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DIAGNOSTIC AUDIOLOGY
A hearing test provides an evaluation of the sensitivity of a person’s sense of hearing and is most often performed by an audiologist using an audiometer. An audiometer is used to determine a person’s hearing sensitivity at different frequencies.
PURE TONE AUDIOMETRY
Pure tone audiometry (PTA) is the key hearing test used to identify hearing threshold levels of an individual, enabling determination of the degree, type and configuration of a hearing loss. Thus, providing the basis for diagnosis and management. PTA is a subjective, behavioural measurement of hearing threshold, as it relies on patient response to pure tone stimuli. Therefore, PTA is used on adults and children old enough to cooperate with the test procedure.
AUDIOGRAM– The obtained hearing thresholds are represented across specific frequencies in audiogram.
OTOSCOPIC EXAMINATION
IMMITTANCE AUDIOMETRY
Immittance audiometry is an objective technique which evaluates middle ear function by three procedures: static immittance, tympanometry, and the measurement of acoustic reflex threshold sensitivity. In this test, a small probe is placed in the ear and the air pressure in the ear canal is varied. This test tells how well the eardrum and other structures in the middle ear are working. In acoustic reflex testing a probe is placed in the ear and a loud tone, greater than 70 dBSPL, is produced. The test measures the reflexive contraction of the stapedius muscle, which is important in protecting the ear from loud noises, such as a person’s own speech which may be 90 dBSPL at the eardrum. This test can be used to estimate the hearing thresholds in patients who are unable to perform normal pure tone audiometry and can also give information about the vestibular and facial nerves and indicate if a lesion may be present.
SPEECH AUDIOMETRY
Speech audiometry has become a fundamental tool in hearing-loss assessment. In conjunction with pure-tone audiometry, it can aid in determining the degree and type of hearing loss. Speech audiometry also provides information regarding discomfort or tolerance to speech stimuli and information on word recognition abilities.
In addition, information gained by speech audiometry can help determine proper gain and maximum output of hearing aids and other amplifying devices for patients with significant hearing losses and help assess how well they hear in noise. Speech audiometry also facilitates audiological rehabilitation management.
SPECIAL TESTS
Special hearing test may be categorized in number of ways, such as:
1 (a) Special test using pure tones
(b) Special test using speech
2 (a) Special tests administered at threshold level
(b) Special test administered at suprathreshold level
3 (a) Special test requiring voluntary behavior responses from patient
(b) Special test doesn’t requiring voluntary behavior responses from patient
4 (a) Special tests designed for assessment of Cochlear pathology.
(b) Special test designed for assessment of Retro Cochlear pathology
The test for cochlear evaluation using pure tone as stimulus includes:
1. Differential Limen of Intensity (DLI)
2. Short Increment Sensitivity Index (SISI)
3. Alternate Binaural Loudness Balance Test (ABLB)
4. Monaural Loudness Balance Test (MLB)
While, test using speech as stimulus, includes SRT, WRS, MCL, UCL (LDL-Loudness Discomfort Level), and Dynamic range.
Test for Retro cochlear evaluation using pure tone stimulus includes Tone Decay Test administered at threshold and supra threshold level including Supra Threshold Adaptation Test (STAT). While, the using speech stimulus is used WRS, PIPB functions, Roleover Effect Index and test for Central Auditory Processing Disorder (CAPD)
Besides these tests, the other tests which were to be used earlier for differential diagnosis of Cochlear pathology and Retro Cochlear Pathology, includes:
– Beckhesy Audiometry
– Brief tone Audiometry
– Diplacusis Test
TONE DECAY TESTS (TDT)
In clinical practice, Tone Decay is either measured at or near threshold or well above threshold, thus Tone Decay can be classified into 2 groups:
1. Threshold Tone Decay
2. Supra Threshold Tone Decay
Threshold Tone Decay (TTD) is defined as reduction in the sensitivity resulting from the presence of a barely audible tone while Supra Threshold Tone Decay refers to loss of audibility as a result of stimulation which is presented at higher presentation level.
TD is a powerful diagnostic procedure for Retro Cochlear Pathology. It is only one of the tests of battery that has been considered sensitive for differential diagnosis between Cochlear Pathology and Retro Cochlear Pathology.
ALTERNATE BINAURAL LOUDNESS BALANCE TEST(ABLB)
This technique was initially described by Fowler, 1986, It is helpful in detecting the recruitment in clients with bilateral hearing loss. ABLB compares loudness growth between 2 different frequencies in the same ear. ABLB is a pure tone test which is done when there is a threshold difference of more than 20 dB between ears at the test frequencies and the better ear is relatively normal. The purpose of ABLB test is to compare the growth of loudness in an impaired ear with the normal growth of loudness in the opposite / normal ear.
DIFFERENTIAL LIMEN OF INTENSITY(DLI)
DLI of recruitment are based on the measurement of rate of change of loudness as the intensity increases. The rate of change in loudness with increase in intensity is greater in recruiting ears than non-recruiting ears. The change in intensity in dB which results in a just barely noticeable loudness change is known as Intensity Diffrential Limen for Loudness.
Leushior&Zwislocki (1948), gave recruitment test which was first designed IDL test for detection of recruitment in unilateral ear. The test involves an amplitude modulated tone as the criteria for the detection of the presence of recruitment in the ear.
DENNIS & NAUNTON TEST:
Dennis &Naunton, 1950, develop another recruitment test based on IDL for loudness. This test is often referred to as memory method for measuring the IDL.
PERFORMANCE INTENSITY PHONETICALLY BALANCE (PIPB)
PIPB Function/ Articulation Curve/ Roll-over Effect
The study of intelligibility of PB word list at different intensity level is termed as PIPB function or PIPB curve. PIPB curve is a graph showing the correct % of speech discrimination material as a function of intensity. The graph usually shows the discrimination score on the Y-axis and the sensation level on the X-axis. The study of PIPB function helps in determining the differential diagnosis of cochlea and RCPs. PIPB function used as the method of screening for disorders of central auditory nervous system.
THE HEARING IN NOISE TEST
The Hearing in Noise Test (HINT) measures a person’s ability to hear speech in quiet and in noise. In the test, the patient is required to repeat sentences both in a quiet environment and with competing noise being presented from different directions. The test measures signal to noise ratio for the different conditions which corresponds to how loud the sentences needed to be played above the noise so that the patient can repeat them correctly 50% of the time.
WHISPERED VOICE TEST
A simple and accurate test for detecting hearing impairment. It is the only test of hearing that requires no equipment. There is some concern regarding the lower sensitivity in children and the overall reproducibility of the test, particularly in primary care settings.
BEKESY AUDIOMETRY
A type of hearing test in which the subject controls the intensity of the stimulus by pressing a button while listening to a pure tone whosefrequency slowly moves through the entire audible range. The intensity diminishes as long as the button is pressed. When the intensity istoo low for the subject to hear the tone, the button is released and the intensity begins to increase. When the subject again hears thetone, the button is again pressed, yielding a zigzag tracing. Continuous and interrupted tones are used, and the tracings of the two arecompared. The test may be used to differentiate between hearing losses of cochlear and neural origins.
TUNING FORK TESTS
(Rinne, Weber, ABC, Schwabach’s Test)
(a) Rinne test. In this test air conduction of the ear is compared with its bone conduction.
(b) Weber test. In this test, a Vibrating tuning fork is placed in the middle of the forehead or the vertex and the patient is asked in which ear the sound is heard.
(c) Absolute bone conduction (ABC) test. In ABC test, patient’s bone conduction is compared with that of the examiner (presuming that the examiner has normal hearing).
(d) Schwabach’s test. Bone conduction of patient is compared with that of the normal hearing person (examiner) but meatus is not occluded.
ELECTROCOCHLEOGRAPHY
Electrocochleography (ECochG) is the technique of recording the electrical responses of the cochlea.It helps in assessment ofMeniere`s disease, and also helps in measurement and monitoring of the cochlear and auditory nerve function during surgery involving the auditory periphery
AUDITORY BRAINSTEM RESPONSE
The auditory brainstem response (ABR) is an auditory evoked potential extracted from ongoing electrical activity in the brain and recorded via electrodes placed on the scalp. The resulting recording is a series of vertex positive waves of which I through V are evaluated. The ABR is used for newborn hearing screening, auditory threshold estimation, intraoperative monitoring, determining hearing loss type and degree, and auditory nerve and brainstem lesion detection.
ADVANCE ABR TECHNIQUES
STACKED ABR The stacked ABR is the sum of the synchronous neural activity generated from five frequency regions across the cochlea in response to click stimulation and high-pass pink noise masking. The development of this technique was based on the 8th cranial nerve compound action potential. The Stacked ABR is a valuable screening tool for the detection of small acoustic tumors because it is sensitive, specific, widely available, comfortable, and cost-effective.
AUDITORY STEADY-STATE RESPONSE (ASSR)
Auditory Steady State Response is an auditory evoked potential, elicited with modulated tones that can be used to predict hearing sensitivity in patients of all ages.
It is an electrophysiologic response to rapid auditory stimuli and creates a statistically valid estimated audiogram. The ASSR uses statistical measures to determine if and when a threshold is present and is a “cross-check” for verification purposes prior to arriving at a differential diagnosis.
OTOACOUSTIC EMISSION
Otoacoustic emission (OAE) is a sound which is generated from within the inner ear. Otoacoustic emissions arise through a number of different cellular and mechanical causes within the inner ear. There are two types of otoacoustic emissions: spontaneous otoacoustic emissions (SOAEs), which can occur without external stimulation, and evoked otoacoustic emissions (EOAEs), which require an evoking stimulus.
Otoacoustic emissions are clinically important because they are the basis of a simple, non-invasive test for hearing defects in newborn babies and in children who are too young to cooperate in conventional hearing tests. Otoacoustic emissions also assist in differential diagnosis of cochlear and higher level hearing losses.
MIDDLE-LATENCY RESPONSE
The MLR is derived from the medial geniculate body, inferior colliculus and the primary auditory cortex. The MLR was used to identify residual low frequency hearing and MLR provided the only available threshold data because brainstem damage compromised the use of the ABR for hearing assessment.
LATE LATENCY RESPONSE
These auditory evoked potentials are brain responses that are evoked by sound and processed in or near the auditory cortex, and they are therefore referred to as cortical auditory evoked potentials (CAEPs).
P300
The P300 (P3) wave is an event related potential (ERP) component elicited in the process of decision making. It is considered to be anendogenous potential, as its occurrence links not to the physical attributes of a stimulus, but to a person’s reaction to it. It is usually elicited using the oddball paradigm, in which low-probability target items are mixed with high-probability non-target (or “standard”) items.
SN10 potential
A scalp negative wave was observed by Davis and Hirsh, 1979 and called slow negative response at 10msec (SN10).SN10 can be a useful tool for ABR audiometry and possibly an adjunct in hearing screening
ELECTRONYSTAGMOGRAPHY
Electronystagmography (ENG) is a diagnostic test to record involuntary movements of the eye caused by a condition known asnystagmus. It can also be used to diagnose the cause of vertigo, dizziness or balance dysfunction by testing the vestibular system.
The standard ENG test battery consists of three parts:
• oculomotor evaluation
• positioning and positional testing
• caloric stimulation of the vestibular system
The comparison of results obtained from various subtests of ENG assists in determining whether a disorder is central or peripheral.
VIDEONYSTAGMOGRAPHY
Videonystagmography (VNG) refers to the same test battery like ENG run using goggles with video cameras to monitor the eyes. Both the video cameras and the electrodes can measure eye movements to evaluate signs of vestibular dysfunction or neurological problems. Generally these tests are performed in a room that is dark or with low lighting. The examiner asks random questions that are meant to occupy the person being tested and keep them alert. ENG/VNG tests are the most common set of tests administered to people with dizziness, vertigo, and/ or imbalance.
ROTATION TESTS
Rotation tests are another way of evaluating how well the eyes and inner ear work together. These tests also use video goggles or electrodes to monitor eye movements. The head is rotated side to side at moderate or slow speeds, and associated eye movements are analyzed. There are different kinds of rotation tests: auto head rotation, computerized rotary chair, or a screening test.
VIDEO HEAD IMPULSE TESTING (VHIT)
It helps to evaluates how well the eyes and inner ears work together. A small set of glasses with a camera are used to monitor eye movements.
VESTIBULAR EVOKED MYOGENIC POTENTIAL (VEMP)
VEMP testing is used to evaluate whether certain vestibular organs and associated nerves are intact and functioning normally. Responses in this test are measured from different muscles in the neck and around the eyes. VEMP testing uses adhesive, skin surface electrodes (like ENG or some rotational tests) and earphones (like those used during a hearing test). Sound is played for a few seconds through the earphones, the vestibular organs are stimulated and activate muscle responses, and electrodes record the results.
COMPUTERIZED DYNAMIC POSTUROGRAPHY (CDP)
CDP tests postural stability or the ability to maintain upright posture in different environmental conditions. Maintenance of postural stability depends on sensory information from: the body’s muscles/joints, eyes, and inner ears. This testing investigates relationships among these three sensory systems and records the balance and posture adjustments made when different challenges are presented. This test may also be used in a rehabilitative setting after a diagnosis has been determined, and is not performed on all people in the diagnosis phase.
CRANIO-CORPO-GRAPHY
Cranio-Corpo-Graphy (CCG) documents and evaluates disorders of the equilibrium function measured by investigation procedures such as the Unterberger test, the LOLAVHESLIT test, the NEFERT test, the Romberg’s testand the WOFEC test.Cranio-corpo-graphy is a tool within neurootological treatment .
STENGER TEST
A test for detecting simulation of unilateral hearing impairment, in which a tone below the admitted threshold is presented to the test ear and a tone of lesser intensity is presented to the other ear. If the subject is feigning a hearing loss, the lesser tone cannot be appreciated.It is also used to detect functional hearing loss.
LOMBARD’S TEST
This test is based on “Lombard’s principle”. This principle says that one raises his / her voice when speaking in noisy environment. While performing this test,
the patient is allowed to read a book. Noise is introduced into the ear. The noise is gradually increased till the patient raises his / her voice or stops the process of reading.
If there is no change in voice loudness level the patient does not have functional hearing defect.
TEST FOR CENTRAL AUDITORY PROCESSING DISORDER
SCAN: A SCREENING TEST FOR AUDITORY PROCESSING DISORDERS.
SCAN is used to identify children who have auditory processing disorders and who may benefit from intervention. The test is administered to children ages 5 to 11 in approximately 20 minutes. Three subtests include low pass filtered words, auditory figure ground and competing words.
SCAN A: A Test for Auditory Processing Disorders in Adolescents and Adults was designed for individuals over 11 years. This instrument includes an additional subtest using competing sentences as stimuli.
Dichotic Speech Tests
In these tests different speech items are presented to both ears either simultaneously or in an overlapping manner and the child is asked to repeat everything that is heard (divided attention) or repeat whatever is heard in one specified ear (directed attention). The more similar and closely acoustically aligned the test items, the more difficult the task.One of the more commonly used tests in this category is the Dichotic Digits test.
Monaural Low-Redundancy Speech Tests
Monaural low-redundancy speech tests represent a group of tests designed to test an individual’s ability to achieve auditory closure when information is missing. The speech stimuli used in these tests have been modified by changing one or more of the following characteristics of the speech signal: frequency, timing (phase), or amplitude characteristics. The test items are presented to each ear individually and the child is asked to repeat the words that have been presented. A percent correct score is derived for each ear and these are compared to age-appropriate norms.
BEHAVIORAL OBSERVATION AUDIOMETRY
Assesses hearing acuity using unconditioned responses to sound (i.e., reflexive and orienting behaviors). Appropriate for children from birth through age 7 months. The infant is observed for changes in behavior after presentation of an acoustic stimulus in the sound field (through speakers) or with Hear-Kit Noisemakers. This screening test provides information about age-appropriateness of an infant’s response to supra-threshold sound. Can rule out significant hearing loss.
CONDITIONEDPLAY AUDIOMETRY
Conditioned play audiometry (CPA) allowsto test the hearing of very young toddlers and preschoolers. CPA uses behavioral conditioning to get kids to respond to sounds. It is designed for children between 2 and 5 years of age.CPA measures hearing sensitivity to determine both a child’s type and degree of hearing loss, if any.
VISUAL REINFORCEMENT AUDIOMETRY
Visual reinforcement audiometry (VRA) is a test to assess hearing in infants and toddlers too young for normal tests. VRA relies on behavioral conditioning to train very young kids to respond to sounds. It is designed for children aged 6 months to around 2 to 3 years old.
CONDITIONED ORIENTATION REFLEX
Conditioned Orientation Reflex (COR) Audiometry: same as VRA, but more than one sound source and puppet reinforcer used.
TANGIBLE REINFORCEMENT OPERENT CONDITIONING AUDIOMETRY (TROCA)
same as VRA, but more than one sound source and tangible reinforcer used.
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Speech Disorders
Speech disorders refer to problems in producing the sounds of speech or with the quality of voice, where language disorders are usually an impairment of either understanding words or being able to use words.
HEARING IMPAIRMENT
Hearing loss is considered to be the most prevalent congenital abnormality in newborns and is more than twice as prevalent as other conditions that are screened for at birth, such as sickle cell disease, hypothyroidism, phynilketonuria, and galactosaemia (Finitzo & Crumley, 1999). It is one of the most common sensory disorders and is the consequence of sensorineural and/or conductive malfunctions of the ear. The impairment may occur during or shortly after birth (congenital or early onset or may be late onset) caused post natal by genetically factors, trauma or disease. Hearing loss may be pre-lingual (i.e., occurring prior to speech and language acquisition) or post-lingual (i.e., occurring after the acquisition of speech and language).
Since hearing loss in infants is silent and hidden, great emphasis is placed on the importance of early detection, reliable diagnosis, and timely intervention (Spivak et al., 2000).
Symptoms:
• Problem in hear environmental and sounds
• Unable to learn language
• Speech difficulty
• Educational problems
• Unable to produce normal voice
Management:
• Audiological support
• To fit proper hearing aid to amplify sound
• Special education support
• Speech and language therapy
• Auditory verbal therapy for cochlear implant user
AUTISM SPECTRUM DISORDER
The autism spectrum or autistic spectrum describes a range of conditions classified as neuro-developmental disorders in the fifth revision of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders 5th edition (DSM-5). The types of ASD have been divided into three main category that’s are:
• Asperger’s syndrome
• Pervasive developmental disorder, not otherwise specified (PDD-NOS)
• Autistic disorder
These disorders are characterized by social deficits and communication difficulties, stereotyped or repetitive behaviors and interests, sensory issues, and in some cases, cognitive delays.
ASPERGER’S SYNDROME
Asperger syndrome (AS), also known as Asperger’s syndrome, Asperger disorder (AD) or simply Asperger’s, is an autism spectrum disorder (ASD) that is characterized by significant difficulties in social interaction and nonverbal communication, alongside restricted and repetitive patterns of behavior and interests. It differs from other autism spectrum disorders by its relative preservation of linguistic and cognitive development. Although not required for diagnosis, physical clumsiness and atypical (peculiar or odd) use of language are frequently reported. The mildest form of autism, Asperger’s syndrome (AS), affects boys three times more often than girls.
Symptoms:
The symptoms of Asperger’s syndrome vary and can range from mild to severe. Common symptoms include:
• Problems with social skills: Children with Asperger’s syndrome generally have difficulty interacting with others and often are awkward in social situations. They generally do not make friends easily. They have difficulty initiating and maintaining conversation.
• Eccentric or repetitive behaviors: Children with this condition may develop odd, repetitive movements, such as hand wringing or finger twisting.
• Unusual preoccupations or rituals: A child with Asperger’s syndrome may develop rituals that he or she refuses to alter, such as getting dressed in a specific order.
• Communication difficulties: People with Asperger’s syndrome may not make eye contact when speaking with someone. They may have trouble using facial expressions and gestures, and understanding body language. They also tend to have problems understanding language in context and are very literal in their use of language.
• Limited range of interests: A child with Asperger’s syndrome may develop an intense, almost obsessive, interest in a few areas, such as sports schedules, weather, or maps.
• Coordination problems: The movements of children with Asperger’s syndrome may seem clumsy or awkward.
• Skilled or talented: Many children with Asperger’s syndrome are exceptionally talented or skilled in a particular area, such as music or math.
Management:
Right now, there is no cure for Asperger’s syndrome, but therapy may improve functioning and reduce undesirable behaviors. Treatment may include a combination of:
• Special education
• Behavior modification
• Speech, physical, or occupational therapy
• Social skills therapies
• Cognitive behavioral therapy
• Parent training and education program
• Medication ( mainly for anxiety, depression, hyperactivity, and obsessive-compulsive behavior)
PERVASIVE DEVELOPMENTAL DISORDER, NOT OTHERWISE SPECIFIED (PDD-NOS)
A pervasive developmental disorder not otherwise specified (PDD-NOS) is one of the three autism spectrum disorders (ASD) and also one of the five disorders classified as a pervasive developmental disorder (PDD).[2] According to the DSM-IV, PDD-NOS is a diagnosis that is used for “severe and pervasive impairment in the development of reciprocal social interaction or verbal and nonverbal communication skills, or when stereotyped behavior, interests, and activities are present, but the criteria are not met for a specific PDD” or for several other disorders. This mouthful of a diagnosis applies to most children with autistic spectrum disorder. Children whose autism is more severe than Asperger’s syndrome, but not as severe as autistic disorder, are diagnosed with PDD-NOS.
Symptoms:
General symptoms that may be present to some degree in a child with a PDD include:
• Difficulty with verbal communication, including problems using and understanding language
• Difficulty with non-verbal communication, such as gestures and facial expressions
• Difficulty with social interaction, including relating to people and to his or her surroundings
• Unusual ways of playing with toys and other objects
• Difficulty adjusting to changes in routine or familiar surroundings
• Repetitive body movements or patterns of behavior, such as hand flapping, spinning, and head banging
• Changing response to sound; the child may be very sensitive to some noises and seem to not hear others.
• Temper tantrums
• Difficulty sleeping
• Aggressive behavior
• Fearfulness or anxiety
Management:
Right now, there is no cure for PDD-NOS, but therapy may improve functioning and reduce undesirable behaviors. Treatment may include a combination of:
• Special education
• Behavior modification
• Speech, physical, or occupational therapy
• Social skills therapies
• Cognitive behavioral therapy
• Parent training and education program
• Medication ( mainly for anxiety, depression, hyperactivity, and obsessive-compulsive behavior)
AUTISM
Autism is a neurodevelopmental disorder characterized by impaired social interaction, verbal and non-verbal communication, and restricted and repetitive behavior. These signs often develop gradually, though some children with autism reach their developmental milestones at a normal pace and then regress. The diagnostic criteria require that symptoms become apparent in early childhood, typically before age three.
While autism is highly heritable, researchers suspect both environmental and genetic factors as causes. In rare cases, autism is strongly associated with agents that cause birth defects.
Autism affects information processing in the brain by altering how nerve cells and their synapses connect and organize; how this occurs is not well understood. Early speech or behavioral interventions can help children with autism gain self-care, social, and communication skills.
Symptoms:
The severity of symptoms varies greatly, but all people with autism have some core symptoms in the areas of:
• Social interactions and relationships. Symptoms may include:
o Significant problems developing nonverbal communication skills, such as eye-to-eye gazing, facial expressions, and body posture.
o Failure to establish friendships with children the same age.
o Lack of interest in sharing enjoyment, interests, or achievements with other people.
o Lack of empathy. People with autism may have difficulty understanding another person’s feelings, such as pain or sorrow.
• Verbal and nonverbal communication. Symptoms may include:
o Delay in, or lack of, learning to talk. As many as 40% of people with autism never speak.1
o Problems taking steps to start a conversation. Also, people with autism have difficulties continuing a conversation after it has begun.
o Stereotyped and repetitive use of language. People with autism often repeat over and over a phrase they have heard previously (echolalia).
o Difficulty understanding their listener’s perspective. For example, a person with autism may not understand that someone is using humor. They may interpret the communication word for word and fail to catch the implied meaning.
• Limited interests in activities or play. Symptoms may include:
o An unusual focus on pieces. Younger children with autism often focus on parts of toys, such as the wheels on a car, rather than playing with the entire toy.
o Preoccupation with certain topics. For example, older children and adults may be fascinated by video games, trading cards, or license plates.
o A need for sameness and routines. For example, a child with autism may always need to eat bread before salad and insist on driving the same route every day to school.
o Stereotyped behaviors. These may include body rocking and hand flapping.
Many people with autism have symptoms similar to attention deficit hyperactivity disorder (ADHD). But these symptoms, especially problems with social relationships, are more severe for people with autism.
Management:
Early diagnosis and treatment helps young children with autism develop to their full potential. The primary goal of treatment is to improve the overall ability of the child to function.
• Special education
• Behavior modification
• Speech, physical, or occupational therapy
• Social skills therapies
• Cognitive behavioral therapy
• Parent training and education program
• Medication ( mainly for anxiety, depression, hyperactivity, and obsessive-compulsive behavior)
ATTENTION DEFICITE HYPERACTIVEDISORDER (ADHD):
Attention deficit hyperactivity disorder (ADHD, similar to hyperkinetic disorder in the ICD-10) is a neurodevelopmental psychiatric disorder in which there are significant problems with executive functions (e.g., attentional control and inhibitory control) that cause attention deficits, hyperactivity, or impulsiveness which is not appropriate for a person’s age. These symptoms must begin by age six to twelve and persist for more than six months for a diagnosis to be made.
Symptoms:
Children who have symptoms of inattention may:
• Be easily distracted, miss details, forget things, and frequently switch from one activity to another
• Have difficulty focusing on one thing
• Become bored with a task after only a few minutes, unless they are doing something enjoyable
• Have difficulty focusing attention on organizing and completing a task or learning something new
• Have trouble completing or turning in homework assignments, often losing things (e.g., pencils, toys, assignments) needed to complete tasks or activities
• Not seem to listen when spoken to
• Daydream, become easily confused, and move slowly
• Have difficulty processing information as quickly and accurately as others
• Struggle to follow instructions.
Children who have symptoms of hyperactivity may:
• Fidget and squirm in their seats
• Talk nonstop
• Dash around, touching or playing with anything and everything in sight
• Have trouble sitting still during dinner, school, and story time
• Be constantly in motion
• Have difficulty doing quiet tasks or activities.
Children who have symptoms of impulsivity may:
• Be very impatient
• Blurt out inappropriate comments, show their emotions without restraint, and act without regard for consequences
• Have difficulty waiting for things they want or waiting their turns in games
• Often interrupt conversations or others’ activities.
Associated disorders
In children ADHD occurs with other disorders about ⅔ of the time.[10] Some commonly associated conditions include:
• Learning disabilities have been found to occur in about 20–30% of children with ADHD. Learning disabilities can include developmental speech and language disorders and academic skills disorders. ADHD, however, is not considered a learning disability, but it very frequently causes academic difficulties.
• Tourette syndrome has been found to occur more commonly in the ADHD population.
• Oppositional defiant disorder (ODD) and conduct disorder (CD), which occur with ADHD in about 50% and 20% of cases respectively. They are characterized by antisocial behaviors such as stubbornness, aggression, frequent temper tantrums, deceitfulness, lying, and stealing. About half of those with hyperactivity and ODD or CD develop antisocial personality disorder in adulthood. Brain imaging supports that conduct disorder and ADHD are separate conditions.
• Primary disorder of vigilance, which is characterized by poor attention and concentration, as well as difficulties staying awake. These children tend to fidget, yawn and stretch and appear to be hyperactive in order to remain alert and active.
• Hypokalemic sensory overstimulation is present in less than 50% of people with ADHD and may be the molecular mechanism for many people with ADHD.
• Mood disorders (especially bipolar disorder and major depressive disorder). Boys diagnosed with the combined ADHD subtype are more likely to have a mood disorder. Adults with ADHD sometimes also have bipolar disorder, which requires careful assessment to accurately diagnose and treat both conditions.
• Anxiety disorders have been found to occur more commonly in the ADHD population.
• Obsessive-compulsive disorder (OCD) can co-occur with ADHD and shares many of its characteristics.
• Substance use disorders. Adolescents and adults with ADHD are at increased risk of developing a substance use problem. This is most commonly with alcohol or cannabis. The reason for this may be an altered reward pathway in the brains of ADHD individuals. This makes the evaluation and treatment of ADHD more difficult, with serious substance misuse problems usually treated first due to their greater risks.
• Restless legs syndrome has been found to be more common in those with ADHD and is often due to iron deficiency anaemia. However, restless legs can simply be a part of ADHD and requires careful assessment to differentiate between the two disorders.
• Sleep disorders and ADHD commonly co-exist. They can also occur as a side effect of medications used to treat ADHD. In children with ADHD, insomnia is the most common sleep disorder with behavioral therapy the preferred treatment. Problems with sleep initiation are common among individuals with ADHD but often they will be deep sleepers and have significant difficulty getting up in the morning. Melatonin is sometimes used in children who have sleep onset insomnia.
Management:
• Special education
• Behavior modification
• Speech, physical, or occupational therapy
• Social skills therapies
• Cognitive behavioral therapy
• Parent training and education program
• Medication (Decreased appetite, Sleep problems, Hyperactivity manage)
CEREBRAL PALSY :
Cerebral palsy (CP) is a broad term used to describe a group of chronic “palsies” — disorders that impair control of movement due to damage to the developing brain. CP usually develops by age 2 or 3 and is a nonprogressive brain disorder, meaning the brain damage does not continue to worsen throughout life. However, the symptoms due to the brain damage often change over time — sometimes getting better and sometimes getting worse. CP is one of the most common causes of chronic childhood disability.
Between 35% and 50% of all children with CP will have an accompanying seizure disorder and some level of mental retardation. They also may have learning disabilities and vision, speech, hearing, or language problems.
Much remains unknown about the disorder’s causes, but evidence supports theories that infections, birth injuries, and poor oxygen supply to the brain before, during, and immediately after birth result are common factors.
Types:
The cerebral palsy can be classified into two manner:
Types according to muscle tone
• spastic: the most common type of cerebral palsy; reflexes are exaggerated and muscle movement is stiff
• dyskinetic: dyskinetic cerebral palsy is divided into two categories. Athetoid cerebral palsy which is marked by involuntary, slow, writhing movements and dystonic cerebral palsy where trunk movements are more affected than limb muscles, resulting in a twisted posture
• ataxic: voluntary muscle movements are not well coordinated
• hypotonic: muscle tone is decreased or floppy
• mixed: combinations of the symptoms listed above
Types according to affected areas
• Monoplegia
• Diplegia
• Hemiplegia
• Quadriplegia
Symptoms:
• Low or high muscle tone (baby feels ‘floppy’ when picked up)
• Problems sucking and swallowing.
• Seizures.
• Unable to hold up its own head while lying on their stomach or in a supported sitting position
• Muscle spasms or feeling stiff
• Delayed motor development (gross motor and fine motor)
• Speech and language developmental delay.
• Excessive drooling or problems with swallowing
• Difficulty with sucking or eating
• Difficulty with precise motions, such as picking up a crayon or spoon
• Poor muscle control, reflexes and posture
• Tremors or involuntary movements
• Delayed development (can’t sit up or independently roll over by 6 months)
• Feeding or swallowing difficulties
• Preference to use one side of their body
Management:
• Speech and language therapy
• Physiotherapy
• Behavioral therapy
• Occupational therapy
• Special education
• Medication (Intervention for epilepsy, pain management, sleep disorder)
MENTAL RETARDATION
According to DSM-IV mental retardation is characterized by significantly sub average intellectual functioning (an IQ of approximately 70 or below) with an onset before 18yrs of age, associated with significant deficit or impairment in adaptive functioning (a collection of skills the people learn to function effectively in their everyday life) . Four degrees of severity of mental retardation can be specified, reflecting the level of intellectual impairment: Mild, Moderate, Severe and Profound ( Mild Mental Retardation IQ Level 50-55 to approximately 70, Moderate Retardation: IQ Level 35-40 to 50-55, Severe Mental Retardation: IQ Level 20-25 to 35-40, Profound Mental Retardation: IQ Level below 20 or 25).
A retarded person is generally limited at least to some extent in six adaptive skills needed for daily living-communication, social skills, academic skills, sensorimotor skills, self-help skills and vocational skills.
Symptoms:
As a family, you may suspect your child has an intellectual disability when your child has any of the following:
• Lack of and slow development of Speech and language skills.
• Lack of or slow development of motor skills, and self-help skills, especially when compared to peers
• Failure to grow intellectually or continued infant-like behavior
• Lack of curiosity
• Problems keeping up in school
• Failure to adapt (adjust to new situations)
• Difficulty understanding and following social rules
• Delayed development such as sitting, crawling, standing, walking, or talking;
• Persistence of childlike behavior, possibly demonstrated in speaking style;
• Trouble understanding social rules and customs such as taking turns, or waiting in line;
• Failure to appreciate and avoid dangerous situations such as playing in the street, or touching a hot stove;
• A lack of curiosity or interest in the world around them;
• Difficulty learning new information despite significant effort and repetition;
• Difficulty learning new skills despite significant practice;
• Difficulty solving ordinary, simple problems;
• Trouble remembering things;
• Difficulty meeting educational demands;
• Excessive behavioral problems such as impulsivity and poor frustration tolerance.
Management:
• Speech and language therapy
• Physiotherapy
• Behavioral therapy
• Occupational therapy
• Special education
• Medication (Intervention for epilepsy, pain management, sleep disorder)
LEARNING DISABILITY
Learning disabilities is a generic term that refers to a heterogeneous group of disorders manifested by significant difficulties in the acquisition and use of listening, speaking, reading, writing, reasoning or mathematical abilities. These disorders are intrinsic to the individual and presumed to be due to central nervous system dysfunction. Many possible causes are Genetic factors, Brain injury (due to physical trauma or lack of oxygen before/during/after birth), Biochemicals that are missing i.e. the ones needed for proper CNS functioning, Biochemicals that are present i.e. food additives, dyes etc, Environmental factors such as lead or fluorescent lighting, Psychological or social influences.
They have the following disturbances: perceptual difficulties, cognitive difficulties, inattention and hyperactivity, social and emotional disabilities, reading and writing disabilities, arithmetic and mathematical disabilities and language disabilities.
Types:
• Dyslexia
• Dysgraphia
• Dyscalculia
• Dyspraxia
• Auditory Processing Disorder (APD)
• Language Processing Disorder
• Non-Verbal Learning Disabilities
• Visual Perceptual/Visual Motor Deficit
• ADHD
• Executive Functioning
• Memory
Symptoms:
• Short attention span,
• Poor memory,
• Difficulty following directions,
• Inability to discriminate between/among letters, numerals, or sounds,
• Poor reading and/or writing ability,
• Eye-hand coordination problems; poorly coordinated,
• Difficulties with sequencing, and/or
• Disorganization and other sensory difficulties.
• Performs differently from day to day,
• Responds inappropriately in many instances,
• Distractible, restless, impulsive,
• Says one thing, means another,
• Difficult to discipline,
• Doesn’t adjust well to change,
• Difficulty listening and remembering,
• Difficulty telling time and knowing right from left,
• Difficulty sounding out words,
• Reverses letters,
• Places letters in incorrect sequence,
• Difficulty understanding words or concepts, and/or
• Delayed speech development; immature speech.
Management:
Dyslexia
• Special teaching techniques. These can include helping a child learn through multi-sensory experiences and by providing immediate feedback to strengthen a child’s ability to recognize words.
• Classroom modifications. For example, teachers can give students with dyslexia extra time to finish tasks and provide taped tests that allow the child to hear the questions instead of reading them.
• Use of technology. Children with dyslexia may benefit from listening to books on tape or using word-processing programs with spell-check features.
Dysgraphia
• Special tools. Teachers can offer oral exams, provide a note-taker, and/or allow the child to videotape reports instead of writing them.
• Use of technology. A child with dysgraphia can be taught to use word-processing programs or an audio recorder instead of writing by hand.
• Other ways of reducing the need for writing. Teachers can provide notes, outlines, and preprinted study sheets.
Dyscalculia
• Visual techniques. For example, teachers can draw pictures of word problems and show the student how to use colored pencils to differentiate parts of problems.
• Use of memory aids. Rhymes and music are among the techniques that can be used to help a child remember math concepts.
• Use of computers. A child with dyscalculia can use a computer for drills and practice.
Dyspraxia
• Quiet learning environment. To help a child deal with sensitivity to noise and distractions, educators can provide the youngster with a quiet place for tests, silent reading, and other tasks that require concentration.
• Alerting the child in advance. For example, a child who is sensitive to noise may benefit from knowing in advance about such events as fire drills and assemblies.
• Occupational therapy. Exercises that focus on the tasks of daily living can help a child with poor coordination.
AUDITORY PROCESSING DISORDER
Also known as Central Auditory Processing Disorder, individuals with Auditory Processing Disorder (APD) do not recognize subtle differences between sounds in words, even when the sounds are loud and clear enough to be heard. They can also find it difficult to tell where sounds are coming from, to make sense of the order of sounds, or to block out competing background noises.
Symptoms:
• Has difficulty processing and remembering language-related tasks but may have no trouble interpreting or recalling non-verbal environmental sounds, music, etc.
• May process thoughts and ideas slowly and have difficulty explaining them
• Misspells and mispronounces similar-sounding words or omits syllables; confuses similar-sounding words (celery/salary; belt/built; three/free; jab/job; bash/batch)
• May be confused by figurative language (metaphor, similes) or misunderstand puns and jokes; interprets words too literally
• Often is distracted by background sounds/noises
• Finds it difficult to stay focused on or remember a verbal presentation or lecture
• May misinterpret or have difficulty remembering oral directions; difficulty following directions in a series
• Has difficulty comprehending complex sentence structure or rapid speech
• “Ignores” people, especially if engrossed
• Says “What?” a lot, even when has heard much of what was said
Strategies:
• Show rather than explain
• Supplement with more intact senses (use visual cues, signals, handouts, manipulatives)
• Reduce or space directions, give cues such as “ready?”
• Reword or help decipher confusing oral and/or written directions
• Teach abstract vocabulary, word roots, synonyms/antonyms
• Vary pitch and tone of voice, alter pace, stress key words
• Ask specific questions as you teach to find out if they do understand
• Allow them 5-6 seconds to respond (“think time”)
• Have the student constantly verbalize concepts, vocabulary words, rules, etc.
DYSCALCULIA
Individuals with this type of Learning Disability may also have poor comprehension of math symbols, may struggle with memorizing and organizing numbers, have difficulty telling time, or have trouble with counting.
Symptoms:
• Shows difficulty understanding concepts of place value, and quantity, number lines, positive and negative value, carrying and borrowing
• Has difficulty understanding and doing word problems
• Has difficulty sequencing information or events
• Exhibits difficulty using steps involved in math operations
• Shows difficulty understanding fractions
• Is challenged making change and handling money
• Displays difficulty recognizing patterns when adding, subtracting, multiplying, or dividing
• Has difficulty putting language to math processes
• Has difficulty understanding concepts related to time such as days, weeks, months, seasons, quarters, etc.
• Exhibits difficulty organizing problems on the page, keeping numbers lined up, following through on long division problems
Strategies:
• Allow use of fingers and scratch paper
• Use diagrams and draw math concepts
• Provide peer assistance
• Suggest use of graph paper
• Suggest use of colored pencils to differentiate problems
• Work with manipulatives
• Draw pictures of word problems
• Use mnemonic devices to learn steps of a math concept
• Use rhythm and music to teach math facts and to set steps to a beat
• Schedule computer time for the student for drill and practice
DYSGRAPHIA
A person with this specific learning disability may have problems including illegible handwriting, inconsistent spacing, poor spatial planning on paper, poor spelling, and difficulty composing writing as well as thinking and writing at the same time.
Symptoms:
• May have illegible printing and cursive writing (despite appropriate time and attention given the task)
• Shows inconsistencies: mixtures of print and cursive, upper and lower case, or irregular sizes, shapes or slant of letters
• Has unfinished words or letters, omitted words
• Inconsistent spacing between words and letters
• Exhibits strange wrist, body or paper position
• Has difficulty pre-visualizing letter formation
• Copying or writing is slow or labored
• Shows poor spatial planning on paper
• Has cramped or unusual grip/may complain of sore hand
• Has great difficulty thinking and writing at the same time (taking notes, creative writing.)
Strategies
• Suggest use of word processor
• Avoid chastising student for sloppy, careless work
• Use oral exams
• Allow use of tape recorder for lectures
• Allow the use of a note taker
• Provide notes or outlines to reduce the amount of writing required
• Reduce copying aspects of work (pre-printed math problems)
• Allow use of wide rule paper and graph paper
• Suggest use of pencil grips and /or specially designed writing aids
• Provide alternatives to written assignments (video-taped reports, audio-taped reports)
DYSLEXIA
The severity of this specific learning disability can differ in each individual but can affect reading fluency, decoding, reading comprehension, recall, writing, spelling, and sometimes speech and can exist along with other related disorders. Dyslexia is sometimes referred to as a Language-Based Learning Disability.
Symptoms:
• Reads slowly and painfully
• Experiences decoding errors, especially with the order of letters
• Shows wide disparity between listening comprehension and reading comprehension of some text
• Has trouble with spelling
• May have difficulty with handwriting
• Exhibits difficulty recalling known words
• Has difficulty with written language
• May experience difficulty with math computations
• Decoding real words is better than nonsense words
• Substitutes one small sight word for another: a, I, he, the, there, was
Strategies:
• Provide a quiet area for activities like reading, answering comprehension questions
• Use books on tape
• Use books with large print and big spaces between lines
• Provide a copy of lecture notes
• Don’t count spelling on history, science or other similar tests
• Allow alternative forms for book reports
• Allow the use of a laptop or other computer for in-class essays
• Use multi-sensory teaching methods
• Teach students to use logic rather than rote memory
• Present material in small units
LANGUAGE PROCESSING DISORDER
A specific type of Auditory Processing Disorder (APD). While an APD affects the interpretation of all sounds coming into the brain (e.g., processing sound in noisy backgrounds or the sequence of sounds or where they come from), a Language Processing Disorder (LPD) relates only to the processing of language. LPD can affect expressive language (what you say) and/or receptive language (how you understand what others say).
Symptoms:
• Has difficulty gaining meaning from spoken language
• Demonstrates poor written output
• Exhibits poor reading comprehension
• Shows difficulty expressing thoughts in verbal form
• Has difficulty labeling objects or recognizing labels
• Is often frustrated by having a lot to say and no way to say it
• Feels that words are “right on the tip of my tongue”
• Can describe an object and draw it, but can’t think of the word for it
• May be depressed or having feelings of sadness
• Has difficulty getting jokes
Strategies:
• Speak slowly and clearly and use simple sentences to convey information
• Refer to a speech pathologist
• Allow tape recorder for note taking
• Write main concepts on board
• Provide support person or peer tutor
• Use visualization techniques to enhance listening and comprehension
• Use of graphic organizers for note taking from lectures or books
• Use story starters for creative writing assignments
• Practice story mapping
• Draw out details with questions and visualization strategies
NON-VERBAL LEARNING DISABILITIES
Non-Verbal Learning Disability (NVD or NVLD), is a disorder which is usually characterized by a significant discrepancy between higher verbal skills and weaker motor, visual-spatial and social skills.
Symptoms:
• Has trouble recognizing nonverbal cues such as facial expression or body language
• Shows poor psycho-motor coordination; clumsy; seems to be constantly “getting in the way,” bumping into people and objects
• Using fine motor skills a challenge: tying shoes, writing, using scissors
• Needs to verbally label everything that happens to comprehend circumstances, spatial orientation, directional concepts and coordination; often lost or tardy
• Has difficulty coping with changes in routing and transitions
• Has difficulty generalizing previously learned information
• Has difficulty following multi-step instructions
• Make very literal translations
• Asks too many questions, may be repetitive and inappropriately interrupt the flow of a lesson
• Imparts the “illusion of competence” because of the student’s strong verbal skills
Strategies:
• Rehearse getting from place to place
• Minimize transitions and give several verbal cues before transition
• Avoid assuming the student will automatically generalize instructions or concepts
• Verbally point out similarities, differences and connections; number and present instructions in sequence; simplify and break down abstract concepts, explain metaphors, nuances and multiple meanings in reading material
• Answer the student’s questions when possible, but let them know a specific number (three vs. a few) and that you can answer three more at recess, or after school
• Allow the child to abstain from participating in activities at signs of overload
• Thoroughly prepare the child in advance for field trips, or other changes, regardless of how minimal
• Implement a modified schedule or creative programming
• Never assume child understands something because he or she can “parrot back” what you’ve just said
• Offer added verbal explanations when the child seems lost or registers confusion
VISUAL PERCEPTUAL/VISUAL MOTOR DEFICIT
A characteristic seen in people with learning disabilities such as Dysgraphia or Non-verbal LD, it can result in missing subtle differences in shapes or printed letters, losing place frequently, struggles with cutting, holding pencil too tightly, or poor eye/hand coordination.
Symptoms:
• May have reversals: b for d, p for q or inversions: u for n, w for m
• Has difficulty negotiating around campus
• Complains eyes hurt and itch, rubs eyes, complains print blurs while reading
• Turns head when reading across page or holds paper at odd angles
• Closes one eye while working, may yawn while reading
• Cannot copy accurately
• Loses place frequently
• Does not recognize an object/word if only part of it is shown
• Holds pencil too tightly; often breaks pencil point/crayons
• Struggles to cut or paste
• Misaligns letters; may have messy papers, which can include letters colliding, irregular spacing, letters not on line
Strategies:
• Avoid grading handwriting
• Allow students to dictate creative stories
• Provide alternative for written assignments
• Suggest use of pencil grips and specially designed pencils and pens
• Allow use of computer or word processor
• Restrict copying tasks
• Provide tracking tools: ruler, text windows
• Use large print books
• Plan to order or check out books on tape
• Experiment with different paper types: pastels, graph, embossed raised line paper
EXECUTIVE FUNCTIONING
Affects, planning, organization, strategizing, attention to details and managing time and space.
An inefficiency in the cognitive management systems of the brain that affects a variety of neuropsychological processes such as planning, organization, strategizing, paying attention to and remembering details, and managing time and space. Although not a learning disability, different patterns of weakness in executive functioning are almost always seen in the learning profiles of individuals who have specific learning disabilities or ADHD.
MEMORY
Affects storing and later retrieving information or getting information out.
Three types of memory are important to learning, “working memory”, “short term memory” and “long term memory.” All three types of memory are used in the processing of both verbal and non-verbal information.
1. “Working memory” refers to the ability to hold on to pieces of information until the pieces blend into a full thought or concept. For example, reading each word until the end of a sentence or paragraph and then understanding the full content.
2. “Short-term memory” is the active process of storing and retaining information for a limited period of time. The information is temporarily available but not yet stored for long-term retention.
3. “Long-term memory” refers to information that has been stored and that is available over a long period of time. Individuals might have difficulty with auditory memory or visual memory.
It all work together to learn:
One reads a sentence and holds on to it, then the next and the next. By the end of the paragraph, he pulls together the meaning of the full paragraph. This is working memory. He continues to read the full chapter and study it. Information is retained long enough to take a test and do well. This is short-term memory. But, unless the information is reviewed and studied over a longer period of time, it is not retained. With more effort over time, the information might become part of a general body of knowledge. It is long-term memory. If there are deficits in any or all of these types of memory, the ability to store and retrieve information required to carry out tasks can be impaired.
ACQUIRED CHILDHOOD APHASIA
Acquired childhood aphasia (ACA) defined as a language disorder secondary to cerebral dysfunction in childhood, but appearing after a period of normal language development. ACA is rare. Two major features of acquired childhood aphasia appeared to be consistently identified. First, the onset of acquired childhood aphasia is precipitated by some type of cerebral insult. The cerebral insult, in turn can result from a verity of causes, including head trauma, cerebrovascular accident, brain tumors, infections and seizure disorders.
CLEFT LIP & PALATE
Cleft lip and cleft palate, also known as orofacial cleft and cleft lip and palate, is a group of conditions that includes cleft lip (CL), cleft palate (CP), and both together (CLP). A cleft lip contains an opening in the upper lip that may extend into the nose. The opening may be on one side, both sides, or in the middle. A cleft palate is when the roof of the mouth contains an opening into the nose. These disorders can result in feeding problems, speech problems, hearing problems, and frequent ear infections. Less than half the time the condition is associated with other disorders.
Cleft lip and palate is due to tissues of the face not properly joining together during development. They are a type of birth defect. The cause in most cases is unknown. Risk factors include smoking during pregnancy, diabetes, an older mother, obesity, and certain medications such as some used to treat seizures.
Symptoms:
• Cleft is visible in lips or palate
• Difficulty with feedings
• Difficulty swallowing, with potential for liquids or foods to come out the nose
• Nasal speaking voice
• Speech difficulties.
• Chronic ear infections
Management:
• Lip and palate surgical treatment
• Dental surgery
• Speech and language therapy
• ENT specialist
• Audiologist.
SPECIFIC LANGUAGE IMPAIRMENT
SLI can be defined as “delayed acquisition of language skill, occurring in conjunction with normal functioning in intellectual, social-emotional, and auditory domains”. Children with SLI are more likely to have parents and siblings with a history of language learning problems and often score less on language ability than same age peers with no such history. Children with SLI are also at a risk of for reading disorders when they reach school age.
Symptoms:
• Have difficulty saying what they want to, even though they have ideas
• Talk in sentences but be difficult to understand
• Sound muddled; it can be difficult to follow what they are saying
• Find it difficult to understand words and long instructions
• Have difficulty remembering the words they want to say
• Find it hard to join in and follow what is going on in the playground
• A hard time understanding what other people have said
• Problems following directions that are spoken to them
• Problems organizing their thoughts
Children with an expressive language disorder have problems using language to express what they are thinking or need. These children may:
• Have a hard time putting words together into sentences, or their sentences may be simple and short and the word order may be off
• Have difficulty finding the right words when talking, and often use placeholder words such as “um”
• Have a vocabulary that is below the level of other children the same age
• Leave words out of sentences when talking
• Use certain phrases over and over again, and repeat (echo) parts or all of questions
• Use tenses (past, present, future) improperly
Management:
• Speech and language therapy
• Special education
STUTTERING
Stuttering or stammering is a speech disorder in which the flow of speech is disrupted by involuntary repetitions and prolongations of sounds, syllables, words or phrases as well as involuntary silent pauses or blocks in which the person who stutters is unable to produce sounds .The impact of stuttering on a person’s functioning and emotional state can be noted. This may include fears of having to enunciate specific vowels or consonants, fears of being caught stuttering in social situations, self-imposed isolation, anxiety, stress, shame, being a possible target of bullying (especially in children), having to use word substitution and rearrange words in a sentence to hide stuttering, or a feeling of “loss of control” during speech.
Stuttering is generally not a problem with the physical production of speech sounds or putting thoughts into words. Although the exact etiology, or cause, of stuttering is unknown, both genetics and neurophysiology are thought to contribute.
Symptoms:
• Frustration when attempting to communicate
• Hesitating or pausing before starting to speak
• Declining to speak
• Inserting extra sounds/words into sentences, such as “uh” or “um”
• Repeating words or phrases
• Tension in the voice
• Rearranging words in a sentence
• Making long sounds with words, like “My name is Amaaaaaaanda.”
Management:
• Speech therapy
• Psychological counseling
• Anxiety management
CLUTTERING
Cluttering is a fluency disorder characterized by a rate that is perceived to be abnormally rapid, irregular, or both for the speaker (although measured syllable rates may not exceed normal limits). These rate abnormalities further are manifest in one or more of the following symptoms: (a) an excessive number of disfluencies, the majority of which are not typical of people with stuttering; (b) the frequent placement of pauses and use of prosodic patterns that do not conform to syntactic and semantic constraints; and (c) inappropriate (usually excessive) degrees of coarticulation among sounds, especially in multisyllabic words.
Symptoms:
• Does not sound “fluent,” that is, does not seem to be clear about what he or she wants to say or how to say it.
• Has excessive levels of “normal disfluencies,” such as interjections and revisions.
• Has little or no apparent physical struggle in speaking.
• Has few if any accessory (secondary) behaviors.
• Talks “too fast” based on an overall impression or actual syllable per minute counts.
• Sounds “jerky.”
• Has pauses that are too short, too long, or improperly placed.
• Confusing, disorganized language or conversational skills.
• Limited awareness of his or her fluency and rate problems.
• Temporary improvement when asked to “slow down” or “pay attention” to speech (or when being tape recorded).
• Mispronunciation or slurrring of speech sounds or deleting non-stressed syllables in longer words (e.g., “ferchly” for “fortunately”).
• Speech that is difficult to understand.
• Several blood relatives who stutter or clutter.
• Social or vocational problems resulting from cluttering symptoms.
• Learning disability not related to reduced intelligence.
• Sloppy handwriting.
• Distractibility, hyperactivity, or a limited attention span.
• Auditory perceptual difficulties.
Management:
• Speech therapy
• Psychological counseling
MISARTICULATION
A generic term for any disorder of speech quality, which is characterised by distortion, omission, substitution or addition of phonemes. It is characterized by difficulty learning to produce sounds physically. Misarticulation haveis not any type of physical disorder ,it is a bad habit so its may be recover 100%. But need of proper speech therapy.
Symptoms:
• Articulation errors
Management:
• Speech and language therapy
• Audiologist (to determine the hearing ability)
VOICE DISORDER
Voice disorders are medical conditions involving abnormal pitch, loudness or quality of the sound produced by the larynx and thereby affecting speech production. Voice disorders fall into three main categories: organic, functional, or a combination of the two. Organic voice disorders fall into two groups: structural and neurogenic. Structural disorders involve something physically wrong with the mechanism, often involving tissue or fluids of the vocal folds. Neurogenic disorders are caused by a problem in the nervous system. A functional disorder means the physical structure is normal, but the vocal mechanism is being used improperly or inefficiently.
A final category of voice disorder is the psychogenic disorder, in which a poor voice quality becomes a symbolic, or outward, manifestation of some unresolved psychological conflict. Some common voice disorders are Puberphonia, Vocal fold nodules, Vocal fold cysts, Vocal cord paresis, Reinke’s edema, Spasmodic dysphonia, Foreign accent syndrome, Bogart–Bacall syndrome, Laryngeal papillomatosis, Laryngitis etc.
Symptoms:
• Hoarseness
• Low-pitched voice
• Breathy voice
• Singers may notice a loss of vocal range.
• A voice that tires easily
• Some throat pain while talking
• A change in the sound of the voice, from hoarseness to croaking or complete loss of voice
• A feeling of having to clear your throat
• Trouble breathing or swallowing
• Change of pitch
• Unable to get louder
• Vocal strain or fatigue
• Loss of voice Reduced pitch range or sudden change in overall pitch
• Tremulous quality in the voice
• Diplophonic (double-toned) quality
• Decreased breath support during speech
• Possible breathing difficulties
Treatment:
• Medication
• Surgical
• Voice therapy
APHASIA
Aphasia is the name given to a collection of language disorders caused by damage to the brain. The difficulties of people with aphasia can range from occasional trouble finding words to losing the ability to speak, read, or write, but does not affect intelligence. The term “aphasia” implies a problem with one or more functions that are essential and specific to language function. It is not usually used when the language problem is a result of a more peripheral motor or sensory difficulty, such as paralysis affecting the speech muscles or a general hearing impairment.
Aphasia is most commonly caused by stroke. It can also be caused by other brain diseases, including cancer (brain tumor), epilepsy, and Alzheimer’s disease, or by a head injury.
Most classifications of the aphasias tend to divide the various symptoms into broad classes. A common approach is to distinguish between the fluent aphasias (where speech remains fluent, but content may be lacking, and the person may have difficulties understanding others), and the nonfluent aphasias (where speech is very halting and effortful, and may consist of just one or two words at a time).
Symptoms:
Verbal Expression Impairments
Common verbal expression impairments include
• Difficulty finding words (anomia)
• Speaking with effort or haltingly
• Speaking in single words (e.g., names of objects)
• Speaking in short, fragmented phrases
• Omitting smaller words like “the,” “of,” and “was” (telegraphic speech)
• Putting words in the wrong order
• Substituting sounds and/or words (e.g., bed is called “table” or dishwasher a “wishdasher”)
• Making up words (e.g., jargon)
• Fluently stringing together nonsense words and real words, but leaving out or including an insufficient amount of relevant content.
Auditory Comprehension Impairments
Common auditory comprehension impairments include
• Difficulty understanding spoken utterances
• Providing unreliable answer to “yes/no” questions
• Failing to understanding complex grammar (e.g., The dog was chased by the cat.)
• Requiring extra time to understand spoken messages (e.g., like translating a foreign language)
• Finding it very hard to follow fast speech (e.g., radio or television news)
• Misinterpreting subtleties of language (e.g., takes the literal meaning of figurative speech such as “It’s raining cats and dogs.”)
• Lacking awareness of errors.
Very often, a person with aphasia experiences both expressive and receptive difficulties, but each to varying degrees. In addition, the person with aphasia may have similar (parallel) difficulties in written expression and reading comprehension.
Reading Comprehension Impairments (Alexia)
Common reading comprehension impairments include
• Difficulty comprehending written material
• Difficulty recognizing some words by sight
• Inability to sound out words
• Substituting associated words for a word
• Difficulty reading noncontent words (e.g., function words such as to, from, the).
Written Language Impairments (Agraphia)
Common written language impairments include
• Difficulty writing or copying letters, words, and sentences
• Writing single words only
• Substituting incorrect letters or words
• Spelling or writing nonsense syllables or words
• Writing run-on sentences that don’t make sense
• Writing sentences with incorrect grammar.
Management:
• Speech and language therapy
• Reading and writing management
• Physiotherapy
• Psychological counseling
• Medication
• Family support
DYSARTHRIA
Dysarthria is a motor speech disorder resulting from neurological injury of the motor component of the motor-speech system and is characterized by poor articulation of phonemes. In other words, it is a condition in which problems effectively occur with the muscles that help produce speech, often making it very difficult to pronounce words. It is unrelated to any problem with understanding cognitive language. Any of the speech subsystems (respiration, phonation, resonance, prosody, and articulation) can be affected, leading to impairments in intelligibility, audibility, naturalness, and efficiency of vocal communication.
Neurological injury due to damage in the central or peripheral nervous system may result in weakness, paralysis, or a lack of coordination of the motor-speech system, producing dysarthria. These effects in turn hinder control over the tongue, throat, lips or lungs for example; swallowing problems (dysphagia) are also often present.
The causes of dysarthria can be many, including toxic, metabolic, degenerative disease, traumatic brain injury etc.
Symptoms:
• Slurred speech
• Slow speech
• Inability to speak louder than a whisper or speaking too loudly
• Rapid speech that is difficult to understand
• Nasal, raspy or strained voice
• Uneven or abnormal speech rhythm
• Uneven speech volume
• Monotone speech
• Difficulty moving your tongue or facial muscles
• Changes in voice quality, such as hoarse or breathy voice or speech that sounds “nasal” or “stuffy”
• Limited tongue, lip, and jaw movement
• Abnormal pitch and rhythm when speaking
• Speech that’s slurred, jerky, or garbled and difficult to produce and/or understand
• Problems controlling pitch, loudness, and rhythm when speaking
• Slow speech or rapid, mumbled speech
• Speaking softly or barely able to whisper
• Limited ability to move the tongue, lips, and jaw
• Changes in the voice quality (nasal, hoarse, or stuffy)
• Chewing and swallowing problems
• Drooling or poor control of saliva
Management:
• Speech and language therapy
• Physiotherapy
• Psychological counseling
• Medication
• Family support
APRAXIA
Apraxia is a motor disorder caused by damage to the brain, in which someone has difficulty with the motor planning to perform tasks or movements when asked, provided that the request or command is understood and he/she is willing to perform the task. Apraxia is an acquired disorder of motor planning, but is not caused by in coordination, sensory loss, or failure to comprehend simple commands. It is caused by damage to specific areas of the cerebrum.
Apraxia is most often due to a lesion located in the left hemisphere of the brain, typically in the frontal and parietal lobes. Lesions may be due to stroke, acquired brain injuries, or neurodegenerative diseases. It is also possible for apraxia to be caused by lesions in other areas of the brain including the right hemisphere.
Symptoms:
• Difficulty stringing syllables together in the appropriate order to make words, or inability to do so
• Minimal babbling during infancy
• Difficulty saying long or complex words
• Repeated attempts at pronunciation of words
• Speech inconsistencies, such as being able to say a sound or word properly at certain times but not others
• Incorrect inflections or stresses on certain sounds or words
• Excessive use of nonverbal forms of communication
• Distorting of vowel sounds
• Omitting consonants at the beginnings and ends of words
• Seeming to grope or struggle to make words
Childhood apraxia of speech rarely occurs alone. It is often accompanied by other language or cognitive deficits, which may cause:
• Limited vocabulary
• Grammatical problems
• Problems with coordination and fine motor skills
• Difficulties chewing and swallowing
• Clumsiness
Management:
• Speech and language therapy
• Physiotherapy
• Psychological counseling
• Medication
• Family support
DEMENTIA
Dementia is a broad category of brain diseases that cause a long term and often gradual decrease in the ability to think and remember such that a person’s daily functioning is affected. Other common symptoms include emotional problems, problems with language, and a decrease in motivation. A person’s consciousness is not affected. The most common type of dementia is Alzheimer’s disease. Other common types include vascular dementia, Lewy body dementia, and frontotemporal dementia. Less common causes include normal pressure hydrocephalus, Parkinson’s disease, syphilis, and Creutzfeldt–Jakob disease among others.
Symptoms:
• Memory
• Word finding difficulty
• Mood changes
• Difficulty in normal tasks
• Communication and language
• Ability to focus and pay attention
• Reasoning and judgment
• Visual perception
• Confusion
• Being repetitive
• Struggling to adapt to change
• Personality changes
• Inability to reason
• Inappropriate behavior
• Paranoia
• Agitation
• Hallucinations
• Difficulty with coordination and motor functions
• Problems with disorientation, such as getting lost
Management:
• Speech and language therapy
• Physiotherapy
• Psychological counseling
• Medication
• Family support
PARKINSON DISEASE
Parkinson’s disease is a degenerative disorder of the central nervous system mainly affecting the motor system. The motor symptoms of Parkinson’s disease result from the death of dopamine-generating cells in the substantia nigra, a region of the midbrain. The causes of this cell death are poorly understood. Early in the course of the disease, the most obvious symptoms are movement-related; these include shaking, rigidity, slowness of movement and difficulty with walking and gait. Later, thinking and behavioral problems may arise, with dementia commonly occurring in the advanced stages of the disease, whereas depression is the most common psychiatric symptom. Other symptoms include sensory, sleep and emotional problems.
Symptoms:
• Tremor
• Slowed movement (bradykinesia)
• Rigid muscles
• Impaired posture and balance
• Loss of automatic movements
• Speech changes
• Stiff muscles (rigidity) and aching muscles
• Slow, limited movement
• Weakness of face and throat muscles
• Difficulty with walking and balance
• Writing changes
Management:
• Speech and language therapy
• Physiotherapy
• Psychological counseling
• Medication
• Family support
RIGHT HEMISPHERE BRAIN DAMAGE
Right hemisphere brain damage is damage to the right hemisphere of the brain. It is associated with a number of cognitive and behavioral difficulties in humans. The damage may be due to physical incidents, stroke, or aging. Patients with RHD perform poorly in three specific tasks characterizing emotions in faces; matching emotional expressions; and grouping pictorially presented and written emotional scenes.
Paralinguistic comprehension problems involving sarcasm, irony, etc. have also been detected in these patients. Individuals with RHD also find it difficult to extract the theme of a story, or arrange sentences based on the theme of a story. Adults with RHD may exhibit behavior that can be characterized by insensitivity to others and preoccupation with self; unawareness of the social context of conversations; and verbose, rambling and tangential speech.
Symptoms:
• Attention
• Perception
• Reasoning and problem solving
• Memory
• Social communication (pragmatics)
• Organization
• Insight
• Orientation
• Visual confrontation naming is used on the Boston naming test. e.g. patients are asked to name pictures.
• Body Part Naming
• Auditory Comprehension of Complex Material
• Word Fluency
• Writing (RHD patients may substitute or omit graphemes)
• Auditory comprehension of difficult material
• Oral sentence reading
Management:
• Speech and language therapy
• Physiotherapy
• Psychological counseling
• Medication
• Family support
COMMON SYNDROMES CAUSES SPEECH & LANGUAGE PROBLEM DOWN SYNDROME
Down’s syndrome, also known as trisomy 21, is a genetic disorder caused by the presence of all or part of a third copy of chromosome 21.It is typically associated with physical growth delays, characteristic facial features, and mild to moderate intellectual disability. The average IQ of a young adult with Down syndrome is 50, equivalent to the mental age of an 8- or 9-year-old child, but this varies widely. Down syndrome is one of the most common chromosome abnormalities in humans, occurring in about one per 1000 babies born each year
LANDAU-KLEFFNER SYNDROME
Landau-Kleffner Syndrome [LKS] has been described more frequently than any other type of acquired childhood aphasia LKS manifests itself between 3 and 7 yrs. Males are most of often affected. EEG is invariably abnormal but clinical seizures do not occur in all children with LKS Until the onset of symptoms, the child’s language, cognitive and psychomotor skills develop uneventfully seizures and aphasia are equally likely to be the first symptom of the syndrome. Sudden or gradual inattentiveness to sound and loss of language abilities present. Etiology remains unknown, Landau and Kleffner hypothesized that the persistent convulsive discharges observed in the temporal lobe might cause the functional ablation of the primary cortical areas sub serving language and result in language deficits.
WILLIAMS’S SYNDROME
Williams’s syndrome is a neuro- developmental disorder characterised by a distinctive pattern of dysnorphic facial features, cardiovascular disease, connective tissue abnormalities, delayed development leading to mental retardation or learning disabilities, a specific cognitive profile and an unusual personality profile. It is caused by the deletion of a specific sequence of genes, which occurs randomly. A defect in the metabolism of vitamin D is postulated as the cause of William syndrome.
FRAGILE X SYNDROME
Fragile x syndrome [FXS] is the leading inherited cause of mental retardation and is second only to Down syndrome as a genetic cause of mental retardation. It is an x-linked disorder. There are a variety of physical and behavioural sequelae that are associated with FXS. Physical sequelae includes large ears, prominent forehead high arched palate and for males macro or childish. Behavioural sequelae include cognitive impairments ranging from mental retardation is most males and roughly half of all females have mild learning disabilities or even normal IQS. Many individuals with FXS, even those with relatively mild cognitive and physical impairments also display behaviours suggesting high levels of anxiety hyper around particularly in social situations .
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