Related Disabilities

TRAUMATIC BRAIN INJURY (TBI)

Kinds of TBIs Seen in Children

Children can be feature both focal/penetrating traumatic brain injuries (e.g., gunshot wound, car accident causing objects to enter through the brain) or diffuse injuries (e.g., shaken baby syndrome, concussion, anoxia, whiplash).

Delay or Disorder?

A TBI is classified as a disorder due to a medical interruption that may impact a child's typical language development and age appropriate communication milestones.

Language Content

A child TBI may result in anomia/word-finding difficulty. Furthermore, the child may be more likely to produce tangential speech and disorganized speech that may include random information unrelated to the conversational topic.

Language Form

Children that have suffered TBIs may have difficulty organizing basic-to-complex sentences or formulating fluent speech based on grammatical rules of native language.

Language Use

Children that have suffered TBIs may have difficulty initiating and maintaining conversation, difficulty with turn-taking during conversation, and an impaired ability to use and interpret nonverbal language such as gestures, facial expressions, and body language.

Video

Meet Ryan, a 5-year-old boy who is recovering from a TBI that took place when he was 3. The video highlights Ryan's journey, and the amazing progress he has made with his speech!

Hearing Loss

Diagnostic Criteria

Hearing loss is a fairly common diagnosis, affecting about 2-3 out of every 1000 children. Each person's hearing loss is unique and can differ based on type (conduction, sensorineural, mixed), degree (severity), etiology (cause), and timing (when hearing loss occurred). Every child is required to undergo a newborn hearing screening within a few days of birth because early identification of hearing loss or impairment is extremely important. As children get older, audiological assessments will consist of behavioral audiometry, which requires interaction and responses from the child. Audiological assessment will reveal the type of hearing loss the child presents with.

Children diagnosed with a hearing loss in Connecticut are automatically referred for language services, even if spoken language is not the family's preferred modality for communication. This is essential to ensure that children are receiving adequate language input to acquire language appropriately and effectively. If a child is not able to effectively communicate, especially from a younger age, then significant delays in speech, language, and even cognitive abilities will be evident. We will discuss the specific language areas which may be impacted by hearing loss below:

Impact on Language content

Language content includes development of phonology (speech sounds) and semantics (vocabulary). Children with hearing loss may have diminished ability to process speech effectively. Some speech sounds are softer than others, which may make them less accessible to people with hearing loss. If someone cannot hear a sound, they may also have difficulty producing it and producing words containing it. Sounds at a higher frequency (softer sounds) include "s,” “sh,” “f,” “t,” and “k”. The "speech banana" depicted below shows where different sounds lie on an audiogram. This can be used with an audiogram to show what sounds they do not have access to based on their hearing loss.

While every case is unique, hearing loss can produce challenges related to word learning and the development of vocabulary if spoken language is the primary mode of communication used with the child. In combination with decreased word learning, deaf or hard of hearing (DHH) children may have difficulty understanding abstract terms, function words, and words with multiple meaning.

Impact on language form

Language form includes morphology (parts of words including endings like -s and -ed) and syntax (sentence structure). Hearing loss may impact a child's ability to hear, understand, and utilize word endings. For example, "s" is one of the speech sounds that DHH children may have a more difficulty hearing and producing (see the speech banana above) and it is used for verb tenses (i.e. third person present, "he runs"), pluralization (i.e. "the cats"), and creation of possessives (i.e. "Mommy's turn").

DHH children may also have a diminished understanding of how to interpret and create more complex sentences. If their input is limited, they may keep their sentences shorter and use simpler structure than peers their same age. This can be linked to their decreased word learning and can put them at a disadvantage as they progress through school.

Impact on How language is used

Pragmatics are the ways in which we use language. DHH children may have increased difficulty utilizing spoken language and interacting with others due in part to the reasons stated above. As they are not acquiring language the same way as their peers, they are not learning the same rules about how to use language. If their hearing loss impacts how they hear their own voice, they may develop poor speaking volume, rate, pitch, and intonation patterns. DHH children also report higher rates of loneliness and feeling unhappy around others their age because they cannot interact comfortably. Hearing loss may impact turn taking and playing with others, especially those without hearing loss who do not understand this difference. DHH children may not respond appropriately, have trouble engaging in conversation, and have difficulty following directions.

Example

Childhood Apraxia of speech (CAS)

Diagnostic Criteria

Childhood Apraxia of Speech (CAS) is a motor speech sound disorder. Children with CAS know what they want to say, but the messages that get sent from their brain to their articulators to coordinate speech movements do not go through correctly. It is not something that can be outgrown, and it is crucial for these children to receive treatment so that they are able to make progress. There is no known cause of CAS, and the signs and symptoms can vary widely across cases.

Some of the common characteristics seen in children that can be unique to children with CAS and help to diagnose the disorder include: vowel distortions, using incorrect stress in a word, difficulty imitating words, voicing errors that are inconsistent, difficulty with smooth transitions between sounds or syllables, and overall inconsistency with errors. These characteristics can help to differentially diagnose CAS from other speech and language difficulties present within the pediatric population. Having a CAS diagnosis can affect aspects of individuals' language content, form, and use.

The diagnosis of Childhood Apraxia of Speech is typically determined by a licensed speech-language pathologist, as they have extensive education and training in evaluating and treating speech and language disorders. To diagnose CAS, a case history and administration of formal and informal assessments will be conducted. Some of these assessments may include a standardized articulation assessment (i.e., GFTA/KLPA), phonological inventory, a language sample, and an oral mechanism exam.

Impact on Language Content (Semantics):

Childhood Apraxia of Speech (CAS) can affect language content, which includes semantics (meaning of words and word combinations). Children with CAS can have many phonological errors, which will impact the meaning of words and word combinations. The phonological errors can distort the meaning of the word if the communication partner cannot understand what the child is saying or if the distortion changes the meaning of the word. This can further effect word combinations because of difficulty with precise articulation. In addition, since children with CAS have errors on single words, they will likely also have them on combinations of words in which meaning will be effected.

Impact on Language Form (Phonology, Morphology, Syntax):

Childhood Apraxia of Speech (CAS) can affect language form, which includes both phonology (study of speech sounds), morphology (small units of meaning) and syntax (rules of combining words to form sentences). In regard to phonology, CAS can affect a child's speech sounds in a few different ways. Because the messages from the brain don't get through to the articulators accurately, it can effect their phonological skills and the sounds they produce in speech. Children with CAS often have errors in their speech sounds, including inconsistent errors, distortions of both vowels and consonants, and incorrect voicing. For example, they may pronounce the word "pig" as "big" and use the voiced consonant "b" instead of the voiceless "p".

One of the hallmark characteristics of children with CAS is that they produce inconsistent errors. This means that they will often make different errors each time they produce the target word. For example, if the target word they are being given is "pen" and the child says "fen", "pel", and "pog", the errors that they are making are inconsistent across various positions and sounds.

In addition to children with CAS having incorrect voicing, they also can produce distortions of consonants and vowels. Distortions of vowels in particular can largely impact a child's intelligibility and their productions of consonants as well. Since the messages from the brain do not go through correctly to the articulators, distortions of consonants and vowels occur because of their difficulty to position and sequence their articulators, like their tongue and lips.

CAS can also impact morphology and syntax, in part due to difficulties with phonology. If they are making phonological errors and have a hard time with precise articulation, the meaning of words (morphology) can be impacted if the sound error changes the meaning of the word. For example, if the target word is "bow" and the child says "low," the communication partner will likely misinterpret the meaning of the message the child is aiming to convey. Further, if the child has imprecise speech, the individual may have a more a challenging time combining words into sentences (syntax). Difficulty with syntax can negatively impact a child's overall functional communication.

Impact on Language Use (Pragmatics):

Having a diagnosis of Childhood Apraxia of Speech (CAS) has the potential to negatively affect individuals' social use of language, or pragmatics. This can be seen in situations related to social functioning including peer friendships. Children tend to be very social, and often collaborate with others when they are learning new skills, playing, or learning in the classroom. Interactions with others are integral for children to develop and learn language skills. For children with CAS, it can be difficult to participate socially with peers because they may be rejected by kids their age because of their communication differences. Friendships with others tend to rely on communication of thoughts and feelings as well as reciprocation, which children can learn through play. However, this can be difficult for children with CAS because they are often more isolated than their peers, which can impact their ability to participate in these opportunities for communication growth. It is important for the SLP to treat the whole child, and also keep in mind social opportunities while also supporting their speech and language skills.

What might CAS look like?

This video explains CAS and showcases examples of children who exhibit different CAS severity levels.

Intellectual Disability (ID)

Diagnostic Criteria:

Intellectual disability (ID) is a neurodevelopmental disorder that must meet three criteria to be diagnosed.

Must display significant limitations in aspects of intellectual functioning such as problem solving, reasoning, and learning
Must display significant limitations in adaptive behaviors including social, conceptual and practical skills used for functioning in one's daily life
and, the onset of these limitations must occur before the age of 22, during the developmental period.

This diagnosis cannot be made solely by an SLP, but information pertaining to assessments an SLP gives could benefit other professionals who can diagnose Intellectual Disability.

Individuals with Intellectual Disabilities frequently display with language delays, and only some are diagnosed with a language disorders. Thorough and comprehensive assessments and evaluations are the most effective way of determining this difference and in developing a treatment plan.

It is also very common to see Intellectual Disabilities co-occur with other diagnoses including Autism Spectrum Disorder (ASD), Down Syndrome, Cerebral Palsy, Fragile X Syndrome, and Fetal Alcohol Syndrome.

Impact on content (semantics)

Intellectual Disabilities may play a role in an individuals language content, which involves the meaning of words and vocabulary. Individuals with ID usually have strengths with concrete vocabulary (words that relate to the characteristics of objects) and things that we can see or figure out through our senses.

Despite this understanding of concrete information, more abstract information and its meaning is usually something that tends to be more impacted. Similarly, figurative language (often used to talk about something without making direct comparisons) and understanding what is being referred to is also impacted.
Understanding and following multi-step instructions as well as understanding question words (e.g., who, what, where, when, why, whom, whose, whether, etc.) tends to be impacted as well.

Impact on language form (phonology, morphology, and syntax):

Intellectual disabilities may have an impact on language form. This includes phonology (speech sounds), morphology (word structure), and syntax (sentence structure). Difficulties with language form can vary between individuals and may depend on the underlying cause of the intellectual disability.

Individuals with ID may have reduced speech intelligibility due to co-occurring factors such as hearing loss or facial abnormalities. This is often seen in children with Down syndrome. Also, children with ID may present with typical and atypical phonological processes.
Delays in morphological development are also common in children with ID. Specific presentation of morphological difficulties will vary.
Difficulties with syntax are commonly seen in children with ID. As with morphological difficulties, the specific presentation of syntactical difficulties can vary. For example, children with Down syndrome often have difficulty with the production of syntax, however, comprehension is a relative strength.

Impact on language use (pragmatics):

Individuals with an intellectual disability often have difficulties with the social use of language, also known as pragmatics. Difficulties surrounding social skills may include:

Challenges with social judgment and decision making
Difficulty understanding social cues and rules
Emotional and behavioral regulation difficulties, which may have an adverse impact on social interactions

Video: The video below shows Stasyia, who has Down syndrome. She is practicing her prepositions with a speech therapist!

Autism Spectrum Disorder

What is Autism Spectrum Disorder (ASD)?

A neurological and developmental disorder that impacts social communication, behaviors, and learning of children.
Children with ASD all experience different signs and symptoms. One child's experiences will not match another, even though they may both have the diagnosis of ASD. ASD can be comorbid with a language disorder or some children may have a language delay in addition to the ASD diagnosis. This would be determined by the language signs and symptoms present in the child. Additionally, some children with ASD do not have a comorbid language disorder or delay.
Signs & symptoms: Challenges in areas such as...
- - Social communication
    - - Ex. eye contact, gestures, conveying emotions
  - Social interaction skills
    - - Ex. conversational turn-taking, building and maintaining friendships
  - Repetitive behaviors
    - - Ex. specific routines and interests
The severity of the symptoms due to these challenges with social communication and restricted/repetitive behaviors are assessed over time to create a diagnosis of ASD
- - This diagnosis is related back to the severity of symptoms due to the challenges on a child's ability to develop or engage in everyday life

Impacts on Language Content

Language content includes semantics. Semantics is the meaning of words and phrases.
- 1. Individuals may have trouble using the context of a word to understand its meaning. This can be especially difficult with words that have multiple meanings (i.e. won versus one).
  2. Children with ASD may have trouble understanding that different words can have the same meaning. For example, the phrase "final stop" has the same meaning as "destination" even though the produced word/phrase are completely different.

Impacts on Language Form

Language form includes phonology, morphology, and syntax. Phonology is all about sounds and how they are combined. Morphology is the units of meaning that make up words. Lastly, syntax is the combination of words to create sentences.
- 1. Some children with ASD struggle to use pronouns in the correct contexts. For example, a child may say "her is running", rather than "she is running".
  2. It is common for children with ASD to experience difficulty with grammatical errors and grammatical judgement. For example, a child may say, "I walk to the park and play with friends" instead of "I walked to the park and played with friends". This is an example of a tense-agreement error.

Impacts on Language Use

Language use includes pragmatics. Pragmatics is how content and form are used in a social context.
- 1. Communicating wants and needs - Individuals with ASD may have difficulties expressing their needs or wants
  2. Building relationships - Individuals with ASD may have trouble relating to their peers and engaging in mutual play. This can be isolating as they enter school-age and are surrounded by peers in the classroom.
  3. Understanding Sarcasm - due to difficulties with understanding social cues, individuals with ASD may not be able to differentiate when a peer is being serious or not.

Video of a Child with ASD: The video is of Alistair, a five almost six year old who has ASD and presents with a language delay.

Attention Deficit Hyperactivity Disorder (ADHD)

What is ADHD?

Attention Deficit Hyperactivity Disorder (ADHD)— also referred to by its more outdated term of Attention Deficit Disorder (ADD)— is a common disorder associated with a lack of attention and/or hyperactivity that interferes with daily functioning or overall development.

Most ADHD symptoms appear as early as 3 to 6 years of age, and can continue through adolescence and adulthood. Signs of ADHD may include getting distracted easily, moving and squirming excessively, and difficulty keeping thoughts organized.

ADD/ADHD and Language Development

In terms of language development, ADHD is often associated with language delays involving receptive and expressive language. Receptive language refers to listening and understanding what's being said whereas expressive language refers to speaking and being understood. Because a child with ADHD naturally has a hard time focusing and paying attention, they may miss important developmental information, resulting in a language delay.

Impact on Content (semantics):

Semantics refers to understanding the meaning of words.

Since children with ADD/ADHD have difficulty with auditory processing and memory, they often struggle to comprehend and understand spoken language. Learning word meaning is much harder in distracting environments because it requires greater selective attention.
Kids with ADD and ADHD often have difficulty with reading comprehension as well. This is complicated by a slower processing speed. As always, a noisy environment will make it harder to read as well! All of this makes it harder to derive meaning from what is being read.

Impact on Form (phonology, morphology, and syntax):

Phonology refers to understanding the sounds of speech. Syntax refers to how words and morphemes (smallest unit of meaning) come together to make sentences.

Since kids with ADHD have difficulty paying attention due to hyperactivity, skills necessary for literacy like phoneme awareness and phonological processing may develop later.
Children with ADHD tend to use less subordinate clauses and complex sentences. This may be linked to ADHD symptoms or to could relate to a comorbid disorder that affects syntax.

Impact on Use (pragmatics):

Pragmatics refers to how language is used to convey things in social interactions.

Children with ADHD may talk excessively and therefore run into trouble with taking turns during a conversation. Difficulties with working memory make it harder for them to self-monitor and pick up on the social cues that form the give and take of conversations.
Similarly, children with ADHD may jump quickly from topic to topic pretty quickly in conversations. Because of disruptions to working memory, planning, and inhibition, they may struggle with topic maintenance.

Video of a child with ADHD:

This video showcases the difference between a child with ADHD and a child without ADHD. Both children are 6 years old and are interviewed with the same questions. Notice how one child seems to be more fidgety, tends to go a bit off topic, and struggles more with school.

Down Syndrome

What is Down Syndrome?

The diagnostic criteria for a child with Down syndrome is based on the appearance of the child or genetic testing that shows a mutation of the 21st chromosome. Children with Down syndrome commonly present with low muscle tone, short stature, a nasal bridge that is flat in appearance, and a protruding tongue. Language delays are commonly linked to Down syndrome.

Impacts of Down Syndrome on Language

Content

Early language content for children with Down Syndrome is very similar to typically developing children but it occurs at a reduced rate. While language acquisition varies, as it does for all children, most children with Down Syndrome are late in saying their first words, and their vocabulary grows more slowly than in typical children. Although they may use the same range of two-word phrases as all children, they may exhibit difficulty in producing grammatically correct sentences. The reduced rate of language acquisition can result in telegraphic language accompanied by signs and gestures. These features may make children with Down Syndrome difficult to understand for unfamiliar communication partners.

Form

Language form is impacted by Down Syndrome at the level of phonology, morphology, and syntax. Children with Down Syndrome often continue to use phonological processes longer than is expected of their age which impacts overall speech intelligibility. Syntax and grammar are also impacted as children often produce shorter and less complex sentence structures and use less grammatical morphemes compared to children their age.

Use

Language use is often affected in children who have Down Syndrome by the lack of initiation in topics with same-aged peers. It can be more difficult for a child with Down Syndrome to recognize and repair breakdowns in communication. For example, if a peer is not understanding what they are saying they may just continue talking because they are not aware they are not being understood.

Video of a child with Down Syndrome

This video is an example of a 5 year old girl doing at home practice with the support of an Augmentative Alternative Communication Device (AAC) device. It shows emergence of both expression of two-word utterances and new vocabulary.

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