people, mostly children age 2 through 6

According to the United States Department of Education, speech, language, and hearing impairments account for 20.1 percent of all Special Education students in the United States.

Benefits of speech therapy

Communication skills play an important part in life's experiences. In elementary school, children are developing language and learning to read and write. In order for a child to learn, he has to communicate and interact with his peers and adults. Spoken language is the basis for written language. As a child grows and develops, the two types of language interact and build upon each other to improve literacy and language. This process continues throughout a person's life. If a child has a communication disorder, they are often delayed in other areas, such as reading and math. The child may be very bright but unable to express themselves correctly, and the learning process can be affected negatively.

Speech therapy can help children learn to communicate effectively with others and learn to solve problems and make decisions independently. Communication with peers and educators is an essential part of a fulfilling educational experience. Also, children who are able to overcome communication disorders feel a great sense of pride and confidence. Children who stutter may be withdrawn socially, but with the help of therapy and improved confidence, they can enjoy a fully active social life (ASHA).

References

"Speech, Language, Swallowing and Hearing Information and Resources". American Speech-Language-Hearing Association.
Boone, Daniel R.; Plante, Elena (1993). Human communication and its disorders. Englewood Cliffs, N.J: Prentice Hall. ISBN 0-13-444076-5. OCLC 25632170.
Goffman, Lis; Jeanette Leonard (May 2000). "Growth of Language Skills in Preschool Children With Specific Language Impairment - Implications for Assessment and Intervention". American Journal of Speech-Language Pathology. 9 (2): 151–161.
Oyer, Herbert J., Barbara J. Hall, and William H. Haas. "Speech, Language, and Hearing Disorders". Boston: Allyn and Bacon, 1994.
United States. Department of Labor: Bureau of Labor Statistics. 'Speech-Language Pathologists.' "Occupational Outlook Handbook". 2006–2007 ed. 20 April 2006 <http://www.bls.gov/oco/ocos099.htm>.
Department of Education. "Twenty-fourth Annual Report to Congress on the Implementation of the Individuals with Disabilities Education Act". 2001. Washington D.C.. Table 11-5, p. 11–22.
National Institutes of Health: National Institute on Deafness and Other Communication Disorders. "Statistics on Voice, Speech, and Language". 18 June 2004. 23 March 2006 <http://www.nidcd.nih.gov/health/statistics/vsl.asp>.

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Speech and language pathology in school settings