FACTORS RELATED TO SPEECH SOUND Chapter 4
DISORDERS
STRUCTURE AND FUNCTION OF THE SPEECH AND HEARING MECHANISM
Otitis Media with Effusion (OME)
It has long been supposed that frequent episodes of middle ear disease in children, which
are accompanied by a buildup of liquid in the middle ear space (also called otitis media
with effusion, or OME), may result in a delay in speech sound development.
The assumption is that the accumulating liquid blocks the transmission of sound, resulting in a
mild to moderate hearing loss, which may then impact speech sound acquisition.
However, research results to confirm these assumptions have been mixed. Shriberg, Flipsen,
and colleagues (2000) identified 27 separate studies conducted on possible speech delay
associated with frequent episodes of otitis media (OME). Of the 27 studies, (63%)
suggested no impact, whereas (78%) suggested some impact.
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Several reasons might account for these inconsistent findings:
First, the majority of children experience at least one episode of OME during the preschool
years, a single episode would be unlikely to lead to a problem or delay in the acquisition and
production of speech sounds.
A second factor in the mixed findings for OME is that the studies differed as to the reliability of
documenting actual episodes of OME. Some investigators relied solely on parent report,
medical records, visualizing the tympanic membrane, tympanometry.
Third, few studies document or report the hearing status of the children during OME episodes.
Finally, socioeconomic status (SES) of the children. In general children from low SES backgrounds
appear to be at higher risk for SSDs in general. This may be because of poorer-quality
language stimulation, but it may also relate to poorer access to health care.
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Speech Sound Perception
The vast majority of children with SSDs have normal hearing acuity (i.e., they pass
a standard hearing screening). Those who don’t may qualify as hearing impaired.
These skills are necessary for normal speech sound acquisition so that the child can
(1) make the association between the sounds of the native language and the
meaning that can be expressed with those sounds.
(2) make the association between the sounds the child generates and the
movements of the vocal tract.
(3) make the association between the sounds the child produces and the
meaningful units of the language.
(4) adapt their productions to changes to their own vocal tract (i.e., adjust for their
own growth).
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General versus Phoneme-Specific Measures
Researchers such as Locke (1980a), however, pointed out that in children with SSDs, the critical
issue is their ability to discriminate the particular sound or segments that they misarticulate.
Locke recommended going a step further, urging that measures of speech sound perception
should be not only phoneme specific but also context specific. He argued that perceptual tasks
should reflect the child’s production errors and reflect those phonetic environments (words) in
which error productions occur and include both the error productions and the target
productions.
Locke studied a group of 131 children who performed a perceptual task in which the
examiner produced imitations of the participants’ error productions. The participants were then
required to judge whether the examiner’s productions were correct productions of the target
word. Locke reported that 70 percent of the children correctly perceived the correct and
incorrect forms of the target words, thus indicating that many children could correctly
discriminate sounds made by an adult that had been produced in error. About one-third of the
contrasts misproduced were also misperceived.
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External and Internal Discrimination
• External discrimination, (making the association between the sounds of the
language in the environment and meaning). External discrimination can also
include external self discrimination, which involves listening to and making
judgments of tape-recorded samples of one’s own speech. In both cases, the
listener uses air conduction auditory cues.
• Internal discrimination or internal monitoring evaluating one’s own ongoing
speech sound productions. During internal discrimination, the speaker has
available both air- and bone-conducted auditory cues. Testing the ability to
internally discriminate typically involves asking the child to judge the
accuracy of his or her own productions of words or sounds immediately after
they are produced.
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A classic example of the difference between external and internal
discrimination was reported by Berko and Brown (1960), who described
what has come to be known as the /fIs/ phenomenon. A child attempts to
say a word (e.g., fish) but produces an error (e.g., /fIs/). The examiner then
asks, “Did you say /fIs/?”, to which the child responds, “No, /fIs/.” The child
recognizes the error in the examiner’s speech but not in his or her own. Thus,
he or she has good external discrimination skills but poor internal
discrimination skills.
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Self-Monitoring
• The ability to identify errors in one’s own speech (what we earlier called
internal discrimination) has long been suggested as being important to
therapy progress. The ability to hear the differences in another person’s
speech or one’s own taped productions does not, however, guarantee that
a particular child will actively listen for and pay attention to those
differences (i.e., that he or she will self-monitor).
• .
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MINOR STRUCTURAL VARIATIONS OF THE SPEECH MECHANISM
Lips
• Any impairment that would inhibit lip approximation or rounding might result in
misarticulation of these sounds.
• Fairbanks and Green (1950) examined measurements of various dimensions of
the lips in 30 adult speakers with superior consonant production and 30 with
inferior consonant production and reported no differences between the two
groups.
• Certain deformities of the lips such as the enlarged lips in Ackerman syndrome
(Ackerman, Ackerman, and Ackerman, 1973) or congenital double lips (Eski,
Nisanci, Aktas, and Sengezer, 2007) may interfere with speech production, but
not in every case. Most such cases can be corrected surgically.
• These findings suggest that only major deviations in lip structure or function are
likely to impact speech sound production
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Teeth
Many English consonants require intact dentition for correct production.
Researchers investigating the relationship between deviant dentition and consonant production
have examined the presence or absence of teeth, position of teeth, and dental occlusion.
Occlusion refers to the alignment of the first molar teeth when the jaws are closed, and
malocclusion refers to the imperfect or irregular position of those teeth when the jaws are
closed.
• In normal occlusion (also called Class I), the upper first molar is positioned half a tooth
behind the lower first molar.
• In a Class II malocclusion, the positions of the upper and lower first molars are reversed
(i.e., the upper is half a tooth ahead).
• In a Class III malocclusion, the upper first molar is more than half a tooth behind.
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Tongue:
• The tongue is generally considered the most important articulator for speech
production. Tongue movements during speech production include tip elevation,
grooving, and protrusion. The tongue is relatively short at birth and grows longer
and thinner at the tip with age.
• Ankyloglossia, or tongue-tie, is a term used to describe a restricted lingual
frenum (sometimes called the frenulum). Clinically, it is usually defined as the
inability to protrude the tip of the tongue past the front teeth. A review by
Segal, Stephenson, Dawes, and Feldman (2007) indicated that prevalence
estimates for ankyloglossia range from 4.2 to 10.7 percent of the population.
The variability in these estimates is likely related to differences in definitions for
ankyloglossia.
• Frenum clipping may make a positive difference in the speech of individuals with
severe ankyloglossia.
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• Macroglossia (a tongue that is too large). Whether it is true macroglossia or
relative macroglossia (a normal-sized tongue in a small oral cavity), the
presumption is that the tongue has insufficient room to maneuver to perform
speech. However, the tongue is a muscular structure capable of considerable
change in length and width and thus, regardless of size, is generally capable
of the mobility necessary for correct sound productions. Put another way, it
seems likely that individuals with macroglossia should be able to compensate.
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Hard Palate
• Brunner, Fuchs, and Perrier (2009) examined palatal shapes and acoustic
output from 32 adult found that those with flat-shaped palates showed less
variability in tongue height than those with dome-shaped palates. Despite this
finding, both groups showed similar acoustic variability in their production of
vowels, suggesting that compensation for different palatal shapes is quite
possible for normal speakers.
• On the other hand, differences were noted in a study of Arabic speakers by
Alfwaress and colleagues (2015). They compared 30 individuals aged 15 to
20 years with a consistent substitution of /j/ for the Arabic trilled /r/ against
an age-matched control group of 30 speakers with no errors. The experimental
group had significantly shorter maxillary length and dental arch lengths as
well as narrower intercanine widths compared to the control group.
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ORAL SENSORY FUNCTION
• Bordon (1984) indicated the need for awareness of kinesthesis (sense of movement)
and proprioception (position) during therapy. Almost any phonetic placement
technique used to teach speech sounds
• The investigation of somesthesis (sense of movement, position, touch, and awareness
of muscle tension) has focused on
• (1) overall oral sensitivity,
• (2) temporary sensory deprivation during oral sensory anesthetization (nerve block
anesthesia) to determine the effect of sensory deprivation on speech production, and
• (3) assessment of oral sensory perception such as two-point discrimination or oral
form discrimination to see whether such sensory perception was related to
articulatory skill.
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1. Oral form recognition improves with age through adolescence.
2. The role of oral sensory feedback in the acquisition of speech sounds is unclear.
3. During anesthesia, intelligibility is generally maintained, but articulation tends to be
less
accurate.
4. Individuals with poor articulation tend to achieve slightly lower scores on form
perception
tasks than their normal-speaking peers. However, some individuals with poor form
identification skills have good articulation skills.
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5. Although some individuals with SSDs may also have oral sensory deficits, the
neurological mechanisms underlying the use of sensory information during experimental
conditions
may differ from those operating in normal conversational speech.
6. Information concerning oral sensory function has not been shown to have clinical
applicability.
7. It is important to distinguish between the effects of sensory deprivation in individuals
who
have already developed good speech skills and the effects in individuals with SSDs.
8. The effects of long-term oral sensory deprivation have yet to be explored
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MOTOR ABILITIES
Oral-Facial Motor Skills
• Speech is a dynamic process that requires precise coordination of the oral musculature.
During ongoing speech production, fine muscle movements of the lips, tongue, palate,
and jaw constantly alter the dimensions of the oral cavity. Tests of diadochokinetic
(DDK) rate, which involve rapid repetition of syllables, are typically a part of a speech
mechanism examination and are intended to evaluate oral motor skills independent of
phonological skills.
• The syllables most frequently used are /pʌ/, /tʌ/, and /kʌ/ in isolation and the
sequences /pʌtʌ/, /tʌkʌ/, /pʌkʌ/, /pʌtʌkʌ/. These tasks are typically done at
maximum rates (i.e., speakers are told to produce them “as fast as possible”).
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• An alternative measure of motor skill related to speech is the evaluation of habitual
articulation rate (the pace at which speech is being produced most of the time). Flipsen
(2002a) presented longitudinal data from children with SSDs which suggested that (when
measured in phones per second, but not in syllables per second) articulation rate in the
preschool years may be slower for these children than their typically developing peers.
By adolescence, however, their rates appeared to be similar to their typically developing
peers. This finding suggests that there may be at least a delay in the development of
speech motor skills in children with SSDs.
• A third perspective on possible motor deficits in SSDs has involved measuring tongue
strength. Potter and Short (2009) reported increases in tongue strength with age in a
group of 150 children aged 3 to 16 years. Differences in tongue strength in typically
developing children compared to children with SSDs have not been consistently found.
Dworkin and Culatta (1985) found no significant difference in the maximum amount of
tongue force that could be exerted by children with SSDs compared to children without
any speech difficulties.
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• A final perspective on motor skill for speech production is based on the interaction of
the articulators during speech (the complex coordination of the movements of both
clearly different articulators). Recent findings using electropalatography (EPG )have
allowed us to document the fine-grained sequencing of these speech production
movements.
• In a /kt/ sequence as in the word doctor, there are moments when both the tongue tip
and the tongue body are raised simultaneously in a so-called double articulation. The
ability to accurately and reliably coordinate such sequences in the context of rapidly
produced connected speech may not reach adult skill level until the early teen years
(Fletcher, 1989)
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ORAL MYOFUNCTIONAL DISORDERS/TONGUE THRUST
Tongue thrust has been defined as frontal or lateral movement of the tongue
during swallowing (Mason, 2011). According to Mason and Proffit (1974),
“tongue thrusting is one or a combination of three conditions:
(1) during the initiation phase of the swallow a forward gesture of the tongue
between the anterior teeth so that the tongue tip contacts the lower lip;
(2) during speech activities, fronting of the tongue between or against the
anterior teeth with the mandible hinged open (in phonetic contexts not
intended for such placements); and
(3) at rest, the tongue is carried forward in the oral cavity with the mandible
hinged slightly open and the tongue tip against or between the anterior
teeth. (p. 116)
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Tongue thrust during swallow and/or tongue fronting at rest can usually be
identified by visual inspection. Mason (1988, 2011) has pointed out that
two types of tongue fronting should be differentiated. The first is described
as a habit and is seen in the absence of any abnormal oral structures. The
second is obligatory and may involve factors such as airway obstruction or
enlarged tonsils, with tongue thrusting being a necessary adaptation to
maintain the size of the airway to pass food during swallow. Wadsworth,
Maul, and Stevens (1998) indicated that tongue thrust swallow frequently
co-occurred with resting forward tongue posture (63%), open bite (86%),
overjet (57%), abnormal palatal contour (60%), and open mouth posture
(39%).
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Impact of Tongue Thrust on Dentition
• The current view is that the resting posture of the tongue affects the position of
the teeth and jaws more than tongue thrust or speaking does (Mason, 1988,
2011; Proffit, 1986).
• Tongue thrusting may, however, play a role in maintaining or influencing an
abnormal dental pattern when an anterior resting tongue position is present. If
the position of the tongue is forward (forward resting position) and between
the anterior teeth at rest, this condition can impede normal teeth eruption and
may result in an anterior open bite and/or a Class II malocclusion.
• However, tongue-thrusting patients, in the absence of an anterior tongue-
resting position, are not thought to develop malocclusions.
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TREATMENT ISSUES
Of most interest to SLPs would be the potential effect of oromyofunctional therapy
(OMT) on SSDs.
https://www.youtube.com/watch?v=nU3BEJK5Ya0&ab_channel=SarahHornsby
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Pacifier
Given that between 55 and 80 percent of infants are reported to use pacifiers
does the use of such devices interfere with speech sound acquisition?
The more an infant used a pacifier, the higher the risk speech production skills
might be affected. Although this limited group of reports suggests that children
who use pacifiers may be at some risk for SSDs, definitive conclusions are
premature. Based on the available research, the use of pacifiers likely does not
interfere with acquisition of speech sounds in most children.
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Why might pacifier use (or other forms of non-nutritive sucking such as thumb
sucking) affect speech development? Although speculative at this point, several
reasons might be proposed.
First, the presence of a pacifier might alter tongue resting posture.
Second, the pacifier might affect tooth emergence and/or alignment.
Third, having a pacifier in the mouth might reduce the amount of time the infant
spends practicing speech.
Finally, the presence of the pacifier might make parents and others less likely to
interact and thereby reduce opportunities for both practicing speech and
receiving feedback from others.
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COGNITIVE-LINGUISTIC FACTORS
Intelligence
The relationship between intelligence (as measured by IQ tests) and SSDs has
been a subject of many years of investigation. Early studies (Reid, 1947a,
1947b; Winitz, 1959a, 1959b) reported low positive correlations between
scores obtained on intelligence tests and scores on articulation tests.
Johnson, Beitchman, and Brownlee (2010) reported findings from a
20-year follow-up study. Findings indicated no significant difference in IQ scores
between those who had been diagnosed as speech impaired as preschoolers and
those who had normal speech. Thus, one did not appear to be a good predictor
of the other.
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A second perspective on the relationship between intelligence and phonology may
be gleaned from studies of the phonological status of individuals with
developmental delays.
Shriberg and Widder (1990) summarized findings from nearly four decades of
speech research in cognitive impairment as follows:
1. Persons with cognitive impairments are likely to have speech sound errors.
2. The most frequent type of error is likely to be deletions of consonants.
3. Errors are likely to be inconsistent.
4. The pattern of errors is likely to be similar to that of very young children or
children with SSDs of unknown origin.
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Language Development:
Given that the speech sound system (phonology) is part of the language system, we might also expect an
interaction between phonology and other aspects of language
Syntax: Schmauch, Panagos, and Klich (1978) studied 5-year-old children with both speech sound and language
problems. These investigators reported a 17 percent increase in speech sound errors as the syntactic demands
increased. They also reported that later developing consonants were those most influenced by syntactical
complexity and that the errors reflected quantitative rather than qualitative changes
Morphology is another aspect of language that has been investigated relative to speech sounds. Paul and Shriberg
(1982) studied phonologic productions as they relate to particular morphophonemic structures. Continuous speech
samples were obtained from 30 children with speech delays. Some of the participants were able to maintain a
similar level of speech sound production in spite of producing more complex syntactic targets
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ACADEMIC PERFORMANCE
To appreciate the specific connection between SSDs and reading, recall that written language is based on
spoken language. With an alphabetic language like English, the written symbols represent the sounds of
the language (albeit imperfectly because the Latin alphabet was not originally intended for English). To
both decode (read) and encode (spell) words, the reader/ speller must
(1) appreciate that words are composed of smaller units and
(2) learn the relationships between the written symbols (letters) and the spoken symbols (phonemes) they
represent. Put another way, the successful reader must have phonological awareness and understand the
letter–sound correspondences (these will be discussed in more detail in Chapter 12). Children with SSDs
overall have been shown to have difficulty in both of these areas (Bird, Bishop, and Freeman, 1995;
Sutherland and Gillon, 2005).
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PSYCHOSOCIAL FACTORS
Age: A positive correlation between improvement in articulation skills and age in
typically developing children appears to exist. Findings from at least two large
studies suggest that maturation generally may be a factor in speech sound
acquisition, and improvement in articulation skills may continue after age 9 years in
typically developing children. However, after about age 9, the amount of
improvement in articulation skills absent of intervention is limited in typically
developing children.
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Gender: The sex of a child appears to have some impact on speech sound acquisition.
At very young ages, females tend to be slightly ahead of males, but the differences
disappear as the children get older. As a consequence, many current tests of speech
sound acquisition include separate normative data for males and females. Gender
differences are reflected by the identification of significantly more male than female
children as having SSDs.
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Socioeconomic Status: t SSDs are not strongly associated with low SES (i.e., growing
up in a low SES household does not suggest a problem with speech sounds). However,
low SES may interact with other factors such as medical attention and preschool
stimulation and opportunities to result in a SSD.
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Familial Tendencies:
It is not uncommon for SLPs to observe a family history of speech and language disorders. Neils and
Aram (1986) obtained reports from the parents of 74 preschool language-disordered children and
indicated that 46 percent reported that other family members had histories of speech
Shriberg and Kwiatkowski (1994) reported data from 62 children aged 3 to 6 years with
developmental phonologic disorders. They found that 39 percent of the children had one member of
the family with a similar speech problem, whereas an additional 17 percent (total = 56%) had more
than one family member with a similar speech problem.
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Lewis (2009) reminds us of the complexity of the search because genes don’t directly lead to the
disorder but rather direct the production of proteins that then influence various aspects of
development. She also points out that speech and language behaviors are likely related to a
variety of neurological and biochemical processes, each of which may be active to differing
degrees at different points in the developmental period. Those processes may also be involved
with various speech and language. Despite the complexity of the task, Lewis notes that candidate
gene regions on several different chromosomes (e.g., 1, 3, 6, 7, 15) have been implicated as
possible sources of speech sound production disorders by different investigator groups.
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Sibling Influences
Another factor of interest to investigators of SSDs has been sibling number and birth order. Because the
amount of time that parents can spend with each child decreases with each child added to a family.
Koch (1956) studied the relationships between certain speech and voice characteristics in 384 young
children (5-6 years )and siblings in two-child families. on the basis of age, socioeconomic class, and
residence.
Koch reported that firstborn children had better articulation than those born second, and the wider the
age difference between a child and his or her sibling, the better the child’s articulation.
Likewise, Davis (1937) reported that children without siblings demonstrated superior articulatory
performance to children with siblings and to twins.
On the other hand, Wellman, Case, Mengert, and Bradbury (1931) did not find a significant relationship
between the number of siblings and level of articulation skill for 3-year-olds.
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PERSONALITY
The relationship between personality characteristics and phonologic behavior has been investigated
to determine whether particular personality patterns are likely to be associated with SSDs.
Researchers have examined not only the child’s personality traits but also those of the child’s
parents, using various assessment tools.
Bloch and Goodstein (1971) concluded, in a review of the literature, that investigations of
personality traits and emotional adjustment of individuals with SSDs have shown contradictory
findings and attributed this to two major problems with the investigations:
(1) the criteria for defining articulatory impairment has varied from one study to the next and
(2) the validity and reliability of tools or instruments used to assess personality and adjustment have
varied
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THANK YOU
