Types of alalia, its causes, pathogenesis, differential diagnosis and treatment options. A drug with the trade name Neuromidin from Olainfarm. Efficiency analysis.
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BehindBolotnaya A.M., Makarina-Kibak L.E., Greben S.A.
Zabolotnaya A.M., Makarina-Kibak L.E., Greben S.A.,
Center of Otorhinolaryngology, Minsk, Belarus
Disorders of expressive and receptive speech: from etiology to treatment
Summary. The types of alalia, its causes, pathogenesis, differential diagnosis and treatment options are considered. It has been established that adding a drug with the trade name “Neuromidin” from the company “Olainfarm” (international name - ipidacrine) to the complex of rehabilitation measures accelerates and improves psycho-speech development in children. The effectiveness analysis was carried out on the basis of completing the minutes of the meetings of the multidisciplinary team.
Alalia is the most severe speech disorder and is divided into two large groups: motor and sensory. In preschool age, it occurs in approximately 1% of children, among schoolchildren - in 0.2–0.6%, while in boys it is 2–3 times more common than in girls.
Motor alalia, or expressive speech disorder according to ICD-10, F.80.1, is an underdevelopment expressed by difficulties in mastering the active vocabulary and grammatical structure of the language with a fairly intact understanding of speech. It is based on a disorder or underdevelopment of analytical-synthetic activity, expressed, in particular, by the replacement of subtle and complex articulatory differentiations with coarser and simpler ones. Motor alalia develops when the functions of the cortical end of the speech motor analyzer (Broca's center) and its pathways are impaired. Sensory alalia, or receptive speech disorder according to ICD-10, F.80.2 – underdevelopment of impressive speech, when there is a gap between the meaning and the sound envelope of words; the child’s understanding of the speech of others is impaired, despite good hearing and intact abilities to develop active speech. The cause of sensory alalia is damage to the cortical end of the auditory-speech analyzer (Wernicke's center) and its pathways.
Etiology. The immediate causes of alalia may be:
– prenatal hazards (affect during the period of intrauterine development): toxicosis, viral, endocrine and other diseases of the mother during pregnancy, injuries, immunological incompatibility of the blood of the mother and fetus, etc.;
– natal hazards (damage during childbirth): umbilical cord entanglement, traumatic brain injury, rapid birth, etc.;
– postnatal hazards (exposure to various harmful factors after birth): meningitis, encephalitis, head injuries, tumors, etc.;
– perinatal pathology (a combination of exposure to harmful factors on the fetus in the prenatal period, during childbirth, and in the first days after birth).
Pathogenesis.With alalia, brain cells are underdeveloped. They stop their development at the neuroblast stage. This underdevelopment of the brain can be congenital or acquired early in the pre-speech period (in the first three years of a child’s life, when the cells of the cerebral cortex are intensively formed and when the child’s experience with speech is still very small). Further developmentbrain systems most important for speech function occurs on a pathological basis.
Underdevelopment of the brain or its early damage leads to a decrease in the excitability of nerve cells and to changes in the mobility of basic nervous processes, which entails a decrease in the performance of cells in the cerebral cortex. Traces of underdevelopment of the brain remain for many years or for life.
Differential diagnosis. To make a diagnosis, it is necessary to carry out a differential diagnosis of alalia with other pathologies, as well as different types of alalia among themselves. Differential diagnosis of the two types of alalia is presented in Tables 1-7.
Table 1. Differential diagnosis of motor and sensory alalia
| Comparison criterion | Msweet alalia | Sensory alalia |
| Speech perception | Speech perception is intact at the perceptual level | Grossly violated |
| Speech understanding | Speech understanding is age-appropriate, possibly without relying on visual perception of articulation | Speech understanding is impaired, may improve slightly with visual perception of the speaker’s articulation |
| Auditory attention | Safe | Violated |
| Echolalia | Absent | Present |
| Repeating what you heard | Find it difficult to repeat a word or phrase | Repeat without understanding the meaning of the spoken word |
| Communication | There is a desire for language communication (non-verbal and verbal) | Reluctance (and inability) to communicate |
| Mimicogesticulatory speech | Active use of gestures, expressive facial expressions | Lack of gestures and amicable or inexpressive facial expressions |
| Availability of compensatory means | Melodics, onomatopoeia, and “sound gestures” act as compensatory means. | Lack of compensatory means |
| Dynamics of speech improvement | Dynamics is noted in mastering speech during its spontaneous and directed formation | Extremely low tempo with directed speech formation |
Table 2. Differential diagnosis of motor alalia and hearing impairment
| Comparison criterion | Motor alalia | Sensory alalia |
| Hearing | Hearing function is intact | Hearing function is impaired |
| Spontaneous speech acquisition | Some possibility of spontaneous speech acquisition (although limited and generally defective) | Speech is not developed outside of special training |
| Expressive speech | The presence of individual words roots, pseudowords, onomatopoeias | Lack of expressive speech |
| Prosodic components of speech | Prosody (speech melody, rhythm, pauses, stress) intact | Prosody is impaired |
| Mimic-gestural speech | Accompanied by words, sound complexes, non-verbal vocalizations | Mimic-gestural speech is actively used, but is not verbally accompanied |
Table 3. Differential diagnosis of motor alalia and speech delay
| Comparison criterion | Msweet alalia | BehinddeRandka speech development |
| Rate of speech acquisition | A delay in the rate of normal speech acquisition is combined with pathological manifestations - violations of the structural and functional aspects of speech | Delay in the rate of speech development, its spasmodic nature |
| Spontaneous language acquisition | A child cannot independently master lexico-grammatical generalizations | Possibility for a child to independently acquire some norms of their native language |
| Impressive speech | Difficulty understanding grammatical changes in words, mixes up quasi-homonyms (similar sounding words) | Understands spoken speech well, there is no confusion in understanding the meanings of similar sounding words |
| Expressive speech | – The utterance program is disrupted; – persistent gross violations of the structure of words, phrases (telegraphic style); – agrammatism; – with the accumulation of vocabulary, agrammatism intensifies | – There is a program of speech utterance; – there are no gross violations of the structure of the word and phrases, agrammatism |
| Features of dynamics in correctional work | – Cannot overcome the defect without corrective action; – residual effects are possible at school age | – Capable of independently mastering speech generalizations; – speech insufficiency is overcome spontaneously; – correction is aimed at the sound side of speech; – speech insufficiency is overcome by school |
| Anatomical and physiological features | CNS disorders are persistent organic in nature | Are reversible neurodynamic in nature or not observed |
| Features of mental activity | Sometimes they need to overcome verbal negativism | Motivation for activity is formed, there is no verbal negativism |
Table 4. Differential diagnosis of motor alalia and anarthria (dysarthria)
Msweet alaliaAnARTRAndI (dysarthria)
| Comparison criterion | Msweet alalia | AnARTRAndI (dysarthria) |
| Speech motor skills | The motor level of speech production is completely or relatively preserved and potentially allows for the articulatory act | Disturbances in the articulatory component of speech constitute the essence of this pathology. |
| Systematic nature of the violation | The entire language system is disrupted (pronunciation, vocabulary, grammar) | One of the subsystems is disrupted - phonetic |
| Sound disturbances scat- wear: 1. Mechanism 2. Polymorph ness | 1. Pronunciation disorders sounds are a consequence of disruption of phonemic production commercial operations – selection and commercial phoneme binning. 2. Many sounds affected violations (distortions, replacement us, omissions, repetitions, re- restorations), have simultaneous but also the correct pronunciation. 3. Various types predominate disruption of sound pronunciation (use indications, substitutions, omissions). 4. Small substitutions dominate number of sounds. 5. It can be both correct and distorted production wearing sound. 6. Replacement of articulatory complexes and articulatory simple sounds. 7. Pronunciation of sound in composition syllables are relatively intact, in composition of the word - violated | 1. Pronunciation disorders caused primarily by violations phonetic (motor) skills operations. 2. Only single sounds have it is correct at the same time pronunciation. 3. With erased dysarthria, have the same type of disorders (either distortions or omissions, or replacement). 4. Pain distortions dominate a large number of sounds. 5. For all distorted sounds characterized by constant distortion tion. 6. Replacements are predominantly art- ticulatory complex sounds. 7. Pronunciation of sounds is impaired both in words and in syllables |
Table 5. Differential diagnosis of motor alalia and childhood motor aphasia
| Comparison criterion | Msweet alalia | Childhood motor aphasia |
| Anamnesis | The action of pathological factors is observed in the prenatal and early postnatal period (up to 3 years) | Exposure to pathological factors occurs after 3 years of age |
| Mechanism of violation | Underdevelopment of speech as a system | Selectivity in damage to any of the speech subsystems (lexical, grammatical, phonemic) |
| The need for corrective action | Targeted speech correction is necessary | Spontaneous speech recovery is possible |
| Central nervous system disorders | Symptoms of brain damage are not pronounced | Symptoms of local brain damage |
Table 6. Differential diagnosis of motor alalia and speech disorders caused byAndnTelleliteral insufficiency
| Comparison criterion | Msweet alalia | Intellectual disability |
| Essence of the violation | A form of pathology of speech activity, the result of failure to assimilate the structural and functional patterns of language in ontogenesis while preserving non-linguistic mental processes | Speech development disorders are the result of pathology of cognitive activity |
| Pre-speech development | Age appropriate | Delay in timing of humming and babbling |
| Dynamics of speech development | They do not acquire speech spontaneously, there are no jumps in the rate of speech development | – By the age of 6–7 years, based on imitation, they master a simple grammatical stereotype; – as the stereotype is mastered, speech tempo accelerates |
| Impressive speech, establishing cause-and-effect relationships | Understanding of addressed speech is relatively intact, understands complex syntactic constructions, makes an attempt to express cause-and-effect relationships in speech using linguistic means available to him (intonation, pseudowords, onomatopoeia, “sound gestures”, kinetic speech) | Express only the most basic cause-and-effect relationships; understanding speech is difficult |
| Formal language speech disorders (grammatical structure of speech) | Agrammatism (at the level of syntax of connected text and individual statements, at the morphological level), difficulties in finding words, choosing morphemes and establishing the order of words | Speech is logically poor or illogical - may be correct in formal linguistic (grammatical) terms |
| Stock of knowledge and ideas | Difficult to actualize in speech | Limited |
Table 7. Differential diagnosis of motor alalia and autism (Kanner syndrome)
| Comparison criterion | Msweet alalia | Autism |
| A-priory | Speech pathology | A special mental anomaly, the formation of emotional contact with the outside world is impaired |
| Early speech development | Speech does not develop fully | Early speech development is the norm; the pace can outpace peers. When speech is lost, he talks to himself and in his sleep |
| Reaction to addressed speech | Preserved constant reaction to the speech of others | Does not respond to addressed speech, but the process of understanding speech is not impaired |
| Psychopathological symptoms | None | Psychopathological symptoms, phobias and unpredictable reactions are noted |
| Features of mental development | There may be mental retardation, developmental deficiency | Mental retardation and uneven distortion of mental processes may be observed |
| Expressive speech | They actively use the rudiments of speech (verbal and non-verbal), the state of speech does not depend on the environment | Simultaneous use of babbling and complexly organized utterances that are correct in the linguistic structure, do not use the words YES and I, persistent agrammatism in an unfamiliar environment |
| Mimic-gestural speech | Actively used in communication | Does not use gestures and facial expressions (decay) |
| Echolalia | Not noted | There are immediate and delayed echolalia |
| Prosody | Not broken | Peculiar violations of the prosodic side of speech - slowing down the tempo, chanted and rhymed pronunciation, high pitch of the voice |
| Communication | Desire for contacts (except for cases of verbal negativism) | Refusal to communicate |
| Emotional-volitional sphere | Adequacy of emotions | Inadequate emotional reactions |
| Motor skills | Relatively safe (exceptions) | Stereotypy in movements and actions, peculiarity of gait, walking up stairs, difficulties in spatial orientation, shaking the body, self-stimulation |
Treatment. Of decisive importance in the treatment and education of children with alalia is the plasticity of the child’s brain - the ability of healthy brain cells to replace those that, for one reason or another, are not included get to work. The nerve cells of the cerebral cortex, which are responsible for higher mental functions, do not have innate specialization. There is only an innate preparedness of nerve cells for any type of activity. But, if necessary, you can force “healthy” structures intended for one thing to do something else. This is possible provided that the nerve pathways connecting individual parts of the brain are preserved. During the period of speech development, their condition is more important than the condition of the speech zones themselves. The plasticity of the child’s brain fundamentally distinguishes it from the adult, whose intact areas are difficult to include in the compensatory process. It is the plasticity of nervous tissues in childhood that allows us to help children with alalia. Even in the most severe cases of alalia, the situation is not hopeless if treatment is started on time. It is important to begin multiple complex treatment as early as possible. Banal knowledge of normal speech development (timely appearance of humming, babbling, words, phrases) should facilitate the early referral of a child with speech development different from the norm to specialists: a neurologist, psychiatrist, speech therapist.
Treatment of alalia is always comprehensive, carried out by a group of specialists, including speech therapy, medication, massage, physiotherapy, psychological and psychotherapeutic correction. Drug treatment should be intensive and amount to 3-4 courses per year. Doctors have long known about the effectiveness of nootropics in the treatment of this pathology, but, unfortunately, not everyone is informed about the therapeutic effect of Neuromidin (ipidacrine). As an anticholinesterase drug, ipidacrine was synthesized quite a long time ago, but was used mainly for the syndrome of muscle hypotension. Subsequently, it was noticed and proven that drugs in this group, including Neuromidin, improve cognitive functions, including speech.
The above-mentioned drug has two mechanisms of action: on the one hand, it inhibits cholinesterase, on the other, it blocks potassium permeability of the membrane. The combination of two effects leads to improved neuromuscular transmission. As a result, the conduction of excitation in the peripheral nervous system is restored, the central nervous system is stimulated, speech, memory, and learning ability improve. It should be noted and emphasized another interesting and important property of Neuromidin - its mild sedative effect. This is important due to the fact that in half of the cases the disorder of expressive and receptive speech is accompanied by hyperactivity syndrome. Thus, the appointment of Neuromidin helps to avoid overexcitation of the child. In the Republican Scientific and Practical Center of Otorhinolaryngology, Neuromidin has been used in the treatment of patients with alalia since 2008. During this time, 292 children with alalia aged 5 to 10 years were treated as inpatients. For a comparative analysis, we took patients with alalia treated in 2007 and 2011. Using a random sampling method, 60 stories with the above diagnosis were analyzed for each year, respectively. The rehabilitation course lasted 25 days and included the prescription of drugs that improve metabolic processes in the nervous system (Actovegin, Pantogam, Encephabol, etc.), speech therapy classes, massage, physiotherapeutic treatment, DENS therapy, psychotherapy, music therapy.
All patients treated in 2011, whose neurological status was hypotonia of muscles, including articulatory ones (an indirect sign is hypersalivation), and also there was no convulsive readiness of the brain on EEG, were prescribed the tablet drug "Neuromidin" in a dosage of 1–1.5 mg/kg per day in 2 doses (morning and evening).
To assess the effectiveness of treatment, we used the minutes of meetings of the multidisciplinary team developed by the Ministry of Health of the Republic of Belarus (“System for providing specialized care to children with mental and behavioral disorders by a multidisciplinary team of specialists,” instructions for use dated July 26, 2008. No. 053-06 06), which provided a qualitative assessment of gross and fine motor skills, asthenic symptoms, emotional disorders, monosymptomatic neuroses, cognitive processes (memory, attention, thinking, speech), mental performance, behavior, and level of intellectual development.
Multidisciplinary team meetings were held three times: at the beginning, middle and end of treatment. The team included a psychiatrist, an otorhinolaryngologist, a speech therapist, a psychologist, and a psychotherapist.
During the treatment of patients (2011), by the end of therapy using Neuromidin, there was an improvement in gross and fine motor skills in 87% of patients, cognitive processes, including speech - in 92%, mental performance - in 95%, emotional regulation - in 76 %, reduction in behavioral disorders – in 70% of patients. This drug was well tolerated, and no side effects of the prescribed therapy were noted. A comparative analysis of the treatment of alalia in 2007 (without the inclusion of Neuromidin) showed the distribution of figures as follows: improvement in gross and fine motor skills - in 62% of patients, cognitive processes, including speech - in 71%, mental performance - in 75%, emotional regulation – in 64%, reduction in behavioral disorders – in 65% of patients (see figure). The greater effectiveness of treatment of children with alalia when included in the Neuromidin regimen is associated with its mechanism of action - improving impulse conduction in the nervous system by increasing the activity of the neurotransmitter acetylcholine, which, on the one hand, directly stimulates speech, learning, memory, attention, motor activity of articulatory muscles, on the other hand, it has a slight sedative effect, which, in turn, increases the perseverance and performance of young patients, necessary for their studies with a speech therapist (indirect effect).
Conclusions:
1. Neuromidin is the drug of choice and can be used in the complex treatment of children with alalia.
2. Taking Neuromidin should be long-term and last at least 4 weeks.
3. Prescribing the drug is especially important in the presence of muscle hypotonia and lack of epiactivity (there may be a concomitant hyperactivity syndrome).
4. The use of Neuromidin is accompanied by good tolerability, side effects areno therapy was started.
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Children with expressive language disorder like Jackie are not mentally retarded, nor do they have one of the common developmental disorders that affect speech and language (see Chapters 9 and 10). One of the defining characteristics of expressive language disorders is actually a discrepancy between what children understand (receptive language) and what they can say (expressive language). For example, when Jackie's parents asked her to go upstairs, find her socks, and put them on, she could do it. When her mother asked her to describe her actions, the girl simply replied: “I found socks.” Table 11.1 contains the main DSM-IV-TR diagnostic criteria for expressive language disorder.
The language abilities of children with expressive language disorders vary significantly depending on the severity of the disorder and the age of the child. Most often, these children begin to speak quite late and progress slowly in language development. Their vocabulary is often limited, and their speech consists of short sentences with a simple grammatical structure. To qualify for diagnosis, the problems must be so severe that they interfere with the child's progress in preschool, school, and daily interactions.
Two closely related types of communication disorders require clarification. Mixed receptive-expressive language disorder
may occur when communication problems increase due to difficulty understanding certain aspects of speech. Although children with this disorder have normal hearing, they cannot understand the meaning of certain sounds, words, and sentences. In severe cases, the child's ability to understand basic words or simple sentences may be impaired, and he or she may have trouble pronouncing sounds and letters and remembering and producing sounds in the correct sequence (APA, 2000). Naturally, these problems cause the child to appear inattentive or uncontrollable, and the disorder may be misdiagnosed.
Imagine how you would feel if you came to Greece to visit an English-speaking hostess and her Greek husband. In the absence of the hostess, an attempt to strike up a friendly conversation with the owner may be unsuccessful, moreover, it may upset you. Even if you both understand a few of the other person's words, most likely you won't have a real conversation. If you've ever experienced a communication barrier like this, you can probably appreciate a lot of the frustration and discomfort that comes with having an expressive language disorder.
When a language development problem is a problem of articulation or sound production rather than word recognition, a diagnosis of phonological disorder may be made. Children with this disorder have difficulty controlling their speech rate or recognizing when they are behind their peers in learning the articulation of certain sounds. Typically, sounds that are difficult to articulate are those that are acquired later in the process of intellectual development, such as l, r, s, z, ch and shch (APA, 2000). Depending on the severity of the disorder, the speech of these children may seem unusual, sometimes even unintelligible. For example, six-year-old James still says "woo-ka" instead of "hand" and "you-ba" instead of "fish." Of course, preschoolers often mispronounce words or confuse the sounds they hear, which is a normal part of the language learning process. But when these same problems go beyond the threshold of normal development or interfere with educational and social activity, they deserve special attention.
Prevalence and course
Typically, problems in speech expression and articulation are discovered during the period when children learn new sounds or begin to express their thoughts. The severity of the disease can vary greatly.
For example, mild forms of phonological disorder are relatively common in early childhood, affecting about 10% of preschoolers. Many of them recover from these types of problems, and by the age of six or seven, only 2-3% of children have problems that meet the criterion for a phonological disorder. Similarly, expressive language disorder (affecting 2–3%) and mixed expressive-receptive disorder (affecting <3%) are both relatively common in primary school-aged children (APA, 2000). Fortunately, by mid- to late adolescence, most children with language development disorder acquire normal speech (APA 2000). About half are completely free of their problems, while the other half show significant improvement but may still have some degree of impairment into late adolescence. In contrast to the congenital type of disorder, the course and prognosis of the disease for children with the acquired type of communication disorder (occurring as a result of brain injury or paralysis) depends largely on the severity of the damage, on what part of the brain is damaged, and on the age of the child at moment of injury and on the degree of speech development at this time (APA, 2000).
Although the language problems themselves usually disappear or improve over time, children with communication disorders often exhibit significant patterns of negative behavior beginning in early childhood (Beitchman & Young, 1997; Toppelberg & Shapiro, 2000). Behavioral disorders such as hyperkinetic disorder and attention deficit disorder can worsen existing communication problems in the way children interact with peers or cope with academic tasks. As teachers increasingly recognize the importance of giving children with special needs opportunities to interact with typically developing children, school systems have begun placing children with a variety of problems in regular rather than segregated classrooms. Placing developmentally delayed children with their normal peers is based on the premise that children with special needs will benefit from exposure to typically developing peers and will be spared the effects of labeling and institutionalization. As shown in Box 11.2, the effect of peer interaction in the social domain reminds us of the benefits of environmental factors that influence the developmental course of children with special needs.
Mild communication disorders are more common in boys (8%) than girls (6%) (Tomlin, Forrest, Pu, & Kim, 1997). However, because boys have more behavior problems in addition to language difficulties, they are more noticeable; They are more likely than girls to be diagnosed with communication disorders and school skills disorders (F. B. Wood & Felton, 1994).
Table 11.1 Main diagnostic criteria for expressive language disorder according to DSM-IV-TR
A. Data from standardized, individually measured parameters of language development are significantly lower than standardized indicators of the level of development of nonverbal intelligence and development of receptive language.
B. Expressive language difficulties interfere with learning, communication, and professional activities.
Box 11.2 Which is preferable: a special PLAN environment or being with normal children?
Teachers and researchers have become interested in the potential of children with expressive language disorder and similar communication disorders, which are often revealed in play with peers. Are children with communication disorders expected to make significant developmental gains when they are around similar children, or do they benefit more from being around typically developing peers? Researchers have asked this question by observing interactions between peers from these two groups (Guralnick, Connor, Hammond, Gootman and Kinnish, 1996).
The researchers found many similarities between members of these two groups, namely: the ability to interact for a long time during the game, successful communication among themselves, conflict resolution and responsiveness to various social problems. Significant differences also emerged. Despite their environment, children with communication disorders who engaged in short, active conversations showed low levels of positive behavior and rarely answered questions correctly when asked.
As expected, typically developing children, regardless of environment, were better than children with communication disorders at engaging their peers in games. At the same time, children with disabilities were comparatively better able to interact with a normally developed group of peers than with their “colleagues” in misfortune. This finding confirms the need for joint education and upbringing of children with problems and normally developed peers as long as these problems are relevant.
Genetics
Speech production processes appear to be largely genetically determined (S. L. Miller & Tallal, 1995). Approximately three out of four children with specific language disorders had a family history of learning disabilities (Spitz, Tallal, Flax, & Benasich, 1997; Tallal, Ross, & Curtiss, 1989a). This idea is confirmed by research by other scientists (Bishop et al., 1999).
In addition, scientists tend to see the cause of the disorders in question in special brain damage that leads to communication disorders and can be inherited. A comparative analysis of the health status of families of sick children showed that dysfunction of the temporal lobe of the brain is more common in children whose families had a history of learning disabilities due to language disorders (Keen & Lovegrove, 2000; Merzenich et al., 1996).
Brain. Speech processes occur mainly in the left temporal lobe (Fig. 11.1). Continuous feedback from the nerve center helps enhance the development of speech perception and expression. The better children understand speech, the more clearly they will express their thoughts. On the other hand, their utterance of sounds, in turn, helps them later express their thoughts in words. Lack of comprehension and lack of feedback reduce word production and hinder the development of articulatory skills (Spreen, Risser, & Edgell, 1995).
Anatomical studies, along with studies of the nervous system's perceptual abilities, indicate that phonological disorders are associated with problems in brain function in the posterior left hemisphere (Lyon, 1996b). Studies of brain blood flow have shown that poor pronunciation results from underactivity of the left temporal lobe (F. B. Wood, Felton, Flowers, & Naylor, 1999). Thus, phonological disorders may be caused by neurological deficits or abnormalities in the posterior left hemisphere that control the ability to process phonemes (S. Shaywitz & Shayitz).
Infectious diseases of the middle ear. Another biological cause of weakened speech may be repeated otitis media or inflammation of the middle ear in the 1st year of life, since hearing loss is a consequence of frequent or prolonged bouts of infection. Acute inflammation of the middle ear can cause early speech problems that resolve relatively quickly. If the disease course is different, the causes may be more neurological in nature and the disease may last much longer (Lonigan & Fischel, 1992). Children with chronic otitis media experience some difficulty communicating with peers when trying to speak like them (Shriberg, Friel-Patti, Flipsen & Brown, 2000).
Although the neurophysiological view of the causes of speech disorders, which suggests that speech disorders are caused by disturbances in brain function, prevails, it is still not clear how such anomalies arise. The most likely assumption is that language disorders are the result of an interaction of genetic influences, delayed or pathological brain maturation, and perhaps minimal brain dysfunction that is not clinically detectable (S. Shaywitz & Shaywitz, 1999)
Fortunately for left-handed people, “abnormal hand use” and brain “difference” are not related to speech disorder or learning disability, despite numerous attempts to find such a connection.
Home environment. To what extent does the child's home environment contribute to speech disorders? Perhaps some parents are unable to stimulate their children's speech development? Since the role of parents in the development of children is extremely important, psychologists carefully study these controversial issues.
When we first came home to Jackie, we noticed that her stepfather, a very calm person, often communicated with her through gestures, facial expressions or short phrases. Her mother used more primitive vocabulary when talking to her daughter than when communicating with her six-year-old sister Jackie. These observations are similar to those of Whitehurst and colleagues (1988), who conducted a comparative study of verbal communication in families with and without children with language disorders. Scientists have found that parents change the way they speak to their children depending on their abilities. If a child speaks in simple sentences consisting of two or three words, then the parents try to speak the same way. We emphasize that, except in cases where the child is completely abandoned or is treated poorly, it is unlikely that speech disorders are the fault of the parents. Parental speech and language stimulation may influence the rate and range of language development, but not the specific damage characteristic of the disorder (Ta11 et al., 1996).
Fortunately, speech disorders and associated communication difficulties usually resolve spontaneously by age six and do not require intervention. However, even in this case, parents should understand the reason for the child's speech delay and make sure that they are doing everything possible to stimulate language development. For example, special education preschools have seen encouraging results using a combination of computers and teacher assistants to teach young children, a technique that promotes the acquisition of new language skills (Hitchcock & Noonan, 2000).
Home exercises that children did with their parents have also been shown to be very helpful in the complex process of learning language skills (Whitehurst, Fischel, Arnold & Lonigan). For example, for Jackie, we developed a technique that her parents and teachers could use based on her abilities. Jackie loved to draw and talk about her drawings, so why not use her interest in drawing to develop speech? Seeing me in the classroom, the girl ran towards me shouting: “I drew mom, dad, cat and lake.” We decided that her behavior could be regulated by trying not to notice the difficulties or diverting attention from them, often taking short breaks. Jackie spent a lot of time at the computer, and soon she could distinguish letters and short words, as well as move shapes on the screen. Her speech steadily improved, and by the age of five she could pronounce all the letters of the alphabet and was eager to go to kindergarten.
A specific developmental disorder in which a child's ability to use expressive spoken language is markedly below the level appropriate for his mental age, although speech comprehension is within normal limits. There may or may not be articulation disorders.
Diagnostic instructions:
Although there is considerable interindividual variation in normal language development, the absence of single words or word-related language units by 2 years, or simple expressions or two-word phrases by 3 years, should be considered significant signs of delay. Late impairments include: limited vocabulary development; overuse of a small set of common words; difficulties in choosing suitable words and substitute words; abbreviated pronunciation; immature sentence structure; syntactic errors, especially omissions of word endings or prefixes; incorrect use or absence of grammatical features such as prepositions, pronouns, and conjugations or inflections of verbs and nouns. There may be an overly generalized use of rules, as well as a lack of fluency in sentences and difficulty in establishing sequence when retelling past events.
Often, a lack of spoken language is accompanied by a delay or disturbance in verbal and audio pronunciation.
The diagnosis should be made only when the severity of the delay in expressive language development exceeds the normal range for the child's mental age; Receptive language skills are within normal limits for the child's mental age (although they may often be slightly below average). The use of nonverbal cues (such as smiles and gestures) and "inner" speech reflected in imagination or role-play is relatively intact; the ability to communicate socially without words is relatively intact. The child will strive to communicate, despite the speech impairment, and to compensate for the lack of speech with gestures, facial expressions or non-speech vocalizations. However, co-occurring disturbances in peer relationships, emotional disturbances, behavioral disturbances and/or hyperactivity and inattention are common. In a minority of cases, there may be associated partial (often selective) hearing loss, but this should not be so severe as to lead to speech delay. Inadequate conversational engagement or more general environmental deprivation may play an important or contributing role in the genesis of impaired expressive language development. In this case, the environmental causative factor should be noted through the appropriate second code from Class XXI of ICD-10. Impaired spoken language becomes evident from infancy without any long, distinct phase of normal speech use. However, it is not uncommon to see the use of a few isolated words appear normal at first, followed by speech regression or lack of progress.
It should be noted:
Often similar expressive speech disorders are observed in adults; they are always accompanied by a mental disorder and are organically caused. In this regard, in such patients, the subheading “Other non-psychotic disorders due to brain damage and dysfunction or somatic illness” (F06.82x) should be used as the first code. The sixth character is placed depending on the etiology of the disease. The structure of speech disorders is indicated by the second code R47.0.
Included:
Motor alalia;
Delayed speech development according to the type of general speech underdevelopment (GSD) level I - III;
Developmental dysphasia of expressive type;
Developmental aphasia of expressive type.
Excluded:
Developmental dysphasia, receptive type (F80.2);
Developmental aphasia, receptive type (F80.2);
Pervasive developmental disorders (F84.-);
General disorders of psychological (mental) development (F84.-);
Acquired aphasia with epilepsy (Landau-Klefner syndrome) (F80.3x);
Selective mutism (F94.0);
Mental retardation (F70 - F79);
Organically caused speech disorders of the expressive type in adults (F06.82x with the second code R47.0);
Dysphasia and aphasia NOS (R47.0).
Severe language impairment that cannot be explained by mental retardation, inadequate learning, and is not associated with a pervasive developmental disorder, hearing impairment, or neurological disorder. This is a specific developmental disorder in which the child's ability to use expressive spoken language is markedly below the level appropriate for his mental age. Speech understanding is within normal limits.
Prevalence
The incidence of expressive language disorders ranges from 3 to 10% in school-age children. It is 2-3 times more common in boys than in girls. More common among children with a family history of articulation disorders or other developmental disorders.
What causes Expressive Language Disorder:
The cause of expressive language disorder is unknown. Minimal brain dysfunction or delayed formation of functional neuronal systems have been suggested as possible causes. A family history indicates that this disorder is genetically determined. The neuropsychological mechanism of the disorder may be associated with a kinetic component, with an interest in the process of the premotor parts of the brain or posterior frontal structures; with unformed nominative function of speech or unformed spatial representation of speech (temporo-parietal sections and the area of the parieto-temporo-occipital chiasm) subject to normal left hemisphere localization of speech centers and dysfunction in the left hemisphere.
Symptoms of Expressive Language Disorder:
Severe forms of the disorder usually appear before age 3. The absence of individual word formations by age 2 and simple sentences and phrases by age 3 is a sign of delay. Later disorders - limited vocabulary development, use of a small set of template words, difficulties in choosing synonyms, abbreviated pronunciation, immature sentence structure, syntactic errors, omission of verbal endings, prefixes, incorrect use of prepositions, pronouns, conjugations, inflections of verbs, nouns. Lack of fluency in presentation, lack of consistency in presentation and retelling. Understanding speech is not difficult. Characterized by adequate use of non-verbal cues, gestures, and the desire to communicate. Articulation is usually immature. There may be compensatory emotional reactions in relationships with peers, behavioral disorders, and inattention. Developmental coordination disorder and functional enuresis are often associated disorders.
Diagnosis of Expressive Language Disorder:
Indicators of expressive speech are significantly lower than indicators obtained for nonverbal intellectual abilities (nonverbal part of the Wechsler test).
The disorder significantly interferes with success in school and everyday life that requires verbal expression.
Not associated with pervasive developmental disorders, hearing impairment, or neurological disorder.
Differential diagnosis
Should be carried out with mental retardation, For which is characterized by a complete impairment of intelligence in the verbal and non-verbal spheres; With general developmental disorders, which are characterized by a lack of internal language of symbolic or imaginary play, inadequate use of gestures, and an inability to maintain warm social relationships.
At acquired aphasia or dysphasia characterized by normal speech development before injury or other neurological disorders.
Treatment for Expressive Language Disorder:
Speech and family therapy is preferred. Speech therapy includes mastering phonemes, vocabulary, and sentence construction. If there are signs of secondary or concomitant behavioral or emotional disturbances, medication and psychotherapy are indicated.