Speech-language pathology in school settings

Speech-language pathology is a fast-growing profession that, according to the Bureau of Labor Statistics, offers about 96,000 jobs in the United States alone. It relates to many educational disciplines such as communication sciences, linguistics, special education, and health care. This article will explore some of the fundamental elements of speech-language pathology, looking at the career in an educational setting.

Speech-language pathology
There are many different terms used to refer to professionals in this field, the most common of which are speech-language pathologist (SLP) and speech therapist. Speech-language pathology involves the study, diagnosis, and treatment of communicative disorders. An SLP seeks to improve an individual’s capacity for communication through various techniques or the use of special equipment. Some of the responsibilities of an SLP include evaluating individuals with communicative problems, diagnosing disorders and creating treatment plans, and carrying those plans out. Also, an SLP may conduct research in the field, run a private practice, or work with large companies to improve employee-customer communication ('American Speech-Language-Hearing Association'). This article will focus on the aspects of speech-language pathology as practiced with young children in a school setting.

For most people, the terms speech, language, and communication have nearly the same definition. However, in the realm of speech-language pathology, there are important distinctions to be made.

Speech is the spoken production of language and the process through which sounds are produced. Several parts of the body work together to produce sound waves, and this motor production of speech is called articulation. The parts of the vocal tract involved with speech include the lips, tongue, teeth, throat, vocal folds, and lungs. Speech disorders affect the physical mechanisms of communication and cause problems with articulation or phonology. Examples of speech disorders include stuttering, lisping, and voice disorders (Oyer 7).

Language is a system used to represent thoughts and ideas. Language is made up of several rules that explain what words mean, how to make new words, and how to put words together to form sentences. A community must share the same language in order to attach meaning to utterances. Language may be spoken, written, read, or heard. It can also be composed of gestures, as in American Sign Language, or pictures and symbols, such as the Blissymbol communication system. Humans are the only creatures innately capable of using language to discuss an endless number of topics. Language disorders are more difficult to treat and are often developmental, but may also be acquired. Examples include aphasia and specific language impairment (also called speech delay) (Oyer 6).

Communication is the exchange of information and ideas through the use of speech and language. The transfer of information is often spoken, but may also be implied through body language or contextual cues such as intonation or hesitation. Usually, communication is a four-step process:


 * 1) Encoding: the speaker creates the message in his mind
 * 2) Transmittal: the speaker sends the message
 * 3) Reception: the listener receives the message
 * 4) Decoding: the listener breaks down the message in his mind

If a problem occurs at any step of the process, the message might not be communicated. Without the ability to communicate through speech and language, we would not be able to tell a doctor that we have a stomach ache, choose food from a menu, or say “I love you” to our children. Communication is a most basic component of human nature and it develops before we are even conscious of it.

Development of speech and language
Every child develops at a different rate, but most go through the same stages. Listed below are the average ages of some important language and comprehension milestones as developed by the American Speech-Language-Hearing Association. Please note that like with any developmental timeline, these stages may be quite varied and perhaps met in a different order. A child who accomplishes these milestones differently may not necessarily have a developmental delay or speech disorder (and a child who hits these stages early is not necessarily a prodigy!).


 * birth to 3 months
 * startles to loud sounds
 * smiles when spoken to
 * responds to pleasure with 'cooing' noises
 * 4 months to 6 months
 * notices and pays attention to sounds and music
 * shifts eyes in direction of sounds
 * makes babbling noises that resemble speech
 * 7 months to 1 year
 * recognizes basic familiar words such as cup or ball
 * imitates different speech sounds
 * produces first words such as bye-bye or mama
 * 1 year to 2 years
 * listens to simple stories
 * identifies pictures by name when directed (point to the cow, e.g.)
 * speaks two-word sentences such as more juice or where daddy?
 * 2 years to 3 years
 * understands differences in meaning for basic words (up-down or in-out)
 * produces three-word sentences
 * can name most objects
 * 3 years to 4 years
 * understands questions
 * talks about events
 * speech is understood by most people
 * 4 years to 5 years
 * pays attention and responds to stories and questions
 * speaks clearly
 * tells detailed, ordered stories

Problems can arise at any stage of development, as well as much later in life. They can be the result of a congenital defect, a developmental disorder, or an injury. If a problem is suspected, an assessment should be made by an SLP who can diagnose and treat communication disorders.

Diagnosis of communication disorders
In a school setting, children are often screened when they start kindergarten. This process involves a rapid assessment to determine which children need further testing, diagnosis, or treatment. Often, a screening is a sort of informal interview between an SLP and a child or group of children. The child may be asked to give their name, count, pronounce the names of pictured objects, and answer open-ended questions. The purpose of these tasks is to elicit a brief language sample from the child which the SLP will use to evaluate articulation, fluency, and other aspects of speech. Screenings usually last about five minutes (Oyer 10).

After a screening is done, an individual diagnosis must be made. This involves a one-on-one evaluation which may last two hours or more. If an individual has been referred for testing, either by a doctor, teacher, or other professional, the screening process is skipped and testing starts here. This session allows the SLP to gather information that will help in the diagnosis of a speech or language problem, as well as provide insight to possible causes, goals and objectives for therapy, and which techniques will work best for that individual. Individual evaluations often include the following components:


 * A visual examination of the oral cavity and throat (typically with a flashlight and tongue depressor) to determine whether the physical structures appear to be capable of speech production
 * Tests of articulation of speech sounds in words and sentences as well as alone
 * A measure of the ability to hear the difference between correct speech sounds and sounds actually produced
 * Tests of expressive language and spontaneous speech
 * Evaluations of fluency and voice
 * A hearing test
 * A case history

After this evaluation, the SLP will review the results and information gathered and determine whether the individual would benefit from speech therapy. Goals and objectives of therapy are outlined and a specific treatment plan is created, drawing on the strengths and weaknesses and unique situation of that individual (Oyer 11).

Common communication and language disorders
Disorders that affect children may affect adults differently, or even not at all. As the body grows and develops, the types of disorders that affect an individual change. Children typically exhibit developmental language disorders, but may also experience problems due to illness or injury.

In developing children, language disorders are often related to congenital disabilities or neurological or physiological results of childhood illness. These seemingly unrelated problems can have a serious impact on speech and language development. Children that have cognitive impairments are often delayed in development of communication skills. Different genetic syndromes that often cause cognitive impairment, such as Down syndrome or Williams syndrome, often affect different areas of speech. Children with autism tend to have difficulty communicating and expressing their emotions or desires. Sometimes this is due to specific problems with articulation or semantics, but often it is an issue of neurological development directly related to autism. Brain injuries, tumors, or seizures in children can also cause loss of language skills. Children with attention deficit hyperactivity disorder (ADHD) commonly have learning difficulties which also affect their language development. Emotional disturbances early in childhood can also have an impact on the growth of basic communicative skills. Perhaps more obvious are the developmental and communicative consequences of childhood hearing loss (Boone 200-05).

Some disorders commonly diagnosed in children:

Specific language impairment
Some children have language development deficits that cannot be linked to neurological, intellectual, social, or motor causes. The child’s language skills grow much more slowly than those of typically-developing children. While other children are speaking in complete sentences, using conjugated verb forms, the SLI child’s speech sounds telegraphic- lacking grammatical and functional morphemes (e.g., He go store. rather than He goes to the store.) Their vocabulary remains relatively small while other children are adding new words every day. The SLI child often produces short sentences in order to avoid embarrassment and may have problems understanding complex or figurative structures (such as metaphors or multi-clausal sentences). Problems due to SLI can also lead to learning disabilities as the child fails to understand information being presented in science, language arts, or math classes. Studies suggest that the cause of SLI is a biological difference in brain anatomy and development (Boone 204). Treatment objectives generally focus on vocabulary development, verb morphology, memory and recall, and narrative skills (Goffman 154).

Articulation disorders
An articulation disorder may be diagnosed when a child has difficulty producing phonemes, or speech sounds, correctly. When classifying a sound, speech pathologists refer to the manner of articulation, the place of articulation, and voicing. A speech sound disorder may include one or more errors of place, manner, or voicing of the phoneme.

Different types of articulation disorders include:


 * omissions : certain sounds are deleted, often at the ends of words; entire syllables or classes of sounds may be deleted; e.g., fi' for fish
 * substitutions : one sound is substituted for another, often with similar places or manners or articulation; e.g., fith [sic] for fish
 * distortions : sounds are changed slightly by what may seem like the addition of noise, or a change in voicing; e.g., filsh for fish
 * additions : an extra sound is added to one already produced correctly; often occurs at the ends of words; may include changes in voicing; e.g., fisha for fish (Boone 256-58)

The phonemes that present the greatest challenge for children include /l/ as in pull, /r/ as in mirror, /ʃ/ ("sh") as in shut, /tʃ/ ("ch") as in church, /dʒ/ ("j") as in fudge, /z/ as in zoo, /ʒ/ ("zh") as in measure, /θ/ ("th") as in math and /ð/ ("th") as in this (Boone 112).

Articulation disorders may be attributed to a variety of causes. A child with hearing loss may not be able to hear certain phonemes pronounced at certain frequencies, or hear the error in their own production of sounds. Oral-motor problems may also be at fault, such as apraxia (a problem with coordination of speech muscles) or dysarthria (abnormal facial muscle tone, often due to neurological problems such as cerebral palsy). Abnormalities in the structure of the mouth and other speech muscles can cause problems with articulation; cleft palate, tongue thrust, and dental-orthodontia abnormalities are some common examples. Finally, it is difficult for children to hear and produce all of the different phonemes of a given language. Development is slow, and may take up to seven years. Sometimes, as children grow, articulation problems fade and disappear without treatment. Often, however, therapy is necessary. Treatment therapies may target semantic differences related to phonemic differences (e.g., teaching a child the difference between toe and toad, underlining the importance of the final consonant), physical-motor differences (e.g., using a mirror to show a child the correct tongue placement for a particular sound), or behavior-modification techniques (e.g., repetitive production through prompts and fun learning games). Support and reinforcement of therapy practices, both in the classroom and at home, are crucial to the success of articulation disorder treatment (Boone 122-24, 259-62, 274-76).

It is necessary to note the difference between articulation disorders and dialectical variations. There are several dialects of English spoken in the United States, influenced by socioeconomic status, geographic isolation, and other languages either brought to the U.S. by settlers or indigenous languages of the Native Americans. These social dialects are rule-governed and are not to be considered lesser than, but simply different from standard English. Examples of dialectical features that may be mistaken for articulation disorders include the 'r-lessness' of New York City speech in words like floor, here, and paper as well as the reduction of consonant clusters in African-American Vernacular English (AAVE). If a word ends with two or more consonants such as in cold, and is followed by another word that begins with a consonant such as cuts, cold is shortened to col, producing col cuts. These features alone should not be treated as articulation disorders to be 'cured' by speech therapy. However, it is possible for a child with a dialectal variation to also have a communication disorder. It is important for a speech pathologist to be able to tell the difference (Oyer 170).

Voice disorders
Children may experience problems with their voice due to misuse or abnormalities in the vocal mechanisms. There are two types of voice disorders: those of phonation, and those of resonance. Both types can be the result of either abuse or physical structure. Voice disorders are among the most successfully treated speech and language problems because they can be solved with surgery or reconditioning of the voice (Boone 286).

A phonation disorder is a problem with pitch, loudness, or intensity that originates in the vocal folds of the larynx. Phonation disorders may be functional, caused by continuous yelling or throat clearing, excessive smoking, or speaking at an abnormally low frequency or pitch. The results may be an increased size or thickening of the vocal folds, lesions or polyps on the vocal folds, or problems with elasticity of the larynx. In these cases, the treatment involves resting the voice and learning to speak at optimal pitches and volumes, as well as eliminating external causes such as smoking. Phonation disorders may also be organic, due to viral growths, cancer, paralysis of laryngeal nerves, surgical intubation, or external traumas such as being hit in the throat with a baseball. These problems may require surgical removal of growths or reconstruction of the larynx, accompanied by voice therapy (Boone 287-96).

A resonance disorder occurs when any part of the vocal tract is altered or dysfunctional.

In the case of an oral resonance disorder, the tongue sits too high in the front or back of the mouth. When the tongue is too far forward in the mouth, a type of ‘baby voice’ occurs, and a lisp may also result. Treatment involves practicing back vowels such as /a/ in father, /o/ in boat, and /u/ in spoon, accompanied by back consonants like /k/ in broke and /g/ in bog. When the tongue sits toward the back of the mouth, the voice sounds dull, and problems with articulation at the front of the mouth may also occur. Treatment focuses on front consonants such as /w/ in where or work, /p/ in pink, /b/ in ball, /f/ in laugh, /v/ in leave, /l/ in mail, and /th/ in with or bath coupled with high-front vowels like /i/ in wheat, /I/ in fit, /e/ in pay, /E/ in bet, and /ae/ in slat. This type of resonance disorder is commonly seen in children with severe hearing impairment.

Nasal resonance disorders occur when the space between the oral and nasal cavities remains open or closed, producing a hypernasal or denasal resonance. Causes of hypernasality include paralysis of the velum, a short velum, or a cleft palate which allows air to escape to the nasal cavity. The speech of actor James Stewart is a recognizable example of hypernasality (although in this case, there was no structural problem; rather, he employed the highly nasal voice as part of his character). Denasality is often caused by a structural blockage which doesn’t allow air to pass between the oral and nasal cavities. A child experiencing denasality may sound like they have a bad cold. If a structural problem is to blame, surgery is the most common treatment. After surgery, or if there is no structural cause, voice therapy is often given, involving massive amounts of practice (Boone 305-12).

Fluency disorders
As a child’s language and vocabulary grows, they may struggle to locate a particular word or sound. Normal dysfluency occurs in developing children as a repetition of whole words or phrases while the child searches for a particular thought or word. Around age three-and-a-half, children may compulsively repeat words or phrases. This tends to fade by the time the child is five. Stuttering, in contrast, results in repeated or prolonged speech sounds or syllables. Often, involuntary blocks in fluency will be accompanied by muscle tension due to frustration. The mouth may tighten up or the eyes may blink rapidly. A child may become so embarrassed by stuttering that they talk as little as possible to avoid the struggle. This may have serious academic and social implications. The cause of stuttering is unknown, yet widely debated. Most theories suggest emotional, psychological, or neurological origins. Psychological treatment aims at improving the self-image of the child and the child’s attitude toward the problem, while other therapies attempt to increase fluency by modifying the rhythm and rate of speech (Boone 316-29, 335-38).

How many people are affected by communication disorders?
According to the National Institutes of Health, it is estimated that, in the United States,


 * between 8 and 10 percent of people have a communication disorder
 * 7.5 million people have voice disorders
 * cleft palate affects 1 in 700 live births
 * 5 percent of children have noticeable communication disorders
 * stuttering affects more than 3 million people, mostly children age 2 through 6

According to the United States Department of Education, speech, language, and hearing impairments account for 20.1 percent of all Special Education students in the United States.

A typical in-school speech therapy session
The treatment of speech, language, and hearing impairments is handled differently by public and private schools throughout the country, although many programs have the same basic components. The model given below is that used by Mary Jablonski who has been working as a professional speech therapist in an elementary school for 22 years.

Therapy usually takes place in the speech pathologist’s office, although it may be conducted in a classroom. Students are put into small groups of three or four students of similar age and severity of disorder. Students meet for 30-minute to one-hour sessions from one to five days a week, depending on the diagnosis, severity, and disorder.

The children sit with the therapist and discuss any problems that they may be having or any progress that they have made. Students are encouraged to have a few minutes of conversation to loosen up their speech muscles. Also, the social interaction that results can be extremely beneficial to children with communication disorders who may be shy or socially withdrawn. The rest of the session is spent doing an activity. Students may play games, make crafts, draw pictures, sing songs, or act out short skits or role-playing exercises. These activities focus on improving students’ communication skills using several techniques, as noted by ASHA:


 * improving coordination of speech muscles through strengthening exercises, such as pushing the tongue against a tongue depressor, and training exercises involving sound repetition and imitation
 * improving communication between the brain and the body through visual and auditory aids such as mirrors and tape recorders
 * improving fluency through breathing exercises

Games and activities can be tailored to each individual’s problem areas. For example, a game board might have pictures of familiar items along a path. All of the items will have the target sound at the beginning of the word, in the middle, or at the end. A board for the s sound may have images of socks, a whistle, glasses, scissors, or a horse. Players roll dice and when they land on a particular picture, they have to pronounce the word correctly, focusing on the target sound. This game can be reproduced using pictures with /f/ sounds or /th/ sounds, etc. Games such as The Entire World of R™ Game Boards and The Entire World of R™ Say and Sequence Playing Card System treat the difficult /r/ phoneme while keeping the children’s energy and interest levels high. They enjoy the friendly competition and small-scale social interaction.

Students can use mirrors to look into their mouths as they practice sounds to make sure that their tongue, teeth, and lips are in the right places. A child’s speech may be recorded and played back so the child can hear what they are saying. Often, a child may think they're producing sounds the same as everyone else. Hear their recorded voice helps them realize what they are doing wrong.

If a child is having a difficult time producing a particular sound, the speech pathologist may remind them of the oral cues that go along with the sound. Here are some common cues:


 * For /th/, stick out the tongue and blow air through the mouth
 * For /f/, bite the lower lip and push the air through the teeth
 * For /r/, raise the back of the tongue to the roof of the mouth, or pretend the back of the tongue is an elevator and there is a little man on it who wants to ride to the top

At the end of the session students are usually given a reward for good behavior. This could be a sticker, a pencil, or a small toy. They are also given worksheets to complete at home with their parents. The worksheets usually involve verbal interaction through games and coloring activities. Parental involvement and reinforcement play an integral part in a student’s progress. When a child succeeds and improves through therapy, the benefits can be overwhelming.

Benefits of speech therapy
Communication skills play an important part in life’s experiences. In elementary school, children are developing language and learning to read and write. In order for a child to learn, he has to communicate and interact with his peers and adults. Spoken language is the basis for written language. As a child grows and develops, the two types of language interact and build upon each other to improve literacy and language. This process continues throughout a person’s life. If a child has a communication disorder, they are often delayed in other areas, such as reading and math. The child may be very bright but unable to express themselves correctly, and the learning process can be affected negatively.

Speech therapy can help children learn to communicate effectively with others and learn to solve problems and make decisions independently. Communication with peers and educators is an essential part of a fulfilling educational experience. Also, children who are able to overcome communication disorders feel a great sense of pride and confidence. Children who stutter may be withdrawn socially, but with the help of therapy and improved confidence, they can enjoy a fully active social life (ASHA).

Throughout her many years of working with children, Mary Jablonski recalls two particular success stories:

A. M. had problems with /s/, /th/, /r/, and /l/ sounds when he started kindergarten. I worked with him until he was in sixth grade. He transformed from a shy and quiet child to an outgoing, cheerful, friendly, and intelligent young man. I received a letter from him some time ago, explaining that he was in Europe, performing in operas. He wanted to thank me for his speech therapy experience. Unable to produce clear speech, he would never have had the confidence or ability to be an opera singer.

C. D. had problems producing several speech sounds. She was very difficult to understand when she started therapy. I worked with her through sixth grade and watched her, too, develop into a very outgoing and enthusiastic young woman. She graduated from high school at the top of her class and was asked to name her most influential teacher. Out of all of the instructors she had in her 13 years of education, she chose me. I had given her the gift of confidence and the ability to communicate effectively and get the most out of her educational experience.

Conclusion
Communication is at the heart of human existence. Proper skills are necessary to communicate effectively. When children develop those skills slowly or fail to develop them at all, there may be a communication disorder at fault. Disorders are diagnosed through assessments and tests and can be treated through interactive speech therapy. Over 1 million American students in kindergarten through twelfth grade are being treated for a communication disorder or impairment every year (American Speech-Language-Hearing Association). A speech therapist works with children in schools to improve their oral motor skills and speech production. Improved communication through speech therapy can result in a better educational, social, and emotional experience for a child.