Speech Disorders

Children who start talking later are called late talkers.
Delayed speech development occurs when a child speaks fewer than 50 words by 24 months and has a very small vocabulary compared to other two-year-olds in the following months. If the child is largely age-adequate in other areas of development (e.g. motor, thinking and play development), experts call him a late talker (Kauschke, 2017). The children often do not yet speak combinations of two words (e.g. daddy ball). They communicate by pointing to things, child language (e.g. “woof-woof”), sounds or facial expressions and gestures.

In most cases, no clear cause (e.g. hearing impairment) can be identified for delayed language development (AWMF guideline, 2013). A genetic predisposition is suspected as the main cause. Parents are not to blame for their child’s delayed language development. Nor are children too lazy to speak, as is often assumed. Growing up multilingual is not a risk for delayed language development. If a multilingual child growing up speaks less than 50 words in total by 24 months, it is advisable to clarify delayed language development just as in monolingual children. 

Language development disorders are language disorders that occur during child development and may persist into adolescence and adulthood.
They affect language comprehension, sound acquisition, vocabulary, grammar, text comprehension, text production and communication (pragmatics). Parents often notice that their children speak unclearly, unintelligibly or little.
-> A speech development disorder occurs at the beginning or during a child’s development and is partly caused, for example, by a hearing impairment, disabilities or also long-term middle ear infections at the time of the “speech-sensitive phase” (2nd and 3rd year of life). If there is no identifiable cause for Language development disorder it is called a “specific language development disorder”.

Specific LDS occurs in both monolingual and multilingual children.
In multilingual children, the disorder then manifests itself in all acquired languages.

The following are some examples:
Disorders in phonetic acquisition
-Sound substitutions
– Omission of sounds (e.g. tterfly instead of butterfly)
-Deletion of unstressed syllables (e.g. nane instead of banana)

Vocabulary disorders
-Low vocabulary (use of fewer words)
-Use of multipurpose words (e.g. thing) or simple verbs (e.g. make)
-Search behaviour and word-finding problems

Problems with grammar
– Omission of words (e.g. “___boy buys apples”)
-Unusual position of the verb in the main clause (e.g. “Grandma pies bakes”)
-No or incorrect plural indications (e.g. house instead of houses)

Diagnostics to determine the need for treatment are carried out by speech therapists. 

“Noah doesn’t speak in kindergarten! Yet he can already express himself very intelligibly at home. At first, we thought he had to get used to the new situation first, but after 3 months, nothing has changed substantially!
This is how parents or educators describe the behaviour of selective mutist children. Selective mutism (Latin: mutuus = mute) means that children cannot speak in certain circumstances, but communicate in age-appropriate ways in other situations. The disorder is often accompanied by social anxiety, sleep regulation disorders and food and excretory control.

Causes
Risk factors include attachment insecurity, bilingualism or bilingual culture, language development disorders, family experiences of stress and strain, introverted temperament and family role models. At worst, these factors can lead to silent behaviour. At first, silence was an attempt to find a solution to a child’s excessive demands, but later it can solidify into selective mutism:

The affected child falls out of the social situation linguistically, but often also communicatively.
This then leads to a vicious cycle of avoiding linguistic communication and missing out on linguistic and social-emotional learning. In many cases, the disorder arises during the child’s transition to kindergarten, where the first (significant) non-familial environment is perceived as threatening and foreign (early mutism). The risk of the disorder occurring later is much lower.

Frequency
Selective mutism is a rare disorder: 0.1-0.7% of children are affected. The disorder affects girls 1.6-2.6 times more often than boys (Katz-Bernstein, 2011, 31f).

Symptoms
The difference between shyness and selective mutism
Shy children actively seek ways to gain trust in an environment that is strange to them, so they gradually open up after a period of habituation. Mutistic children, on the other hand, remain silent and do not develop strategies to adapt to the new situation. Some children also “freeze” in their physically expressive behaviour and facial expressions in a conspicuous way, others also avoid all physical noises such as coughing. 

Dyslexia is a developmental disorder in reading and writing that is not due to a lack of instruction, a lack of opportunity to learn, a lack of intelligence or a physical condition (e.g. visual impairment).
The terms “dyslexia” or “dyscalculia” are often used instead of “dyslexia”. This variety of terms results partly from the fact that different professions have been dealing with the phenomenon for more than a century and have described it in their professional language (e.g. psychology, medicine, psychiatry, patholinguistics, (speech) education, speech therapy, etc.).

The terms are not clearly distinguishable from each other. Moreover, no term is always used with a uniform meaning.

From a scientific point of view, one speaks of so-called “partial performance disorders” that have an aggravating effect on the acquisition of reading and/or writing and can and should be diagnosed differentially.

If dyslexia is not diagnosed early and treated in a targeted way, it has an aggravating effect on the educational biography and, in many cases, leads to delays in school, work and home – and often to psychological stress.

The World Health Organisation (WHO) classifies dyslexia as a disease in the International Classification of Diseases (ICD 10) and groups the following manifestations under diagnosis code F.81 (“Circumcribed developmental disorders of school skills”):

Reading and spelling disorder (F81.0)
Isolated spelling disorder (F81.1)
Research groups that have focused on the role of working memory (WMC) in reading and spelling in recent years have also found evidence for the existence of Isolated Reading Disorder, as problems in reading were associated with other problems in WMC than problems in spelling.

However, the diagnosis of “isolated reading disorder” is so far found only in the DSM-5, the main classification model of psychiatric disorders in the US region.

Symptoms
Typical symptoms of a reading disorder:
Many errors in reading words
Difficulties in learning to associate and remember letters and sounds (word-sound relationships)
Problems combining (synthesising) individual sounds into words.
Automatic reading remains delayed and faulty
Significantly reduced reading speed
Decreased reading comprehension
Typical symptoms of a spelling disorder:

Difficulty learning and remembering the sound-letter relationship (phoneme-grapheme correspondence).
Problems “hearing” individual sounds from words (phoneme analysis)
Spellings that are not sound-like (omission, substitution and replacement of letters unrelated to the sound of the word)
Frequent errors and several incorrect spellings of a word
Remembering the correct spelling of word parts and words often fails.
These abnormalities do not change despite more practice at home.
Important precursor functions develop as early as preschool age. The prerequisite for the development of thinking, learning and speaking is perception, i.e. the reception of stimuli and their processing in the brain. Children with dyslexia show above-average perceptual difficulties and language development problems. Inattention, clowning, motor restlessness, frustration, lack of self-confidence, abdominal pain, headaches or nausea are frequent accompanying symptoms.

To diagnose dyslexia in the sense of the ICD-10 (see above), a comprehensive medical examination is required. This should exclude all causes that may also lead to difficulties in learning to read and spell (e.g. visual and auditory disorders, childhood depression, neurological diseases) as the cause of the dyslexia, test reading and spelling performance, and examine school performance, learning status, general development and subsequent problems as well as general conditions. This comprehensive examination is performed in children and adolescents by doctors in child and adolescent psychiatry and psychotherapy or by child and adolescent psychotherapists.
Criteria for making a diagnosis can be found in the guideline “Diagnostics and treatment of children and adolescents with reading and/or spelling disorders”. 

Articulation disorders (phonetic disorders) are deviations in the pronunciation of sounds or sound combinations due to speech motor problems.
From these should be distinguished phonological disorders, which result in the inability to use sounds in the correct place in the word. In articulation disorders, the formation of one or more sounds does not correspond to the so-called “standard pattern” of a language, i.e. a sound is not formed or is formed incorrectly. In German, the sibilants (s, z, sch, ch1 [ich sound]) are most often affected. In Russian sounds (/r/, /sch/, /z/, (zh/, /s/ and /tsch/ are most often effected. In English there are disorders such as:

Addition:Adding sounds or syllables to words that don’t belong there (for example, “puh-lay” instead of “play”).

Distortion:´Changing a sound, which might seem like a lisp (when “s” sounds like “th”).
Omission:Leaving certain sounds out of their speech altogether (for example, never using “sc” in “school or “scratch”).
Substitution:Always substituting one sound for another (for example, using “s” instead of “th” or “w” in place of “r”).

The articulatory salience of the sounds /s/ and /z/ is also called “sigmatism” (colloquially: “lisp”) and occurs in various forms ( German, Russian languages and other)

Causes
Articulation disorders can occur as primary (disorder in articulation development) and secondary disorders (resulting, for example, from hearing disorders or diseases/misfigurations in the oral cavity). They can have functional or neurogenic causes. Deformities of the articulatory organs (e.g. cleft lip and palate) can also lead to impaired articulation.

Functional abnormalities are most common,
i.e. there are no organic causes, but the child has difficulty performing an articulation movement precisely. It is not uncommon for children to have speech models that have similar pronunciation or they suffer from a so-called myofunctional disorder with too little muscle tone in the mouth area. Usually, children do not articulate sounds accurately enough and practise an incorrect sound pattern during sound acquisition. The longer and more intensively a child has trained (automated) incorrect articulation, the more difficult it can be to learn and use the correct target movement in everyday life.

If pronunciation is impaired by diseases of the peripheral or central nervous system, a child’s intelligibility is usually more clearly limited, sometimes even impossible, i.e. the child suffers from dysarthria.

Frequency
Articulation disorders are relatively common in children in the process of language acquisition, i.e. about 13.5% of 4-6-year-old children show articulation disorders.

Symptoms
Example:
German:”θuθi wants θüθeθ Eiθ.” (Susi wants sweet ice cream).
Russian:“лак „ instead of „рак“
English: using “s” instead of “th” or “w” in place of “r”)

In the example sentence, all s-sounds are pronounced interdental, i.e. the tongue slides between the teeth when /s/ is pronounced. In addental formation, the tongue is placed not between, but too close to the front teeth.

In both cases, the result is an altered sound of /s/, which can be perceived as “lisping”.

Sensorineural hearing loss is defined as hearing loss caused by damage to the inner ear and/or the auditory nerve.
These can be distinguished from central hearing loss, also known as Auditory processing and perception disorder. In addition, hearing can also be affected by disturbances in the outer and middle ear, known as conductive disorders.

Causes
In most cases, a child’s hearing impairment arises due to heredity or as a result of diseases during (rubella, viral infections, meningitis) or after (meningitis, mumps, measles, CMV infections, middle ear infection) pregnancy.

In addition to permanent hearing damage, so-called tympanic effusion, in which fluid collects behind the eardrum, can lead to temporary hearing impairment, which can also affect speech development.
Frequency
Impaired hearing occurs in children at a frequency of 0.1-1% and is accompanied by impaired hearing, i.e. impaired or missing auditory perception.

This can lead to developmental disorders manifesting at the linguistic, cognitive or pragmatic level.
Symptoms
The following symptoms may occur with hearing impairment (also in combination):

Decreased hearing and language development
No or delayed onset of the 2nd baba phase (see speech development)
Vague, backward articulation
In the case of high-pitched hearing loss: especially sibilants (/s/, /z/,) and voiceless final consonants (e.g. /t/ in /s/ in ice or /f/ ) are affected.
Impaired directional hearing
Difficulty hearing in background noise (at the family table, in kindergarten)
If hearing disorders in children are detected too late, impairments in language acquisition and communication occur.
Since there are sensitive stages to the maturation of the auditory pathway and language acquisition process, hearing aids should be provided as soon as possible after diagnosis.

What can parents do?
If your child is unresponsive or unresponsive to acoustic stimuli, if you notice striking irregularities in speech development and increasingly frustrated behaviour in interacting with peers, consult a specialist in phoniatrics and paediatric audiology.

Even if the hearing screening does not reveal anything in the newborn, a hearing disorder may develop in the course of the child’s development. 

Accelerations and delays in speech flow may occur, as well as repetitions, elongations, contractions and blocks.
Speech flow disorders can occur in the form of stuttering and/or poluttering.

Stuttering
Stuttering is a disorder of speech flow in which the flow of speech is interrupted by repetitions, elongations and blockages.
Stuttering provokes uncertainty and prejudice – but wrongly so, according to research in recent years. Stuttering can be specifically recognised in all age groups and properly treated if necessary.
Knowledge about the causes and prevalence of stuttering also helps to identify the speech disorder and provide specific guidance to those affected and parents.

Poluttering
Poluttering is a disorder of speech in which the flow of speech is described as too fast and irregular.
It can also occur when the speaker is not understood at all. Affected individuals may have limited awareness of disorders, a low attention span, disturbances in perception and articulation, and difficulty in formulating (Weiss, 1964).
Compared to stuttering, poluttering is a relatively unknown speech disorder, so it is often diagnosed very late or not at all. This disorder is not widely known in society.

Causes Stuttering
According to current knowledge, stuttering is largely genetic. This means that a predisposition to stuttering may be hereditary.

This predisposition appears to cause abnormalities in the brain. This has been proven in imaging studies of subjects who stutter. The neurologically induced dysfunction of the speech motor system initially causes the core symptoms.

This refutes the previously prevalent theory that a particular parenting behaviour or negative experiences in childhood are causes of stuttering.
However, it is still not definitively clear why some people stutter and others do not. There is no clear cause that applies to all people who stutter.

The frequency and severity of symptoms can be triggered, perpetuated or even amplified by various factors, for example by a taboo on stuttering or supposedly well-intentioned advice such as “speak slowly”.

Stuttering is not a mental or intellectual disorder.

Poltern
It is debated whether polterning is caused by the fact that language utterances are pronounced before their planning is complete.

However, the exact causes have not yet been sufficiently elucidated

Poluttering is not a mental disorder.
In many anamnesis interviews, polteren was found to be more common in families (Weiss, 1964, Becker & Grundmann, 1970, Op’t Hof & Uys, 1974: all in Sick, 2014), so genetic predispositions are also discussed. 

Verbal developmental dyspraxia manifests as an inability to correctly plan and execute movements.
It should be distinguished from phonetic disorder, phonological disorder and neurologically induced apraxia of speech.

From an early age, affected infants/children show problems with food intake, i.e. they swallow frequently (cough) because the process of sucking-swallowing-breathing is disturbed. A lot of saliva is produced during the transition from mushy to solid food. In some cases, the children may be found to be clumsy in their gross motor skills, i.e. they often stumble. The speech development of these children is characterised by the fact that they produce only a few sounds. Consonants are missing in their first sound productions, they produce a kind of “vowel language” (e.g. “aaoo”). They are also called “silent babies” and have delayed speech development (“late talkers”).

The term “infantile apraxia of speech” is sometimes used synonymously with verbal developmental dyspraxia. However, this can be misleading, as verbal apraxia of speech is not based on a direct neurological impairment.

Causes
Scientific studies suggest that verbal developmental dyspraxia is genetically caused, i.e. the brain regions responsible for controlling speech movements appear to be affected.

Symptoms
The affected person’s speech is unintelligible. The child can speak few or no consonants (consonant sounds) and vowels (vowel sounds) may also be affected. The articulatory errors the children make are inconsistent and may be different with each word (e.g. ball, bai, hall, all, …). The children are aware of interference, meaning that they notice that speaking is not easy for them and that others struggle to understand them. Nevertheless, they are usually eager to communicate and turn to their peers and try to communicate “with hands and feet”.
The disorder occurs in a small group of children with speech disorders.
About three times as many boys as girls are affected. 

Orofacial myofunctional disorders, also called orofacial dysfunctions (OFD), are motor and/or sensory abnormalities of the muscle functions in the oral-facial area that deviate from normal (physiological) development.
sensory abnormalities of the muscle functions in the mouth-facial area that deviate from normal (physiological) development. The open mouth position and the often resulting defective resting position of the tongue on the palate are of primary importance. In addition, dysfunctional movement patterns in breathing, chewing, biting, swallowing, speaking and vocalising may occur, usually as a result of OMF. Besides these effects, non-physiological developments in structural abnormalities, such as a narrow jaw with malocclusion or tooth misalignment, can also be seen.

Speech therapy treatment of orofacial myofunctional disorders (OMD) is called myofunctional therapy (MFT).
Causes
The development of an OMD cannot usually be attributed to one specific cause.
Open-mouthed posture is currently considered the main cause and equally the main symptom. It is called postural weakness (or habitual open-mouthed posture) when there is no medical cause, such as obstructed nasal breathing due to infections, allergies or asthma. It can also be maintained by external factors (habits), such as thumb sucking, frequent pulling in or licking of the lips, or too frequent use of the dummy. Failure to close the lips completely leads to an imbalance between the external and internal lip, tongue and cheek muscles, on the one hand, and the bony structures enclosed by them, on the other.

However, lack of training of the muscles (e.g. due to little chewing) can also be a factor in the development of OMS. Another possibility is genetic causes, for example in connection with syndromes.

Symptoms
One or more of the following signs may indicate OMD:

Open mouth position (no full lip contact at rest; tongue not resting against the palate at rest; dry, cracked lips; curled lower lip; shortened, raised upper lip; tense chin muscle; no lip contact during and after speaking; snoring; tired appearance; growth of the face in length and less in width).
Impaired respiratory function (e.g. mouth breathing)
Impaired chewing function (avoiding or rejecting hard food; chewing food is not sufficiently crushed; chewing with open mouth; increased salivation when chewing; smeared mouth when eating; one-sided chewing; unilateral or no lateral movement of the lower jaw; tongue has difficulty moving chewing food left and right)
Impaired swallowing function (tense lips; tense chin muscle; forward movement of the head; tongue pushes chewing material forward or sideways through the teeth when swallowing)
Impaired articulation and vocalisation (slurred speech with little lip movement; mispronunciation or lack of pronunciation of sounds; strained vocalisation, harsh vocal tone).
Further signs may include

Tongue sucking/impossibility of tongue clicking
Limited tongue mobility (especially tongue cannot move freely, needs support from lower lip)
Shortened tongue/lip frenulum with limited function (e.g. tongue can only move little sideways or upwards)
Reduced oral perception and discrimination ability

What can parents do?
If parents observe one or more of these signs in their child, they should first contact a paediatrician or orthodontist. If a child breathes more through the mouth or if the mouth is often open, an ENT( ear, nose and throat specialist) should also be consulted at an early stage. specialist should be consulted at an early stage. The specialists will write a prescription for speech therapy if treatment is needed. Speech therapists determine the extent and severity of the disorder at the outset and discuss the planned therapy with the individual and their relatives. If necessary, this therapy is carried out in close interdisciplinary cooperation with other specialisms.

Besides treatment by speech therapists, prevention is of great importance in OMD. From about 6 months and throughout development, chew-intensive feeding supports the transition from the sucking-swallowing pattern of breastfeeding/bottle feeding to the chewing-swallowing pattern. At the same time, it promotes proper development of both the entire musculature of the mouth face and the bony structures of this area.

To promote competent lip closure and tongue position on the palate, a dummy should only be used very sparingly and deliberately (like a medicine). In case of prolonged sucking habits, as with the thumb, a speech therapy or medical consultation is recommended.

Auditory processing and perception includes the perception of acoustic stimuli (even when masked by background noise), as well as the discrimination, recognition and evaluation of acoustic cues (Ptok, Kiese-Himmel & Nickisch, 2018).

Auditory processing and perception disorders (AVWS), also called auditory processing disorders (AVS), are

Disorders in the perception and processing of auditory information at the central level
(in the area of the brainstem and auditory cortex in the brain). There is neither a disorder of the auditory organ (auricle, eardrum, middle ear, inner ear, auditory nerve) nor a reduction in intelligence.

The processing of hearing is divided into auditory subfunctions, which can be affected in different ways and to varying degrees. The auditory subfunctions include:

Localisation (direction and distance of the sound source)
Discrimination (distinguishing)
Selection (filtering out) and
Dichotic hearing (binaural hearing).

Causes
Causes are believed to be medical factors or environmental influences. Medical causes include prolonged middle ear infections in early childhood, early brain damage or delays in brain maturation.

Causes can often only be suspected and not clearly demonstrated.
Possible negative environmental influences include both too low a supply (too little communicative activity with the child) and too high a supply (prolonged television use, parallel conversations with radio or television use) of auditory speech stimuli.

Frequency
About 2-3% of all children have problems with central auditory processing. Boys are affected twice as often as girls.

Abnormalities are common in association with speech disorders.
However, it is unclear whether AVWS are part of a language development disorder or constitute an independent disorder. They are often only noticed in the course of a language development disorder.

Symptoms
In selection disorder (filtering out information), for example, it is more difficult or impossible to follow a conversation with a person if background noise, such as traffic noise, can be heard at the same time. For example, children with selection disorder find it difficult to filter out sounds from words at school when there is ambient noise, i.e. they do not understand what the teacher is saying.
When discrimination is impaired, similar-sounding sounds or syllables (e.g. /p/ – /b/ or /pa/ – /ba/) are not perceived as different. This can lead to spoken words not being understood or even misunderstood.

What can parents do?
If an auditory processing and perception disorder is reasonably suspected, parents should seek medical and speech therapy advice. If a special medical examination of central hearing is necessary, an appointment should be made in good time, as many examination centres have long waiting lists so that each child can be examined in detail.

12.Neurological disorders (aphasia, apraxia of speech, dysarthria)

Aphasia
Partial or complete loss of language skills acquired until the event (acute brain injury) (from about 2.5 years or language development at at least word level). All the symptoms that adults show in aphasia can also be observed in children and adolescents.

These may include:
omissions, substitutions, additions and/or transpositions.
Swapping words (e.g. table instead of chair)
Word-finding disorders
A- or paragrammatism
Reading and/or writing disorders
Communication and pragmatic disorders

Apraxia
Phonetic abnormalities or distortions of sounds à incomprehensible pronunciation
Substitution and interchange of sounds
Mixture of types of errors
Searching movements of the articulatory organs (tongue, lips, etc.)
Variation of errors in the repetition of words/phrases
Delayed speech
Literal speech (“I don’t want that today”)
Stress errors

Dysarthria
Limited mobility of tongue and lip
Unclear and vague pronunciation
Voice too high or too low
Changed voice tone (rough, hoarse, voiceless, nasal, …)
Increased salivation, reduced swallowing frequency.

Children with infantile cerebral palsy mainly suffer from limited motor skills due to early brain damage (0 – 2 years).
The increased muscle tension usually makes it difficult for children with spastic movement disorders to learn to walk, as they can only make insufficiently coordinated and dosed movements with their legs.

The motor disorders may be accompanied by cognitive (perceiving, learning, remembering, thinking) and sensory (seeing, hearing, smelling, tasting, feeling) impairments (Kuschmann, 2015).

Symptoms
Depending on the brain injury:

Spastic movement disorder (with excessive, rather stiff muscle tension) (frequency of occurrence: 80% (Kuschmann, 2015)).
Movement disorders (athetosis) (about 15%)
Problems coordinating movements (ataxia) (about 5%)
Muscle tension that is too weak (hypotonic) (making movements difficult or impossible).
Spastic movement disorders are the most common and can occur, for example, in the legs, on one side or throughout the body.

What can parents do?
Parents often already have reliable contacts when infantile cerebral palsy is diagnosed (paediatricians, therapists). Nevertheless, it can be very helpful to establish contact with other parents with disabled children and exchange experiences with different treatment methods, for example. Kentalis or early intervention centres offer various medical and therapeutic services (paediatrics, speech therapy, occupational therapy, physiotherapy, music therapy, etc.) and parental support; in some cases, a local self-help group can also be contacted.