Language has a distinct survival value, in that it affords people the ability to warn others of danger.  By voicing likes and dislikes, it also gives humans an ability to modify their environment.  The abilities to read a book, watch a documentary, and listen to age-old wisdom allows people to go beyond their own physical capabilities and experiences.  Language is furthermore useful in getting along with others, and is the single most useful tool in learning and transmitting information (Rousey, 1984).  In order to succeed in school, students must be able to understand classroom instructions, learn from a text, understand written instructions, and infer and share knowledge from one situation to another (Lees & Urwin, 1991).  However, there are many students for whom these tasks prove difficult.  In addition to specific speech and language disorders, conditions affecting motor planning and control, as well as many developmental disorders cause some impairment of speech or language (Wang & Baron, 1997).

Speech
Speech is the use of sound to transmit ideas (Wang & Baron, 1997).  It is the individual sounds, called phonemes, which make up language and communication (Rousey, 1984).  Speech disorders affect one’s ability to produce phonemes (meaningful sounds), but not to understand or express language.  There are four basic characteristics of speech.  Articulation is the physical production of sounds by the lips, tongue and teeth.  It is estimated that at the age of one, a child is 25% understandable to non-family members.  By age two this reaches 50%, and finally 100% at age 4 (Wang & Baron, 1997).  Articulation attempts may be classified as correctly articulated, omitted, distorted, or substituted.  Often there will be variation and inconsistency in articulation.  A person may sometimes, but not always, misarticulate, or may misarticulate a certain sound in one part of a word, but not in another.  It has been suggested that children do not knowingly misarticulate, and are probably unaware of the problem (Rousey, 1984).  Many people with articulation difficulties also have hearing impairments.  Others may be “tongue-tied,” in which case the movement of their tongues is restricted by a short frenulum, which is the band of tissue connecting the underside of the tongue to the floor of the mouth.  Resonance is the balance of airflow between the nose and mouth.  It can be affected by soft, hard, or cleft palates, all of which cause difficulty regulating the airflow between the nose and mouth.  In the case of velocardiofacial (VCF) syndrome, the palate appears to be in tact, but the underlying muscles do not function properly.  Resonance can also be affected by nasal obstruction, such as in the case of chronic allergic congestion, septal deviation in the nose, or enlargement of the adenoids.  Voice refers to the vibration of the vocal cords in the larynx, and may be defined as high, deep or hoarse.  Voice is associated with pitch, loudness, softness, and hoarseness.  Abnormalities in voice can be caused by injury to the laryngeal apparatus (such as in the cases of laryngitis, or vocal cord polyps, both caused by viruses), abusive vocal patterns (including excessive shouting or deliberate alterations of pitch), and neurological injuries which cause paralysis of one or both sides of the voice box.  Fluency refers to the rate and rhythm of speech.  The most common abnormality of fluency is stuttering (Wang & Baron, 1997).

Language
Language is the single most complex skill people acquire, and its development is often used as a gauge for general development (Wang & Baron, 1997). Expressive language requires coordination of the abilities to represent words symbolically, use words, understand the relationships of words to each other, string words together meaningfully and grammatically and use socially appropriate and contextually relevant language (Leonard, 1998).  Early language delays can be predictive both of low IQ and of reading difficulties (Lees & Urwin, 1991).  The motor apparatus required for talking is more complex than for the one for walking (Wang & Baron, 1997).  Language is the code which gives meaning to sounds, gestures, or other representations (Wang & Baron, 1997).  Verbal language involves putting sounds together into meaningful units (Rousey, 1984).  The form of language includes phonology, the set of sounds, and grammar, the arrangement of words or parts of words.  The context of language is semantics, which is the meaning attached to these words.  Language also involves pragmatics, which refers to how language is adapted to specific social situation, to convey emotion, and to emphasize meanings, as well as for discourse and narration (Wang & Baron, 1997).

Mechanics of Language
Verbal communication is extremely complex, and begins with multiple sounds occurring simultaneously across many frequencies, with a rapid transition from one frequency to another.  The ear must tune into these sounds, decipher them, and translate them into electrical impulses.  These electrical signals are sent by nerve cells to the primary auditory cortex in the temporal lobe, which processes these impulses and sends them to the language area of the cortex, where they are likely stored for a short time.  The primary auditory cortex is also called Wernicke’s area, and is responsible for recognizing patterns of auditory signals.  Each different signal (word) activates a distinct set of neurons, which in turn activate other neurons, which may include a picture of the item, anecdotes, or functions.  Memory is also critical to language processing, especially when the language is complex (for example, “the boy who the girl with the ponytails hugged is crying”.)  Expression requires a reversal of this process.  An inner representation of the word is sent to the speech area, also called Broca’s area, in the inferior frontal lobe.  Broca’s area then converts thoughts into the patterns of neurons required to produce speech.  Speech itself then requires coordination of the lips, tongue, palate, jaw, larynx, and diaphragm.  Dysfunction in any step of these processes can interfere with the comprehension or expression of language (Wang & Baron, 1997).

Speech and Language Development
Humans begin to learn the sounds of their native language even before birth.  Even very young infants are able to distinguish between their native language and a foreign language (Wang & Baron, 1997).  Language development follows the same general pattern in all cultures, and children across the globe acquire communication skills at about the same age.  It is believed that humans have an inborn language capacity, that language develops as a result of this capacity, rather than emerging out of need or utility (Rousey, 1984).  Communication begins with social smiling, cooing (around two or three months) and consonant babble (around six months).  In addition to vocal babble, babies who are signed to will babble with their hands.  Around 18 months vocabulary acquisition accelerates, and children use non-words in a form which mimics the intonation of real language.  Grammar begins to emerge around age three, and the child begins to speak in phrases and full sentences, using pronouns, prepositions, plurals, and verb conjugations.  By preschool children have mastered their native language, and are able to alternate turns in a conversation, tell a cohesive story and modulate tone and pitch to match their conversational partners.  They also begin to speak “motherese” to younger children (Wang & Baron, 1997).

Language acquisition requires the ability to hear spoken language, an environment in which language is spoken by competent speakers in a variety of communicative contexts, the ability to process language and make sense of it, and the ability to use the organs of speech to form the units of spoken language so that others can understand them.  Language acquisition can be affected by input, processing, or output.  Factors affecting language input include environment, social circumstances, bilingualism, sensory deprivation, hearing loss and visual problems.  Language processing can be affected by general cognitive difficulties, specific affective deficiencies (including autism), and specific language deficiencies.  Output can be affected by factors such as oromotor control and structural abnormalities (Lees & Urwin, 1991).  Language and speech acquisition are also affected by readiness, physical capacities (including auditory, intellectual, neuromuscular and brain-integrating abilities), environmental influences (including child-rearing practices, amounts of positive and negative feedback for attempts at verbal communication, and opportunities for expression), and general criteria (including the abilities to understand language, to listen creatively and generalize meanings from past knowledge, to talk creatively, and to form new combinations of words, new speech and new verbal experiences) (Rousey, 1984).

When to Refer a Child to a Speech Pathologist
In general, a child’s parent or teacher should refer him/her to a speech pathologist when:
1) the problem persists longer than 6 months.
2) the degree of frustration or anxiety the child experiences result in increased difficulty.
3) the child avoids speaking situations because of decreased confidence (Rousey, 1984).
4) the child has a vocabulary of fewer than 20 words at the age of 2.
5) there is concern about vocabulary, grammar development or comprehension.
6) changes in vocal quality or fluency become evident (Wang & Baron, 1997).

Speech and Language Therapy
Therapy is often implemented when a child exhibits a significant difference between chronological age and communicative skill level or between general development and communication skills.  Therapy is an interactive social process, and may take one of the following three forms:
Preventative – used for young children at high risk for the purpose of avoiding the development of a communication disorder
Remedial – used to increase abilities and functioning in the areas of communication which are impaired
Compensatory – alternative strategies are taught in order to bypass limitations

Classification of Communication Disabilities
There are many different ways in which communication disabilities can and have been classified, in addition to classifications within specific disorders.  However, there are three primary distinctions which can be made among communication disabilities:
Specific to language or part of a general disorder – There are numerous examples of disorders and syndromes which are associated with communication disabilities.  Children who have cognitive disabilities or global developmental delays almost always experience language delays.  One reason for this is that it is rare for language to be more advanced than general ability.  However, not all language delays and disabilities are associated with general disorders.
Comprehension, expression or both affected – An expressive language disorder indicates that the person struggles primarily or exclusively with expressing (speaking or writing) language.  In the cases of mixed receptive and expressive language disorders, both comprehension and expression are affected, meaning that the person also has difficulties understanding language.  Disorders in which only comprehension is affected are rare.
Acquired or congenital – Congenital disabilities are present at birth, and can be caused by genetics, brain abnormalities, hearing loss, and impaired phonological processing.  Included in this category are disabilities such as Down Syndrome and William’s Syndrome.  Babies considered to be at high risk include those who are born prematurely, have hearing loss or developmental delays.  Acquired communication disabilities include traumatic brain injuries, Landau-Kleffner Syndrome, and frequent ear infections, which are associated with language delays in psychologically impoverished home environments.
When assessing communication disabilities it is also important to keep in mind that they may occur in one or more domains of communication, with or without physical disability, behavioral issues or other medical problems (Wang & Baron, 1997)

How to Help
- Early intervention is always quicker and more effective.  When in doubt, refer a child to a speech pathologist for evaluation.
- Always assume that a child is expressing him/herself to the best of his/her abilities (Rousey, 1984).
- Simplify your language.  This includes complexity, use of vocabulary, memory load required, and pragmatic knowledge.  For example, “everybody, I want you to finish what you are doing now, but before you sit down, make sure your tables are tidy, please” would be easier to understand if stated:  “everyone finish now, tidy tables and sit down for the story.”
- Break instructions apart into smaller segments.  Consider giving instructions between each step.
- Use keywords and/or gesture cues to insure student attention.
- Use a more constructivist approach, building from personal experience.  Links between concepts are made primarily with words, which creates disadvantages for language impaired children.  Use other approaches, or have children create their own links.
- Help children recognize the predictable sequences of activity.  Often students with language disabilities will have difficulties with concepts of time and space.
- Assist students in organizing information, including sequencing.  Keep in mind individual levels of physical coordination.
- When summarizing information, give specifics rather than more general information.  This applies especially to directions.
- Make the child a personal chart of things which need to be done.
- Monitor the number of information carrying words you use.
- Pay attention – if the child looks puzzled, s/he probably didn’t understand.  Try rephrasing, splitting sentences into several shorter phrases, or adding gestural cues.
- Help children to cross-reference different concepts, beginning from concepts they already know.  This will help with word retrieval problems (Lees & Urwin, 1991).

Prognosis
The prognosis for speech and language therapy ultimately depends upon the underlying cause(s) of communication impairment.  Typical prognoses for some of the more common causes of communication disabilities include:
Cerebral palsy and severe neural-motor apraxia – good language expression may be possible, especially with the use of computerized communication boards
Dysphasia due to traumatic brain injury – improvement should occur with recovery although subtle impairments are likely to persist
General cognitive impairment – language should improve greatly with therapy although it will probably not surpass general cognitive abilities
Autism – if expressive language has not developed by the age of 6 it is not likely to
Articulation disorders – should resolve with age-appropriate therapy
Specific Language Impairments – although substantial improvements are likely to occur, subtle impairments will likely be retained

Communication Disabilities and Behavior
Children who have speech or language delays are more likely to have behavioral disorders, and vice versa.  These children are likely to display attention deficit, poor peer relations, solitariness, difficulty with management or temper, disobedience, aggressiveness, anxiety and undue fears and inhibitions.  Disobedience and inappropriate behavior is often a direct result of an inability to comprehend instructions completely and correctly.  This can cause confusion and bewilderment, and often these inappropriate responses causes children who have communication disabilities to become the butts of laughter, which has negative effects on peer relations and self-esteem.  Peer relationships are further hindered by children’s difficulties with both verbal and non-verbal communication.  As a result, they often show submissiveness and a lack of leadership.  When communication does occur, these children are less able to deal with conflicts and disagreements verbally, which makes them more likely to use physical force or to withdraw socially.  However, when students have a positive attitude toward communication, they are persistent and will make significant efforts to make themselves understood.  The success of this effort relies on communication partners who are both patient and sympathetic (Leonard, 1998).

Behavior problems vary greatly among children with communication disabilities, and appear to be most prevalent among children with severe, persisting articulation disorders as they reach adolescence.  There is also a greater incidence of behavior problems among children who have larger gaps between their comprehending and expressing abilities.  Older, brighter students also experience more adjustment problems their younger, less bright counterparts (Leonard, 1998).

Augmentative and Alternative Communication (AAC)
For students with severe communication disabilities, augmentative or alternative communication (AAC) may be necessary to facilitate communication and provide the least restrictive environment, as mandated by the Individuals with Disabilities Education Act of 1990 (IDEA).  AAC may be used as a source of primary or supplementary communication, and may be aided or unaided.  Unaided AAC requires no equipment, but is done using the body.  All people use unaided AAC to some degree when they wave at someone, shake their heads, or beckon someone (Stainback & Stainback, 1997).  The most common form of AAC among people with communication disabilities is sign language.  Sign language is a distinct method for communication using hand gestures within a distinct grammar and sentence structure.  Sign language requires a communication partner who also signs.  Although there has been concern that use of sign language will delay the development of spoken language for those children who are capable of speech, this concern is unfounded.  In fact, use of sign language allows for richer social interaction and decreases frustration, with speech developing at the rate which it would have anyway (Lees & Urwin, 1991).

Aided AAC systems require use of tools or equipment.  These tools may be tangible symbols, real or partial objects or representational symbols.  Equipment could be as simple as a homemade communication board or as complicated as a computer.  One common form of aided AAC is a communication board.  These are often used with children who have no capability of speech.  They select images or representation on a board by signaling with eyes, hands, or other body part.  Communication boards require communication partners who can interpret meaning from the symbol system (Stainback & Stainback, 1997).  Communication boards also require cognitive, visual, and motor skills from the child (Lees & Urwin, 1991).  Technology such as personal communicators and personal computers is another option in enhancing communication.  In addition, AAC systems are often combined in order to maximize communication (Stainback & Stainback, 1997).
 

Stuttering
Stuttering is the most prevalent language disorder, and is characterized by hesitations, blocks, repetition of syllables, sounds, or words, prolongations, and interjections of nonspeech sounds (Rousey, 1984).  Although no underlying anatomical or physiological defect has been implicated in stuttering, it can have psychological consequences, which make early identification and treatment critical (Wang & Baron, 1997).  Stuttering affects 1% of the population across all cultures, and 85% of stutterers are identified before the age of 5.  Stuttering is four times more prevalent in boys than in girls.  Stuttering is not a result of personality disorders, psychological difference, intelligence, heredity, or specific environmental factors alone.  Current theory suggests that stuttering is caused by an inherited predisposition triggered by the environment or by the manifestation of a personality or psychological problem in the self-esteem.  Interestingly enough, stutterers generally have little difficulty when singing or speaking in unison, and stuttering decreases when talking to someone younger, and when talking aloud in the absence of a listening.  Stutterers also find it easier when the same material is read or spoken repeatedly over a concentrated period of time (Rousey, 1984).

Levels of Stuttering
One:  Stuttering is infrequent, and occurs primarily when attempting to communicate verbally in times of great excitement.  There is little awareness or concern about the difficulty.  The most frequent manifestations are repetition of entire words, single sounds or syllables.  Most preschoolers fall into this category.
Two:  There continues to be little concern or anxiety, but the person may begin to think of his/herself as a stutterer.  There is an increase in prolongations, and some hesitancy to speak.
Three:  The person exhibits increased frustration and awareness of the difficulty.  Repetitions become forced as the person tries to push the sound or words out.  Many Level Three stutterers will use tricks, such as finger snapping, to help themselves through difficult situations.
Four:  The person avoids speaking situations of anticipated difficulty, and has identified specific feared words and/or sounds (Rousey, 1984).

How to Help
Do make speaking as pleasant as possible.  Facilitate the easy use of speech, including the use of singing, reading, and talking in unison.
Do help a child handle any disruptive factors.
Do eliminate competing environmental stimuli, including the radio or television.
Do alter environmental pressures, including time.
Do analyze situations which produce more stuttering.  Examine to whom the child is talking, time of day, and reactions of others.
Do analyze situations which produce less or no stuttering.
Do be a good listener.  Focus your energy and attention on the child.
Do make speech activities and expectations age-appropriate and realistic.
Do examine the relationship between the child and others.
Don’t call attention to the difficulty, or label it a “trouble.”
Don’t tell the child to slow down, repeat, or take a deep breath.  These requests increase the pressure the child feels.
Don’t become impatient.  This increases anxiety.
Don’t ask the child to speak in high-risk situations.  These include when the child is tired, in a hurry, or angry.
Don’t demand answers to questions which are difficult or impossible to answer or rhetorical in nature.  This includes questions such as “Why did you spill the juice?”
Don’t force the child to speak in the midst of distractions (Rousey, 1984).
 

Articulation and Grammar Difficulties – The Red Flag Theory
One theory suggests that articulation and grammar difficulties should be viewed as a red flag for some other problem that a child is having.  This theory is based on the fact that grammar is learned through practice and interaction.  However, children rarely mislearn language because they have heard it used incorrectly.  This indicates that the child’s difficulty has another cause.  This is especially true when the student sometimes makes the correct sounds. In such a case, the child does not have a physical problem, so the theory posits that the misarticulation is an indication of something else going on in the child’s life.  Furthermore, theory proponents argue that certain sounds are directly linked to certain developmental needs.  Persistent patterns of sound substitution or distortion spring from an internal need to communicate developmental needs.  This is found in children since they do not have the language or cognitive abilities to communicate their needs to others, as adults would.  Instead, articulation difficulties spring from their unconscious minds, and different needs are associated with specific sound difficulties.  The most common needs which misarticulation may indicate include:
Need for successful separation from home – These children will talk quite a bit about the great things they have at home.  They are often absent for unspecific reasons, such as headaches or stomachaches.  If this need is suspected or confirmed, teachers should be sure to emphasize the benefits of school, and may consider having the student compare and contrast school and home.
Parenting/Nurturance need – These children are often described as clingy, and enjoy any kind of physical closeness.
Need for trusting – Children with this need will display an overly-developed interest in and concentration on self, as well as concern over any broken promises.
Need for age-appropriate behavior – Although these children appear to be very grown-up and responsible, they still have a need to spend time being children.
Need for cooperation, sharing, and participation – These children are often described as being stubborn, strong-willed, sneaky, resistive, and controlling, and often exhibit manipulative behavior.
Need for self-concept/identity – This category includes children who are unsure of themselves and reluctant to assert themselves.
Need for verbal assertiveness – These children find it difficult to verbalize their needs, and as a result are often seen as being tough, bossy, or ordering (Rousey, 1984).

Bibliography
Lees, J. & Urwin, S.  (1991).  Children with language disorders.  London:  Whurr Publishers.

Leonard, L. B. (1998).  Children with specific language impairment.  Cambridge, Mass.:  The MIT Press.

Rousey, C. G.  (1984).  A practical guide to helping children with speech and language problems:  For parents and teachers only.  Springfield, Illinois:  Charles C Thomas.

Stainback, S. & Stainback, W.  (1996).  Inclusion:  A guide for educators.  Baltimore:  Paul H. Brooks Publishing Co., Inc.

Wang, P. P. & Baron, M. A. (1997).  Language:  A code for communicating.  In M. L. Batshaw (Ed.), Children with disabilities (4th ed.) (pp. 275-292).  Baltimore:  Paul H. Brooks Publishing Company.
 
 

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