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Speech and Language Impairments

The Individuals with Disabilities Education Act, or IDEA, defines the term “speech or language impairment” as follows:

“(11)  Speech or language impairment  means a communication disorder, such as stuttering, impaired articulation, a language impairment, or a voice impairment, that adversely affects a child’s educational performance.” [34 CFR §300.8(c)(11]

(Parent Information and Resources Center, 2015)

Table of Contents

What is a Speech and Language Impairment?

Characteristics of speech or language impairments, interventions and strategies, related service provider-slp.

• A Day in the Life of an SLP

Assistive Technology

Speech and language impairment  are basic categories that might be drawn in issues of communication involve hearing, speech, language, and fluency.

A speech impairment is characterized by difficulty in articulation of words. Examples include stuttering or problems producing particular sounds. Articulation refers to the sounds, syllables, and phonology produced by the individual. Voice, however, may refer to the characteristics of the sounds produced—specifically, the pitch, quality, and intensity of the sound. Often, fluency will also be considered a category under speech, encompassing the characteristics of rhythm, rate, and emphasis of the sound produced.

A language impairment is a specific impairment in understanding and sharing thoughts and ideas, i.e. a disorder that involves the processing of linguistic information. Problems that may be experienced can involve the form of language, including grammar, morphology, syntax; and the functional aspects of language, including semantics and pragmatics.

(Wikipedia, n.d./ Speech and Language Impairment)

*It’s important to realize that a language delay isn’t the same thing as a speech or language impairment. Language delay is a very common developmental problem—in fact, the most common, affecting 5-10% of children in preschool.  With language delay, children’s language is developing in the expected sequence, only at a slower rate. In contrast, speech and language disorder refers to abnormal language development.  Distinguishing between the two is most reliably done by a certified speech-language pathologist.  (CPIR, 2015)

The characteristics of speech or language impairments will vary depending upon the type of impairment involved. There may also be a combination of several problems.

When a child has an  articulation disorder , he or she has difficulty making certain sounds. These sounds may be left off, added, changed, or distorted, which makes it hard for people to understand the child.

Leaving out or changing certain sounds is common when young children are learning to talk, of course. A good example of this is saying “wabbit” for “rabbit.” The incorrect articulation isn’t necessarily a cause for concern unless it continues past the age where children are expected to produce such sounds correctly

Fluency  refers to the flow of speech. A fluency disorder means that something is disrupting the rhythmic and forward flow of speech—usually, a stutter. As a result, the child’s speech contains an “abnormal number of repetitions, hesitations, prolongations, or disturbances. Tension may also be seen in the face, neck, shoulders, or fists.”

Voice  is the sound that’s produced when air from the lungs pushes through the voice box in the throat (also called the larnyx), making the vocal folds within vibrate. From there, the sound generated travels up through the spaces of the throat, nose, and mouth, and emerges as our “voice.”

A voice disorder involves problems with the pitch, loudness, resonance, or quality of the voice. The voice may be hoarse, raspy, or harsh. For some, it may sound quite nasal; others might seem as if they are “stuffed up.” People with voice problems often notice changes in pitch, loss of voice, loss of endurance, and sometimes a sharp or dull pain associated with voice use.

Language  has to do with meanings, rather than sounds.  A language disorder refers to an impaired ability to understand and/or use words in context. A child may have an expressive language disorder (difficulty in expressing ideas or needs), a receptive language disorder (difficulty in understanding what others are saying), or a mixed language disorder (which involves both).

Some characteristics of language disorders include:

• improper use of words and their meanings,
• inability to express ideas,
• inappropriate grammatical patterns,
• reduced vocabulary, and
• inability to follow directions.

Children may hear or see a word but not be able to understand its meaning. They may have trouble getting others to understand what they are trying to communicate. These symptoms can easily be mistaken for other disabilities such as autism or learning disabilities, so it’s very important to ensure that the child receives a thorough evaluation by a certified speech-language pathologist.

(CPIR, 2015)

• Use the (Cash, Wilson, and DeLaCruz, n.d) reading and/or the [ESU 8 Wednesday Webinar] to develop this section of the summary. 

Cash, A, Wilson, R. and De LaCruz, E.(n,d.) Practical Recommendations for Teachers: Language Disorders. https://www.education.udel.edu/wp-content/uploads/2013/01/LanguageDisorders.pdf 

[ESU 8 Wednesday Webinar] Speech Language Strategies for Classroom Teachers.- video below

Video: Speech Language Strategies for Classroom Teachers (15:51 minutes)’

[ESU 8 Wednesday Webinars]. (2015, Nov. 19) . Speech Language Strategies for Classroom Teachers. [Video FIle]. From https://youtu.be/Un2eeM7DVK8

Most, if not all, students with a speech or language impairment will need  speech-language pathology services . This related service is defined by IDEA as follows:

(15)  Speech-language pathology services  include—

(i) Identification of children with speech or language impairments;

(ii) Diagnosis and appraisal of specific speech or language impairments;

(iii) Referral for medical or other professional attention necessary for the habilitation of speech or language impairments;

(iv) Provision of speech and language services for the habilitation or prevention of communicative impairments; and

(v) Counseling and guidance of parents, children, and teachers regarding speech and language impairments. [34 CFR §300.34(c)(15)]

Thus, in addition to diagnosing the nature of a child’s speech-language difficulties, speech-language pathologists also provide:

• individual therapy for the child;
• consult with the child’s teacher about the most effective ways to facilitate the child’s communication in the class setting; and
• work closely with the family to develop goals and techniques for effective therapy in class and at home.

Speech and/or language therapy may continue throughout a student’s school years either in the form of direct therapy or on a consultant basis.

A Day in the Life of an SLP

Christina is a speech-language pathologist.  She works with children and adults who have impairments in their speech, voice, or language skills. These impairments can take many forms, as her schedule today shows.

First comes Robbie.  He’s a cutie pie in the first grade and has recently been diagnosed with childhood apraxia of speech—or CAS. CAS is a speech disorder marked by choppy speech. Robbie also talks in a monotone, making odd pauses as he tries to form words. Sometimes she can see him struggle. It’s not that the muscles of his tongue, lips, and jaw are weak. The difficulty lies in the brain and how it communicates to the muscles involved in producing speech. The muscles need to move in precise ways for speech to be intelligible. And that’s what she and Robbie are working on.

Next, Christina goes down the hall and meets with Pearl  in her third grade classroom. While the other students are reading in small groups, she works with Pearl one on one, using the same storybook. Pearl has a speech disorder, too, but hers is called dysarthria. It causes Pearl’s speech to be slurred, very soft, breathy, and slow. Here, the cause is weak muscles of the tongue, lips, palate, and jaw. So that’s what Christina and Pearl work on—strengthening the muscles used to form sounds, words, and sentences, and improving Pearl’s articulation.

One more student to see—4th grader Mario , who has a stutter. She’s helping Mario learn to slow down his speech and control his breathing as he talks. Christina already sees improvement in his fluency.

Tomorrow she’ll go to a different school, and meet with different students. But for today, her day is…Robbie, Pearl, and Mario.

Assistive technology (AT) can also be very helpful to students, especially those whose physical conditions make communication difficult. Each student’s IEP team will need to consider if the student would benefit from AT such as an electronic communication system or other device. AT is often the key that helps students engage in the give and take of shared thought, complete school work, and demonstrate their learning. (CPIR, 2015)

Project IDEAL , suggests two major categories of AT computer software packages to develop the child’s speech and language skills and augmentative or alternative communication (AAC).

Augmentative and alternative communication  ( AAC ) encompasses the communication methods used to supplement or replace speech or writing for those with impairments in the production or comprehension of spoken or written language. Augmentative and alternative communication may used by individuals to compensate for severe speech-language impairments in the expression or comprehension of spoken or written language. AAC can be a permanent addition to a person’s communication or a temporary aid.

(Wikipedia, (n.d. /Augmentative and alternative communication)

Center for Parent Information and Resources (CPIR)  (2015), Speech and Language Impairments, Newark, NJ, Author, Retrieved 4.1.19 from https://www.parentcenterhub.org/speechlanguage/

Wikipedia (n.d.) Augmentative and alternative communication. From https://en.wikipedia.org/wiki/Augmentative_and_alternative_communication 

Wikipedia, (n.d.) Speech and Language Impairment. From  https://en.wikipedia.org/wiki/Speech_and_language_impairment 

Updated 8.8.23

Understanding and Supporting Learners with Disabilities Copyright © 2019 by Paula Lombardi is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License , except where otherwise noted.

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Speech and Language Disorders in Children: Implications for the Social Security Administration's Supplemental Security Income Program (2016)

Chapter: 1 introduction.

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1 Introduction Speech and language are central to the human experience; they are the vital means by which people convey and receive knowledge, thoughts, feel- ings, and other internal experiences. Acquisition of communication skills begins early in childhood and is foundational to the ability to gain access to culturally transmitted knowledge, to organize and share thoughts and feelings, and to participate in social interactions and relationships. Speech and language skills allow a child to engage in exchanges that lead to the ac- quisition of knowledge in his or her community and the educational arena. Communication skills are crucial to the development of thinking ability, a sense of self, and full participation in society. Speech and language disorders—disruptions in communication development—can have wide-ranging and adverse impacts on the ability not only to communicate but also to acquire new knowledge and par- ticipate fully in society. Most children acquire speech and language by a seemingly automatic process that begins at birth and continues through adolescence. Typically, basic communication skills are developed (although not complete) by the time a child enters kindergarten, enabling the child to begin learning from teachers and interacting fluently with peers and caregivers (Oller et al., 2006). Severe disruptions in speech or language acquisition thus have both direct and indirect consequences for child and adolescent development, not only in communication but also in associated abilities such as reading and academic achievement that depend on speech and language skills. When combined with other developmental risks, such as poverty (Williams, 2013), severe speech and language disabilities can 15 

16 SPEECH AND LANGUAGE DISORDERS IN CHILDREN become high-impact, adverse conditions with long-term cognitive, social, and academic sequelae and high social and economic costs. STUDY CONTEXT Like other entitlement programs, the Supplemental Security Income (SSI) program has generated considerable and recurring interest in its growth, effectiveness, accuracy, and sustainability. Questions have arisen in both the media and policy-making settings regarding the appropriateness of SSI benefits for children with speech and language disorders. As an example, the Boston Globe published a series of articles in December 2010 describing the experiences and challenges of families who either were currently receiving or had sought to become eligible to receive SSI benefits for their children. These articles focused on the growing number of children enrolled in SSI on the basis of speech and language disorders. In response to issues raised in these articles, members of Congress directed the U.S. Government Accountability Office (GAO) to conduct an assessment of the SSI program for children. This assessment was designed to examine decade-long trends in the rate of children receiving SSI benefits based on mental impairments;1 the role played by medical and nonmedical informa- tion, such as medication use and school records, in the initial eligibility determination; and steps taken by the Social Security Administration (SSA) to monitor children’s continued eligibility based on disability. The GAO assessment was conducted between February 2011 and June 2012. Midway through the assessment, on October 27, 2011, the Subcommittee on Human Resources of the House Ways and Means Committee convened a hearing on SSI for children, including an interim report by the GAO on its findings regarding the SSI program for children. In that report, the GAO found that between 2000 and 2011, the annual number of children applying for SSI benefits had increased from 187,052 to 315,832. Of these applications, 54 percent had been denied. The GAO also found that mental impairments constituted approxi- mately 65 percent of all child SSI allowances. The three most prevalent primary mental impairments2 for children found eligible were attention deficit hyperactivity disorder (ADHD), speech and language impairments,3 1  The SSI program categorizes “speech and language impairments” as mental disorders. 2  See the report Mental Disorders and Disabilities Among Low-Income Children for trends in prevalence for mental disorders (NASEM, 2015). 3  Impairment code 3153 was changed from “speech and language delays” to “speech and language impairments” in August 2015. 

INTRODUCTION 17 and autism/developmental delays.4 From December 2000 to December 2011, the total number of children receiving SSI benefits for mental im- pairments had increased annually, from approximately 543,000 in 2000 to approximately 861,000 in 2011, an almost 60 percent increase. Secondary impairments were present for many of those found medically eligible. In ad- dition, the GAO estimated that in 2010, 55 percent of children with speech and language impairments who received SSI benefits had an accompanying secondary impairment recorded; 94 percent of those recorded secondary impairments were other mental disorders. In its final report, the GAO suggested that several factors may have contributed to the observed changes in the size of the SSI program for children, including • long-term receipt of assistance, with fewer children leaving the dis- ability program prior to age 18; • increased numbers of children living in poverty in the United States; • increased awareness and improved diagnosis of certain mental impairments; • a focus on identifying children with disabilities through public school special education services; and • increased health insurance coverage of previously uninsured children. The GAO found an increase between 2000 and 2010 in both applica- tions and allowances (applicants determined to meet the disability criteria) for children with speech and language impairments (GAO, 2012). During this period, the number of applications for speech and language impair- ments increased from 21,615 to 49,664, while the number of children found to meet the disability criteria increased from 11,565 to 29,147 (GAO, 2012). The cumulative number of allowances for children with speech and language impairments has continued to increase. In December 2014, 213,688 children were receiving benefits as the result of a primary speech or language impairment (16 percent of all children receiving SSI benefits) (SSA, 2015). The factors that contributed to these changes are a primary focus of this report and are discussed at length in Chapters 4, 5, and 6. Based on the GAO findings, the SSA determined that additional study was needed to understand the increases in the total number of children 4  “Autism/developmental delays” is language drawn directly from the GAO report. How- ever, autism spectrum disorder is a distinct neurodevelopmental disorder with distinct clinical characteristics. For further reading on autism spectrum disorder, see Mental Disorders and Disabilities Among Low-Income Children (NASEM, 2015). 

18 SPEECH AND LANGUAGE DISORDERS IN CHILDREN receiving SSI benefits as a result of speech and language disorders. This study was requested to meet that need. STUDY CHARGE AND SCOPE In 2014, the SSA’s Office of Disability Policy requested that the Institute of Medicine (IOM) of the National Academies of Sciences, Engineering, and Medicine convene a consensus committee to (1) identify past and current trends in the prevalence and persistence of speech and language disorders among the general U.S. population under age 18 and compare those trends with trends among the SSI childhood disability population; and (2) provide an overview of the current status of the diagnosis and treatment of speech and language disorders and the levels of impairment due to these disorders in the U.S. population under age 18. (See Box 1-1 for the committee’s full statement of task.) This report addresses the charge defined in the committee’s statement of task. It should be noted that this report is not intended to provide a comprehensive discussion of speech and language disorders in children, but to provide the SSA with information directly related to the administration of the SSI program for children with these disorders. In addition, this com- mittee was not charged with providing an evaluation of the SSI program or addressing any other questions related to policy or rulemaking. Finally, it is important to note that this study was conducted at the same time that the Committee on the Evaluation of the Supplemental Security Income (SSI) Disability Program for Children with Mental Disorders study was under way. Although the two studies have related statements of task and were both sponsored by the SSA, the work was conducted by two distinct committees, which held separate meetings and underwent indepen- dent report review processes. The report Mental Disorders and Disabilities Among Low-Income Children was released in September 2015 (NASEM, 2015). A brief summary of that report’s key findings and conclusions is included in Appendix G. The following subsections describe how the committee used its state- ment of task to guide its review and analysis and to determine the inclusion or exclusion of related or noteworthy topics. Speech and Language Disorders and Corresponding Treatments Numerous childhood speech and language disorders and other condi- tions associated with these disorders are worthy of rigorous examination. Similarly, many approaches are used to treat childhood speech and language disorders. As noted above, however, this report does not provide an ex- haustive review of all such disorders or of their corresponding treatments. 

INTRODUCTION 19 BOX 1-1 Statement of Task An ad hoc committee will conduct a study to address the following task order objectives: •  dentify past and current trends in the prevalence and persistence of I speech disorders and language disorders for the general U.S. population under age 18 and compare those trends to trends in the Supplemental Security Income (SSI) childhood disability population; and •  rovide an overview of the current status of the diagnosis and treatment P of speech disorders and language disorders, and the levels of impairment in the U.S. population under age 18. To accomplish this goal, the committee will: •  ompare the national trends in the number of children with speech C disorders and language disorders under age 18 with the trends in the number of children receiving SSI on the basis of speech disorders and language disorders; and describe the possible factors that may contribute to any differences between the two groups; and •  dentify current professional standards of pediatric and adolescent health I care for speech disorders and language disorders and identify the kinds of care documented or reported to be received by children in the SSI childhood disability population. To perform the above activities, the committee shall do the following with respect to the two child populations: •  dentify national trends in the prevalence of speech disorders and I language disorders in children and assess factors that influence these trends. •  dentify the causes of speech disorders and language disorders and I determine how often these disorders are the result of known causes. •  dentify the average age of onset and the gender distribution and assess I the levels of impairment within age groups. •  ssess how age, development, and gender may play a role in the A progression of some speech disorders and language disorders. •  dentify common comorbidities among pediatric speech disorders and I language disorders. •  dentify which speech disorders and language disorders are most ame- I nable to treatment and assess typical or average time required for im- provement in disorder to manifest following diagnosis and treatment. •  dentify professionally accepted standards of care (such as diagnos- I tic evaluation and assessment, treatment planning and protocols, and educational interventions) for children with speech disorders and with language disorders. 

20 SPEECH AND LANGUAGE DISORDERS IN CHILDREN Rather, in accordance with the committee’s statement of task, this report describes primary categories of childhood speech and language disorders that occur most commonly in the population of children served by the SSI program and provides an overview of treatments for these disorders. Therefore, the exclusion of any conditions or treatments should not be viewed as an oversight, but as a necessary narrowing of the focus of this study to the issues of greatest relevance to the SSI program. Data and Data Sources The committee consulted a variety of data sources to identify trends in the prevalence and persistence of speech and language disorders (prevalence and trends in prevalence are discussed below). These sources included data from clinical samples (i.e., Pennington and Bishop, 2009), population- based studies (i.e., Law et al., 2000; Tomblin et al., 1997), nationally representative surveys (e.g., the National Survey of Children’s Health), and administrative or service-based data from federal programs (Medicaid Analytic eXtract [MAX] data, Individuals with Disabilities Education Act [IDEA] child count data, and the SSA’s program data). These sources differ substantially with respect to how they define and/or designate speech and language disorders in children, how they collect information (e.g., parental reporting, medical records, test results), which variables are examined (e.g., level of severity or duration of disorders, child and/or family demographic information), and the period(s) of time examined, among other factors. As a result, readers of this report will encounter numbers and estimates that appear quite different from chapter to chapter. Recognizing the challenge this variation presents to readers, the committee carefully describes the dif- ferent types of data and how estimates were derived throughout the report. (A full discussion of data limitations is included in Chapter 5.) In addition to the challenges that the committee encountered in using available data, the absence of other relevant data limited the committee’s ability to generate more precise population estimates, to compare changes over time, and to conduct further analyses. This absence of data included data sources and data collection efforts that do not currently exist, as well as data that were unavailable to the committee (or to the general public). For example, the committee’s efforts to determine prevalence estimates of children with speech and language disorders could have been improved by access to a national data source derived from health services or health insurance records. Similarly, the committee’s efforts to describe trends in childhood speech and language disorders could have been improved through an analysis of longitudinal data from programs (i.e., Medicaid and SSI) or national surveys. At this time, no such national-level data sources or longitudinal data collection efforts exist for these conditions. 

INTRODUCTION 21 Furthermore, the committee’s efforts to document the persistence of speech and language disorders among children who receive SSI benefits and the types of treatment received by these children would have been improved by access to certain types of unpublished SSA administrative data, such as age-18 redeterminations and continuing disability reviews. However, these data were not available to the committee for the purpose of this study. Finally, the committee had access to an analysis of MAX data that included limited analyses related to speech and language disorders (see Chapter 5). Because these data are drawn from a study that was commissioned for another report (see NASEM, 2015), this committee was unable to conduct additional analyses, which would have allowed for comparisons between speech and language disorders and other health conditions. Severity of Speech and Language Disorders This report frequently refers to “severe” speech and language disorders in children. However, the word “severe” has different meanings depend- ing on the context in which it is used. In clinical research, severity may be measured according to how far below average children score on tests compared with children of the same age (i.e., in standard deviations from a norm-referenced score or quotient) or “percentage of delay” relative to chronological age. In the context of the SSI program, however, the word “severe” has a specific legal meaning that is related to the standard of dis- ability for children in the Social Security Act. Specifically, the regulations explain that “an impairment or combination of impairments must cause ‘marked and severe functional limitations’ in order to be found disabling.”5 Elsewhere, the regulations explain that “a child’s impairment or combina- tion of impairments is ‘of listing-level severity’ if it causes marked limitation in two areas of functioning or extreme limitation in one such area.”6 These areas of functioning include acquiring and using information, attending to and completing tasks, interacting and relating with others, moving about and manipulating objects, caring for himself or herself, and maintaining health and physical well-being. Chapter 4 includes an in-depth review of how children are evaluated for disability as part of the SSI eligibility deter- mination process. Readers of the report should therefore consider the word “severe” as a clinical expression of impairment level except when it is used in the context of the SSI program. 5  20 C.F.R. 416.902. 6  20 C.F.R. 416.925(b)(2). 

22 SPEECH AND LANGUAGE DISORDERS IN CHILDREN Identifying Severe Speech and Language Disorders When prevalence estimates (for any condition) are based on a threshold or cutoff score imposed on a continuous normal distribution, the cutoff score will necessarily determine the percentage of individuals falling above and below it. The committee used cutoffs (two and three standard devia- tions below the mean) that are consistent both with conventional definitions of severe disorders in medicine, psychology, and other fields and with the quantitative standards used by the SSA for defining severe speech and lan- guage disorders (see Chapter 4). Many researchers and organizations have noted the need to consider additional sources of evidence, including subjec- tive judgments of functioning, in addition to norm-referenced cutoff scores. For example, the World Health Organization’s International Classification of Functioning, Disability and Health is one widely accepted approach to describing the severity of medical and developmental conditions (WHO, 2001). This, too, is consistent with the SSA’s approach, which requires qualitative evidence that is consistent with quantitative scores when the lat- ter are available. Unfortunately, high-quality data from large, representative populations that have been assessed with both quantitative and qualitative metrics are not available. Prevalence and Trends in Prevalence As part of its charge, the committee was asked to “identify past and current trends in the prevalence and persistence of speech disorders and language disorders for the general U.S. population (under age 18) and compare those trends to trends in the SSI childhood disability population.” Prevalence is defined as “the number or proportion of cases or events or attributes among a given population” (CDC, 2014). The term “prevalence” is often used to describe “point prevalence,” which refers to “the amount of a particular disease present in a population at a single point in time” (CDC, 2014). Given the lack of longitudinal data on speech and language disorders in SSI administrative data and the paucity of similar data for the general population, the committee determined that the best way to identify trends in prevalence using available data sources would be to examine trends in point prevalence—that is, the number of children with speech and lan- guage disorders at a given time and over time both for the general U.S. population (under age 18) and in the SSI childhood disability population. To identify trends in prevalence in these groups, the committee reviewed multiple estimates of point prevalence over time from a variety of sources, including studies using clinical samples, nationally representative surveys, and administrative or service data from federal programs (see Chapter 5). 

INTRODUCTION 23 When these estimates are arranged in chronological order, they produce a trend line—or a trend in prevalence. However, comparing trends in prevalence between these two popula- tions posed a number of challenges beyond a lack of longitudinal data. These challenges, described in Chapters 4 and 5, include inherent differ- ences in the sample populations (e.g., socioeconomic status, levels of sever- ity) and differences in how children with speech and language disorders are identified and categorized. In addition, many of the estimates of prevalence and trends in prevalence presented in this report lack statements of preci- sion, such as confidence intervals or error bars. Recognizing this limitation, the committee provides detailed information regarding sample sizes and methods used to calculate estimates. These can be found in Chapters 2 and 5 and Appendixes C and D. Despite the numerous challenges and limita- tions, the committee used the available data to describe changes in both groups7 over time, in accordance with its charge. Poverty Because financial need is a basic condition of eligibility for SSI, the first step in determining eligibility is assessment of family financial status. As a result, the majority of children who receive SSI benefits are from families with a household income less than 200 percent of the federal poverty level (FPL). The number of families with incomes less than 200 percent of the FPL changes over time. That is, as economic conditions deteriorate, more families join the ranks of those with incomes at or below a defined poverty level. This most recently occurred following the 2008-2009 recession in the United States. Table 1-1 presents the absolute number of children under age 18 living in poverty and the percentage of children who were below the FPL annually from 2004 to 2013. The pattern shows that the percentage of children in poverty increased after 2006, peaked in 2010, and declined afterward, although by 2013 it was well above the 2006 level (NASEM, 2015). This pattern suggests that more children would have met the financial eligibility criteria for SSI benefits during the period that followed the 2008- 2009 recession in the United States. Thus, an increase in the number of children with speech and language disorders receiving SSI may not reflect an increase in these disorders, but instead may arise from an increased number of children with these disorders who meet the poverty threshold for SSI eligibility (NASEM, 2015). However, there are no reliable estimates of the 7  In accordance with the committee’s charge, this includes children with speech and language disorders of any level of severity in the general population and children with these disorders in the SSI population, whose impairments are inherently severe. 

24 SPEECH AND LANGUAGE DISORDERS IN CHILDREN TABLE 1-1  U.S. Children Living in Poverty (below 100 percent of the federal poverty level), 2004-2013 (numbers in thousands) Below the Federal Poverty Level Total Number of Children in Number of Year General U.S. Population Children Percent of Total 2004 73,241 13,041 17.8 2005 73,285 12,896 17.6 2006 73,727 12,827 17.4 2007 73,996 13,324 18.0 2008 74,068 14,068 19.0 2009 74,579 15,451 20.7 2010 73,873 16,286 22.0 2011 73,737 16,134 21.9 2012 73,719 16,073 21.8 2013 73,625 14,659 19.9 SOURCE: DeNavas-Walt et al., 2014. number of children living in poverty who also have speech and language disorders. Therefore, this report examines the interaction of poverty and dis- ability as well as changes in childhood poverty rates and the changes observed in the SSI program for children with speech and language disor- ders. Additional data provided in this report allow for comparisons and analyses of SSI determinations, allowances, and total child SSI recipients as a proportion of low-income populations within the United States. This discussion can be found in Chapters 4 and 5. Limitation of Review of the SSI Program to Children Under Age 18 As noted in the committee’s statement of task, this review was limited to children under age 18, the age range served by the SSI childhood pro- gram. Therefore, data on redetermination at age 18 are not included in this report, although at age 18, SSI recipients must be reevaluated for eligibility to continue receiving SSI disability benefits as adults. One notable exception is that the committee includes program data on children and youth with disabilities served under IDEA Parts B and C; these data, which could not be disaggregated, include children and youth aged 0-21. Data related to topics beyond the scope of this review, such as continuing disability reviews and age-18 redeterminations, were not made available to the committee by the SSA. 

INTRODUCTION 25 Age of Onset As part of its task, the committee was asked to identify the average age of onset of speech and language disorders. The onset of a disorder and its chronicity may have important implications related to the burden placed by the disorder on an individual and his or her family, as well as the types and duration of supports an individual will require. Chapter 3 reviews the evi- dence on persistence of speech and language disorders in children. However, the committee found that in most cases, a simplistic concept of onset does not apply to speech and language or other developmental disorders. The notion of onset of a condition implies that prior to the onset, affected individuals had these functions but then experienced a decline or loss of function. In general, developmental disorders are identified when expected functional skills in children fail to emerge. These expectations usually are based on ages when children typically begin to show these skills. The crite- ria for determining that a child is presenting severe and long-lasting devel- opmental problems often allow for a period of uncertainty. The underlying factors that contribute to developmental disorders are likely to have been present well before the signs are manifest in the child’s development. For example, the babbling of infants who later display severe speech disorders often lacks the consonant-like sounds (closants) seen in typically developing children (Oller et al., 1999). However, there is considerable variability in typical development, so that babbling features alone cannot be used as an accurate diagnostic test for speech disorder. A major effort in clinical research on developmental disorders has been to identify early risk factors and subclinical signs, so as to support earlier identification and treatment. This research also supports the general assumption that for most developmental disorders, identification is likely to occur during very early stages of development. Therefore, this report re- views what is known about the age of identification of speech and language disorders as it relates to expected developmental milestones. It is generally more accurate to describe the “age of identification” of a speech or lan- guage disorder than to focus on the “age of onset.” It is worth noting that the age at which a speech or language disorder is identified may be further influenced by a number of factors, including access to care, socioeconomic status, and other demographic factors. Gender The committee was charged with identifying the “gender distribu- tion” of speech and language disorders in children and with assessing “how gender may play a role in the progression” of these disorders. This report highlights findings on gender distribution from clinical research and 

26 SPEECH AND LANGUAGE DISORDERS IN CHILDREN national survey data. However, the evidence base on the effects of gender on the efficacy of treatment and the progression or persistence of speech and language disorders is limited. In its review of the literature, the committee found that few studies examined differential effects of treatment on males and females or included longitudinal data that demonstrated gender differ- ences in the persistence or progression of speech and language disorders. State-to-State Variation in the SSI Program Determinations of eligibility for the SSI program are managed at the state level. Through its examination of the evidence, the committee became aware that states vary considerably in the number and rate of applica- tions leading to determinations and in the rate of allowances. This report includes some state-level data to provide an overall perspective, but it does not explore the potential factors contributing to state-to-state variation in the rates of SSI disability, which was beyond the scope of this study. Readers can refer to a recent research brief by the Office of the Assistant Secretary for Planning and Evaluation, The Child SSI Program and the Changing Safety Net (Wittenburg et al., 2015), or to Mental Disorders and Disabilities Among Low-Income Children (NASEM, 2015) for further information on geographic variation in child SSI program growth and participation. Exclusion of Recommendations Finally, the committee was not asked to provide the SSA with recom- mendations on the SSI program for children. Doing so would be beyond not only the scope of this study as laid out in the statement of task but also the expertise of this committee. Rather, the committee was tasked with gathering information and reporting on the current state of knowledge on the diagnosis, prognosis, and treatment of speech and language disorders in children, as well as trends in the prevalence of these disorders in children. The information presented in this report (and in the recent Academies report on trends in low-income children with mental disorders in the SSI program [NASEM, 2015]) provides a solid evidentiary basis that can in- form the SSA’s programs and policies, as well as the work of an array of related stakeholders. STUDY APPROACH The study committee included 13 members with expertise in speech- language pathology, auditory pathology, pediatrics, developmental-behavioral pediatrics, epidemiology, biostatistics, neurology, neurodevelopmental 

INTRODUCTION 27 disabilities, adolescent health, health policy, and special education. (See Appendix H for biographies of the committee members.) A variety of sources informed the committee’s work. The committee met in person five times: two of those meetings included public work- shops to provide the committee with input from a broad range of experts and stakeholders, including parents and professional organizations; federal agencies (e.g., the Centers for Disease Control and Prevention, the SSA, and the National Institute of Deafness and Other Communication Disorders); and researchers from a range of relevant disciplines, including speech and language pathology and epidemiology. In addition, the committee con- ducted a review of the literature to identify the most current research on the etiology, epidemiology, and treatment of pediatric speech and language disorders. The committee made every effort to include the most up-to- date research in peer-reviewed publications. However, strong evidence was sometimes found in older studies that had not been replicated in recent years. In these instances, the older studies are cited. The committee also reviewed findings from a supplemental study using Medicaid data to create an approximate national comparison group for the SSI child population.8 (See Chapter 5 for additional information about this supplemental study.) Finally, the committee reviewed data collected from SSI case files of children who were eligible for SSI benefits under the category of “speech and lan- guage impairment.” (See Chapter 4 and Appendix C for more information about this review.) DEFINITIONS OF KEY TERMS Language has long been described as a verbal or written code for conveying information to others, and speech refers to oral communication (Bloomfield, 1926). All languages include words (vocabulary), word end- ings (morphology), and sentence structure (syntax), and speech includes the pronunciation of the sounds (phonemes) of the language. Language devel- opment also encompasses acquisition of the social rules for communicating and conversing in society (pragmatics). These rules include participating appropriately in conversations, as well as using and comprehending appro- priate gestures and facial expressions during social interaction (Gallagher and Prutting, 1983). The communication and social aspects of speech and language must be coordinated rapidly and fluently when one is speaking. Given the complex nature of speech and language development, mul- tiple factors can contribute to deficits in their acquisition and use (e.g., motor impairments, processing deficits, cognitive impairments). Disruptions 8  This supplemental study was commissioned by the Committee on the Evaluation of the Supplemental Security Income Disability Program for Children with Mental Disorders. 

28 SPEECH AND LANGUAGE DISORDERS IN CHILDREN in communication development are broadly classified as speech disorders and language disorders. Speech disorder is defined as disruption in the production of the pho- netic aspects of words, phrases, and sentences so that communication is partially or, in severe cases, completely unintelligible to listeners. Stuttering is a form of speech disorder that involves disruptions in the rate and/or fluency of speaking due to hesitations and repetitions of speech sounds, words, and/or phrases. Language disorder is defined as impairment of expression and compre- hension because of a disruption in the acquisition of vocabulary (words), word endings, and sentence structure. In severe cases of language disorder, a child experiences extreme difficulty using correct words and proper gram- mar and may also have difficulty comprehending what others are saying. Box 1-2 presents the clinical definitions of speech and language disorders. BOX 1-2 Clinical Definitions of Speech and Language Disorders Speech: the production (pronunciation) of meaningful sounds from the complex coordinated movements of the oral mechanism Speech disorders: deficits that may cause speech to sound abnormal or prevent it altogether Examples of disordered speech: M  ild to moderate—speaking with a lisp, substituting or deleting sounds in words (e.g., saying “twee” for “three,” saying “jo” for “joke”) Severe—making multiple pronunciation errors so that speech is largely or even totally unintelligible Language: the code or system of symbols for representing ideas in various modalities, including understanding (comprehending) and speaking, reading, and writing Language disorders: conditions that interfere with the ability to understand the code, to produce the code, or both Examples of disordered language: Mild to moderate—omitting word endings, using an incorrect pronoun Severe—very low vocabulary, inability to comprehend, grossly inaccurate word order 

INTRODUCTION 29 BOX 1-3 Primary Versus Secondary Speech and Language Disorders Primary speech and language disorders: no other etiology or “cause” is evident Examples of primary speech and language disorders: • Speech sound disorders • Voice disorders • Stuttering • Expressive language disorder • Receptive language disorder • Combined receptive and expressive language disorder • Social communication disorder Secondary speech and language disorders: can be attributed to another condition Examples of contributors to secondary speech and language disorders: • Hard of hearing or deaf • Intellectual disability • Autism spectrum disorder • Cleft palate • Cerebral palsy Furthermore, speech and language disorders can be categorized as primary, meaning the disorder does not arise from an underlying medical condition (e.g., cerebral palsy, Down syndrome, hearing impairment), or secondary, meaning the disorder can be attributed to another condition (see Box 1-3). This report discusses both primary and secondary speech and language disorders, but it focuses mainly on speech and language dis- orders that are identified as the primary condition. This corresponds with the categories of speech and language disorders in the SSI program that the report examines. SIGNIFICANCE AND IMPACT OF SEVERE SPEECH AND LANGUAGE DISORDERS Speech and language disorders can have a significant adverse impact on a child’s ability to have meaningful conversations and engage in age- appropriate social interaction. These disorders are serious disabilities with long-term ramifications for cognitive and social-emotional development and for literacy and academic achievement and have lifelong economic and social impacts, and these disruptions are evidenced in increased risk for 

30 SPEECH AND LANGUAGE DISORDERS IN CHILDREN learning disabilities, behavior disorders, and related psychiatric conditions. The following sections describe the variety of ways in which speech and language disorders can impact children and their families. Impact on Social-Emotional and Cognitive Development Child development is best viewed in the context of a dynamic interac- tion between social-emotional and cognitive development (Karmiloff-Smith et al., 2014). A seminal paper by Sameroff (1975) brought attention to the critical role of parent–child interactions and social-communicative exchanges in children’s social and emotional development. In this communicative- interactive model, social development is the direct product of parent–child (or caregiver–child) interaction (Sameroff, 2009). Specifically, parent–child communication interactions, including speech and language skills, are foundational to emotional attachment, social learning, and cognitive de- velopment in addition to communication development. Communication interactions—social “back and forth” exchanges—are a natural part of parent-child communication, with more than 1 million of these parent– child exchanges occurring in the first 5 years of a child’s life (Hart and Risley, 1995). Figure 1-1 illustrates how social interaction between parent and child leads to the development of speech. FIGURE 1-1 Example of communication-interaction for speech development. 

INTRODUCTION 31 In the decades since Sameroff’s (1975) original article, the communi- cation-interaction model has been applied to multiple aspects of develop- ment, including speech (Camarata, 1993), language (Nelson, 1989), the development of self (Damon and Hart, 1982), and cognitive development (Karmiloff-Smith et al., 2012). Karmiloff-Smith (2011) adapted the com- munication-interaction perspective as a means of mapping developmental processes across multiple domains of genetics and neuroimaging, as well as cognitive and linguistic abilities. In essence, she argues that dynamic communication interactions between parent and child serve not only as learning opportunities but also as the core of the genetically mediated neu- ral phenomena occurring for childhood brain development, often referred to as neural plasticity and remodeling. Viewed in this way, communicative interchanges are fundamental to the developmental experiences that shape a child’s neural architecture and, more important, brain function. Severe speech and language disorders can derail this typical cascade of develop- ment and have profound and wide-ranging adverse impacts (Clegg et al., 2005). Impacts on Literacy and Academic Achievement Figure 1-2 illustrates the importance of language development for the development of literacy skills and the relationship of both to academic achievement across a range of subject areas. Considerable data suggest that severe speech and language disorders are associated with reading disabili- ties and general disruptions in literacy (Fletcher-Campbell et al., 2009). In FIGURE 1-2 The relationship among language development, literacy skills, and academic achievement. 

32 SPEECH AND LANGUAGE DISORDERS IN CHILDREN essence, reading involves mapping visual symbols (letters) onto linguistic forms (words). When the acquisition and mastery of oral vocabulary are impaired, it is not surprising that the mapping of symbols such as letters onto words is also disrupted. In addition, broader language and speech disorders can make processing the visual symbols much less efficient and disrupt their mapping onto meaning. Even after vocabulary has been ac- quired, cognitive problems with translating text to language can continue (Briscoe et al., 2001). In languages such as English that use phonetic text, severe speech disorders also can disrupt the phonological processing asso- ciated with reading (Pennington and Bishop, 2009). In sum, severe speech and language disorders often have direct or indirect adverse impacts on the development of literacy and fluid reading. In addition to their direct impact on literacy, severe speech and lan- guage disorders can have a deleterious cascading effect on other aspects of academic achievement. To illustrate, in a 15-year follow-up study of chil- dren with speech and language disorders, a high percentage (52 percent) of the children initially identified with such disorders had residual learning dis- abilities and poor academic achievement later in life (King, 1982). Similarly, Hall and Tomblin (1978) report poor overall long-term achievement in language-impaired children. More recently, a study of preterm infants with language disorders indicated multiple disruptions in subsequent achieve- ment (Wolke et al., 2008). And Stoeckel and colleagues (2013) found a strong correlation between early language problems and later diagnosis of written-language disorders. Because so much of academic achievement is predicated on acquiring information through reading and listening com- prehension, early severe speech and language disorders often are associated with poor achievement beyond reading problems. As illustrated in Figure 1-3, the most recent data from the Institute of Education Sciences of the U.S. Department of Education indicate that 21 percent of all special education eligibility in the United States is for speech and language impairments—three times greater than eligibility for autism or intellectual disability. Speech and language disorders are among the highest-incidence conditions among children in special education. Moreover, these data may underestimate the prevalence of speech and language disorders because the highest-incidence condition—specific learn- ing disability—includes many students who were previously categorized as having a speech or language impairment (Aram and Nation, 1980; Catts et al., 2002). Although mild speech and language impairments in preschool will sometimes be transient, severe forms of the disorders have a high prob- ability of being long-term disabilities (Beitchman et al., 1994; Bishop and Edmundson, 1987), with that probability rising with the disorder’s severity. 

INTRODUCTION 33 Specific Learning DisabiliƟes 36 Speech or Language Impairments 21 Other Health Impairments 12 AuƟsm 7 Disability Type Intellectual Disability 7 Developmental Delay 6 EmoƟonal Disturbance 6 MulƟple DisabiliƟes 2 Hearing Impairments 1 Orthopedic Impairments 1 0 5 10 15 20 25 30 35 40 Percent FIGURE 1-3  Percentage distribution of children aged 3-21 served under the Indi- viduals with Disabilities Education Act (IDEA) Part B, by disability type: school year 2011-2012. SOURCE: Kena et al., 2014. Economic and Family Impacts In a review of the economic impact of communication disorders on so- ciety, Ruben (2000, p. 241) estimates that “communication disorders may cost the United States from $154 billion to $186 billion per year.” Severe speech and language disorders elevate risk for a wide variety of adverse eco- nomic and social outcomes, such as lifelong social isolation and psychiatric disorders, learning disabilities, behavior disorders, academic failure, and chronic underemployment (Aram and Nation, 1980; Baker and Cantwell, 1987; Beitchman et al., 1996; Johnson et al., 1999; Stothard et al., 1998; Sundheim and Voeller, 2004). Following a cohort of individuals with severe language disorders in childhood longitudinally through school age and adolescence and into early adulthood, Clegg and colleagues (2005, p. 128) found that “in their mid-30s, those who had language disorders as children had significantly worse social adaptation with prolonged unemployment and a paucity of close friendships and love relationships.” Research shows that children living in poverty are at greater risk for a disability relative to their wealthier counterparts, and that childhood dis- ability increases the risk of a family living in poverty (Emerson and Hatton, 2005; Farran, 2000; Fujiura and Yamaki, 2000; Lustig and Strauser, 2007; Msall et al., 2006; NASEM, 2015; Parish and Cloud, 2006). For example, 

34 SPEECH AND LANGUAGE DISORDERS IN CHILDREN data from the U.S. Census 2010 showed that families raising children with a disability experienced poverty at higher rates than families raising children without a disability (21.8 and 12.6 percent, respectively) (Wang, 2005). At the same time, childhood poverty and the accompanying deprivations have significant adverse implications for children with disabilities and their fami- lies. Families with children with disabilities are also more likely to incur increased out-of-pocket expenses; for example, for child care or for trans- portation to locations with specialized medical care (Kuhlthau et al., 2005; Newacheck and Kim, 2005). Data from the National Survey of Children with Special Health Care Needs help illustrate the impact on families of caring for children with communication disorders. For example, the survey asked whether family members cut back on or stopped working because of their child’s health needs. Fifty-two percent of the survey respondents whose children had “a lot of difficulty speaking, communicating, or being understood” responded affirmatively to this question (Wells, 2015). In sum, given the complex multidimensional nature of language ac- quisition and the integral role of speech and language across multiple domains of early child development, speech and language disorders occur at relatively high rates (Kena et al., 2014). In 2011-2012, 21  percent of children served under IDEA Part B had speech or language impairments (Kena et al., 2014). These disorders also are associated with a wide range of other conditions (Beitchman et al., 1996), such as intellectual disabilities (Georgieva, 1996), autism spectrum disorder (Geurts and Embrechts, 2008; Sturm et al., 2004), hearing loss (Yoshinaga-Itano et al., 1998), learning disabilities (Pennington and Bishop, 2009; Schuele, 2004), ADHD (Cohen et al., 2000), and severe motor conditions such as cerebral palsy (Pirila et al., 2007). NOTABLE PAST WORK As noted earlier, in the period between 2000 and 2011, speech and language impairments were among the three most prevalent impairments in children in the SSI disability program (preceded by ADHD and followed by autism spectrum disorder) (GAO, 2012). In an effort to understand these trends in comparison with trends in the general population, the SSA requested that the IOM conduct two studies: the previously mentioned study on childhood mental disorders (including ADHD and autism spec- trum disorder)9 and this study on childhood speech and language disor- ders. While these impairments frequently co-occur and may have similar 9  Information on the Committee on the Evaluation of the Supplemental Security Income Disability Program for Children with Mental Disorders can be found online at http://iom. nationalacademies.org/activities/mentalhealth/ssidisabilityprograms.aspx. 

INTRODUCTION 35 diagnostic characteristics, the separate studies allowed two independent committees to examine distinct literatures and data sources and to review different standards of care and treatment protocols. The study on children with mental health disorders was conducted from January 2014 through August 2015; the final report of that study was released in September 2015 (NASEM, 2015). While this report is the first examination of the SSI disability pro- gram for children with speech and language disorders conducted by the Academies, the IOM, and the National Research Council (NRC) have a long history of studying issues related to disability in children and adults and the SSA’s disability determination process. In addition to the recently released Mental Disorders and Disabilities Among Low-Income Children (NASEM, 2015), earlier reports by the IOM and the NRC that informed this committee’s work include The Dynamics of Disability: Measuring and Monitoring Disability for Social Security Programs (IOM and NRC, 2002), The Future of Disability in America (IOM, 2007b), Improving the Social Security Disability Decision Process (IOM, 2007a), HIV and Disability: Updating the Social Security Listings (IOM, 2010b), Cardiovascular Disability: Updating the Social Security Listings (IOM, 2010a), and Psychological Testing in the Service of Disability Determination (IOM, 2015). Along with this earlier work of the Academies, the committee drew important lessons from the body of data and research aimed at identifying trends in the prevalence and persistence of speech and language disorders, as well as addressing diagnosis and treatment of and levels of impairment associated with these disorders. FINDINGS AND CONCLUSIONS Findings 1-1. Developmental disorders are identified when expected functional skills in children fail to emerge. 1-2. Underlying factors that contribute to developmental disorders are likely to have been present well before the signs are manifest in the child’s development. 1-3. In a 15-year follow-up study of children with speech and language disorders, 52 percent of the children initially identified with such disorders had residual learning disabilities and poor academic achievement later in life. 1-4. Twenty-one percent of all special education eligibility in the United States is for speech and language impairments—three times greater than eligibility for autism or intellectual disability. 

36 SPEECH AND LANGUAGE DISORDERS IN CHILDREN Conclusions 1-1. It is generally more accurate to describe the “age of identifica- tion” of a speech or language disorder than to focus on the “age of onset.” 1-2. Mild speech and language impairments in preschool will some- times be transient; severe forms of these disorders have a high probability of being long-term disabilities. ORGANIZATION OF THE REPORT This report consists of six chapters. It is organized to provide readers with important background information on speech and language disorders in children in the general population before describing the subset of chil- dren with severe speech and language disorders who receive SSI benefits. To take readers through this progression, the report describes the SSI program in some detail. This description is intended to orient readers to the determi- nation process that shapes the population served by the program: children with severe speech and language disorders who are also from low-income, resource-limited families. The report then compares changes over time in the prevalence of speech and language disorders in the general and SSI child populations, based on the best evidence available. The report culminates with a summary of the committee’s overall findings and conclusions. The contents of each chapter are as follows: • Chapter 2 provides an overview of childhood speech and language disorders in the general U.S. population. The chapter begins with an overview of speech and language development in children. It then examines the diagnosis of speech and language disorders in children, causes and risk factors, and prevalence. The chapter also includes evidence related to common comorbidities of childhood speech and language disorders. • Chapter 3 reviews what is known about the treatment and per- sistence of speech and language disorders in children. This review includes current standards of care for these disorders, an overview of treatment approaches for different speech and language disor- ders, and expected responses to treatment. • Chapter 4 provides an overview of the SSI program for children, how it has changed over time, and how those changes have shaped the population of children receiving SSI benefits. It describes the eli- gibility determination process and the speech and language-related criteria that are used to evaluate children. Finally, the chapter in- cludes case examples and a review of a random sample of case files 

INTRODUCTION 37 of children who receive SSI benefits based on speech and language disorders. This information offers insight into the characteristics of children with speech and language disorders who apply for SSI and helps demonstrate the evidence considered by the SSA when making a disability determination for a case. • Chapter 5 compares trends in speech and language disorders among children (under age 18) in the general population with trends in these disorders among participants in the SSI childhood disability program. The chapter reviews the data sources used by the com- mittee to describe the epidemiology of speech and language disor- ders in children in both populations. It also identifies gaps in the evidence that impede more precise estimates of trends in prevalence for speech and language disorders and comorbid conditions. • Finally, Chapter 6 provides a summary of the committee’s over- all findings and conclusions and their implications in the follow- ing three areas: speech and language disorders in children in the general population, speech and language disorders among chil- dren who receive SSI benefits, and comparisons between these two groups. The report includes several appendixes. Appendix A provides a glossary of terms used throughout the report, while Appendix B includes summaries of data sources that informed the committee’s work. Appendix C includes administrative/service data that the committee used to examine changes in program participation over time and national survey data that the commit- tee used to estimate changes in prevalence over time. Appendix D provides the methods that the committee used to calculate trends in the national survey data. Appendix E includes a description of the methods used to review case files, and Appendix F lists the agendas and speakers for the committee’s public workshops. A brief summary of Mental Disorders and Disabilities Among Low-Income Children, the report of the Committee on the Evaluation of the Supplemental Security Income Disability Programs for Children with Mental Disorders, is included in Appendix G. Finally, Appendix H contains biographical sketches of the committee members. REFERENCES Aram, D. M., and J. E. Nation. 1980. Preschool language disorders and subsequent language and academic difficulties. Journal of Communication Disorders 13(2):159-170. Baker, L., and D. P. Cantwell. 1987. A prospective psychiatric follow-up of children with speech/language disorders. Journal of the American Academy of Child & Adolescent Psychiatry 26(4):546-553. 

38 SPEECH AND LANGUAGE DISORDERS IN CHILDREN Beitchman, J. H., E. Brownlie, A. Inglis, J. Wild, R. Mathews, D. Schachter, R. Kroll, S. Martin, B. Ferguson, and W. Lancee. 1994. Seven-year follow-up of speech/language- impaired and control children: Speech/language stability and outcome. Journal of the American Academy of Child & Adolescent Psychiatry 33(9):1322-1330. Beitchman, J. H., B. Wilson, E. Brownlie, H. Walters, and W. Lancee. 1996. Long-term con- sistency in speech/language profiles: I. Developmental and academic outcomes. Journal of the American Academy of Child & Adolescent Psychiatry 35(6):804-814. Bishop, D. V. M., and A. Edmundson. 1987. Language-impaired 4-year-olds: Distinguishing transient from persistent impairment. Journal of Speech and Hearing Disorders 52(2): 156-173. Bloomfield, L. 1926. A set of postulates for the science of language. Indianapolis, IN: Bobbs-Merrill. Briscoe, J., D. V. M. Bishop, and C. F. Norbury. 2001. Phonological processing, language, and literacy: A comparison of children with mild-to-moderate sensorineural hearing loss and those with specific language impairment. Journal of Child Psychology and Psychiatry 42(3):329-340. Camarata, S. 1993. The application of naturalistic conversation training to speech production in children with speech disabilities. Journal of Applied Behavior Analysis 26(2):173-182. Catts, H. W., M. E. Fey, J. B. Tomblin, and X. Zhang. 2002. A longitudinal investigation of reading outcomes in children with language impairments. Journal of Speech Language and Hearing Research 45(6):1142-1157. CDC (Centers for Disease Control and Prevention). 2014. Principles of epidemiology glossary. http://www.cdc.gov/ophss/csels/dsepd/SS1978/Glossary.html (accessed August 11, 2015). Clegg, J., C. Hollis, L. Mawhood, and M. Rutter. 2005. Developmental language disorders—a follow-up in later adult life. Cognitive, language and psychosocial outcomes. Journal of Child Psychology and Psychiatry 46(2):128-149. Cohen, N. J., D. D. Vallance, M. Barwick, N. Im, R. Menna, N. B. Horodezky, and L. Isaacson. 2000. The interface between ADHD and language impairment: An examina- tion of language, achievement, and cognitive processing. Journal of Child Psychology and Psychiatry 41(3):353-362. Damon, W., and D. Hart. 1982. The development of self-understanding from infancy through adolescence. Child Development 53(4):841-864. DeNavas-Walt, C., B. D. Proctor, and J. C. Smith. 2014. Income and poverty in the United States: 2013. Washington, DC: U.S. Census Bureau. Emerson, E., and C. Hatton. 2005. The socio-economic circumstances of families with dis- abled children. Disability and Society 22(6):563-580. Farran, D. 2000. Another decade of intervention for children who are low-income or disabled: What do we know now? In Handbook of early childhood intervention (2nd ed.), edited by J. P. Shonkoff and S. J. Meisels. Cambridge, England: Cambridge University Press. Pp. 510-548. Fletcher-Campbell, F., J. Soler, and G. Reid. 2009. Approaching difficulties in literacy develop- ment assessments, pedagogy and programmes. Thousand Oaks, CA: Sage Publications. Fujiura, G. T., and K. Yamaki. 2000. Trends in demography of childhood poverty and dis- ability. Exceptional Children 66(2):187-199. Gallagher, T. M., and C. A. Prutting. 1983. Pragmatic assessment and intervention issues in language. San Diego, CA: College-Hill Press. GAO (U.S. Government Accountability Office). 2012. Supplemental security income: Better management oversight needed for children’s benefits: Report to congressional requesters. http://purl.fdlp.gov/GPO/gpo25551 (accessed June 12, 2015). Georgieva, D. 1996. Speech and language disorders in children with intellectual disability [microform], edited by M. Cholakova. Washington, DC: ERIC Clearinghouse. 

INTRODUCTION 39 Geurts, H. M., and M. Embrechts. 2008. Language profiles in ASD, SLI, and ADHD. Journal of Autism and Developmental Disorders 38(10):1931-1943. Hall, P. K., and J. B. Tomblin. 1978. A follow-up study of children with articulation and language disorders. Journal of Speech and Hearing Disorders 43(2):227-241. Hart, B., and T. R. Risley. 1995. Meaningful differences in the everyday experience of young American children. Baltimore, MD: Paul H. Brookes Publishing Co. IOM (Institute of Medicine). 2007a. Improving the social security disability decision process, edited by J. D. Stobo, M. McGeary, and D. K. Barnes. Washington, DC: The National Academies Press. IOM. 2007b. The future of disability in America, edited by M. J. Field and A. M. Jette. Washington, DC: The National Academies Press. IOM. 2010a. Cardiovascular disability: Updating the social security listings. Washington, DC: The National Academies Press. IOM. 2010b. HIV and disability: Updating the social security listings. Washington, DC: The National Academies Press. IOM. 2015. Psychological testing in the service of disability determination. Washington, DC: The National Academies Press. IOM and NRC (National Research Council). 2002. The dynamics of disability: Measuring and monitoring disability for social security programs, edited by G. S. Wunderlich, D. P. Rice, and N. L. Amado. Washington, DC: National Academy Press. Johnson, C. J., J. H. Beitchman, A. Young, M. Escobar, L. Atkinson, B. Wilson, E. B. Brownlie, L. Douglas, N. Taback, I. Lam, and M. Wang. 1999. Fourteen-year follow-up of children with and without speech/language impairments. Journal of Speech Language and Hearing Research 42(3):744. Karmiloff-Smith, A. 2011. Static snapshots versus dynamic approaches to genes, brain, cogni- tion, and behavior in neurodevelopmental disabilities. In Early development in neuroge- netic disorders, Vol. 40, edited by D. J. Fidler. London, UK: Elsevier. Pp. 1-15. Karmiloff-Smith, A., D. D’Souza, T. M. Dekker, J. Van Herwegen, F. Xu, M. Rodic, and D. Ansari. 2012. Genetic and environmental vulnerabilities in children with neurode- velopmental disorders. Proceedings of the National Academy of Sciences of the United States of America 109:17261-17265. Karmiloff-Smith, A., B. J. Casey, E. Massand, P. Tomalski, and M. S. C. Thomas. 2014. Environmental and genetic influences on neurocognitive development: The importance of multiple methodologies and time-dependent intervention. Clinical Psychological Science 2(5):628-637. Kena, G., S. Aud, F. Johnson, X. Wang, J. Zhang, A. Rathbun, S. Wilkinson-Flicker, and P. Kristapovich. 2014. The condition of education 2014. NCES 2014-083. Washington, DC: U.S. Department of Education, National Center for Education Statistics. King, R. R. 1982. In retrospect: A fifteen-year follow-up report of speech-language-disordered children. Language, Speech, and Hearing Services in Schools 13(1):24-32. Kuhlthau, K., K. Hill, R. Yucel, and J. Perrin. 2005. Financial burden for families of children with special health care needs. Maternal and Child Health Journal 9(2):207-218. Law, J., J. Boyle, F. Harris, A. Harkness, and C. Nye. 2000. Prevalence and natural history of primary speech and language delay: Findings from a systematic review of the literature. International Journal of Language & Communication Disorders/Royal College of Speech & Language Therapists 35(2):165-188. Lustig, D. C., and D. R. Strauser. 2007. Causal relationships between poverty and disability. Rehabilitation Counseling Bulletin 50(4):194-202. Msall, M. E., F. Bobis, and S. Field. 2006. Children with disabilities and supplemental security income: Guidelines for appropriate access in early childhood. Infants & Young Children 19(1):2-15. 

40 SPEECH AND LANGUAGE DISORDERS IN CHILDREN NASEM (National Academies of Sciences, Engineering, and Medicine). 2015. Mental disorders and disabilities among low-income children. Washington, DC: The National Academies Press. Nelson, K. E. 1989. Strategies for first language teaching. In The teachability of language, edited by M. Rice and R. L. Schiefelbusch. Baltimore, MD: Paul H. Brookes Publishing Co. Pp. 263-310. Newacheck, P. W., and S. E. Kim. 2005. A national profile of health care utilization and expen- ditures for children with special health care needs. Archives of Pediatric and Adolescent Medicine 159(1):10-17. Oller, D. K., R. E. Eilers, A. R. Neal, and H. K. Schwartz. 1999. Precursors to speech in infancy: The prediction of speech and language disorders. Journal of Communication Disorders 32(4):223-245. Oller, J. W., S. D. Oller, and L. C. Badon. 2006. Milestones: Normal speech and language development across the life span. San Diego, CA: Plural Publishing. Parish, S. L., and J. M. Cloud. 2006. Financial well-being of young children with disabilities and their families. Social Work 51(3):223-232. Pennington, B. F., and D. V. Bishop. 2009. Relations among speech, language, and reading disorders. Annual Review of Psychology 60:283-306. Pirila, S., J. van der Meere, T. Pentikainen, P. Ruusu-Niemi, R. Korpela, J. Kilpinen, and P. Nieminen. 2007. Language and motor speech skills in children with cerebral palsy. Journal of Communication Disorders 40(2):116-128. Ruben, R. J. 2000. Redefining the survival of the fittest: Communication disorders in the 21st century. The Laryngoscope 110(2):241-245. Sameroff, A. 1975. Transactional models in early social relations. Human Development 18(1-2):65-79. Sameroff, A. 2009. The transactional model. Washington, DC: American Psychological Association. Schuele, C. M. 2004. The impact of developmental speech and language impairments on the acquisition of literacy skills. Mental Retardation and Developmental Disabilities Research Reviews 10(3):176-183. SSA (Social Security Administration). 2015. SSI monthly statistics, December 2014. http:// www.ssa.gov/policy/docs/statcomps/ssi_monthly/2014/index.html (accessed February 18, 2015). Stoeckel, R. E., R. C. Colligan, W. J. Barbaresi, A. L. Weaver, J. M. Killian, and S. K. Katusic. 2013. Early speech-language impairment and risk for written language disorder: A population-based study. Journal of Developmental and Behavioral Pediatrics 34(1):38. Stothard, S. E., M. J. Snowling, D. Bishop, B. B. Chipchase, and C. A. Kaplan. 1998. Language- impaired preschoolers: A follow-up into adolescence. Journal of Speech, Language, and Hearing Research 41(2):407-418. Sturm, H., E. Fernell, and C. Gillberg. 2004. Autism spectrum disorders in children with nor- mal intellectual levels: Associated impairments and subgroups. Developmental Medicine & Child Neurology 46(7):444-447. Sundheim, S. T., and K. K. Voeller. 2004. Psychiatric implications of language disorders and learning disabilities: Risks and management. Journal of Child Neurology 19(10):814-826. Tomblin, J. B., N. L. Records, P. Buckwalter, X. Xhang, E. Smith, and M. O’Brien. 1997. Prevalence of specific language impairment in kindergarten children. Journal of Speech, Language, and Hearing Research 40:1245-1260. Wang, Q. 2005. Disability and American families: 2000. Bulletin 62(4):21-30. 

INTRODUCTION 41 Wells, N. 2015. Families of Children/Youth with Special Health Care Needs. Workshop presentation to the Committee on the Evaluation of the Supplemental Security Income (SSI) Disability Program for Children with Speech Disorders and Language Disorders on March 9, Washington, DC. WHO (World Health Organization). 2001. International classification of functioning, dis- ability and health. Geneva, Switzerland: WHO. Williams, F. 2013. Language and poverty: Perspectives on a theme. Philadelphia, PA: Elsevier. Wittenburg, D., J. Tambornino, E. Brown, G. Rowe, M. DeCamillis, and G. Crouse. 2015. The Child SSI Program and the changing safety net. Washington, DC: Mathematica Policy Research. Wolke, D., M. Samara, M. Bracewell, N. Marlow, and E. S. Group. 2008. Specific language difficulties and school achievement in children born at 25 weeks of gestation or less. The Journal of Pediatrics 152(2):256-262. Yoshinaga-Itano, C., A. L. Sedey, D. K. Coulter, and A. L. Mehl. 1998. Language of early- and later-identified children with hearing loss. Pediatrics 102(5):1161-1171. 

Speech and language are central to the human experience; they are the vital means by which people convey and receive knowledge, thoughts, feelings, and other internal experiences. Acquisition of communication skills begins early in childhood and is foundational to the ability to gain access to culturally transmitted knowledge, organize and share thoughts and feelings, and participate in social interactions and relationships. Thus, speech disorders and language disorders—disruptions in communication development—can have wide-ranging and adverse impacts on the ability to communicate and also to acquire new knowledge and fully participate in society. Severe disruptions in speech or language acquisition have both direct and indirect consequences for child and adolescent development, not only in communication, but also in associated abilities such as reading and academic achievement that depend on speech and language skills.

The Supplemental Security Income (SSI) program for children provides financial assistance to children from low-income, resource-limited families who are determined to have conditions that meet the disability standard required under law. Between 2000 and 2010, there was an unprecedented rise in the number of applications and the number of children found to meet the disability criteria. The factors that contribute to these changes are a primary focus of this report.

Speech and Language Disorders in Children provides an overview of the current status of the diagnosis and treatment of speech and language disorders and levels of impairment in the U.S. population under age 18. This study identifies past and current trends in the prevalence and persistence of speech disorders and language disorders for the general U.S. population under age 18 and compares those trends to trends in the SSI childhood disability population.

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Language and Speech Disorders in Children

Helping children learn language, what to do if there are concerns.

• Detecting problems

Children are born ready to learn a language, but they need to learn the language or languages that their family and environment use. Learning a language takes time, and children vary in how quickly they master milestones in language and speech development. Typically developing children may have trouble with some sounds, words, and sentences while they are learning. However, most children can use language easily around 5 years of age.

Parents and caregivers are the most important teachers during a child’s early years. Children learn language by listening to others speak and by practicing. Even young babies notice when others repeat and respond to the noises and sounds they make. Children’s language and brain skills get stronger if they hear many different words. Parents can help their child learn in many different ways, such as

• Responding to the first sounds, gurgles, and gestures a baby makes.
• Repeating what the child says and adding to it.
• Talking about the things that a child sees.
• Asking questions and listening to the answers.
• Looking at or reading books.
• Telling stories.
• Singing songs and sharing rhymes.

This can happen both during playtime and during daily routines.

Parents can also observe the following:

• How their child hears and talks and compare it with typical milestones for communication skills external icon .
• How their child reacts to sounds and have their hearing tested if they have concerns .

Learn more about language milestones .  Watch milestones in action.

  Top of Page

Some languages are visual rather than spoken. American Sign Language uses visual signals, including gestures, facial expressions, and body movement to communicate.

Some children struggle with understanding and speaking and they need help. They may not master the language milestones at the same time as other children, and it may be a sign of a language or speech delay or disorder.

Language development has different parts, and children might have problems with one or more of the following:

• Not hearing the words (hearing loss).
• Not understanding the meaning of the words.
• Not knowing the words to use.
• Not knowing how to put words together.
• Knowing the words to use but not being able to express them.

Language and speech disorders can exist together or by themselves. Examples of problems with language and speech development include the following:

• Difficulty with forming specific words or sounds correctly.
• Difficulty with making words or sentences flow smoothly, like stuttering or stammering.
• Language delay – the ability to understand and speak develops more slowly than is typical
• Aphasia (difficulty understanding or speaking parts of language due to a brain injury or how the brain works).
• Auditory processing disorder (difficulty understanding the meaning of the sounds that the ear sends to the brain)

Learn more about language disorders external icon .

Language or speech disorders can occur with other learning disorders that affect reading and writing. Children with language disorders may feel frustrated that they cannot understand others or make themselves understood, and they may act out, act helpless, or withdraw. Language or speech disorders can also be present with emotional or behavioral disorders, such as attention-deficit/hyperactivity disorder (ADHD) or anxiety . Children with developmental disabilities including autism spectrum disorder may also have difficulties with speech and language. The combination of challenges can make it particularly hard for a child to succeed in school. Properly diagnosing a child’s disorder is crucial so that each child can get the right kind of help.

Detecting problems with language or speech

If a child has a problem with language or speech development, talk to a healthcare provider about an evaluation. An important first step is to find out if the child may have a hearing loss. Hearing loss may be difficult to notice particularly if a child has hearing loss only in one ear or has partial hearing loss, which means they can hear some sounds but not others. Learn more about hearing loss, screening, evaluation, and treatment .

A language development specialist like a speech-language pathologist external icon will conduct a careful assessment to determine what type of problem with language or speech the child may have.

Overall, learning more than one language does not cause language disorders, but children may not follow exactly the same developmental milestones as those who learn only one language. Developing the ability to understand and speak in two languages depends on how much practice the child has using both languages, and the kind of practice. If a child who is learning more than one language has difficulty with language development, careful assessment by a specialist who understands development of skills in more than one language may be needed.

Treatment for language or speech disorders and delays

Children with language problems often need extra help and special instruction. Speech-language pathologists can work directly with children and their parents, caregivers, and teachers.

Having a language or speech delay or disorder can qualify a child for early intervention external icon (for children up to 3 years of age) and special education services (for children aged 3 years and older). Schools can do their own testing for language or speech disorders to see if a child needs intervention. An evaluation by a healthcare professional is needed if there are other concerns about the child’s hearing, behavior, or emotions. Parents, healthcare providers, and the school can work together to find the right referrals and treatment.

What every parent should know

Children with specific learning disabilities, including language or speech disorders, are eligible for special education services or accommodations at school under the Individuals with Disabilities in Education Act (IDEA) external icon and Section 504 external icon , an anti-discrimination law.

Get help from your state’s Parent Training and Information Center external icon

The role of healthcare providers

Healthcare providers can play an important part in collaborating with schools to help a child with speech or language disorders and delay or other disabilities get the special services they need. The American Academy of Pediatrics has created a report that describes the roles that healthcare providers can have in helping children with disabilities external icon , including language or speech disorders.

More information

CDC Information on Hearing Loss

National Institute on Deafness and Other Communication Disorders external icon

Birth to 5: Watch me thrive external icon

The American Speech-Language-Hearing Association external icon

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INTRODUCTION

Developmental language disorder is the most common developmental disability of childhood, occurring in 5 to 10 percent of children [ 2 ]. Children learn language in early childhood; later they use language to learn. Children with language disorders are at increased risk for difficulty with reading and written language when they enter school [ 3-5 ]. These problems often persist through adolescence or adulthood [ 6,7 ]. Early intervention may help minimize the more serious consequences of later learning disabilities. (See "Specific learning disorders in children: Clinical features" .)

CLASSIFICATION

The term "speech disorder" refers to an impairment of the articulation of speech sounds, fluency, and/or voice.

● Articulation disorders are characterized by substitutions, omissions, additions, or distortions of speech sounds that interfere with intelligibility.

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22 Speech or Language Impairment

This section includes the IDEA definition of the disability from federal law, along with specific information about eligibility criteria in Virginia. In addition, there is information about the prevalence, causes, and characteristics of this disability, along with specific strategies and accommodations that can meet the needs of students with this disability.

Aligned Standards

CEC Initial Preparation

DEC Preparation

1.4 6.6 6.7

IDEA Definition

§ 300.8 (c) (11)

Speech or language impairment means a communication disorder, such as stuttering, impaired articulation, a language impairment, or a voice impairment, that adversely affects a child’s educational performance.

Eligibility Criteria

VDOE Supplemental Guidance for Evaluation and Eligibility Virginia-specific guidance document that includes sample eligibility checklist (Refer to Table of Contents pages 2-4 and click on page number for disability category)

Advocacy organizations

American Speech-Language-Hearing Association (ASHA) – This advocacy organization provides a variety of information around hearing impairment:

• ASHA advocated for Cognitive Rehabilitation legislation in Texas andfor essential coverage of habilitation and rehabilitation in DC;
• ASHA Talking Points for Applied Behavior Analysis

A  list of speech language and swallowing websites with support groups/advocacy

The Stuttering Foundation

ABOUT speech or language impairment

• 5-10% Americans in the US have a communication disorder (Ruben, 2000).
• 1 in 12 (7.7%) U.S. children ages 3-17 has had a disorder related to voice, speech, language, or swallowing in the past 12 months.
• 34% of children ages 3-10 have multiple communication and/or swallowing disorders.
• 25.4% of those ages 11-17 have multiple disorders (Black et al., 2015).

Visit the US Department of Education’s Open Data Platform to access IDEA Child Count Data by disability category, age, and other demographic and special education variables.

Causes vary based on diagnosis (i.e. aphasia, apraxia, autism spectrum disorder, cleft lip & palate, fluency disorder, social communication disorders, expressive/receptive language disorder, articulation delay or disorder). A resource to look at each of these individually with the definitions, incidence/prevalence, signs/symptoms, causes and additional resources is the Practice Portal and Clinical Topics developed by the American Speech-Language Hearing Association (ASHA).

Characteristics

Characteristics vary based on diagnosis (i.e. aphasia, apraxia, autism spectrum disorder, cleft lip & palate, fluency disorder, social communication disorders, expressive/receptive language disorder, articulation delay or disorder). A resource to look at each of these individually with the definitions, incidence/prevalence, signs/symptoms, causes and additional resources is the Practice Portal and Clinical Topics developed by the American Speech-Language Hearing Association (ASHA).

instructional strategies

Instructional strategies that are effective for all children are also effective for children with communication delays and disorders including:

• Spark interest in the topic first
• Measurable, behavioral objective of the lesson related to the SOL and/or IEP goals
• Link new knowledge to prior knowledge
• Development of vocabulary BEFORE, during, and after the lesson (pre-teaching)
• Instructional sequence = logical steps that include modeling
• Opportunities for guided practice
• Independent practice
• Evaluation format that is used to assess mastery of the concept Immediate corrective feedback
• Conclude with summary of the concept
• Frequent review
• Build background knowledge (group sharing of experiences, family involvement, field trips, videos, direct and explicit instruction, hands-on activities, role-play)

accommodations / modifications

• Speech_Language Impairment – This PowerPoint slide deck provides basic information about speech and language impairment.

An example of a class activity:

GROUP MEDIA PRESENTATION: You will be assigned to a small group of 4-5 students. First, each group will choose one of the following topics in CSD and a target group. Your group will develop an informational presentation on that topic that will be presented/shown in class using one of the formats listed. If you have another format you would like to use, please discuss it with the course instructor for approval PRIOR to your group beginning your plan. POSSIBLE GROUP MEDIA PRESENTATION TOPIC AREAS: Implicit bias in stuttering Hearing loss (general), Phonological disorders in school-age children, The role of the SLP in reading/phonology, Cochlear implants/Hearing aids/BAHA, International Dysphagia Diet Standardization Initiative (IDDSI), Traumatic brain injury; Repeated concussion POSSIBLE TARGET GROUPS: Parents/Caregivers, Children ages 3 – 5, Children ages 5 – 9, Children ages 9 – 12, Teens/Young adults Adults with disabilities, Teachers Family members of adults with disabilities, OTs, PTs, or other medical professionals POSSIBLE MEDIA FORMATS/PLATFORMS: 3 minute video (TikTok), Podcast (4 – 5 minutes), vlog (4-5 minutes), YouTube Video (4-5 minutes, ) Pinterest Board of Resources, Loom Video (4-5 minutes), Voomly Course

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Introduction to Special Education Resource Repository Copyright © 2023 by Serra De Arment; Ann S. Maydosz; Kat Alves; Kim Sopko; Christan Grygas Coogle; Cassandra Willis; Roberta A. Gentry; and C.J. Butler is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License , except where otherwise noted.

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Speech and Language Impairments

• En español | In Spanish
• See fact sheets on other disabilities

Table of Contents

A Day in the Life of an SLP

Christina is a speech-language pathologist. She works with children and adults who have impairments in their speech, voice, or language skills. These impairments can take many forms, as her schedule today shows.

First comes Robbie. He’s a cutie pie in the first grade and has recently been diagnosed with childhood apraxia of speech—or CAS. CAS is a speech disorder marked by choppy speech. Robbie also talks in a monotone, making odd pauses as he tries to form words. Sometimes she can see him struggle. It’s not that the muscles of his tongue, lips, and jaw are weak. The difficulty lies in the brain and how it communicates to the muscles involved in producing speech. The muscles need to move in precise ways for speech to be intelligible. And that’s what she and Robbie are working on.

Next, Christina goes down the hall and meets with Pearl in her third grade classroom. While the other students are reading in small groups, she works with Pearl one on one, using the same storybook. Pearl has a speech disorder, too, but hers is called dysarthria. It causes Pearl’s speech to be slurred, very soft, breathy, and slow. Here, the cause is weak muscles of the tongue, lips, palate, and jaw. So that’s what Christina and Pearl work on—strengthening the muscles used to form sounds, words, and sentences, and improving Pearl’s articulation.

One more student to see—4th grader Mario , who has a stutter. She’s helping Mario learn to slow down his speech and control his breathing as he talks. Christina already sees improvement in his fluency.

Tomorrow she’ll go to a different school, and meet with different students. But for today, her day is…Robbie, Pearl, and Mario.

  Back to top

There are many kinds of speech and language disorders that can affect children. In this fact sheet, we’ll talk about four major areas in which these impairments occur. These are the areas of:

Articulation | speech impairments where the child produces sounds incorrectly (e.g., lisp, difficulty articulating certain sounds, such as “l” or “r”);

Fluency | speech impairments where a child’s flow of speech is disrupted by sounds, syllables, and words that are repeated, prolonged, or avoided and where there may be silent blocks or inappropriate inhalation, exhalation, or phonation patterns;

Voice | speech impairments where the child’s voice has an abnormal quality to its pitch, resonance, or loudness; and

Language | language impairments where the child has problems expressing needs, ideas, or information, and/or in understanding what others say. ( 1 )

These areas are reflected in how “speech or language impairment” is defined by the nation’s special education law, the Individuals with Disabilities Education Act, given below. IDEA is the law that makes early intervention services available to infants and toddlers with disabilities, and special education available to school-aged children with disabilities.

Definition of “Speech or Language Impairment” under IDEA

The Individuals with Disabilities Education Act, or IDEA, defines the term “speech or language impairment” as follows:

Development of Speech and Language Skills in Childhood

Speech and language skills develop in childhood according to fairly well-defined milestones (see below). Parents and other caregivers may become concerned if a child’s language seems noticeably behind (or different from) the language of same-aged peers. This may motivate parents to investigate further and, eventually, to have the child evaluated by a professional.

______________________

More on the Milestones of Language Development

What are the milestones of typical speech-language development? What level of communication skill does a typical 8-month-old baby have, or a 18-month-old, or a child who’s just celebrated his or her fourth birthday?

You’ll find these expertly described in How Does Your Child Hear and Talk? , a series of resource pages available online at the American Speech-Language-Hearing Association (ASHA): http://www.asha.org/public/speech/development/chart.htm

Having the child’s hearing checked is a critical first step. The child may not have a speech or language impairment at all but, rather, a hearing impairment that is interfering with his or her development of language.

It’s important to realize that a language delay isn’t the same thing as a speech or language impairment. Language delay is a very common developmental problem—in fact, the most common, affecting 5-10% of children in preschool. ( 2 ) With language delay, children’s language is developing in the expected sequence, only at a slower rate. In contrast, speech and language disorder refers to abnormal language development. ( 3 )  Distinguishing between the two is most reliably done by a certified speech-language pathologist such as Christina, the SLP in our opening story.

Characteristics of Speech or Language Impairments

The characteristics of speech or language impairments will vary depending upon the type of impairment involved. There may also be a combination of several problems.

When a child has an articulation disorder , he or she has difficulty making certain sounds. These sounds may be left off, added, changed, or distorted, which makes it hard for people to understand the child.

Leaving out or changing certain sounds is common when young children are learning to talk, of course. A good example of this is saying “wabbit” for “rabbit.” The incorrect articulation isn’t necessarily a cause for concern unless it continues past the age where children are expected to produce such sounds correctly. ( 4 ) ( ASHA’s milestone resource pages , mentioned above, are useful here.)

Fluency refers to the flow of speech. A fluency disorder means that something is disrupting the rhythmic and forward flow of speech—usually, a stutter. As a result, the child’s speech contains an “abnormal number of repetitions, hesitations, prolongations, or disturbances. Tension may also be seen in the face, neck, shoulders, or fists.” ( 5 )

Voice is the sound that’s produced when air from the lungs pushes through the voice box in the throat (also called the larnyx), making the vocal folds within vibrate. From there, the sound generated travels up through the spaces of the throat, nose, and mouth, and emerges as our “voice.”

A voice disorder involves problems with the pitch, loudness, resonance, or quality of the voice. ( 6 )   The voice may be hoarse, raspy, or harsh. For some, it may sound quite nasal; others might seem as if they are “stuffed up.” People with voice problems often notice changes in pitch, loss of voice, loss of endurance, and sometimes a sharp or dull pain associated with voice use. ( 7 )

Language has to do with meanings, rather than sounds. ( 8 )  A language disorder refers to an impaired ability to understand and/or use words in context. ( 9 ) A child may have an expressive language disorder (difficulty in expressing ideas or needs), a receptive language disorder (difficulty in understanding what others are saying), or a mixed language disorder (which involves both).

Some characteristics of language disorders include:

• improper use of words and their meanings,
• inability to express ideas,
• inappropriate grammatical patterns,
• reduced vocabulary, and
• inability to follow directions. ( 10 )

Children may hear or see a word but not be able to understand its meaning. They may have trouble getting others to understand what they are trying to communicate. These symptoms can easily be mistaken for other disabilities such as autism or learning disabilities, so it’s very important to ensure that the child receives a thorough evaluation by a certified speech-language pathologist.

What Causes Speech and Language Disorders?

Some causes of speech and language disorders include hearing loss, neurological disorders, brain injury, intellectual disabilities, drug abuse, physical impairments such as cleft lip or palate, and vocal abuse or misuse. Frequently, however, the cause is unknown.

Of the 6.1 million children with disabilities who received special education under IDEA in public schools in the 2005-2006 school year, more than 1.1 million were served under the category of speech or language impairment. ( 11 ) This estimate does not include children who have speech/language problems secondary to other conditions such as deafness, intellectual disability, autism, or cerebral palsy. Because many disabilities do impact the individual’s ability to communicate, the actual incidence of children with speech-language impairment is undoubtedly much higher.

Finding Help

Because all communication disorders carry the potential to isolate individuals from their social and educational surroundings, it is essential to provide help and support as soon as a problem is identified. While many speech and language patterns can be called “baby talk” and are part of children’s normal development, they can become problems if they are not outgrown as expected.

Therefore, it’s important to take action if you suspect that your child has a speech or language impairment (or other disability or delay). The next two sections in this fact sheet will tell you how to find this help.

Help for Babies and Toddlers 

Since we begin learning communication skills in infancy, it’s not surprising that parents are often the first to notice—and worry about—problems or delays in their child’s ability to communicate or understand. Parents should know that there is a lot of help available to address concerns that their young child may be delayed or impaired in developing communication skills. Of particular note is the the early intervention system that’s available in every state.

Early intervention is a system of services designed to help infants and toddlers with disabilities (until their 3rd birthday) and their families. It’s mandated by the IDEA. Through early intervention, parents can have their young one evaluated free of charge, to identify developmental delays or disabilities, including speech and language impairments.

If a child is found to have a delay or disability, staff work with the child’s family to develop what is known as an Individualized Family Services Plan , or IFSP . The IFSP will describe the child’s unique needs as well as the services he or she will receive to address those needs. The IFSP will also emphasize the unique needs of the family, so that parents and other family members will know how to support their young child’s needs. Early intervention services may be provided on a sliding-fee basis, meaning that the costs to the family will depend upon their income.

To identify the EI program in your neighborhood  | Ask your child’s pediatrician for a referral to early intervention or the Child Find in the state. You can also call the local hospital’s maternity ward or pediatric ward, and ask for the contact information of the local early intervention program.

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Help for School-Aged Children, including Preschoolers

Just as IDEA requires that early intervention be made available to babies and toddlers with disabilities, it requires that special education and related services be made available free of charge to every eligible child with a disability, including preschoolers (ages 3-21). These services are specially designed to address the child’s individual needs associated with the disability—in this case, a speech or language impairment.

Many children are identified as having a speech or language impairment after they enter the public school system. A teacher may notice difficulties in a child’s speech or communication skills and refer the child for evaluation. Parents may ask to have their child evaluated. This evaluation is provided free by the public school system.

If the child is found to have a disability under IDEA—such as a speech-language impairment—school staff will work with his or her parents to develop an Individualized Education Program , or IEP . The IEP is similar to an IFSP. It describes the child’s unique needs and the services that have been designed to meet those needs. Special education and related services are provided at no cost to parents.

There is a lot to know about the special education process, much of which you can learn at the Center for Parent Information and Resources (CPIR). We offer a wide range of publications and resource pages on the topic. Enter our special education information at: http://www.parentcenterhub.org/repository/schoolage/

Educational Considerations

Communication skills are at the heart of the education experience. Eligible students with speech or language impairments will want to take advantage of special education and related services that are available in public schools.

The types of supports and services provided can vary a great deal from student to student, just as speech-language impairments do. Special education and related services are planned and delivered based on each student’s individualized educational and developmental needs.

Most, if not all, students with a speech or language impairment will need speech-language pathology services . This related service is defined by IDEA as follows:

(15) Speech-language pathology services includes—

(i) Identification of children with speech or language impairments;

(ii) Diagnosis and appraisal of specific speech or language impairments;

(iii) Referral for medical or other professional attention necessary for the habilitation of speech or language impairments;

(iv) Provision of speech and language services for the habilitation or prevention of communicative impairments; and

Thus, in addition to diagnosing the nature of a child’s speech-language difficulties, speech-language pathologists also provide:

• individual therapy for the child;
• consult with the child’s teacher about the most effective ways to facilitate the child’s communication in the class setting; and
• work closely with the family to develop goals and techniques for effective therapy in class and at home.

Speech and/or language therapy may continue throughout a student’s school years either in the form of direct therapy or on a consultant basis.

Assistive technology (AT) can also be very helpful to students, especially those whose physical conditions make communication difficult. Each student’s IEP team will need to consider if the student would benefit from AT such as an electronic communication system or other device. AT is often the key that helps students engage in the give and take of shared thought, complete school work, and demonstrate their learning.

Tips for Teachers

— Learn as much as you can about the student’s specific disability. Speech-language impairments differ considerably from one another, so it’s important to know the specific impairment and how it affects the student’s communication abilities.

— Recognize that you can make an enormous difference in this student’s life! Find out what the student’s strengths and interests are, and emphasize them. Create opportunities for success.

—If you are not part of the student’s IEP team, a sk for a copy of his or her IEP . The student’s educational goals will be listed there, as well as the services and classroom accommodations he or she is to receive.

— Make sure that needed accommodations are provided for classwork, homework, and testing. These will help the student learn successfully.

— Consult with others (e.g., special educators, the SLP) who can help you identify strategies for teaching and supporting this student, ways to adapt the curriculum, and how to address the student’s IEP goals in your classroom.

— Find out if your state or school district has materials or resources available to help educators address the learning needs of children with speech or language impairments. It’s amazing how many do!

— Communicate with the student’s parents . Regularly share information about how the student is doing at school and at home.

Tips for Parents

— Learn the specifics of your child’s speech or language impairment. The more you know, the more you can help yourself and your child.

— Be patient. Your child, like every child, has a whole lifetime to learn and grow.

— Meet with the school and develop an IEP to address your child’s needs. Be your child’s advocate. You know your son or daughter best, share what you know.

— Be well informed about the speech-language therapy your son or daughter is receiving. Talk with the SLP, find out how to augment and enrich the therapy at home and in other environments. Also find out what not to do!

— Give your child chores. Chores build confidence and ability. Keep your child’s age, attention span, and abilities in mind. Break down jobs into smaller steps. Explain what to do, step by step, until the job is done. Demonstrate. Provide help when it’s needed. Praise a job (or part of a job) well done.

— Listen to your child. Don’t rush to fill gaps or make corrections. Conversely, don’t force your child to speak. Be aware of the other ways in which communication takes place between people.

— Talk to other parents whose children have a similar speech or language impairment. Parents can share practical advice and emotional support. See if there’s a parent nearby by visiting the Parent to Parent USA program and using the interactive map.

— Keep in touch with your child’s teachers. Offer support. Demonstrate any assistive technology your child uses and provide any information teachers will need. Find out how you can augment your child’s school learning at home.

Readings and Articles

We urge you to read the articles identified in the References section. Each provides detailed and expert information on speech or language impairments. You may also be interested in:

Speech-Language Impairment: How to Identify the Most Common and Least Diagnosed Disability of Childhood http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2491683/

Organizations to Consult

ASHA | American Speech-Language-Hearing Association Information in Spanish | Información en español. 1.800.638.8255 | [email protected] | www.asha.org

NIDCD | National Institute on Deafness and Other Communication Disorders 1.800.241.1044 (Voice) | 1.800.241.1055 (TTY) [email protected] | http://www.nidcd.nih.gov/

American Cleft Palate and Craniofacial Association (ACPA) 1.800.242.5338 | https://acpacares.org/

Childhood Apraxia of Speech Association of North America | CASANA http://www.apraxia-kids.org

National Stuttering Foundation 1.800.937.8888 | [email protected] | http://www.nsastutter.org/

Stuttering Foundation 1.800.992.9392 | [email protected] | http://www.stuttersfa.org/

1 | Minnesota Department of Education. (2010). Speech or language impairments . Online at: http://education.state.mn.us/MDE/EdExc/SpecEdClass/DisabCateg/SpeechLangImpair/index.html

2 | Boyse, K. (2008). Speech and language delay and disorder . Retrieved from the University of Michigan Health System website: http://www.med.umich.edu/yourchild/topics/speech.htm

4 | American Speech-Language-Hearing Association. (n.d.). Speech sound disorders: Articulation and phonological processes . Online at: http://www.asha.org/public/speech/disorders/speechsounddisorders.htm

5 | Cincinnati Children’s Hospital. (n.d.). Speech disorders . Online at:  http://www.cincinnatichildrens.org/health/s/speech-disorder/

6 | National Institute on Deafness and Other Communication Disorders. (2002). What is voice? What is speech? What is language? Online at: http://www.nidcd.nih.gov/health/voice/pages/whatis_vsl.aspx

7 | American Academy of Otolaryngology — Head and Neck Surgery. (n.d.).   About your voice . Online at:  http://www.entnet.org/content/about-your-voice

8 | Boyse, K. (2008). Speech and language delay and disorder . Retrieved from the University of Michigan Health System website: http://www.med.umich.edu/yourchild/topics/speech.htm

9 | Encyclopedia of Nursing & Allied Health. (n.d.). Language disorders . Online at: http://www.enotes.com/nursing-encyclopedia/language-disorders

10 | Ibid .

11 | U.S. Department of Education. (2010, December). Twenty-ninth annual report to Congress on the Implementation of the Individuals with Disabilities Education Act: 2007 . Online at: http://www2.ed.gov/about/reports/annual/osep/2007/parts-b-c/index.html

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Speech or Language Impairment

A speech or language impairment (SL) is “a communication disorder, such as stuttering, impaired articulation, a language impairment, or a voice impairment, that adversely affects a child’s educational performance” ( IDEA ).

19% of students qualifying for services under the IDEA have an SL  designation ( National Center for Education Statistics , 2022).

The speech or language impairment category is the second most prevalent type of disability found among school-aged children. Many young children are found to have this disorder. With early intervention, many of the issues facing students with SI can be minimized if not mitigated. This disability affects a child’s ability to communicate clearly.

Some communication disorders include aphasia, which “is a language disorder that results from damage to portions of the brain that are responsible for language” ( NASET ), apraxia, which “is a speech disorder in which a person has trouble saying what he or she wants to say correctly and consistently” ( NASET ), auditory processing disorder which “is a term used to describe what happens when your brain recognizes and interprets the sounds around you” ( NASET ), developmental dyspraxia, which “is a disorder characterized by an impairment in the ability to plan and carry out sensory and motor tasks” ( NASET ), Landau-Kleffner syndrome, which “is a childhood disorder. A major feature of LKS is the gradual or sudden loss of the ability to understand and use spoken language” ( NASET ), laryngeal papillomatosis, which “is a disease consisting of tumors that grow inside the larynx (voice box), vocal cords, or the air passages leading from the nose into the lungs (respiratory tract)” ( NASET ), and spasmodic dysphonia, which “is a voice disorder caused by involuntary movements of one or more muscles of the larynx or voice box” ( NASET ).

While students may struggle with speech and language, they can still have a good sense of humor, be outgoing, and create and sustain lasting friendships; the strengths of students with speech or language impairment are wide and varied. Additionally, students with SL may excel at sports, art, music, writing, science, and math. 

It is important for educators to detect students with speech and language disorders early in their educational experience. Child Find, part of IDEA, is instrumental in early detection and remediation. Speech and language pathologists can assist children in the acquisition of speech and language at a young age. It is much easier for students to learn how to speak properly at a younger age because of how the human brain develops. Children five years and younger will have a much higher rate of successful intervention than older children ( NASET , 2023).

Furthermore, children with speech and language impairments have a much greater chance of becoming isolated from others due to their inability to communicate. This causes emotional stress as well as possible alienation from peers. Speech therapy is a must and can be done while in school. The use of assistive technology is also needed so the student can have a voice that is heard by peers and teachers.

The section below explains some strategies for supporting students experiencing speech or language impairment. Based on what you have read so far, what strategies do you think might be useful for supporting students experiencing speech or language impairment?

Common Teaching Strategies

According to Nemours KidsHealth, here are some ways to help promote learning among students with speech or language impairment:

• Move kids closer to you. Having kids sit closer to the front of the class makes it easier to help them with questions and assignments. Kids also may need to sit closer to you if they have a hearing problem.
• Make sure kids understand and write down assignments correctly to help avoid confusion.
• Give extra time to complete assignments or make-up work when needed.
• Substitute written papers or projects for oral presentations, or allow a student to demonstrate learning one-on-one with you. Asking questions in a way that lets the student give a brief answer can also help.
• Use technology to make learning easier. This may include having real-time captioning on any videos used in the classroom and using voice-recognition software on computers.
• Be patient (and encourage classmates to be patient) when students speak in class.
• Talk about and celebrate differences. Students with speech or language problems want to be accepted like everyone else. But sometimes they’re targeted by others who see them as “different.” Talk about and celebrate differences, and focus on the interests that kids share. Be mindful of bullying, and keep a zero-tolerance policy for that behavior. ( Speech and Language Disorders Factsheet )

Deeper Dive

For more information about speech or language impairment, review the following resources:

• What’s the difference between a speech impairment and a language disorder?
• Language and Speech Disorders in Children
• Comprehensive Overview of Speech and Language Impairments
• Speech and Language Impairments

National Association of Special Education Teachers (NASET). (2023). Comprehensive overview of speech and language impairments. National Association of Special Education Teachers. Retrieved from https://www.naset.org/professional-resources/exceptional-students-and-disability-information/speech-and-language-impairments/comprehenisve-overview-of-speech-and-language-impairments

National Center for Education Statistics. (2022).  Students With Disabilities . Condition of Education. U.S. Department of Education, Institute of Education Sciences.

Speech and Language Disorders Factsheet

U.S. Department of Education. (2018). Sec. 300.8 Child with a disability. Retrieved from https://sites.ed.gov/idea/regs/b/a/300.8

means a communication disorder, such as stuttering, impaired articulation, a language impairment, or a voice impairment, that adversely affects a child’s educational performance

is the national membership organization dedicated solely to meeting the needs of special education teachers and those preparing for the field of special education teaching

Introduction to Special Education Copyright © by Minnesota State is licensed under a Creative Commons Attribution 4.0 International License , except where otherwise noted.

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What Are Language Disorders?

Elizabeth is a freelance health and wellness writer. She helps brands craft factual, yet relatable content that resonates with diverse audiences.

Daniel B. Block, MD, is an award-winning, board-certified psychiatrist who operates a private practice in Pennsylvania.

LightFieldStudios / Getty Images

Children come to the world almost pre-programmed to learn the language of their environment. But while it appears automatic for a child to learn to read, speak, and understand communication around them—the pace at which these skills are learned vary among children. In some cases, children may not meet certain developmental milestones .

A language disorder occurs when a child is unable to compose their thoughts , ideas, and messages using language. This is known as an expressive language disorder. When a child faces difficulty in understanding what is communicated via language, this is called a receptive language disorder.

Sometimes, a child may live with a mix of expressive and receptive language disorders. A lack of understanding or poor expression of language does not always indicate a language disorder, however. This could simply be the result of a speech delay.

Read on to learn about the types, characteristics, causes, and trusted treatment methods to manage language disorders in children .

Types of Language Disorders in Children 

With language , there are specific achievements expected when children mark a certain age. At 15 months, it is likely that a child can recognize between five to ten people when they are named by parents or caregivers. At 18 months, it is expected that a child can respond to simple directives like ‘let’s go outside’ without challenges. This is an already receptive child.

If at 18 months, a child is unable to pronounce ‘mama’ and ‘dada’, or if at 24 months, this child does not have at least 25 words in their vocabulary—this could signal an expressive language disorder.

Receptive Language Disorder

When a child struggles to understand the messages communicated to, or around them, this can be explained as a receptive disorder. Children with receptive challenges will usually display these difficulties before the age of four.  

Receptive difficulties may be observed where a child does not properly understand oral communication directed at, or around them.

In such cases, the child struggles to understand the spoken conversations or instructions directed around them. Likewise, written words may be difficult to process. Simple gestures to come, go, or sit still may also prove challenging to comprehend.

Expressive Language Disorders

Expressive language disorders occur when a child is unable to use language to communicate their thoughts or feelings.

In this sense, oral communication is just one of the affected areas. A child may also consider written communications difficult to express.

Children with expressive disorders will find it difficult to name objects, tell stories, or make gestures to communicate a point. This disorder can cause challenges with asking or answering questions, and may lead to improper grammar usage when communicating.

Symptoms of Language Disorders

Language disorders are a common observation in children. Up to 1 out of 20 children exhibit at least one symptom of a language disorder as they grow. The symptoms of receptive disorders include:

• Difficulty understanding words that are spoken
• Challenges with following spoken directions
• Experiencing strain with organizing thoughts

Expressive language disorders are identified through the following traits in children:

• Struggling to piece words into a sentence
• Adopting simple and short words when speaking 
• Arranging spoken words in a skewed manner
• Difficulty finding correct words when speaking
• Resorting to placeholders like ‘er’ when speaking
• Skipping over important words when communicating
• Using tenses improperly 
• Repeating phrases or questions when answering

Causes of Language Disorders

With a language disorder, the child does not develop the normal skills necessary for speech and language. The factors responsible for language disorders are unknown, this explains why they are often termed developmental disorders .  

Disabilities or Brain Injury

Despite the uncertainty around the causes of these disorders, certain factors have strong links to these conditions. In particular, other developmental disorders like autism and hearing loss commonly co-occur with language disorders. Likewise, a child with learning disabilities may also live with language disorders.

Aphasia is another condition linked with language disorders. This condition develops from damage to the portion of the brain responsible for language. Aphasia may be caused by a stroke, blows to the head, and brain infections.  The injury may increase the chances of developing a language disorder.  

Diagnosis of Language Disorders

To determine if a child has a language disorder, the first step is to receive an expert’s assessment of their condition.

A speech-language pathologist or a neuropsychologist may administer standardized tests. These are to review the child’s levels of language reception and expression.

The Link Between Deafness and Language Problems

In making their assessment, the health expert will conduct a hearing test to discover if the child suffers from hearing loss. This is because deafness is one of the most common causes of language problems.  

Treatment of Language Disorders

Language disorders can have far-reaching effects on the life of a child. These disorders can lead to poor social interactions, or a dependence on others as an adult. Challenges with reception and expression can also lead to reading challenges, or problems with learning .

To manage this condition, parents/guardians should exercise patience and care when dealing with children managing language disorders. While it can be challenging, children already experience frustration when dealing with others and expressing themselves. Caregivers can provide a place of comfort for children who have learning challenges.

For expert guidance, a speech-language pathologist can work with children and their guardians to improve communication and expression.

Because language disorders can be emotionally taxing, parents and children with these disorders can try therapy . This will help in navigating the emotional and behavioral issues caused by language impairments.

NCBI. Speech and Language Disorders in Children: Implications for the Social Security Administration's Supplemental Security Income Program .

MedlinePlus. Language Disorders in Children .

Ritvo A, Volkmar F, Lionello-Denolf K et al. Receptive Language Disorders . Encyclopedia of Autism Spectrum Disorders . 2013:2521-2526. doi:10.1007/978-1-4419-1698-3_1695

Reindal L, Nærland T, Weidle B, Lydersen S, Andreassen O, Sund A. Structural and Pragmatic Language Impairments in Children Evaluated for Autism Spectrum Disorder (ASD) .  J Autism Dev Disord . 2021. doi:10.1007/s10803-020-04853-1

National Institute on Deafness and Other Communication Disorders. Aphasia .

Centers for Disease Control and Prevention. Language and Speech Disorders in Children .

By Elizabeth Plumptre Elizabeth is a freelance health and wellness writer. She helps brands craft factual, yet relatable content that resonates with diverse audiences.

• 2024 Winter
• School of Communication
• Communication Sciences and Disorders
• Introduction to Speech, Language, Learning, and Their Disorders

Introduction to Speech, Language, Learning, and Their Disorders (320-0-1)

Instructors.

Amy Lynn Mack Sindelar

Meeting Info

Frances Searle Building 3220: Mon, Wed 9:30AM - 10:50AM

Overview of class

Overview of normal and disordered communication. Speech, language, hearing, and cognitive development disorders and their psychosocial effects, across the age continuum according to etiology, clinical manifestations, and intervention. Anatomy and physiology of speech, language, and hearing. Service-delivery settings; ethical and legal considerations; professional issues.

Learning Objectives

1. Describe the educational backgrounds, scope of service, and professional credentials of speech language pathologists, audiologists, speech language pathology assistants, and learning disability specialists • Assessed by: Reading/lecture outlines 2. Identify and describe anatomy and physiology significant in the study of speech, language, and learning • Assessed by: Reading/lecture outlines, Research product 3. Describe normal development of speech and language • Assessed by: Research product 4. Describe correlated variables, characteristics, and intervention for speech and language disorders that include: childhood language delays and learning disorders, articulation and phonological delays and disorders, neurogenic communication disorders, fluency disorders, dysphagia and vocal disorders • Assessed by: Reading/lecture outlines, research product, reflection paper

Evaluation Method

• Completion of reading/lecture outlines via provided worksheet • Introduction Survey • Personal Clinical Reflection • Disability, Disorder, Difference in the Media Reflection • Four video observation worksheets • Clinical Question & Research review product

Class Materials (Required)

Owens, Metz, and Farinella (2019). Introduction to Communicative Disorders: A Lifespan Evidence-Based Perspective, 6th ed. Pearson. ISBN-13: 978-0-13-480159-9 Class allows prior editions of textbook Students are encouraged to consult alternate vendors (Amazon, book rentals, etc.)

Introduction to Language and Communication

Specific Language Impairment

( RADLD (Director). (2012, September 20). Literacy difficulties and SLI (DLD) [Video file]. Retrieved from https://www.youtube.com/watch?v=CjF6rx-6KRY)

• Have a standard IQ
• No other neurological impairments
• Impacts a person’s ability to speak, listen, read, and/or write
• Only 1% of the general population
• More boys are diagnosed than girls, 1.33 boys diagnosed per 1 girl diagnose
• Can occur along with other developmental disorders
• Having SLI is a risk factor for having a learning disability
• Possible genetic component
• Learning more than one language does not cause SLI
• Diagnosed through observation, interviews, questionnaire, general learning assessment, and a standardized test on the child’s language abilities

Communication Skills and Disorders

• Explains why they are not able to identify new words to learn
• This causes them not to remember new words that they have heard
• Have difficulties distinguishing between similar sounds
• Difficulties analyzing the structure of words
• Their syntax and sentence structure has deficits
• Produce ungrammatical sentences
• Difficulties understanding sentence with complex structure
• They start speaking later than their peers
• Produce their first words a year later, second birthday

Literacy Skills and Disorders

• Individuals with SLI tend to have issues regarding specific tasks related to reading and literacy, for example, finding rhyming words or alliterative words.
• Errors in reading individual words are more prevalent as individuals with SLI, typically, have lower phonemic awareness.
• Poor reading comprehension skills are more common in individuals with SLI.
• Individuals diagnosed with SLI tend to use fewer words in their writing as well as have a lower diversity of words.
• For structural aspects of writing, including skills such as organization, these skills in most cases are impaired.
• Grammar is an area that individuals with SLI usually struggle with, especially when focusing on verb tenses being accurate.
• The ideas used within the writing of individuals with SLI typically have a poorer quality.
• While comparing individuals with SLI to their typically developing peers, they will usually demonstrate a deficiency in their writing skills, 

Verbal Interventions

• Used to improve the auditory processing in individuals with SLI
• The software which challenges a person’s linguistic and cognitive abilities 
• Consists of different tasks which manipulate speech style, language components, and stimuli
• Fast ForWord is a commonly used intervention software
• A study done by Horst in 2017
• Tested three-year-old children with and without SLI 
• Parents read children’s book repeatedly to their children
• Results found that children with SLI did worse remembering words initially but performed the same remembering the words a week later

Written Communication Interventions

• A structure of interventions that can focus on individual areas of language development deficiencies
• Follows either a top-down or bottom-up approach, which is either focusing on general details with working up to bigger and bigger components of speech or the other way around
• When using this structural form, it is important to use the individual’s language strengths as the base for determining the sequential order
• Allows for co-dependencies of language, which is understanding how to process information based on making associations and representations throughout language
• Introducing situations that encourage the individual to use the targeted area of language (i.e. promoting the use of the “-ed” suffix)
• These exercises usually involve toys or props of some sort.
• Promotes the use of different morphemes within language, which can be applied to increasing grammatical and literacy skills
• Can be approached from multiple angles including in a group setting, in a more one-on-one setting, retelling a story, or coming up with a personal story narrative
• Allows individuals to increase their narrative abilities, or their ability to tell a story in a clear and organized fashion.
• Allows for a better understanding of components like reading text, sentence comprehension, as well as other semantic processes

Classroom Video

Acosta Rodríguez, R. (2016). Intervention in reading processes in pupils with Specific Language Impairment (SLI). Psicothema , 28 (1), 40–46. https://doi.org/10.7334/psicothema2015.144

ASHA. (2020). Speech-Language Pathologists. 

Encyclopedia of Children’s Health. (2020). Specific language impairment.

Hessling, A., & Schuele, C. M. (2020). Individualized Narrative Intervention for School-Age Children With Specific Language Impairment. Language, Speech, & Hearing Services in Schools , 51 (3), 687+. 

Icommunicate therapy. (2019, August 25). Specific language impairment (SLI). 

Joanisse, M., & Seidenberg, M. (1998, September 08). Specific language impairment: A deficit in grammar or processing? 

Justice, K.L.P.T.L. M. (2016). Language development from theory to practice . [Yuzu]. 

Leonard, L. B. (2014). Children with specific language impairment . Cambridge, MA: MIT press

Leonard, L. B. (2017). Children with specific language impairment (Second ed.). Cambridge, Mass.: MIT Press.

Leonard, L. B., Camarata, S. M., Pawlowska, M., Brown, B., & Camarata, M. N. (2008). The acquisition of tense and agreement morphemes by children with specific language impairment during intervention: phase 3. Journal of Speech, Language, and Hearing Research , 51 (1), 120+. 

Nation, K., Clarke, P., Marshall, C. M., & Durand, M. (2004). Hidden language impairments in children: parallels between poor reading comprehension and specific language impairment? Journal of Speech, Language, and Hearing Research , 47 (1), 199+. 

NICDC. (2019, July). Specific Language Impairment. 

Norris, J. A., & Hoffman, P. R. (1990). Language intervention within naturalistic environments. Language, Speech, and Hearing Services in Schools, 21 (2), 72-84. doi:10.1044/0161-1461.2102.72

RADLD (Director). (2012, September 20). Literacy difficulties and SLI (DLD) [Video file]. Retrieved from https://www.youtube.com/watch?v=CjF6rx-6KRY

Roden, I., Früchtenicht, K., Kreutz, G., Linderkamp, F., & Grube, D. (2019). Auditory stimulation training with technically manipulated musical material in preschool children with specific language impairments: An explorative study. Frontiers in Psychology, 10 . doi:10.3389/fpsyg.2019.02026

Rohlfing, K. J., Ceurremans, J., & Horst, J. S. (2017). Benefits of repeated book readings in children with sli. Communication Disorders Quarterly, 39 (2), 367-370. doi:10.1177/1525740117692480

Sedivy, J. (2020). Language in mind: An introduction to psycholinguistics (Second ed.). New York ; Oxford: Oxford University Press, Sinauer Associates.

Strong, G. K., Torgerson, C. J., Torgerson, D., & Hulme, C. (2010). A systematic meta‐analytic review of evidence for the effectiveness of the ‘Fast ForWord’ language intervention program. Journal of Child Psychology and Psychiatry, 52 (3), 224-235. doi:10.1111/j.1469-7610.2010.02329.x

Stavrakaki, S. (2015). Specific Language Impairment : Current Trends in Research . John Benjamins Publishing Company.

Tambyraja, S. R., Schmitt, M. B., Farquharson, K., & Justice, L. M. (2015). Stability of language and literacy profiles of children with language impairment in the public schools. Journal of Speech, Language, and Hearing Research , 58 (4), 1167+. 

Tomblin, J. B., Records, N. L., Buckwalter, P., Zhang, X., Smith, E., & O’Brien, M. (1997). Prevalence of specific language impairment in kindergarten children. Journal of speech, language, and hearing research : JSLHR , 40 (6), 1245–1260. 

Vandewalle, E., Boets, B., Ghesquiere, P., & Zink, I. (2012). Development of phonological processing skills in children with specific language impairment with and without literacy delay: a 3-year longitudinal study. Journal of Speech, Language, and Hearing Research , 55 (4), 1053+. 

Williams, G. J., Larkin, R. F., & Blaggan, S. (2013). Written language skills in children with specific language impairment. International Journal of Language & Communication Disorders , 48 (2), 160–171.

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Speech assessment tool methods for speech impaired children: a systematic literature review on the state-of-the-art in Speech impairment analysis

Gowri prasood usha.

School of Electronics Engineering, Vellore Institute of Technology, Chennai, 600127 India

John Sahaya Rani Alex

Associated data.

Data sharing not applicable to this article as no datasets were generated or analysed during the current study.

Speech is a powerful, natural mode of communication that facilitates effective interactions in human societies. However, when fluency or flow of speech is affected or interrupted, it leads to speech impairment. There are several types of speech impairment depending on the speech pattern and range from mild to severe. Childhood apraxia of speech (CAS) is the most common speech disorder in children, with 1 out of 12 children diagnosed globally. Significant advancements in speech assessment tools have been reported to assist speech-language pathologists diagnosis speech impairment. In recent years, speech assessment tools have also gained popularity among pediatricians and teachers who work with preschoolers. Automatic speech tools can be more accurate for detecting speech sound disorders (SSD) than human-based speech assessment methods. This systematic literature review covers 88 studies, including more than 500 children, infants, toddlers, and a few adolescents, (both male and female) (age = 0–17) representing speech impairment from more than 10 countries. It discusses the state-of-the-art speech assessment methods, including tools, techniques, and protocols for speech-impaired children. Additionally, this review summarizes notable outcomes in detecting speech impairments using said assessment methods and discusses various limitations such as universality, reliability, and validity. Finally, we consider the challenges and future directions for speech impairment assessment tool research.

Introduction

Speaking difficulties, whether in producing sound or in other aspects of articulation, are collectively known as speech impairment. Speaking difficulties encompass several types of disorders and can range from mild to severe. Language Speech Impairment (LSI) [ 86 ] is a form of speech impairment that occurs without any evident underlying mental or physical disorder or direct neurological damage. More specifically, a language disorder describes an impairment in comprehension and spoken, written, and other symbol systems [ 26 ]. Speech sound disorders (SSD) are categorised into articulation, fluency, and voice disorders.

Previous studies have shown that childhood apraxia of speech is one of the most common disorders among children, with 1 out of 12 children globally affected by this condition [ 86 ]. Existing literature indicates that SSD prevalence in children is comparable in monolingual and multilingual communities [ 47 ]. Children with SSD present with low speech lucidity and have retarded speech sound acquisition [ 34 ]. Therefore, helpful speech evaluation tools must be developed to help speech-language pathologists (SLP) detect speech deficits in children as early possible to begin appropriate intervention. To better understand the current scenario and provide a foundation on which subsequent studies can be built on, this paper systematically reviews literature for voice assessment tool methods for children with speech impairments.

Earlier studies have dedicated little attention to understanding the morbid impacts of infectious diseases and epidemics in developing countries. There are several risks associated with these epidemics, such as the possibility of neurocognitive impairments in the children who survive the epidemic [ 17 ]. Therefore, SLPs must be culturally and linguistically competent to deliver effective patient service and not only cater to a specific demographic [ 28 ]. Traditional articulation treatment methods aim to rectify solitary speech sounds instead of phonological interventions that address speech sound systems [ 16 ]. Hence, the most desirable speech assessment tool methods are those that use the latter approach.

Adopting measures that reduce the need for further treatment will positively impact the children and their families, as well as the treatment systems itself [ 60 ]. During preschool, family members often misunderstand children with SSD since they are unintelligible [ 23 ]. The delay in their literacy competencies is often severe and present with concomitant language disorders [ 16 ]. Additionally, poor social relations among children with SSD might negatively impact their self-image [ 10 , 12 ]. Despite such consequences, there is little evidence about the treatments SLPs employ when treating children with SSD [ 16 ]. Efficient and effective treatment methods must therefore be developed and promoted.

According to recent studies, the prevalence of speech and language impairments in children is rising [ 67 , 68 ]. Speech therapy is the most common therapeutic intervention for SSD, but it is also one of the most expensive and challenging treatments available other than surgery. A speech-language evaluation normally costs between $200 to $300, and a half-hour therapy session may cost between $50 to $100 although the actual cost of speech therapy can vary depending on various factors [ 31 ]. In addition, it takes numerous sessions to observe a noticeable improvement in the children. According to research, intensive intervention is more successful and efficient for kids with SSD [ 43 ]. In other words, one might require multiple sessions each week. The research published in the literature thus indicates a likely increase in the number of children with SSD in the future, considering the costs of intervention and frequency, which are the limiting factors. A suitable, efficient, and cost-effective treatment should be available for these children to lower the rate of child SSD and help them navigate the condition.

Children presenting with cleft palate lip are likely to develop speech difficulties that will require speech and language therapy [ 13 ]. According to Cummins et al. (2015), speech is a sensitive output system due to the complexity of speech production; hence, slight physiological and cognitive changes potentially can produce noticeable acoustic changes [ 20 ]. Brookes and Bowley (2014) describe tongue-tie as a congenital state characterised by a short lingual frenulum that could restrict the tongue’s movement and influence its function [ 14 ]. Studies have shown that tongue-tie is a common disorder with a documented 3–4% incidence among infants [ 9 ]. Therefore, a universal criterion for diagnosing children’s language impairments is necessary to reduce present variations.

Fundamental elements of communicative competence encompass a framework that describes reasonably intelligible pronunciation [ 22 ]. Perceptual measures, which form a part of the comprehensive speech evaluation, are concerned with assessing the speaker’s intelligibility [ 10 ], while a systematic speech pathology assessment tool uses articulation to predict the overall intelligibility score [ 12 ]. Intervention outcomes associated with speech impairments, such as increased sentence length, improved articulatory function, and use of grammatical markers, form the traditional focus of studies assessing speech-language therapies’ effectiveness [ 21 ]. This paper aims to conduct a systematic literature review of the speech assessment tools for impaired speech children. Here, we review the speech impairment detection tools to establish current trends and findings in the educational relevant domain.

The current review presents the research and studies involved in speech assessment methods for children and adolescents with different speech impairments from 2010 to 2022. We present the methodology adopted in this study and literature review results in Sections 2 and 3 , respectively. Section  4 presents the discussion, while Section 5 mentions future directions and challenges. Finally, we conclude the study in Section 6 .

In this review, we aim to address the following research questions:

• What are the different types of assessment methods being used?
• For what disordered language or disordered speech and the range of delay or disorder investigated?
• Accuracy of analysis: How do these methods perform, and their efficiency/precision?
• Is there room for improvement in these methods for the early detection of speech and language disorders?

Though these research questions are interrelated and discussed throughout the article, the speech assessment methods and purpose have been discussed mainly in Sections 3 and 4 . Accuracy analysis of the methods is covered in Section 3 and especially in Table ​ Table3 3 on pages 9 and 10, but the efficiency of the method concerning the studies reported has been explained in Section 4 . Finally, the challenges associated with existing methods and the ways to improve them are explored in Section 5 .

Comparison of speech assessment tools

Literature selection criteria

The authors searched for primary and secondary peer-reviewed articles that met the quality assessment criteria in this systematic literature review. Various digital databases were queried using keyword search to select the study’s most appropriate and relevant papers. The criteria for exclusion and inclusion were met in the document studies that were analysed. Therefore, this paper’s research design is a systematic approach that adheres to an outlined study protocol.

The research question was to establish whether methods can detect SSD using different techniques to develop practical speech assessment tools. The reliance on a well-defined methodology ensured that research bias is eliminated to result in fair and objective outcomes. The authors designed, reviewed, and revised the study protocol for the present review. Here, we analysed each peer-reviewed article twice to ascertain that the extracted data complied with the review protocol. The search strategy, criteria for integration and exclusion, and quality assessment process are described in detail in the following sections. We followed the PRISMA protocol to perform the systematic literature review to achieve higher transparency and reliability.

Search strategy

We established the existing studies in speech assessment tools for speech-impaired children by querying online databases such as Medline, ScienceDirect, CINAHL, EMBASE, IEEE Xplore, PsychInfo, Web of Search, SpringerLink, Scopus, First Search, ERIC, ACM Digital Library, Linguistics and Language Behaviour Abstracts, and DARE for articles that contained the keywords speech, speech impairments, speech assessment tools, speech impaired children, speech analysis and SSD in the title, abstract. Additionally, the authors queried Scopus and Web of Science to locate other published articles in little-known online libraries. The rationale behind the search strategy was to find significant peer-reviewed articles with full-text and conference proceedings related to the field of “Speech Impairment” and “Speech Assessment Tools”. The keywords used during the search strategy were expected to yield most of the papers containing speech assessment tools. Google Scholar and Google search engines were also utilised to ensure no relevant article was omitted from the study. The author conducted the entire search process, and the process was finalised on 11th May 2022.

Inclusion and exclusion criteria

The researcher developed a pilot version of the selection criteria that targeted all relevant primary studies and finalised it after revising the review protocol. The authors’ institutional affiliation and names were irrelevant when deciding on the inclusion and exclusion criteria. Exclusion criteria were as follows: Studies that did not include speech assessment tools and those that did not have robust speech assessment mechanisms for speech-impaired children; papers that failed incorporate the speech assessment tool’s interrater reliability were not considered for the study; overlapping studies from various journals and online databases; and peer-reviewed studies published before 2010.

In the end, only 92 items that were written in English from 2010 onwards about speech assessment tools, protocols and methods for speech-impaired children were selected for a systematic analysis. Only original articles were included in the review. Additionally, these studies include interrater reliability of the speech assessment tools between 2010 and 2022. A significant proportion of the 92 articles selected for review had different authors, while a small number authoring more than one paper was found. Fig. ​ Fig.1 1 below shows the scientometric mapping of the type of research conducted by authors in the review articles.

Scientometric mapping of the categories of peer-reviewed papers included in the systematic review

Figure ​ Figure2 2 shows the year-wise category of the papers selected from 2010 to 2022. The full-text paper’s quality is assessed based on the sampling method, the study’s sample size, and whether the survey is cohort or research-based.

Number of papers included in the review published year-wise from 2010 to 2022

Speech impairment analysis methods

Tools, techniques, and protocols.

The planning and coordination of speech arises from complex neurological interactions occurring in certain brain regions while fold vibrations in the larynx generate signals that make speech audible [ 71 ]. According to Strand et al., Paediatric SSD results from various aetiologies and impairs speech production on several levels, including linguistic/phonological and motor speech [ 79 ]. Establishing the degree of contribution of motor speech impairment in the child’s SSD is one of the principal difficulties during differential diagnosis [ 23 ]. Hence, it is necessary to develop a speech assessment tool that will eliminate these existing challenges. In the subsequent sections, we describe and compare the leading speech assessment methods currently employed by paediatricians, clinics, and therapists.

Dynamic Evaluation of Motor Speech Skill (DEMSS)

DMESS tool is designed to help in differential detection of SSD among both young children and older children. It is challenging to isolate deficits in plan and program transitions between the volitional speech articulation positions of SSD children, partly because of the interactive speech and language processes. DMESS is a recent speech assessment tool designed to counter the abovementioned issue [ 79 ]. Strand et al., relied on expert opinions and current literature to conclude that there is consensus among researchers about CAS [ 79 ]. CAS is in the recurrent construction of words or syllables through erroneous vowels and consonants; extended and disorderly co-articulatory shifts linked syllables and sounds; and ill-suited prosody achievement phrasal or lexical string [ 79 ]. Clinical assessment of children with SSD typically involves issuing oral structural-functional tests [ 66 ].

According to Strand et al., as a motor speech examination, the DEMSS systematically varies the length, vowel content, prosodic content, and phonetic complexity within sampled utterances [ 79 ]. DEMSS test is designed to test young children’s speech movements and little ones with severe speech impairment. It does not act as a phonologic proficiency or articulation test which evaluates overall segments in a language. It is designed for children incapable of producing syllables, sounds, or words.

The DEMSS is concerned with earlier developing consonant sounds matched with an array of vowels in numerous evolving syllable shapes [ 59 ]. The DEMSS comprises nine subtests consisting of 66 utterances, as shown in this Table ​ Table1. 1 . The 66 pronunciations contain 171 judgmental items that make four sets of sub-scores [ 79 ]. The severity of the childhood apraxia of speech is determined based on the child’s overall score after taking the test.

Dynamic Evaluation of Motor Speech Skills (DEMSS) Content Coverage

The DEMSS is the most influential speech assessment tool among children with impaired speech. It incorporates the dynamic assessment for judgments about severity and prognosis. The medical practitioner administering the DEMSS test instructs the child to fixate their eyes on the instructor’s face as much as possible while uttering a series of words. Considering the child’s first imitation, the pediatrician might use various levels of cuing to elicit more imitative attempts before compiling the final score. Evidence shows that the DEMSS tool is one of the most suitable speech assessment tools since it indicates the SSD severity. Since the tool utilises a dynamic assessment, the pediatrician incorporates cues and other techniques, such as simultaneous production or slowed rate, to elicit several scoring attempts. The prosody and vowel accuracy scoring are done when the child first attempts an utterance. Overall articulatory accuracy is not scored based on the initial effort but on subsequent trials [ 79 ]. Table ​ Table2 2 illustrates the basic rules clinicians follow when scoring the child within the four sub-scores: vowel accuracy, consistency, overall articulatory accuracy, and prosodic accuracy (lexical stress accuracy), with poor performance symbolised by higher scores [ 79 ].

DMESS Scoring

Motor Speech Examination

MSE, often used to establish the presence or absence of speech motor programming and planning in adults, can also be adapted to diagnose SSD in young children [ 79 ] MSE enables a pediatrician to detect speech construction across utterances that differ in phonetic complexity and length using organised stimuli systematically to vary programming demands. Previous studies have shown that only the Verbal Motor Production for children, among the six documented assessment tools for diagnosing SSD, passed the validity test, although none of the tests recorded reliability [ 79 ]. Therefore, there is a need to develop an MSE tool that provides proof of validity and reliability.

According to Strand et al., providing evidence of reliability is critical to developing speech assessment examinations. Validity in MSE tools can be described as the extent to which the study measures the elements it seeks to evaluate [ 79 ]. Several approaches can document the validity of a given test used in SSD diagnosis. Therefore, the validity and reliability measures of a particular speech assessment tool are critical in determining the overall acceptance of its outcomes.

The most frequently used validity measures methods are the gold standard (acknowledged valid measure) and contrasting correlations and groups between the examinations under investigation [ 79 ]. Another technique used to measure the validity evidence of an MSE test is cluster analysis. Cluster analysis is commonly used to evaluate constructs that identify homogeneous subcategories within broader clusters, including civic language disorders, autism spectrum disorders, and SSDs [ 32 ]. Moreover, they are used to detect non-speech and co-occurring speech characteristics in childhood apraxia of speech [ 79 ]. The test validity is evident if the results of the examination mirror those conducted using different diagnostic tools.

Automatic speech analysis tools

Children with difficulties producing intelligible speech are categorised as having paediatric SSD [ 75 ]. Speech impairment can occur during speech production’s motor planning, linguistic, or motor execution phases [ 77 ]. Technological advancements in automatic speech analysis have reinforced the idea that artificial intelligence can use for speech assessment and intervention for children with SSD [ 3 , 53 ]. Clients and parents have shown interest in the cost-friendly alternative measure since the existing speech assessment and intervention techniques are costly for children who need intensive and long-term speech therapy, placing multiple barriers in the way of effective service delivery. Computer-driven approaches incorporating online gaming are the long-term solution to removing the aforementioned barriers [ 81 ]. Tabby Talks is one of the automated tools for assessing childhood apraxia of speech. Devices are composed of clinician interface, mobile application, and speech processing engine and identify grouping errors, articulation errors, and prosodic errors [ 73 ]. Tabby Talks tool offers the capability to reduce the enormous amount of speech therapists’ work and the time and finance for families.

The earliest forms of automatic speech analysis and recognition (ASA) tools developed in the 1960s and 70s could process isolated sounds from minute to medium pre-defined lexicon [ 44 ]. Linear predictive coding (LPC) was developed to account for variations arising from vocal tract differences. Technological advancements in the 1980s based on statistical probability modelling that a specific set of language symbols matched the incoming utterance signal enhanced the ASA tools.

The predominant technology utilised by most speech recognition systems is the Hidden Markov Models (HMMs), which are designed to undertake temporal pattern recognition [ 44 ]. According to McKechnie et al. (2018), In the 1990s, new pattern recognition innovations led to discriminatory training and kernel-based techniques that functioned as classifiers, such as Support Vector Machines (SVMs). Fig. ​ Fig.3 3 below shows the theme component processes model encompassed in new ASA systems [ 44 ]. Therefore, the superior technological advancements in ASA tools enable the system to sift through speech variations from different speaker.

Model of contemporary ASA speech recognition system

While ASR systems have vastly improved in recent years, children’s ASR remains are not as well-known as adult ASR. Children’s HMM-ASR systems, like deep neural network ASR systems, require much data to train and are extremely reliant on the data they use. Clinical speech data (particularly for children’s speech) is far more challenging than average speech data, and physicians cannot be expected to collect enough data for such systems. More research is needed to develop clinical evaluation systems with minimal training data. The limitation of databases that contain large languages is another element that hinders system development and performance accuracy. The speech acoustic model is the second component that impacts performance accuracy and is based on the speaker mode. The model can either rely on the speaker, be independent of the speaker, or speaker adaptive. The ASA tools system also has two other principal components that influencing its accuracy [ 44 ]. The type of speech (isolated words or continuous speech) and the lexicon’s size impact the feature extraction process, the first component of the ASA tools with improved performance measured through long vocabularies. Therefore, the feature extraction and speech acoustic model affect the performance accuracy of the ASA tools. Notwithstanding the significant improvements in ASA tools, computational modelling systems still experience challenges [ 78 ]. Specifically, young children undergoing developmental growth stages while committing speech errors present even more challenges for ASA tools designed to assess children’s speech [ 44 ]. Therefore, the ASA tools need to consider the impact of impaired speech assessment and children intervention.

The major tool for clinical assessment of speech-language disorders, one of the most common juvenile disabilities, is auditory perceptual analysis (APA). APA outcomes, however, are subject to intra- and inter-rater variability. Manual or hand transcription-based speech problem diagnostic approaches have various drawbacks. To address these constraints, there is a growing interest in creating automated approaches for identifying speech abnormalities in children that quantify speech patterns. Landmark (LM) analysis is a method of identifying auditory events that occur as a result of sufficiently accurate articulatory motions [ 61 ] and it is suggested that LMs be used to detect speech disorders in youngsters automatically. This study offered a series of novel knowledge-based features that were not previously proposed, in addition to the LM-based features that have been proposed in previous studies. To test the usefulness of the innovative features in differentiating speech disorder patients from regular speakers, a comprehensive investigation and comparison of several linear and nonlinear machine learning classification approaches based on raw characteristics and proposed features are done.

The lest speech assessment tool

Language is the medium used to exchange the abovementioned elements between people of different races, colours, and religions [ 84 ] and is defined as the sound produced by the human voice, which the ear receives and interprets by the brain [ 57 ]. The LEST scale was developed to address universal and direct language development assessment in neuro-developmental follow-up clinics. The LEST tool was used for two groups of children; the first group for 0–3 years and the second group for 3–6 years. Each category encompasses items concerning expressive and receptive language development. Therefore, the LEST is one of the various speech assessment tools clinicians use in children with SSD for diagnosis and intervention.

Battery of Western Speech and Language Assessment Tool

Motor aphasia was first diagnosed by the French neurologist Paul Broca in the 1860s. The condition is associated with patients who can comprehend what is said but have difficulties exhibiting speech fluency, leading to communication breakdown. The Battery of Western Speech and Language Assessment Tools was developed to detect this speech impairment condition [ 17 ].

CHOCSLAT – Chinese Healthcare-Oriented Computerised Speech & Language Assessment Tools

The CHOCSLAT relies on technology to identify speech impairments in children. This tool aims to provide a technical advance in helping children who may have speech impairment or language delay. The computer records the utterances for processing and analysis. The C-LARSP (Chinese Language Assessment, Remediation, and Screening Procedure) is used in the grammar assessment section and concentrates on the grammatical classification and meanings of children’s statements.

The grammatical structures are classified by age group (“stage”) and several grammatical levels (clause, phrase, and word prefix/suffix), allowing for evaluation of children’s grammar at seven different age stages, ranging from 1 year to 4 years and 6 months (labelled “4; 6”) and above. The marking scheme incorporates semantic and syntactic features and result in a score ranging from 0 to 5 depending on the child’s response. The Phonology Assessment of Chinese (Mandarin) is used in the phonology test, and consists of 44 prompts, each of which targets a one- or two-character Chinese word. Percent Consonant Correct (PCC), present & absent consonants, and mistake patterns are three characteristics of pronunciation that are measured and analysed (mispronunciations that follow specific patterns). The average accuracy of all sample sentences is used to calculate the total accuracy. With N = 106 sentences, the most recent prototype iteration attained an average accuracy of 0.87. Several challenges were encountered while developing the tool, like using pinyin instead of the International Phonetic Alphabet (IPA) for the transcription, even though pinyin lacks accuracy and specificity compared to IPA. The tool was developed in close collaboration between Chinese experts in applied linguistics, computer scientists, and speech pathologists [ 83 ].

The Clinical Evaluation of Language Fundamentals (CELF) is a comprehensive speech impairment assessment tool to evaluate a child’s speech and language skills competency in various contexts. The aim is to identify the present speech and language disorders, their category, and the necessary intervention to treat the condition [ 57 ]. For children aged 5 to 21, the CELF-4 is considered a standard gold assessment for detecting language problems or delays. CELF-4 acts as a bridge to between the speech pathologist and children, assist in determining why a child may require classroom language adaptations, improvements, or curriculum changes. Its ability to administer subtests in various ways allows for faster testing while delivering extraordinarily reliable and accurate findings. After administering the CELF-4 battery, six indices can be calculated: the core language index and five other language indices. CELF-4 is relevant and is an exciting alternative for children due to its cultural inclusiveness and visual stimuli. The CELF-4 was created to reflect the clinical decision-making process, which begins with a diagnosis and determining the severity of a language disorder, then moves on to identifying relative strengths and weaknesses, making recommendations for accommodations and intervention, and evaluating the effectiveness of the intervention.

PLS-5 English

This tool was developed to assess and analyse language developmental milestones in children to identify the presence or absence of SSDs [ 76 ]. The screening test tool is designed for the children to screen their broad spectrum of language and speech skills from 0 to 7 age. Also, it helps to identify the language disorder within 6 speech and language areas in just 5 to 10 min. PLS-5 contains 2 standardized scales; one is to determine how a child communicates with others (Expressive Communication), and the second is to evaluate a child’s language comprehension. The PLS-5 has a good to excellent test-retest reliability (r = 0.86–0.95). The auditory comprehension and expressive communication scores had an internal consistency of r > 0.80 and r > 0.9, respectively. Test content (comprehensive/skills elicited are diagnostic indicators of whether a child is developing language typically or has a language disorder), response processes (effectively elicited), the internal structure (highly homogeneous within and across scales), and evidence-based relationships with the prior version of the test (r = 0.80 for both subscales) and other tests that measure the same constructs are all used to support the validity of the PLS-5 (moderate to high correlations ranging from 0.70 to 0.82 with the Clinical Evaluation of Language Fundamentals Preschool 2). The PLS-5 produces norm-referenced test results, such as Standard Scores (Mean = 100, SD = 15).

The Goldman-Fristoe Test of Articulation is a tool used to evaluate the articulation of consonant sounds in children to reveal the disorder’s severity if present [ 4 ]. The Goldman Fristoe Articulation test is open to children over the age of 2 and under 22. The GFTA-3 is a widely used standardised speech test that assesses children’s pronunciation using clinically relevant utterances. Using the GFTA-3 assessment framework, clinicians tracked the quality of each child’s phoneme pronunciation; each kid was positioned in a sound booth with a double-walled sound barrier, and a student clinician administered the GFTA-3.

“Sounds in Words” and “Sounds in Sentences” are the two sections of the GFTA-3. For the sounds in words subtest, picture stimuli and target words elicited the production of 23 consonant sounds and 15 consonant clusters, whereas the storey retell task elicited connected speech for the sentence’s subset. Scoring and interpretation depend on omissions, addition (phonetic transcription), and raw score (count number of incorrect responses). The raw score will be converted into standard, percentiles, and age equivalents. The scores are then used to compare individual results to gender-specific norms.

The norms were determined using a national sample of 1,500 examinees by age and gender. Test-retest and internal consistency is used to verify the tool’s reliability. Evidence-based test content, response processes, the performance of a speech sound disorder group, and its relationship with the GFTA-2 are used to support the tool’s validity. The GFTA-3 is appropriate to test those with suspected word production disorder. The GFTA-3 identifies the presence or absence of distinct speech sounds within the client’s repertoire but is not without its disadvantages. The sentence length requirement may be too high, and some graphics may be obscure to some young children. An additional limitation is that it only for children who have trouble pronouncing consonants (b,c,d, etc.) and will not help identify whether a child has articulation issues or problems with vowels.

The Bayley Scale of Infant and Toddler Development (Bayley) evaluates the developmental speech milestones of children aged 1 to 42 months. This tool’s primary aim is to detect any speech disorders in the child to develop the necessary intervention strategies [ 76 ]. The third edition (Bayley-III) is a simple, straightforward, method used to measure cognitive and motor skills and its results are exceedingly reliable. It is delivered with the help of a caregiver or parent, allowing for more input from the child’s natural surroundings. Furthermore, all assessment parameters are based on the child’s age, allowing for more precise developmental assessments. It is a comprehensive solution for assessing the entire kid, including adaptive behaviour, cognitive, language, social-emotional, and motor abilities. The Bayley-III produces composite and subscale scores for fine and gross motor development and composite and subscale scores for cognition and motor ability. For composite scales, raw scores are converted to norm-referenced standard scores (mean = 100, SD = 15), and for motor subscales, scaled scores (mean = 10, SD = 3).

The Differential Ability Scales assessment (DAS-II) assesses children’s cognitive competencies. The device identifies mental and cognitive disorders in children aged 2 to 18 [ 65 ]. The DAS-II is a standardised cognitive assessment tool increasingly being utilised with children with autism spectrum disorders. It is also commonly used to assess students’ cognitive capacity and aid in school planning. The DAS-II has a low item floor and an enlarged ceiling, allowing for adaptive testing in preschoolers or toddlers with potential deficits (especially in language). Furthermore, the DAS and DAS-II have been used to diagnose learning problems by determining processing style and doing an ability-achievement discrepancy analysis, both of which allow for more targeted intervention planning. Despite the popularity of the DAS and DAS-II as cognitive assessments for children with learning impairments or autism, their application in groups of children with hearing loss has not been independently validated.

The test assesses receptive and expressive language skills, nonverbal reasoning, and spatial abilities. The DAS-II has good test-retest reliability (> 0.73 across all index and composite scores), great internal consistency (intercorrelations of 0.84 between the index and composite scores), and good convergent validity when compared to the Weschler series tests and the Mullen Scales of Early Learning. The Nonverbal Reasoning Cluster (r = 0.65) and the Spatial Ability Cluster (r = 0.67) of the DAS have moderate associations with the WISC-III Performance IQ in students with learning difficulties. Table ​ Table3 3 illustrate the comparison of speech analysis tools with accuracy and other significant information.

In both developed and developing countries, smartphones and tablets have become increasingly accessible to children, forming a part of their daily lives. Approximately 88% and 79% of Australian households with children aged 15 and below living in major cities and rural areas, respectively, have fast and stable internet connections [ 44 ]. The statistics also show that 94%, 85%, and 62% of households access the internet via desktop or laptop computers, mobile or smartphone, or tablet, respectively. Although computer and mobile-based speech analysis techniques are not commonly used in children with SSD, they possess capabilities to access easily accessible, affordable, and objective speech assessment tools and interventions [ 46 ]. The development of such computer and mobile-based tools will likely enhance the efficiency of medical practitioners who deal with children with SSD and reduce their caseloads while also increasing accessibility and practice intensity due to reduced barriers resulting from the elimination of the face-to-face SLP [ 27 ].

Despite recognizing that early detection and treatment of communication disorders is critical for school readiness and has been shown to significantly improve communication, literacy, and mental health outcomes for young children, nearly 40% of children with speech and language disorders do not receive appropriate intervention because their impairment goes undetected. The predominant tool for clinical assessment of aberrant speech is auditory perceptual analysis (APA); however, APA outcomes are subject to intra- and inter-rater variability. Another consideration is that some children may be hesitant to participate in lengthy testing sessions, and even if they do, transcription of big data sets of audio recordings is time-consuming and needs therapists with a high level of skill. Because of the constraints of manual or hand transcription-based diagnostic evaluation approaches, there is a growing demand for automated methods to quantify kid speech patterns rapidly and reliably, allowing them to be diagnosed whether they have impaired speech [ 80 ].

Moreover, such approaches are likely to improve the child’s motivation to participate in and study exercises since they perceive them appealing, including audio prompts, reinforcers, or animation, encompass speech recording, playback responses, live manipulation of gameplay and stimuli, and prerecorded models. Nonetheless, the ASA tools that utilise diagnostic or therapeutic software are supposed to match reliability standards applied to human raters for them to be viable [ 44 ]. According to McKechnie et al. (2018), the Commonly accepted percentage agreement criteria for perceptual judgments of speech between two human raters or outcome reliability across two separate assessments of the same behavior range from 75 to 85%. Despite the extensive work on ASR, little work has been reported on developing speech therapy tools with ASR capabilities for use in paediatric speech sound disorders such as CAS. Although automated system is working with 80% accuracy, further work is needed to train automated systems with larger samples of speech to increase accuracy for assessment and therapeutic feedback. Therefore, ASA tools should meet the 80% threshold of reliability to be considered viable for speech assessment in children with SSD.

Protocols are the norms and procedures for assessing speech and language using instruments. Technical specifications for data acquisition, voice and speech tasks, analysis methods, and results for instrumental evaluation of voice/speech production are all included in the protocols. Even though these types of assessments are performed regularly at many research and clinical facilities in the United States, a lack of standardised procedures/protocols currently limits the extent to which the results can be used to facilitate comparisons across clinics and research studies to improve the evidence base for the management of voice disorders. The recommended protocols aim to produce a core set of well-defined measures that can be universally interpreted and compared using instrumental approaches. These recommendations are not intended to preclude the use of additional measures or protocols that individual clinics/clinicians or researchers believe are useful in evaluating vocal function.

MSAP – Madison Speech Assessment Protocol The Madison Speech Assessment Protocol (MSAP) was developed to cater to the need to diagnose speech and language disorders in the United States. The protocol employs 17 speech-related and eight motor and language activities and tasks in a 25-measure battery with a 2-hour run time in various clinical, educational, and research programs [ 75 ].

Connected Speech Transcription Protocol (CoST-P)

A clinically feasible protocol is connected speech transcription for children suffering from Apraxia. This development protocol’s main reason is to assist children aged 6–13 in describing their connected speech. The connected speech can be evaluated to pick up the independent and relational analyses [ 8 ].

Trivandrum Development Screening Chart (TDSC)

The TDSC (0–6 y) is a 51-item screening test created from existing developmental tools and has been validated for children up to the age of six. The TDSC is a straightforward, reliable, and valid screening tool for identifying children with developmental delays in the community. The Child Development Centre, SAT Hospital and Medical College, Trivandrum, conceived and developed it. The ranges for each test item were derived from the Bayley Scales of Infant Development standards (Baroda norms). The sensitivity and specificity of a TDSC chart with one item delay were 84.62% and 90.8%, respectively [ 69 ].

Ages and stages questionnaire test

The Ages & Stages Questionnaires are a developmental screening tool that measures developmental progress in children aged one month to five and a half years. The ages and stages questionnaire was designed to help health professionals and teachers who handle young children identify speech deficits in their patients. The tool relies on parents’ information about their children to detect speech deficits and other critical milestone delays [ 87 ]. Its popularity is due to its parent-centred approach and intrinsic ease of use, which has made it the most extensively used developmental screener in the world. Evidence demonstrates that the earlier a child’s development is examined, the more likely they are to fulfil their full potential. Arabic, Chinese, English, French, Spanish, and Vietnamese tests are accessible. It also takes parents 10–15 minutes to complete, and professionals 2–3 minutes to grade and highlight a child’s strengths and issues. The ASQ exam is used by programmes all over the country because it is highly valid, dependable, and accurate, as well as being cost-effective, easy to score in minutes, and well researched and tested with a varied sample of children. ASQ is a fun and engaging method to collaborate with parents and make the most of their expert knowledge.

The caterpillar novel reading passage

The existing approaches, methods, and materials of speech assessment used by clinicians are affected by limitations in validity and reliability [ 37 ]. The importance of motor speech evaluation is that it enables the diagnosis of speech impairment and further reveals the disorder’s severity [ 38 ]. The assessments’ outcomes are critical in identifying the salient elements of speech production targeted for intervention to enhance communication effectively [ 61 ]. Therefore, motor speech assessment tools are critical since they reveal the degree of speech impairment among children with SSD.

Contextual speech is the most significant speech assessment activity [ 61 ]. Reading the passage provides clinicians with valuable information compared to scores assigned through syllable and word repetition exercises. The passage is designed to present a controlled and repeatable activity in speaking, gauge the speech production system and conduct a differential diagnosis. The evidence shows that pediatricians can diagnose speech and language disorders in children by reading a passage.

The My Grandfather was the most famous speech assessment passage joined by Van Riper in 1963 [ 61 ]. The passage is ill-suited to examine speech motor skills to differentiate the severity and type of motor speech disorder [ 61 ]. The author of the passage, Van Riper, concurred with the fact mentioned above when he described the tool as useful for a quick survey of the student’s (client’s) ability to produce correct speech sounds [ 61 ]. The seminal work of Darley et al. in 1969 is seen as the historical root of the usage of the “My Grandfather” passage in speech and motor assessment on the perceptual traits of dysarthria. Therefore, Van Riper created the “My Grandfather” passage to assess speech and sound recognition among children.

“The Caterpillar” reading novel passage was developed to systematically enhance the “My Grandfather” passage by incorporating activities that evaluate deficits within and across speech subsystems [ 61 ]. To observe the variations between connected and isolated speech performance, embedding the word and syllable repetition activities into the passage is recommended as a best practice for evaluating motor speech disorders. Additionally, the reading passage offers a chance to perceive the motor speech’s performance on exercises that cannot be evaluated in isolation, such as prosodic modulation. Therefore, researchers have an opportunity to assess various speakers’ speech performance through the use of a reading passage as a speech assessment tool.

A number of reviews on speech assessment are available in the literature, of which those with a detailed discussion on the methods for the assessment are less.

A review published in 2012 summarised the findings on speech production issues in people with Down syndrome (DS) to enhance therapeutic services and guide future research in the field [ 36 ]. In their work, the authors selected one speech impairment disorder. Another review article was published in 2013 that aids in determining the interventions for preschool children according to the circumstances utilising a practice-based model of interventions to select the intervention subgroups [ 1 ]. Though the paper included studies from January 1980 to November 2011, it focused only on the interventions.

In 2014, a literature review was published to analyse the elements contributing to the debate over describing and diagnosing CAS and examine a therapeutically relevant body of knowledge on CAS diagnosis [ 7 ]. Thework entirely focused on CAS over the 10 years. Broome et al. conducted a systematic review in 2017 intending to provide a summary and assessment of speech examinations used in children with autism spectrum disorders (ASD). Later, a narrative review was reported to determine the essential components of an evidence-based paediatric speech assessment, combined with the systematic review findings, giving clinical and research guidelines for best practice [ 15 ].The review was published with the research articles published between 1990 and 2014, assessing children’s speech only with ASD.

Another review published in 2018 by Wren et al. aimed to assess the evidence for therapies for SSD in preschool children and categorised them under a classification of interventions for SSD [ 90 ] The intervention studies published up to 2012 were selected for the work. In 2018, a systematic search and review of the published studies on the use of automated speech analysis (ASA) tools for analysing and modifying speech of typically the developing children learning a foreign language as well as children with speech sound disorders were conducted to determine the types, attributes, and purposes of ASA tools being used. The performance of the therapeutic tools and their comparison with the human judgement was also included [ 44 ]. The research articles published between January 2007 and December 2016 were selected for the study.

Low et al. reported a systematic review in 2020 on voice for automated assessments across a more extensive range of psychiatric diseases [ 42 ]. According to the authors, speech processing technology could aid mental health assessments, but several barriers exist, including the need for extensive transdiagnostic and longitudinal investigations. The work concentrated on analysing psychiatric disorders and collected studies from the past 10 years that employ speech to identify the presence or severity of mental disorders. In 2021, another review was published to summarise and evaluate oral sensory problems in children and adolescents with ASD [ 18 ]. A systematic search was reported in the work with the published articles from January 2000 to December 2018, concentrating entirely on ASD. Additionally, the review suggests that oral stimulation employing speech-sensory technologies may be necessary.

The present systematic literature review aimed to identify, categorize, and compare the effective speech assessment methods for analysing multiple speech disorders in children, instead of choosing only a particular disorder or speech analysis tool as observed in the existing reviews. A statistical analysis of the reported speech impairment assessment methods, protocols and case studies from the last 12 years has been included. We have also covered the state-of-the-art solutions with the level of accuracy of each tool and their contribution to the research in the field of interest.

Application of speech assessment tools for speech impairment analysis

Cas disorder.

Different research groups have reported adopting multiple tools for the analysis of CAS. Table ​ Table4 4 shows the studies reported in the last decade using corresponding tools utilised.

Studies Reported on Childhood Apraxia of Speech Disorder

Strand et al. used DMESS to analyse speech and prosody’s motor function for children aged 3–6 years and seven months to diagnose childhood apraxia [ 79 ]. The child performed the stimuli in two ways during this protocol’s application: an initial attempt and after the examiner’s demonstration. The proof of construct validity and reliability presented as intra-judges’ 89%, inter-judges 91%, and test-retest 89%. However, positive and negative risk ratios, sensitivity, and specificity measurements showed that CAS was not over-diagnosed by DEMSS, though children with CAS were not detected in a few cases.

In 2013, Preston et al. conducted a study on ultrasound imaging assessment and treatment on CAS [ 66 ]. The research explored the efficacy of a treatment program for children with severe speech sound errors associated with childhood speech apraxia involving ultrasound biofeedback. Diagnostic ultrasound imaging has, for many decades, been a popular instrument in medical practice, and it offers a healthy and productive way to visualize internal structures of the body. Children are cured of altering their gestures by using real-time ultrasound images to provide visual feedback. A multiple baseline experiment in 18 sessions was conducted in the study by six children between 9 and 15 years of age during therapies centered on developing lingual sound sequences. Even though this study achieved about 80% accuracy, cost, access and training with this technology might limit the implementation of this tool in clinics.

CoST-P utilised CAS in the case study on 12 children aged 6–13 years [ 8 ]. The participants’ related speech parameters were selected to obtain independent and relational analyses. The usage of CoST-P to represent CAS speech characteristics was related to associated speech features. Children with CAS had their connected speech transcribed using the CoST-P. With appropriate reliability and fidelity scores, the CoST-P can be employed in researching children’s connected speech transcription of 50 utterances and takes between 5 and 7 h per child (including orthography, target output, and actual production). Because of the time burden, the current CoST-P is used infrequently in speech-language pathology practice. Even though the tool is an adequate resource for speech-language pathologists and clinical researchers, its usage is challenging.

Terband et al. conducted a study in 2019 to assess CAS by using objective measurement techniques for 3- to 6-year-old ones [ 82 ]. The analysis has made considerable progress regarding the clinical criteria for diagnosing childhood speech apraxia (commonly described as a speech motor planning or programming disorder) in recent years. For participant selection purposes, three segmental and supra-segmental speech features, i.e., error inconsistency, lengthened and interrupted co-articulation, and improper prosody has gained broad acceptance. Few researchers have also attempted to assess the validity of these features empirically. The fact that none of these features operationalized is a fundamental challenge for analytical analysis.

In 2015, Shahin et al. did a study explaining the pipeline to detect speech processing CAS-related common errors [ 69 ] automatically. It is used for children within the age group of 4–16 years. The device achieves an accuracy of pronunciation tests of 88.2% on phoneme and 80.7% on utterance stages, with a classification of lexical stress of 83.3%. Murray et al., in 2015, did a study to establish a variety of objective measures to distinguish CAS from other speech disorders, i.e., multivariate discriminant function analysis [ 53 ]. It involves syllable segregation, matched lexical stress, proper phonemes percentages from a polysyllabic image-name task, and precise articulatory repetition. It reported that the discriminant functional analysis model had achieved 91% accuracy by expert diagnoses. Twenty-eight children met two sets of CASs diagnostic criteria; 4 other children met the CAS criteria’ comorbidity. The researcher used the combination of the best-expected expert diagnoses for Multivariate Discriminating Feature Research.

Abdou et al., to identify the possible presence of CAS in Arabic-speaking children, developed a test battery, thus allowing the planning of appropriate therapy programs [ 3 ]. Seventy monolingual Arabic-speaking Egyptian children, including ten children with suspected CAS, 20 children with phonological disorders, and 40 typically developing children, were given the built-up test battery for CAS. The study concluded that the built-in test battery for CAS diagnosis is a reliable, valid, sensitive instrument that can be used to detect and differentiate between the presence of CAS in Arabic-speaking children and phonological disorders.

SSD and SLD

SSDs and SLDs are mostly seen in children. In some cases, their cause remains yet to be discovered or detected earlier. With the help of verbal tests, screening tests, instruments, and scales and with some tools and techniques, these disorders can be assessed and help clinicians and pathologies in the process of identifying the diseases. Table ​ Table5 5 lists the different styles and methods that can be used, not only for better assessment but also for therapy necessity among children with speech and language disorders.

Studies that Investigated Speech Sound Disorders and Speech-Language Disorders

In 2010, Shriberg et al., to identify diagnostic markers for eight subtypes of SSDs of unknown origin, developed MSAP [ 75 ]. Unlike other existing tools, the tool is not intended only to identify speech Apraxia but also for SSDs. In addition to its presentation, the protocol was also used to study different age groups and was designed to include a description of a classification system for motor speech disorders. Due to the significant prevalence of SSDs in public, Shriberg et al. did another investigation with MSAP to investigate the prevalence and phenotype of CAS in patients with lactose intolerance, albeit much information is absent from the literature. The results showed a high prevalence of the disorder in the investigated sample. Eight of the 33 respondents (24%) reported meeting the current CAS diagnostic criteria. Ataxic or hyperkinetic dysarthria criteria were seemed to be completed by two participants, 1 of whom was among the 8 with CAS. Group results for the remaining 24 respondents were consistent with a classification category called Motor Speech Disorder-Not Specified Otherwise. Here, both the evidence of validity and liability were nil.

In 2012, Carter et al. provided an approach to advancing children’s speech and language evaluation methods, using the morbid results of extreme falciparum malaria research as a guideline [ 17 ]. They chose children exposed to severe malaria to test tools for children with language disabilities. Other causes of language impairment may have features that are not readily available through this adaptation process, such as the impact of social communication on language assessment. The final battery- ‘speech-language assessment tool’ consisted of seven assessments: (1a) receptive language (original estimate changed to an adaptation of the Grammar Reception Test), (2b) syntax (new score system adapted from the Renfrew Action Picture Test), (3) lexical semantics (minor changes to the original), (4) higher-level language (significant changes to reduce the number of different items and increase the number of questions per item), 5) test of word-finding and language-specific test (a new assessment based on the Test of Word Finding), 6) Pragmatics profile of everyday communication skills in children, 7) Peabody picture vocabulary Test.

Nelson et al. conducted a study for using transcription in assessing speech disorders in children [ 54 ]. This research analyzed transcription, facilitators, transcription use issues, and detailed transcription discrepancies with different clients’ groups. Transcription charts (81%), self-practice (68%), and blogs were the three most frequently identified strategies/resources (42%). The use of two vowel notation systems, diminished transcription abilities, problems with service delivery, sampling/recording problems, and transcription to communicate were transcription challenges. This study reported that when recording children’s speech with childhood speech apraxia and craniofacial impairment, participants use detailed transcription more often than transcription to record children’s addresses with SSD of unknown origin.

Mehta et al., in 2015, presented an update on ongoing work using a miniature accelerometer on the neck surface below the larynx to collect a large set of outpatient data on patients with hyper-functional voice disorders (before and after treatment) and matched-control subjects [ 48 ]. Three types of analysis approach were employed to identify the best set of differentiating measures between hyper-functional and standard vocal behavior patterns: (1) ambulatory voice measurements, including vocal dose and voice quality correlates; (2) aerodynamically metric measures, which are based on glottal airflow estimates derived from the specified accelerometer signal and; (3) classification of other physiological signal recordings based on machine learning and pattern-recognition approaches, which were successfully used in analyzing long-term recordings.

In 2010, Mullen and schooling focused on the data collected from prekindergarten NOMS (National Outcomes Measurement System) and K-12 NOMS in school settings [ 52 ]. The primary objective was to serve as a data source for speech-language pathologists who were called upon to provide empirical evidence of the functional results of their clinical services to children and adult patients with different speech-language pathologies. The 2 NOMS components had reported studying more than 2,000 preschool students and 14,000 K-12 students by SLPs working in school settings. In 2013, McLeod et al. conducted a study to describe the speech of preschool children identified by parents/teachers as having difficulty “talking and making speech sounds” and to compare the speech characteristics of those who did not have access to SLP services [ 46 ]. The method of the study includes Stage 1: assessed documented parent/teacher concern about the speech skills of 1,097 children in the year 4- to 5- attending early childhood centers, Stage 2a: 143 children identified with problems, and Stage 2b: parents have returned questionnaires about service access for 109 children.

Towey et al. conducted a study in developing a diagnostic profiling tool for healthcare professionals to identify the potential problems of Chinese-speaking children with speech and language development [ 83 ]. The instrument aimed to provide a technical breakthrough to help kids with speech impairment or language delay. The case study was carried out in different stages, from 1 to 4 years. However, the exactness and specificity offered by the IPA are lacking. Due to data availability limitations, text output from the speech-to-text API is not always an accurate transcription.

The caterpillar passage study conducted by Patel et al. in 2013 describes the passage as an assessment tool or protocol to provide specific tasks aimed at informing the assessment of motor speech disorders with a contemporary, easy-to-read, contextual speech sample [ 61 ]. To demonstrate its usefulness in examining motor speech performance, twenty-two participants, 15, were recorded reading the passage “The Caterpillar” with DYS or AOS and 7 healthy controls (HC). Performance analysis across a subset of segmental and prosodic variables showed that “The Caterpillar” passage showed promise to extract individual impairment profiles that could increase current evaluation protocols and inform motor speech disorder therapy planning.

Hasson et al. conducted a DAPPLE study (Dynamic Assessment of Pre-schoolers’ Proficiency in Learning English) in 2013 [ 29 ]. To examine the ability of children to learn vocabulary, sentence structure, and phonology, the evaluation used a test-teach-test format evaluation, which takes less than 60 min to perform, given to 26 bilingual children: 12 currently on a caseload of speech and language therapy, and 14 children matched by age and socioeconomic status who never referred to speech therapy and language therapy. Qualitative analysis of individual children’s performance on the DAPPLE suggested that it can discriminate against core language deficits from the difference due to a bilingual language learning context.

In 2013, Newbold et al. compared a range of commonly used procedures for perceptual phonological and phonetic analysis of developmental speech difficulties to identify the best ways to measure speech changes in children with severe and persistent language difficulties (SPSD) [ 55 ]. Speech output measures included the percentage of whole words correct (PWC), correct consonant percentage (PCC), total word proximity proportion (PWP), analysis of phonological patterns (process), and phonetic inventory analysis. The study was conducted on 4 SPSD children, registered at 4 years of age and again at 6 years of age, who perform naming and repetition duties.

Eadie et al. conducted a study to assess the prevalence of idiopathic sound speech, the co-morbidity with language and pre-literacy difficulties of language sound disorders, and the factors contributing to the speech outcome for 4 years [ 24 ]. 1494 participants completed 4-year voice, language, and pre-literacy evaluations from an Australian longitudinal cohort. In four areas: child and family, reported parental speech, cognitive-linguistic, and motor abilities, the logistical regression examined SSD predictors. Early 4-year SSD detection should focus on family variables and 2-year language and motor skills measurement.

Morgan et al. conducted a study in 2018 to (i) test for the hypothesis that neurostructural difference in autism spectrum disorder (ASD) and CAS compared to typically developed (TD) is demonstrated by morphometric MRI measurements (ASD vs. TD and CAS vs. TD), (ii) investigating early possible diseasing-specific patterns of the two clinical groups (ASD vs. CAS) for the brain, and (iii) evaluating the machine-learning predictive strength of ASD, CAS, and TD [ 50 ]. T1-weighted brain MRI scans of 68 children (age range: 34–74 months) were analysed and divided into three cohorts: (1) 26 ASD children (mean age ± standard deviation: 56 ± 11 months); (2) 24 CAS children (57 ± 10 months); and (3) 18 TD children (55 ± 13 months). In the ML analysis, the differences between ASD and TD children in brain characteristics were significant, while only some CAS classification trends were detected compared with TD peers.

The aim of the study conducted by Zarifian et al. was to adapt the articulation assessment, subtest the articulation, phonology diagnostic assessment, and determine its reliability and validity for Persian-speaking children [ 91 ]. The Persian version of the articulation assessment (PAA) was administered to 387 children between the ages of 36 and 72 months, with M(SD): 53.7 (± 10.1) per month following the adaptation process. The study included test-retest reproducibility, score-rescore consistency, and validity evaluation through content, convergent, and discriminative validity to establish the instrument’s psychometric properties. The mean scores for articulation disorders were significantly lower than those for normal children in the Persian Articulation Assessment, showing discriminative validity (t = 7.245, df = 34, P < 0.001). The study concluded that it is suggested in the Persian version of Articulation Assessment as a reliable and valid tool for assessing articulation skills in Persian-speaking children.

In 2019, Jesus et al. experimented on the efficacy of a modern tablet-based approach to phonological intervention and compared it to a conventional tabletop approach targeted at children with speech sound problems based on phonology (SSD) [ 34 ]. Twenty-two children with phonological SSD were randomly allocated to 1 out of 2 assessments, tabletop, phone, and evaluation based upon similar activities (11 children in each group), with delivery being the only difference. The same speech-language pathologist treated all children over two blocks of 6 weekly sessions for 12 intervention sessions. The findings provide new evidence concerning using digital materials in children with SSD to improve speech.

A study was conducted to investigate, describe, and analyze the characteristics of speech, intelligibility, orofacial function, and co-existing neurodevelopmental symptoms persisting after six years of age in children with SSD of unknown origin [ 49 ]. They concluded that the children with persistent SSD are at risk of orofacial dysfunction, general motor problems, and other neurodevelopmental disorders, so co-occurring conditions should screen. The study included 61 children of unknown origin with SSD (6–17 years), referred for a speech and oral motor test. Parents completed context Scale Intelligibility (CIS) and a questionnaire containing heredity, health and neurodevelopment, and speech development.

In 2021, Chong et al. took a cross-sectional study in a tertiary center in Malaysia to explore the socio-demographics of children with speech delay [ 19 ]. The study was conducted at speech therapy clinics for children with speech delays less than 72 months old. Both speech and other developmental skills were assessed using the Developmental Quotient scores (DQ). There were 91 children in the study (67 boys and 24 girls), 54.9% of whom had a direct speech delay, and 45.1% had neurodevelopmental disorders. The average age was 39.9 months and 11.52 months. The average speech DQ was 54.76%, with a margin of error of 24.06%. Lower DQs in the speech was linked to lower DQs in other skills (p 0.01). There was no significant relationship between screen time for children and parents and DQs of speech and other skills (p > 0.05).

Speech Articulation Disorder, Cleft Palate Disorder, Tongue-tie, Childhood Dysarthria, Oral Motor Placement Disorder

Most articulation disorders are SSDs and come under motor speech disorders. Table ​ Table6 6 includes Speech Articulation Disorder, Cleft Palate Disorder, Tongue-tie, Childhood Dysarthria, Oral Motor Placement Disorder s tudies selected for the review published between 2010 and 2021 to address speech articulation disorder in children specifically.

Studies that Examined Speech Articulation Disorder, Cleft Palate Disorder, Tongue-tie, Childhood Dysarthria, Oral Motor Placement Disorder

In 2013, Khattab et al. conducted a study to assess oral impairment levels using standardised questionnaires [ 37 ]. Thirty-four Class-I Division-1 patients with malocclusion and moderate upper teeth crowding were randomly distributed into two groups. Seventeen patients in group A were treated with fixed lingual appliances (Stealth®, AO, Sheboygan, Wisc; mean age: 20.6 years; standard deviation [SD]: 2.9 years), whereas 17 patients in group B (mean age: 21.8 years; SD: 3.3 years) treated with conventional fixed labial appliances. Using fricative/s/sound spectrographic analysis, speech performance has been tested before, immediately after (T1), 1 month after, and 3 months after bracket placement.

Wang et al., in 2013, conducted a study on articulatory speech disorder assessment via speech therapy [ 88 ]. The research objective was to compare speech therapy’s efficacy with functional articulation disorders in two groups of children: those without speech Impairment disorder (SID). There were no major differences statistically between the two groups in age, gender, sibling order, parenting education, and pre-test number of pronunciation errors (P > 0.05). After speech therapy assessment (F = 70.393; P < 0.001) and interaction between pre/post-speech therapy assessment (F = 11.119; P = 0.002), the results showed significant changes. Speech therapy improved the articulation performance of children with functional articulation disorders, regardless of whether they have SID, but in children without SID, it results in significantly greater improvement. Thus, the assessment efficiency of speech therapy in young children with articulation disorders may be affected by SID.

In 2017, Afshan et al. introduced an automated approach to children’s speech clinical evaluations using limited data [ 4 ]. Graduate clinicians have assessed the Rhotic sound pronunciation by evaluating words in the GFTA-3 with the letter ‘r.‘ Due to their late acquisition in children; the rhotic sounds were explicitly selected. The remaining kids, used for evaluation, were aligned using the dynamic time to match the five template warping. The difference between both test child’s ‘r’ and model child’s ‘r’ was measured using the cosine distance. Multiple linear regression is shown on the differential scores to generate well-correlated forecasts with Human Clinical Assessments.

The risk of speech disorder is more for children born with cleft palate. Cleft lip or cleft palate are congenital disabilities that result in the incorrect formation of the fetal lip or mouth during pregnancy. Together, these congenital disabilities are usually known as “orofacial clefts.“ Speaking and feeding are difficult in such situations and surgical interventions are required to restore normal scar-free function. Language therapy helps to correct speech problems, if necessary. Zharkova, in 2013, conducted a study to describe ultrasound tongue imagery as a potential tool in cleft palate speakers for quantitative tongue function analysis [ 92 ]. The other three steps compare tongue curve sets to quantify tongue displacement dynamics, token-to-token variability in the tongue’s position, and the extent of separation between tongue curves for different sounds of speech.

Britton et al. conducted a study to develop national standards for speech results and care treatment processes for children with cleft palate ± lip [ 13 ]. In this large, multicenter, prospective cohort study, 12 cleft centres in Great Britain and Ireland collected speech recordings of 1,110 five-year-old with cleft palate who were involved (born 2001 to 2003). Results were compared against the evidence-based method, speech outcome requirements, and statistical analysis performed. The development of standards facilitated increased reporting of speech and treatment results. To Study whether Tele Practice (TP) intervention/assessment in SLP could efficiently improve the speech performance in children with cleft palate (CCP), Pamplona and Ysunza conducted a study in 2020 during COVID − 19 [ 58 ]. There was a significant CA severity improvement at the end of the TP period (p < 0.001). The researcher indicates that TP can be a safe and reliable tool for CA improvement. The COVID-19 pandemic would radically alter healthcare services delivery long-term, so studying and implementing alternative service delivery modes.

Ankyloglossia is a congenital condition in which an abnormally short, thickened, or tight lingual frenulum is born to a neonate, limiting the tongues mobility. In 2015, Ito et al. conducted a study to determine the efficacy of tongue-tie division (frenuloplasty/frenulotomy) in children with ankyloglossia for speech articulation disorder (tongue-tie) articulation test [ 33 ]. Articulation testing was performed in five children (3-8years) with speech problems with tongue-tie division. A speech therapist interviewed the patients and asked them to pronounce what the picture card showed. Substitution and deletion improved relatively early after the tongue-tie division and progressed to distortion, a form of articulation disorder that is less impaired. Thus, distortion required more time for improvement, and in some patients, it remained a lousy speaking habit.

In 2010, Liss et al. investigated automated analysis of speech envelope modulation spectra (EMS), which quantified speech rhythmicity within specified frequency bands and examined whether comparable results could be obtained [ 41 ]. EMS was conducted on sentences produced by 43 speakers with 1 of 4 types of dysarthria and healthy controls. EMS consisted of full-signal slow-rate (up to 10 Hz) amplitude modulations and 7-octave bands ranging from 125 to 8000 Hz in centre frequency. Discriminant function analysis (DFA) determined which sets of predictor variables between groups best discriminated against. For group membership, these variables achieved 84% 100% lassification precision. Dysarthria could be described in acoustic output by quantifiable temporal patterns. EMS shows promise as a clinical and research tool because the analysis is automated and requires no editing or linguistic assumptions.

Paediatric dysarthria is a sound disorder of motor speech that results from neuromuscular weakness, paralysis, or incoordination of the muscles needed for speech production. The child’s speech may be slurred or distorted, and speech may vary in intelligibility based on the extent of neurological weakness. There are some well-established therapy and tools for assessing and treating childhood dysarthria. Scholderle et al. conducted a study in 2020 to collect auditory-perceptual data from typically developing children between 3 and 9 years of age on established symptom categories of dysarthria to create age standards for assessing dysarthria [ 70 ]. We are used to analysing speech recordings of the Bogenhausen Dysarthria Scales’ auditory-perceptual criteria, a standardised German assessment tool for dysarthria in adults. The Bogenhausen Dysarthria Scales (scales and characteristics) cover clinically relevant speech dimensions and assess well-established categories of dysarthria symptoms. Several speech characteristics overlapped with established symptom categories of dysarthria in typically developing children. The results published in the study are a first step towards establishing auditory-perceptual standards for dysarthria in kindergarten and elementary school children.

Al-Qatab and M. Mustafa investigated the acoustic features and feature selection approaches utilised to improve dysarthric speech classification in ASR based on the severity of impairment in 2021 [ 5 ]. They used four acoustic features in their study: prosody, spectral, cepstral, and voice quality, as well as seven feature selection methods: Interaction Capping (ICAP), Conditional Information Feature Extraction (CIFE), Conditional Mutual Information Maximization (CMIM), Double Input Symmetrical Relevance (DISR), Joint Mutual Information (JMI), Conditional redundancy (Condred), and Relief. In addition to that, they used Support Vector Machine (SVM), Linear Discriminant Analysis (LDA), Artificial Neural Network (ANN), Classification and Regression Tree (CART), Naive Bayes (NB), and Random Forest (RF) as classification techniques in the experiment. They stated their experiment has several merits that add knowledge to the classification of dysarthric speech according to the level of severity like, the research has identified the features that can work in most of the classifiers, looked at the importance of feature selection in the classification of dysarthric speech and it looked at the best combination that gives the best classification accuracy in the classification. But their disadvantages were that they used a small database – Nemour and the other was that they did not adopt the state-of-the-art classifiers such as deep learning.

This study by Lehner et al. in 2021 covers the development of KommPaS, a web-based instrument for assessing communication impairment in dysarthria patients [ 40 ] KommPaS (Communication-related Factors in Speech Disorders) allows doctors to crowdsource laypeople to evaluate dysarthric speech samples for communication-related parameters such as intelligibility, naturalness, perceived listener effort, and efficiency (intelligible speech units per unit time). Significant problems about test efficiency, reliability, and validity would be addressed in addition to material influencing variables and the link between the four KommPaS characteristics.

Researchers used the Radboud Dysarthria Assessment in adults (over 18 years old) and the Radboud Dysarthria Assessment in children (5–18 years old) to assess dysarthria, which included observational tasks such as “conversation” and “reading,“ as well as speech-related maximum performance tasks such as “repetition rate,“ “phonation time,“ “fundamental frequency range,“ and “phonation volume” in 2021. Twenty-two people (15 children [5–17 years], seven adults [19–47 years], 14 men and eight females; mean age 19 years, SD 15 years 2 months) took part in the study. All subjects had dysarthria, defined by ataxic components in adults and similar uncontrollable movements in youngsters. Dysarthria in ataxia-telangiectasia is defined by uncontrolled, ataxic, and involuntary movements, which result in monotonous, unsteady, sluggish, hypernasal, and chanted speech, according to Veenhuis et al. They concluded by stating that the Radboud Dysarthria Assessment and the paediatric Radboud Dysarthria Assessment can be used to assess dysarthria in ataxia-telangiectasia.

In 2012, Kayikci et al. conducted a study to evaluate (1) whether Hawley retainers cause speech disturbance and (2) objective and subjective tests the duration of speech adaptation to Hawley retainers [ 35 ]. This study included 12 young people aged 11.11 to 18.03 years. Before and after the Hawley retainer application, speech sounds were assessed subjectively using an articulation test and objectively using acoustic analysis. After wearing Hawley retainers, patients showed statistically significant speech disturbances with consonants [ş] and [z]. Statistically significant changes were reported to the vowels. In 2018, Mugada et al. conducted a study to evaluate the quality of life for Head and neck cancer patients who received the therapy [ 51 ]. The study was conducted for 9 months. The EORTC QLQ-C30 Items (European Organization for Cancer Research and Treatment Quality of Life Questionnaire Core 30) were used, including the H&N-35 module, to evaluate QOL. The contrast of Specific socio-demographic and clinical features with EORTCC domains created between Questionnaire QLQ-C30 and the H&N35 QLQ EORTC. At p < 0.05, the significance level was taken.

Sharma and Singh, in 2016, conducted an observational study on squamous cell carcinoma of the pediatric head and neck, which is rare [ 74 ]. For assessing clinicopathological characteristics, treatment, and outcome of this emerging problem, obtained data on pediatric head and neck cancer in the younger age group (20 years of age) was used. Nine patients aged 20 years or younger were identified for analysis in this study during the said period. Various parameters were recorded and analyzed for the outcome, such as age, clinical features, clinical stage, and patients’ treatment. Further clinical studies need to be conducted to establish etiopathological characteristics and treatment guidelines in this issue.

In 2021, Bachmann et al. conducted a study to adapt the well-known Speech Handicap Index (SHI) to German, test its suitability for assessing the speech-related quality of life, and compare it to the German Voice-Handicap-Index (VHI) to aid in the treatment of oral cancer patients who experience post-treatment speech difficulties. Participants conducted a web-based survey with a 2 (experienced problem: speech/articulation-related vs. voice-related) x 2 (SHI vs. VHI) between-subject experimental design to distinguish between voice and intelligibility deficits and determine the discriminatory ability of the two instruments. They concluded that the German SHI is a more reliable and responsive measure of speech intelligibility and articulation-related quality of life than the VHI.

Cerebral Palsy, Autism Spectrum Speech Disorder, Hearing Loss, Phonology and Articulation, Friedreich Ataxia (FRDA), Aphasia, Epilepsy, Craniofacial Microsomia

Table ​ Table7 7 shows the papers included in the review used in studies investigating cerebral palsy, autism spectrum disorder, hearing loss, phonology and articulation, Friedreich ataxia (FRDA), Aphasia Epilepsy and Craniofacial Microsomia that cause speech impairment in children.

Studies that Investigated Cerebral Palsy and Autism Spectrum Disorder, Hearing Loss, Phonology and Articulation, Friedreich Ataxia (FRDA), Aphasia, Epilepsy, and Craniofacial Microsomia

A preliminary language classification system for cerebral paralysis children was suggested and tested in 2010 by Hustad et al. In the laboratory, 34 children with cerebral paralysis were assembled and collected their speaking and language assessment data (CP; 18 males, 16 female) with an average age of 54 months (SD = 1.8) [ 32 ]. The study provided preliminary support for classifying CP children’s speech and language skills into 4 initial profile groups. To validate the entire classification system, further research is necessary.

This study compared Down syndrome (DS) and TD infants between the ages of 5 and 7 months in a visual orientation test as well as an audiovisual speech processing task, which examined infants’ gazing patterns to communicative signals (i.e., face, eyes, mouth, and waving arm) by Pejovic et al. in 2021 [ 62 ]. The study found that DS infants’ early visual attention and audiovisual speech processing may be disrupted, with implications for their communication development, suggesting new options for early intervention in this clinical population. According to the findings, DS newborns orient their visual attention slower than TD infants. Both groups focused on the eyes rather than the mouth and the face rather than the waving arm. Furthermore, the findings of this research imply that DS children may require more time to detect/attend to communicative cues in face-to-face communication and that caregivers should emphasize face-to-face communication as a way of training attention to communicative cues from an early age.

The evolution of a scale would classify children’s speech performance for use in brain paralysis monitoring registers by Pennington et al. Its reliability across raters and over time analyzed [ 63 ]. Cerebral paralysis speech of 139 children (85 boys, 54 girls; mean age 6.03 years, SD 1.09) were classified from the observation and prior knowledge of the children from their language therapist and speech therapists, parents, and other health professionals. Another group of health professionals also rated children’s speech from the data in their medical notes. Instead, it asked to assess the scale’s simplicity to use, and the scale used Likert scales to describe the child’s speech production. More than 74% of raters reported the scale easy or relatively easy to use; 66% of parents and more than 70% of health care professionals judged the scale to describe children’s speech well or very well. The Viking Speech Scale was a reliable tool for describing the speech performance of children with cerebral paralysis by observing children or reviewing case notes.

Ertmer et al. investigated children with hearing loss to determine whether scores from a commonly used word-based articulation test are closely associated with speech intelligibility [ 25 ]. GFTA – II and 10 short sentences produced words from 44 children with hearing losses. Correlations between 7 word-based predictor variables and percentage-intelligible scores derived from the hearer judgment of stimulus phrases performed. However, regression analysis revealed that the variability in intelligibility scores accounted for no single variable or multivariable model predictor for over 25%.

In 2010, Florian Stelzle et al. conducted a study to introduce and validate a computer-based speech recognition system (ASR) for automatic speech evaluation after dental rehabilitation in edentulous patients with complete dentures [ 78 ]. 28 patients twice recorded reading a standardised text - with and without their complete dentures in situ—the speech quality measured by the percentage of the word accuracy (WA) by a polyphone-based ASR. The wearing of complete dentures, on the other hand, considerably increased the WA of the edentulous patients. The reconstitution of speech production quality is essential for dental rehabilitation and can be improved by complete dentures for edentulous patients. The ASR proved a helpful, practical, and easily applicable tool for an automatic speech evaluation in a standardised way.

Fulcher et al. conducted a study in 2012 to check whether a homogeneous cohort of early identified children (approximately 12 months) with all severities of hearing loss and no other concomitant diagnoses could not only significantly outperform a similarly homogeneous cohort of later identified children (> 12 months and < 5 years), but also achieve and maintain age-appropriate speech/language outcomes by 3, 4 and 5 years of age [ 27 ]. The children had attended the same program of oral auditory-verbal early intervention. Standardized speech/language assessments performed at 3, 4, and 5 years of age typically developing hearing children. The previous children identified have significantly outperformed the late children identified at all ages.93% of all early identified participants scored for speech within normal limits (WNL) by 3 years of age; 90% were WNL for vocabulary understanding, and 95% were WNL for speech production.

Hochmuth et al. carried out a case study on a new Spanish noise sentence test to develop, optimise, and evaluate [ 30 ]. The trial included a fundamental matrix of 10 names, verbs, numerals, names, and adjectives. This matrix is used for test lists of 10 sentences of the same syntactic structure, containing the entire language material. The speech material was the distribution of phonemes in Spanish. Independent measures to examine the training effects, comparability of test lists, open-set vs. closed-set test format, and listeners’ performance from various Spanish varieties were conducted and assessed. In total, 68 normal-hearing native Spanish-speaking listeners were selected. No significant differences indicate that the test applies to Spanish and Latin American listeners for listeners of different Spanish varieties.

A study was conducted by Phillips et al., in a group of children who are deaf or hard-of-hearing to test the concurrent validity of the Leiter International Success Scale-Revised (Leiter-R Brief IQ) and Differential Ability Scales-Second Edition (DAS-II Nonverbal Reasoning Index) [ 65 ]. The participants included 54 children between the ages of 3 and 6 with permanent bilateral hearing loss. The mean values in the two assessments did not vary significantly. Hearing loss severity is not linked to the nonverbal IQ of either the Leiter-R or the DAS-II. Almost a quarter of the assessed children had significant intra-individual differences.

In 2020, Ng et al. described the design and development of CUCHILD, a Cantonese corpus of child speech evaluation tool, on a large scale [ 56 ]. The corpus includes words from 1,986 children between the ages of 3 and 6 years. 130 words with 1 to 4 syllables in length had in the speech materials. Speakers cover children with speech disorders, TD, and those with other speech disorders. The aim is to provide corpus support for scientific, clinical, and technological research relating to child speech evaluation. The corpus’ design is described in detail, including word selection, recruitment of participants, data acquisition process, and data pre-processing.

A cardinal feature of FRDA is dysarthria, which often leads to severe impairments in daily functioning. However, its precise characteristics are only poorly understood to date. In 2013, Brendel et al. carried out a comprehensive evaluation of the severity of dysarthria and the profile of speech motor deficits in 20 patients with a genetic diagnosis of FRDA, based on a carefully selected battery of speech tasks and two commonly used Paraspeech studies, i.e., oral diadochokinesis and sustained vowel production [ 12 ]. Breathing, voice quality, voice instability, articulation, and tempo were identified as the most affected speech dimensions by perceptual ratings of the speech samples. The outcome indicated that FRDA pathology is differentially susceptible to speech production components and trunk/limb motor functions. Evidence has also emerged that part speech tasks do not permit an adequate scaling of FRDA speech deficits.

Functional neuroimaging studies and investigations have shown increased activation of the unaffected hemisphere in aphasia patients, which hypothetically reflects a maladaptive brain reorganisation strategy [ 72 ]. Seniow et al. investigated whether, when combined with speech/language therapy, repetitive magnetic transcription (rTMS) stimulation inhibiting the homologue in the right hemisphere in Broca improves the repair of the language. 40 aphasia patients were randomised to a 3-week aphasia rehabilitation protocol combined with real rTMS by using the Boston Diagnostic Aphasia baseline test. They reported that severe aphasic rTMS showed significantly more improvement than patients receiving repeated sham stimulation.

Petrillo et al. experimented in 2021 for the Italian version of the progressive aphasia severity scale (Italian PASS), which was built according to guidelines for cross-cultural adaptation of self-report measures to aid researchers and clinicians in the diagnosis and follow-up of a primary progressive aphasia (PPA) in Italian populations [ 64 ]. This tool would allow researchers to gather data on patients with PPA’s communicative functioning in everyday contexts, considering standardised tests employed in the clinical setting and the perspectives of their caregivers. Furthermore, it could be particularly beneficial for long-term disease monitoring to track its advancement, and it could be an ideal way to check the success of speech/language treatment in delaying disease progression.

Laganaro et al. released a screening version of a speech assessment protocol (MonPaGe-2.0. s) in 2021 as a response to the demand for objective screening tools for motor speech disorders. It is based on semi-automated acoustic and perceptual assessments of many speech characteristics in French (MSD) [ 39 ]. They tested the screening tool’s sensitivity and specificity and compared the results to external standard evaluation methods. Data from 80 patients with mild to moderate MSD and 62 healthy test controls were compared to normative data from 404 neurotypical speakers, with Deviance Scores calculated on seven speech dimensions (articulation, prosody, pneumophonatory control, voice, speech rate, diadochokinetic rate, intelligibility) using acoustic and perceptual measures. The MonPaGe, TotDevS, and an external MSD composite perceptual score provided by six experts had a good connection. The sensitivity and specificity of the MonPaGe screening technique for diagnosing the existence and severity of MSD have been demonstrated. They concluded that to distinguish MSD subtypes, more implementations are needed to complement the definition of compromised dimensions.

Rolandic epilepsy is associated with developmental language impairment. Literature does not show exactly which domains are affected. In 2013, Overvliet et al. studied performance among children with Rolandic epilepsy and healthy controls in the language domains [ 57 ]. That is a focal study compared to healthy controls of children with Rolandic epilepsy. A CELF language test was carried out on 25 children with Rolandic epilepsy (mean 136.6 months, SD 23.0) and 25 years with healthy inspections matched with age (Clinical Evaluation of Language Fundamentals, Dutch edition). The core language score was significantly lower in children with epilepsy than healthy controls.

Speltz et al., in 2018, assessed whether infant cases with craniofacial microsomia (CFM) show lower neurodevelopmental status than demographically comparable infants without a craniofacial diagnosis (‘controls’) and examined the neurodevelopmental outcomes of cases by facial phenotype and hearing status [ 76 ]. Observational study on 108 cases and 84 controls aged 12–24 months was carried out. The third edition of Bayley scales for children and Toddlers and the fifth edition of the preschool linguist scales have been evaluated by participants (PLS-5). With the Craniofacial Microsomy Phenotypic Assessment Tool, facial features are categorised. Among women and those with higher socioeconomic status, outcomes were better. Facial phenotype and hearing status among cases showed little to no association with results. Although learning problems in older children with CFM have been observed, no evidence of developmental or language delay has been reported among infants.

Challenges, limitations and future research possibilities

With an increasing number of children with speech impairment, improving and devising methods for early detection is paramount to preventing disease progression. The development of this field may help adults and children receive better assessment and treatments from clinical trials and hospitals. Therefore, several tool methods have been proposed to detect and predict this speech impairment; however, these techniques have fundamental limitations. This part discusses some of the challenges and future research directions to help more researchers address them.

One of the challenges against universal screening is that identifying and correctly diagnosing infants with speech impairment at 24 months of age, unless it is a cleft palate, is very difficult. There is still a pressing need to identify the appropriate mix of assessment tool modalities that would improve detection rates and reduce false-positive results. The development of such diagnostic tools can lead to a precise and conclusive diagnosis of speech impairment and the early detection of the condition. Two more challenges that need to be addressed include cost and dataset availability. Sustained efforts into developing a proper universal speech assessment tool will positively impact children’s self-esteem and self-confidence with SSD [ 89 ]. The challenges faced during the study included a lack of databases that are dedicated to assessment tools for speech-impaired children. The absence of comprehensive datasets is a major setback to future development, as most publicly available datasets contain missing values for numerous detection algorithms. Data analysis is also complicated due to a lack of sufficient data. Techniques for early detection of speech problems in children are too costly for families and society to handle. In terms of screening children at an early age, progress is being made in improving screening techniques that can be cost-friendly, eco-friendly, and reliably identify at-risk status. Given the large amount of positive results, more effort is needed to duplicate, expand, and individualise available therapies and screening and diagnostic tools.

Additionally, the available literature is contained in databases that require either subscription or specific institutional credentials to have access. This phenomenon is quite frustrating since scientists should have unlimited access to the available data to conduct their studies seamlessly [ 11 ]. The researcher must perform numerous searches in various databases to capture all the relevant peer-reviewed studies for inclusion in the systematic review. Moreover, several papers were contained in multiple databases, which drastically reduced the number of eligible articles for inclusion in the systematic review.

Furthermore, Due to the limitation of manual or hand transcription-based diagnostic evaluation approaches, there is a growing demand for automated methods to quantify child speech patterns and aid in the rapid and reliable diagnosis of speech impairment [ 80 ]. Automatic assessment models are promising tools for detecting speech impairment. Artificial intelligence approaches, such as deep learning, effectively model exceedingly complex data accurately. These models are more resilient and interpretable than other similar techniques, yet they are computational models that try to find the relationship between a collection of datasets and their results. These models rely on many hyperparameters, all of which must be fine-tuned. Datasets are also crucial to the effectiveness of deep learning models; they must be impartial to achieve the best outcomes. Features in the datasets must also be thoroughly studied and unrelated. Another significant problem is predicting speech impairment in newborns and infants between 0 and 24 months.

The number of children with SSD is expected to rise in the future, along with the cost of treatment and intervention. Various speech assessment tools have been developed to diagnose and treat SSD, such as “The Caterpillar” and “My Grandfather” automatic tools, DEMSS, and MSE. However, their success is limited due to varied cultural practices and orientations, and lack of universality due to limited validity and reliability. Detecting SSD accurately at the child’s preschool years ensures that the condition is eliminated and does not persist into adolescence. Future studies will have to incorporate studies dedicated to testing speech-impaired children’s speech assessment tools’ validity, reliability, and universality. It is essential to ensure that researchers develop a universally accepted speech assessment tool that transcends all cultural barriers to help speech-language pathologists. For example, future studies should include more research on developing a speech assessment tool ideal for multilingual and bilingual children. Furthermore, studies should consist of more than 150 peer-reviewed papers to improve reliability and validity. In total, there still exists a need to develop speech assessment tools independent of human judgment to help diagnose and intervene to aid in the early detection and intervention of SSD in children.

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