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TABLE 4–3. continued
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2–3 years • Joins other children during play briefly
Watches other children play
•
Requests items or activities
•
Starting to use language for jokes or fantasy
•
•
Repairs communication attempts when misunderstood
Engages in longer conversations
•
Plays house
•
Engages in simple group activities
•
•
Defends own possessions
Engages in conversation with self and toys
•
Engages in simple make-believe activities
•
Begins to control behavior verbally
•
•
Uses fingers to indicate age
3–4 years •
Cooperates during play and takes turns
Verbalizes personal experiences
•
•
Practices conversation skills by talking to self or toys (e.g., dolls)
Acts out whole scenes during play
•
•
Becomes frustrated when misunderstood
Expresses ideas and feelings
•
5 years • Mostly direct requests
Repeats statements that are misunderstood
•
•
Starting to use gender topics
Verbally invites others to play
•
•
Good control of the elements of conversation
Using “what if . . . ” or “I hope . . . ” imaginary conditions
•
6 years • Repeats statements that are misunderstood with elaboration
•
Uses adverbial conjuncts, such as now, then, so
Word play, threats, promises
•
•
Asks questions for information
Communicating with more care with unfamiliar people
•
Announces topic shifts
•
7 years • Uses/understands deictic words, such as here, you that one, next week
• Narratives include beginning, end, problem, and resolution
8 years • Adds to concrete topics
9 years • Adds to topics by taking several turns
11 years • Adds to abstract topics
12 years • Uses conjunct words (e.g., anyway, however)
Source: Information obtained from Lanza and Flahive (2008) and Owens (2020).
• Recognizes nonliteral meaning
• Begins considering intentions of others
• Addresses perceived sources of communication breakdown when repairing
• All elements of story grammar present
• Uses disjunct words (e.g., probably)
142
CHAPTER 4 Communication Across the Lifespan: Typical vs. Disordered
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143
Language and Speech Disorders in Children
Language Disorders
Paul et al. (2018) identify the three categories of risk factors for language disorders as established,
biological, or environmental. Established risk factors are those that are certain in an individual due to a
condition, such as Down syndrome or profound hearing loss. Other risk factors include biological risk
factors, such as having a family member with a language or learning problem, being born prematurely,
or having otitis media. In addition, there are factors in an individual’s environment that put them at
risk for a language disorder, such as having extremely young parents, low socioeconomic status, or later
birth order. Biological and environmental factors may put a child at risk but do not ensure a language
disorder. The following is a list of syndromes, disorders, conditions, events, or circumstances that
are associated with language disorders taken from Paul et al. (2018), Gejao et al. (2009), Galimberti
etal. (2018), and the National Institute on Deafness and Other Communication Disorders (National
Institutes of Health, 2023).
n
Individuals with a genetic or chromosomal etiology — congenital or acquired; may be a
disorder of number of chromosomes or structure.
Trisomy 21
Trisomy 9, 13 (Patau), 18 (Edwards)
Cri du chat
Turner syndrome
Klinefelter syndrome
Fragile X syndrome
n
Metabolic etiologies
Phenylketonuria (PKU)
Thyroid disorder
Mucopolysaccharidosis
n
Prenatal or perinatal environment (etiologies)
Exogenous factors — abnormal development due to something outside the organism
Teratogens — drug or agent causing abnormal development: mutagen (teratogen causing
genetic mutation) or iatrogenic (abnormal development caused by medical intervention)
●
Examples of pre/perinatal etiologies: rubella, cytomegalovirus (CMV), maternal syphilis,
HIV/AIDS, herpes simplex, varicella (chicken pox), toxoplasmosis, toxins, fetal alcohol
syndrome, hyperbilirubinemia (jaundice), drugs (prescribed and unprescribed)
●
Examples of postnatal etiologies (acquired): respiratory disorders possibly due to
low birth weight, infections/toxins (e.g., meningitis: bacterial or viral), and trauma
(e.g., stroke, traumatic brain injury, poisoning, near-drowning, or other accidents);
maltreatment (e.g., physical abuse, sexual abuse, emotional abuse, neglect)
n
Neurodevelopmental disorder or developmental language disorder (DLD) information
One of the most common developmental disorders
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Has been referred to as specific language impairment (SLI)
Not explained by other conditions (e.g., autism, lack of exposure to language)
Word learning is difficult, which results in poor vocabulary, grammatical errors, struggles
with conversation, difficulty following directions due to poor understanding of words.
Continues into adulthood and demonstrates difficulties, such as difficulties using complex
sentences, storytelling, reading, writing, grammar, and spelling.
A child likely will not grow out of the disorder. Early treatment and treatment at any age
can be beneficial.
n
Other conditions not mentioned above that may involve language disorders:
Seizure disorder
Intellectual disabilities (ID)
Autism spectrum disorder (ASD)
Attention-deficit/hyperactivity disorder (ADHD)
Anxiety and affective disorders
Conduct and oppositional disorders
Dyslexia
Symptoms of a Language Disorder
The following lists are common symptoms of a language disorders.
n
Difficulty with word meaning
One word may have multiple meanings or a word that may apply to several things is only
used for one specific thing.
Answers questions incorrectly, such as answering “where” questions with time
Difficulty giving concrete definitions
Difficulty with figurative language
n
Difficulty with word structure
Morphological markers
May try to segment words at the phoneme levels rather than the syllable levels
n
Word-finding/word-retrieval difficulties
Unable to retrieve the words when needed
Often uses circumlocution or describing the word that cannot be retrieved
n
Difficulties with phrase and sentence structure
Difficulty with comprehension of phrases and clauses
Difficulty summarizing in their own words
Unable to say things differently or does not realize things can be said differently
CHAPTER 4 Communication Across the Lifespan: Typical vs. Disordered
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Common Speech Disorders
Developmental speech sound disorders are diagnosed using normal milestones and standardized
evaluation tools. Reviewing the normal milestones for phoneme and phonological process/pattern
development will be helpful for referring clients to SLPs. Creating developmental charts, using the
information presented previously (i.e., phoneme development, speech intelligibility, phonological
processes), or purchasing charts from the American Speech-Language-Hearing Association (ASHA) or
other vendors will be helpful for quick reference.
Common Assessment Tools for Language and Speech Development
SLPs will evaluate language in a natural environment that is age appropriate for the client (e.g., during
play or story retell). They will analyze language using a language sample obtained during this interaction. Typically, standardized assessments are included as part of a comprehensive evaluation. These
assessment tools may be included in a report sent to the audiologist. Common assessment tools include
the following (Paul et al., 2018; Shipley & McAfee, 2016):
n
Language
Preschool Language Scale-5 (PLS5): ages birth through 7 years, 11 months
Clinical Evaluation of Language Fundamentals-5 (CELF5): ages 5 to 21 years
Comprehensive Assessment of Spoken Language (CASL): ages 3 to 21 years
Oral-Written Language Scale II (OWLS-II): ages 5 to 21 years
n
Speech
Goldman-Fristoe Test of Articulation 3 (GFTA-3): ages 2 years to 21 years, 11 months
Arizona Articulation Proficiency Scale-4 (Arizona™-4): ages 1 year, 6 months to 21 years,
11 months
Clinical Assessment of Articulation and Phonology-2 (CAAP-2): ages 2 years, 6 months
through 11 years, 11 months
Language and Speech Disorders Throughout the Lifespan
Language and speech disorders are not limited to child development. At any age, an individual may
acquire a language or speech disorder due to a neurologic event, disorder, or condition. The following
sections provide information related to language and speech disorders that are seen most often after
language and speech have already been developed or acquired.
Language
Hallowell (2017) described aphasia as the term used for the loss of language of varying degrees after an
individual has learned language. Acquired language disorders have a neurologic etiology. Stroke is the
most common cause for aphasia, but there are other causes, such as traumatic brain injury, infections,
or space-occupying lesions. Aphasia can affect receptive or expressive language, reading, and writing.
Table 4–4 provides information related to categories and types of aphasia.
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TABLE 4–4. Overview of Aphasias
FLUENT APHASIAS
Wernicke’s aphasia • Fluent speech
• Poor auditory comprehension
• Poor speech imitation skills
• Produces unintended sounds or words
• Produces new words that do not have
meaning
Conduction aphasia •
Rare
• Fluent speech
• Good auditory comprehension
• Poor speech imitation skills
Transcortical sensory
aphasia
Rarest form of fluent aphasia
•
• Fluent speech
• Poor auditory comprehension
• Relatively good speech imitation skills
• Severe anomia (word-finding difficulty)
NONFLUENT APHASIAS
Broca’s aphasia • Halting
Effortful speech
•
• Good auditory comprehension
• Poor repetition skills
• Anomia
Transcortical motor
aphasia
•
Halting
Effortful speech
•
• Mildly impaired auditory comprehension
• Good speech imitation skills
Global aphasia • Profound language impairment
• Halting
• Effortful speech
Poor auditory comprehension
•
• Poor repetition
Source: Data obtained from Hallowell (2017).
CHAPTER 4 Communication Across the Lifespan: Typical vs. Disordered
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KNOWLEDGE CHECKPOINT
While collecting a case history from your patient with aphasia, you notice that he
is answering questions with one-word responses most of the time. When he uses
more than one word, utterances are not full sentences. Some words are left out
of the sentences. He answers all questions correctly but has difficulty producing
words. You ask him to repeat a few words, but this is difficult for your patient.
Your patient is demonstrating Broca’s aphasia, a nonfluent aphasia. This
person may have relatively good comprehension but difficulty producing
language and imitating language. Depending on the testing materials, an audiologist should adapt the evaluation to exclude expressive language tasks. For
example, if the person is required to produce a word they hear, the audiologist
may adapt the task to pointing to picture options of the word.
Speech Disorders Throughout the Lifespan
147
Speech disorders may be acquired throughout the lifespan due to neurological events or conditions.
Freed (2020) described two neurologic motor speech disorders, apraxia of speech and dysarthria.
In addition, Watts and Awan (2019) described voice disorders that can be acquired throughout the
lifespan. Voice disorders may affect speech intelligibility and hinder communication. The following
information provides a summary of speech disorders that may be acquired throughout the lifespan.
n
Acquired apraxia of speech
Neurologic etiology
Difficulty in planning and programming the commands needed for speech
Characterized by slow speech (i.e., lengthened sounds), pauses within and between words,
and distorted sounds within and between words
Speech disorders are not caused by issues with muscles, sensory deficits, or language deficits
n
Dysarthria
Neurologic etiology
Difficulty with articulation caused by disturbances in the central and peripheral nervous system
Characterized by slow and/or slurred speech, low volume, monotone, and/or abnormal
rhythm of speech
n
Voice disorders
Functional etiology: may be caused by vocal behaviors, such as yelling, coughing, throat
clearing
Neurologic etiology: may be caused by neurogenic events or conditions, such as stroke or
Parkinson’s disease
Organic etiology: may be caused by organic disorders, such as gastroesophageal reflux
or cancer
Affect communication by affecting intelligibility for speech
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Q & A
Question: When your client walked into your office, he shuffled his feet rather
than picking up his feet for each step. While sitting for the evaluation, you
noticed his hands were trembling. In addition, he showed little to no facial
expression during conversations. It was difficult to understand him because
he spoke with very low volume and slurred speech. Which disorder or condition do these observations describe? Which speech and voice disorder does this
man display?
Answer:
This client is showing many of the signs of Parkinson’s disease (PD).
The speech and voice disorder associated with PD is hypokinetic dysarthria. A
referral for speech-language services would be appropriate for this patient.
Auditory Hierarchy
Erber (1982) identified four skills within the auditory process that are commonly utilized within the
auditory hierarchy framework. Garber and Nevins (2012) added the skill of patterning to the four
skills identified by Erber to create a more accurate depiction of the auditory hierarchy regarding the
progression of auditory skills. Each skill is listed below, including a description and behaviors that
indicate a listener is demonstrating that specific auditory skill.
1. Detection
n
Definition: capacity to recognize the presence or absence of sound
n
What behaviors would indicate the listener is demonstrating the auditory skill of detection?
Wearing amplification all waking hours
A change in behavior when something is heard (e.g., head turning, eyes widening, stops
crying)
Alerting or quieting to a loud environmental noise (e.g., a pan dropping to the ground,
dog barking)
Alerting to spoken language at a typical volume (e.g., looking up from playing when others
are talking in the room, smiling when hearing mother’s voice)
Detection of Ling 6 sounds (ah, oo, ee, sh, ss, mm) by a change in behavior or a behavioral
response (e.g., raising a hand)
2. Discrimination
n
Definition: perception of differences and similarities between two auditory stimuli (e.g.,
sounds, words, sentences). Auditory perception differences can be based on suprasegmental
(i.e., duration, intensity, pitch) or segmental information (i.e., consonant and vowel sounds).
Discrimination tasks require the listener to simply recognize that the stimuli are the same or
different.
CHAPTER 4 Communication Across the Lifespan: Typical vs. Disordered
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n
What behaviors would indicate that the listener is demonstrating the auditory skill of
discrimination?
Varying responses to two different environmental noises (e.g., doorbell ringing as
compared to a door shutting)
Varying responses to two family members’ voices (e.g., sibling’s voice as compared to
dad’s voice)
Recognizing a difference in words or phrases
3. Patterning
n
Definition: differentiation between sounds based on suprasegmental patterns without true
identification of the sounds
Patterning is a stage that can be a stepping stone to more complex auditory development
for children with newly activated cochlear implants (CIs). Many children with new CIs can
imitate a variety of suprasegmental patterns but do not necessarily have any higher-level
understanding of what they are imitating.
n
What behaviors would indicate the listener is demonstrating the auditory skill of patterning?
Imitation of suprasegmental patterns of spoken language (e.g., imitating the appropriate
duration and pitch of animal sounds) without identification
149
4. Identification
n
Definition: use of auditory stimuli to label things within the environment. Identification
involves the recognition of auditory labels (e.g., identification of “meow” for a cat) typically
through repetition of the word or picture/object pointing without further understanding of
the single label (e.g., a cat is a pet that lives in the home).
n
What behaviors would indicate the listener is demonstrating the auditory skill of
identification?
A young child responding to their own name
Pointing to a color when the color word is presented (e.g., a child points to a red toy when
the word “red” is presented by the parent)
Choosing a correct object like a toy from a field of objects (e.g., a child picking up a dog
when the word “dog” or “woof woof” is presented by a parent)
Identifying the Ling 6 sounds through a picture-pointing or repetition task
5. Comprehension
n
Definition: processing and understanding of spoken language and responding to the auditory
information accurately
n
What behaviors would indicate the listener is demonstrating the auditory skill of comprehension?
Following simple and complex directions (e.g., a child picking up shoes when a parent says
“it’s time to go”)
Repeating longer utterances or phrases (e.g., “The dog ran across the street.”)
Answering questions within a context
Learning a new concept through audition only
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Ling 6 Sounds
To develop skills for listening and talking, it is important that a child has auditory access to the full
spectrum of speech sounds (Moeller & Tomblin, 2015). The Ling 6 sounds are often utilized by
audiologists and other professionals who work with individuals with hearing loss as a straightforward
screening to evaluate auditory access to six different phonemes. This procedure was adapted from
Daniel Ling’s original work targeting low-, middle-, and high-frequency phonemes that represent
the various sounds that occur in running speech (Ling, 1989). The Ling 6 sounds include /a/–“ah,”
/u/–“oo,” /i/–“ee,” /s/–“ss,” /
Ling 6 Sound Test
The Ling 6 Sound Test is typically utilized as a quick diagnostic listening check (Smiley et al., 2004).
The Ling 6 Sound Test assesses the auditory hierarchy skills of detection, discrimination, and identification. It is not a test of comprehension.
1. The audiologist presents the sounds using spoken language in random order.
n
Ensure there is no visual access to the speaker’s mouth (e.g., with the use of a sound
transparent hoop with opaque color).
n
Present each sound with the same duration and inflection as noted in conversational speech
(e.g., do not exaggerate the loudness or length of /s/).
ʃ/–“sh,” and /m/–“mm.”
2. If detection is expected, the young child may indicate that they heard the sound by dropping a
block in a bucket or raising a hand.
3. If discrimination or identification is expected, then the child will point to a picture that
represents the presented sound or repeat back the sound heard.
AUDIOLOGY NUGGET
There are many ways that the Ling 6 Sound Test has been utilized within the
field of audiology (Glista et al., 2014).
n
Using a live-voice picture-pointing or speech imitation task in real-time
situations like a classroom setting as a quick check of current auditory
access to assess function of amplification for children and adults
n
Using a live-voice picture-pointing or speech imitation task via an
audiometer within an audiological evaluation in sound field as a way to
assess hearing aid functioning and current auditory hierarchy level with
each sound (i.e., detection, discrimination, identification of sounds)
n
Using a live-voice picture-pointing or speech imitation task as an aided
outcome measurement that can support hearing aid validation as a quick
assessment of speech sound access
n
Using live voice to complete a listening check on an amplification device
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Updates to the Ling 6 Sounds—The LMH Test
The LMH (Ling, Madell, Hewitt or Low, Medium, High) Test is a screening test that adds four additional consonants to the Ling 6 sounds to gain a better understanding of speech perception (Madell
& Hewitt, 2022). With the LMH Test, four additional consonants, /n/, /h/, /z/, and /
to the original Ling 6 consonants, /a/, /i/, /u/, /s/, /
ʃ/, and /m/, to provide more information regarding
dʒ/, were added
a person’s speech perception within the second and third formants. The LMH Test with 10 phonemes
can be utilized in the same way that the Ling 6 Sound Test can be utilized to quickly screen for issues
in speech perception.
Effects of Hearing Loss in Children
Hearing loss can have a profound effect on one’s life and specifically one’s communication. These
effects on communication are noted in both children and adults with hearing loss. The effects of
hearing loss vary vastly for each child. Regarding spoken language, a child’s speech and language
production is typically a reflection of what the child hears and perceives through auditory information
(Sininger et al., 2010). There are some factors that influence the effects of hearing loss. The following
variables were identified by Tye-Murray (2022) that influence speech and language development for a
child with hearing loss:
n
Severity of hearing loss
n
Contribution and involvement of family
n
Behavioral issues
n
Consistency or lack thereof regarding the wear of amplification
n
Noise levels in home, daycare, and school settings
n
Disabilities in addition to hearing loss
n
Type and value of intervention
n
Type of amplification (e.g., hearing aids or CIs)
Without amplification, the severity or degree of hearing loss can have a direct effect on a person’s
ability to perceive auditory information. As the severity of the degree of hearing loss increases, so do
the effects on auditory information. Estimated effects on auditory information based on the degree of
unaided hearing loss are described below.
n
Normal hearing: no perceived issues due to hearing loss
n
Mild: difficulty hearing soft or quiet conversations and noises. Difficulty understanding
speech in the presence of background noise or in noisy environments (e.g., restaurants).
n
Moderate: difficulty understanding speech even in quiet settings. Louder volume levels are
required for hearing the TV or listening to music on the radio. Many people with this level of
hearing loss require several repetitions of speech during conversations for comprehension.
n
Severe: difficulty with the detection of any speech produced by a communication partner.
With this degree of hearing loss, a person would have to pair visual information (e.g.,
speechreading, sign language) with auditory information for any comprehension of speech.
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