Speech and Language Disorders

Acquired Language Disorder: Aphasia

What is Aphasia?

Aphasia is a language disorder that usually occurs suddenly as a result of a stroke or head injury and is caused by damage to the areas of the brain responsible for language. In most people, the language areas are located in the left hemisphere of the brain. Therefore, in aphasia, the language areas in the left half of the brain are damaged, while the right side of the brain can also be affected by stroke/stroke. This impairment can affect language expression and understanding, as well as reading and writing. Aphasia can also be accompanied by neurological speech disorders such as dysarthria or apraxia of speech.
What are the causes of aphasia?

Aphasia is caused by damage to one or more of the language areas of the brain. Most often the cause of brain damage is a stroke. A stroke occurs when an area of the brain is deprived of blood. Brain cells die when they do not receive their normal blood supply of oxygen and important nutrients. Other causes of brain damage include severe blows to the head, brain tumors, brain infections and other conditions that affect the brain.

Who gets aphasia?

Anyone can have aphasia, including children. However, aphasia is more common in middle-aged and older people. In the United States, according to the National Aphasia Association, about 80,000 people suffer from aphasia due to stroke each year. There are approximately one million individuals with aphasia in the United States. There is no established rate about the prevalence of aphasia in Turkey.

What are the Types of Aphasia?

There are two general classifications of aphasia: fluent and arrested.

Fluent Aphasia
Damage to the temporal lobe of the brain can result in a fluent aphasia called Wernicke's aphasia. In most people, the damage occurs in the left temporal lobe, although it can also occur as a result of damage to the right lobe. People with Wernicke's aphasia may speak in long sentences with no meaning, unnecessary words, or even new words that are generated. For example, a person with Wernicke's aphasia, when asked what they do during the day, may say "second...one day...one day we can do something for someone...the day before we say we can do this...more than one...". So, it is difficult to follow and try to understand this person's speech. People with Wernicke's aphasia often have difficulty understanding speech and are not aware of their mistakes. They usually do not have paralysis or weakness because the localization of the brain damage is not near the areas of the brain that control our movements.

Arrested aphasia
One type of arrested aphasia is Broca's aphasia. People with Broca's aphasia have damage to the frontal lobe of the brain. These people usually speak in short phrases and it takes a lot of effort for them to speak. They may not use conjunctions such as "and" and "but" between words. For example, a person with Broca's aphasia may say "water... table" instead of "Can you give me the glass of water on the table?". People with Broca's aphasia understand the speech of others. They are therefore aware of their difficulties and can easily become frustrated. Because the frontal lobe is also important for motor movements, people with Broca's aphasia have paralysis or weakness on the right side of the body.

Another type of arrested aphasia is global aphasia, which occurs when the language areas of the brain are heavily affected. People with global aphasia have severe communication deficits and their ability to speak and understand spoken language can be very limited.

There are other types of aphasia that result from damage to different language areas in the brain. Some people have difficulty repeating words and sentences, even though they can speak and understand the meaning of words or sentences (e.g. conductive aphasia). Others have difficulty naming objects even though they know what the object is and what it does (e.g. anomic type aphasia).

How is aphasia diagnosed?

Aphasia is usually first recognized by the doctor (neurologist) treating the person who has suffered a brain injury. If the doctor suspects aphasia after a brief bedside assessment, he or she will refer the patient to a speech and language therapist to further evaluate communication skills. The speech-language pathologist assesses the individual's ability to "carry out commands, answer questions, name objects and carry on a conversation" in detail and performs an aphasia test to prepare an appropriate therapy program. Assessments should include motor speech impairments, language comprehension, reading, writing, swallowing, and the ability to use alternative and supportive communication systems. In Turkey, there are GAT (Gülhane Aphasia Test: Tanrıdağ, 1993), GAT-2 (Tanrıdağ, Maviş, Topbaş, 2011), EAT (Atamaz, Yağız On, Durmaz, 2007) and ADD (Maviş & Toğram, 2007) assessment tests prepared for individuals with aphasia.

What is Aphasia Therapy like?

In some cases, aphasia improves without intervention. This type of spontaneous recovery follows a type of stroke called a transient ischemic attack, in which blood flow to the brain is temporarily interrupted but soon recovers. In these cases, language skills may return in a few hours or a few days.

However, in most cases, language recovery is not so rapid or complete. While many people with aphasia experience partial spontaneous recovery with some language skills returning in a few days to a month, in some people the aphasia may be permanent. In these cases, speech and language therapy can help. Relative recovery usually lasts for more than two years. Most health professionals believe that the most effective treatment should begin in the early stages of recovery. Factors affecting recovery include the area of the brain damaged, the extent of the brain damage, the person's age and health status. Other factors include motivation, hand dominance and level of education.

Speech and language therapists dealing with aphasia are specialists in improving the communication skills of people with aphasia by motivating them to use their remaining language skills, by restoring language skills as much as possible, compensating for language problems and teaching other ways of communicating. Individual therapies, tailored to each individual's aphasia type and disability, focus on the functional needs of the person. Group therapies give people with aphasia the chance to use new communication skills in a small group setting. Family involvement is also an important component of aphasia therapy.

Delayed Speech and Language and Specific Language Disorder

Language and speech are different from each other. Language is a system of common rules that people use to share their thoughts and feelings with each other. A language should not only refer to spoken language; writing and signing are also languages. Speech, on the other hand, is the system in which the rules containing these feelings and thoughts are physically produced with the help of the necessary organs.

A child may have the necessary grammar to convey his/her thoughts and feelings, but may not be able to speak because his/her speech organs (tongue, lips, etc.) do not function properly. On the other hand, another child may not be able to speak because of a defect in language development even though his/her speech organs function perfectly, or both may occur at the same time.

Is what my child is experiencing a temporary delay or a disorder?

Children may lag behind their peers in some skills; they may recover quickly and even get better. While a child may develop skills such as walking, eating and toileting normally, his/her speech may be delayed. All children have the same or similar generally accepted developmental stages; however, some children may have a unique developmental timing and may start speaking a little earlier or later than their peers. Parents are very good observers, observing their children's behavior very carefully. They also have an idea about the development of other children around them who are developing normally. So when parents suspect something wrong with their child, they compare their child's performance with that of other children and often at the right time they realize that something is not right and they naturally get worried and seek clarification first from their closest relatives and then from the nearest specialist: My child still doesn't speak. My child expresses himself differently. What my child says is not easily understood.

What is difficult for parents or non-specialists to distinguish is whether the child's speech is delayed or whether it is a speech or language disorder and, above all, whether the child can overcome this problem on his/her own.

Speech and language disorders are not something that pediatricians, psychologists and child development specialists are or should be experts in. Your doctor, child psychologist or preschool teacher may say that your child's physical development is normal, that he/she can hear and can make out words such as "dad, mom", so you should wait until the age of 3 or even 4 before seeing a specialist. Again, specialists from different professions know that many children do not speak at 2 years of age and start speaking fluently at 3 years of age, so they may ask parents not to worry until they know that there is a real problem. This way of thinking leads families to adopt a "let's wait and see" approach, and those of these families whose children are developing at the same rate as their peers may adopt a similar approach as a kind of comforting folk belief by word of mouth:

"Wait and see."
"His uncle/uncle/aunt/brother etc. also spoke late"
"Einstein already spoke at the beginning of school"

Yes, it is possible (although not proven) that Albert Einstein and the other individuals mentioned may have been late talkers, and there may even have been some who overcame the problem on their own. If you look around you a little more carefully, you will notice that there are many 5-6 year olds, even school-age children, who still have speech and language problems. Given that these children were once speech delayed, what about those 5-6 year olds or school-age children who still do not speak like their peers or communicate differently, or in other words, what about the little Einsteins?

The reality is that in studies conducted in many countries around the world, almost 10% of pre-school and school-age children have speech and language disorders. In simple terms, that's one out of every 10 children in your neighborhood. In other words, many of the late-talking brothers, sisters, uncles, aunts, neighbors' children, etc. that your doctor or your environment shows as examples suffer from speech and language problems. Another well-known fact is that many children with delayed speech continue to have speech and/or language disorders into school age and later in life.

When your car breaks down, the risk you take with the mechanic's reassurances such as "let's wait and see" or "the neighbor's car also started late" may result in a little more money out of your pocket or at most the loss of your car. What about when it comes to your child? The risks you take here can lead to social, psychological and behavioral problems in the later stages of the child's life, such as learning disabilities, which are difficult to reverse as they progress. In other words, if you suspect a delay, disorder or difference in your child's communication, it is very important to have a speech and language disorders specialist evaluate and, if necessary, provide education.

What should parents do?

Parents should not spend time listening to what non-specialists have to say, or comfortably assume that their child will catch up with their peers in terms of speech in any case. If you have any doubts about your child's speech or language development, consult a speech and language pathologist. The speech and language therapist will measure the child's understanding and expression of verbal language with the help of tests, evaluate the child's communication with the environment in a natural environment, identify factors that may affect development and advise the family on what to do next.

Why should I consult a specialist?

While waiting even for something simple is a troublesome process, waiting and seeing whether the child will be able to speak or not is a more difficult and troublesome process. It is a bad feeling for parents, especially knowing that the problem can be solved more easily and quickly if it is recognized at an earlier stage.

Even if your child has only a simple delay, you should consult a specialized therapist instead of relying on hearsay. The speech-language pathologist will do a comprehensive evaluation of your child's speech and language skills and will send you home with lots of ideas for strengthening your child's communication skills beyond "let's wait and see" or ask to check in periodically.

Sources:

Feit, D., & Feldman, H. M. (2007). The parents guide to speech and language problems. Mc-Graw Hill: Two Penn Plaza, NY.
Karmiloff, K. & Karmiloff-Smith, A. (2001). Pathways to language: From foetus to adolescent' in 'Developing Child Series', Harvard University Press.
Karmiloff, K. & Karmiloff-Smith, A. (1998). Everything your baby would ask if only he/she could talk, Cassell/Ward Lock, London.
Paul, R. (2001). Language Disorders From Infancy Through Adolescence: Assessment & Intervention. St Louis: Mosby.
www.asha.org
www.kidshealth.org

Speech Impairment due to Cleft Lip and Palate

How does cleft palate lead to speech impairment?

Cleft palate causes one or more of the structures such as lips, hard palate, soft palate, teeth and nose to be structurally defective and these organs cannot perform the movements necessary for articulation properly.

What is the incidence of cleft lip and palate?

According to a study conducted in our country, 1 cleft lip and palate is seen in every 1000 births (Tunçbilek, 1973; as cited in Aras, 1996).

What is the role of speech and language therapist in babies with cleft lip and palate?

Babies with isolated cleft lip usually do not have many problems related to feeding or speech. For this reason, the following information has been prepared to emphasize the role of the speech and language therapist in clefts that involve the lip and palate in general or only the palate.

Nutrition from Birth to 12 Months

The most serious problem faced by newborns with cleft palate is "feeding". Although lip surgeries are performed around 2.5-3 months, palate surgeries are usually not performed before 12 months. During this period, it is important to meet the nutritional needs of the baby to continue its normal development.

The open palate has led to the development of special bottles (such as Mead Johnson and Haberman). Parents who have difficulty feeding the baby due to the inability to create negative pressure use whichever bottle is more convenient. By squeezing the bottle made of soft material into the mouth, mothers help feed the baby who cannot suck. In Turkey, families who have difficulty finding these bottles may choose methods such as spoon feeding.

During the feeding process, it is very important that the child stands vertically at an angle of 45-60 degrees, not horizontally. Vertical feeding will prevent food from escaping into the nose. The parent should constantly monitor the child and stop feeding as soon as they feel that the child is uncomfortable.

Other things to consider during feeding are as follows;

• Burping the child by taking a break every 8 minutes on average,
• Feeding for no more than half an hour,
• Feeding at frequent intervals,
• Seeking help from a speech therapist in case of problems,
• In case of weight loss in the child, check with a doctor

Communication Assessment and Guidance

In some clinics, specialists are contacted during the pregnancy and they provide information about what to expect from the parents. A speech therapist is one of these specialists. Apart from this general information, the speech therapist should evaluate the 6-12 month old baby in terms of communication skills. They should provide the family with guiding information such as how to develop receptive and expressive language skills and how to reinforce the production of certain speech sounds.

Speech Between 12 Months and 3 Years

In this process, the speech therapist should still work with the families instead of working one-on-one with the child and provide the necessary guidance. 50-60% of children with cleft lip and/or palate do not have speech problems. For this reason, the family should be specifically told that they should not treat their children differently from children with normal development. At the same time, the family should be informed about speech problems that may arise. The differences between the concepts of language and speech should be explained, how many words the child forms sentences should be monitored, and it should be checked whether the child understands sentences with 2-3 instructions. In addition, families should pay more attention to whether there are errors in the sounds they use while saying words.

One of the important parameters affecting language and speech is hearing. It should be ensured that the child's hearing is constantly checked by the ENT doctor and audiologist. The family should be warned that recurrent otitis media can lead to permanent hearing problems.

After 3 Years of Age

Speech and language therapy with children with cleft palate begins actively after the age of three. This is necessary for the child to participate in desk activities and to act in accordance with the instructions given.

Speech and language disorders in children with cleft lip and palate

In therapies, language development is evaluated before the child's speech. Kuehn and Henne (2003) stated that even if cleft palate negatively affects the child's speech development, it does not affect language development much, except when accompanied by some additional disorders. Children with language delay should be evaluated by a pediatric neurologist, especially in terms of cognitive skills and syndromes.

Children without age-appropriate language development are not included in articulation therapy. First of all, the child should have the language skills necessary to form sentences using the appropriate number of words, to use the affixes in sentences appropriately and appropriately, in short, to express his/her thoughts comfortably. While children with poor language development receive language therapy, children who do not have problems with this can be started on articulation therapy.

What is hypernasality?

Hypernasality is when the acoustic energy required for speech escapes into the nose in sounds that should come out of the mouth, disrupting the resonance of speech. Since hypernasality often accompanies cleft palate, it can cause a number of articulation problems. Some of these problems can be corrected with speech therapy and are processes that the child develops to compensate for the palate deformity, while others are compulsory disorders based on structural problems (such as hypernasality or dental/jaw anomalies). During the evaluation, the speech therapist should determine which of these disorders are compulsory and which are compensatory processes, and refer them to doctors or orthodontists for structural disorders, and initiate speech therapy for compensatory processes.

What are compensatory speech processes?

Cleft palate-specific compensatory speech processes are usually articulation processes in which sounds that are expected to come from the front of the mouth, such as /t/, /d/, are transformed into consonants such as /k/, /g/.

Speech therapy for cleft lip and palate

The success of speech therapy depends on the success achieved through teamwork. Plastic surgeon, otolaryngologist, geneticist, pediatric neurologist, speech therapist, orthodontist, audiologist, psychologist, social worker are all part of this team. This teamwork is very important for the child with cleft palate to form a positive perspective about himself/herself.

Speech Fluency Disorders (stuttering, rapid-disordered speech, etc.)

In the Speech Fluency Disorders unit, evaluation, counseling and therapy services are provided to individuals of all ages with speech fluency problems.

One of the most common types of speech and language disorders is fluency disorder. According to the classification of the American Hearing and Speech Association (ASHA), it is analyzed under two headings as developmental and acquired. Acquired disorders are psychogenic and neurogenic fluency disorders and have the lowest incidence. For this reason, research and therapies are focused on developmental stuttering and rapid-disrupted speech.

What is cluttering?

Today, researchers continue to conduct research on cluttering, which is briefly defined as abnormally fast and disorganized speech. Cluttering, like stuttering, is a speech fluency disorder, but it is different from stuttering. It is a speech disorder that is excessively fast, disorganized, and often contains irrelevant words or phrases.

Rapid-disordered speech also involves excessive disruptions in the normal flow of speech and may be accompanied by excessively fast speech, irregular pacing, incorrect/incomplete vocalization, and uncertainty about what to say. Currently, therapies for rapid-disordered speech (with techniques used in stuttering therapy) are used to slow speech, reduce disfluencies, and increase awareness and language organization.

The causes of rapid-disrupted speech are explained in the same way as the causes of stuttering, and the incidence has not yet been clearly determined.

What is stuttering?

Stuttering, which is defined by emphasizing different aspects in various sources, is most clearly defined as the disruption of the flow or rhythm of speech with interruptions or obstacles such as blocks. The definition can be expanded a little more and expressed as follows:

Stuttering occurs as a result of involuntary neuromotor impairments that affect the coordination of breathing, phonation and articulation during speech.

Stuttering is usually, but not always

1) as the involuntary loss of control that a person experiences when saying words,
2) manifests as excessive and/or abnormal vocal/syllable repetitions, prolongations, vocal or silent blocks, or avoidance of these behaviors; and
3) it is linked to or triggered by many different psychological stresses and negative emotions."

What is the incidence of stuttering?

According to research, approximately 1% of a population has experienced stuttering at any given time. Based on this data, it is thought that there are approximately 700,000 cases of stuttering in Turkey.

Typically, stuttering begins in childhood and can be observed in 5% of children during this period. 80% of stuttering in childhood disappears spontaneously. Therefore, 4 out of 5 children continue to speak fluently and 1% continue to stutter.

What causes stuttering?

There is no single cause of stuttering. According to research results, typical stuttering that starts in childhood has physiological factors. For example, there are proven genetic influences in about 50% of individuals who stutter. The fact that stuttering increases in stressful situations leads to the belief that the causes are psychological, but this is not true. Psychological factors can "trigger"-or bring on-stuttering, but they are not the cause of stuttering. Learning or habits also play an important role in stuttering. For example, people who stutter may make certain movements (such as tapping their foot or blinking their eyes) that they think will help them when they stutter.

What is speech therapy and how can it help?

People of any age with a speech or language disorder can receive specialized training from a speech therapist who has received specialized training in this area. This specialized training is known as "speech therapy". Speech therapy for stuttering is typically individual therapy between the person who stutters in the setting and the speech therapist. In some cases, family members may also participate in therapy sessions, especially if the person who stutters is a child. Speech therapy can also take place in a group setting with more than one stutterer, e.g. 2 to 6 participants. The goals of speech therapy are quite varied. These include teaching speech in such a way that stuttering does not always occur (fluency shaping); teaching an easier way of stuttering (modification of stuttering); teaching the stutterer to accept or not avoid stuttering (desensitization and avoidance); and other techniques.

What is being done for stuttering in Turkey?

In Turkey, there are many centers that provide short-term therapy for stutterers and "guarantee recovery". In most of these centers they teach a new way of speaking. These new ways are a form of fluency shaping. Some of these centers guarantee recovery. In general, speech-language pathologists are skeptical of such guarantees of improvement. This is because many approaches can reduce stuttering, but few can teach a way of speaking that will enable normal conversations with family, friends and coworkers. Even fewer teach stutterers to change their lives so that they can cope effectively with their stuttering for the rest of their lives.

Motor Speech Disorders: Dysarthria and Apraxia

What are motor speech disorders?

Speech is a sensory and motor process that develops using the voice, hearing, oral-facial apparatus and requires complex neural integration and rapid coordination of many physiological systems. Speech disorders that occur with a neuromotor problem affecting one or more of the respiratory, phonation, resonance, articulation and prosody components of speech are called motor speech disorders. There are two types of motor speech disorders: dysarthria and apraxia.

What is dysarthria?

It is a motor speech disorder in which the respiratory, vocalization, resonance, articulation and prosodic features of speech are affected due to spasticity, flaccidity, coordination disorder, paralysis in the muscles controlling the speech mechanism due to damage to the Central Nervous System and/or Peripheral Nervous System or both systems, thus limiting intelligibility.

In which diseases is dysarthria observed?

The source of neuromotor problems causing dysarthria may be vascular, traumatic, infectious, neoplastic, metabolic, etc. Different lesions and damage to the central and peripheral nervous system produce different types of dysarthria. The term dysarthria is generally used in the literature for acquired neurologic/neurogenic speech disorders that occur in adults due to brain injuries such as stroke and brain trauma. Neuromotor speech disorders observed in childhood are associated with cerebral palsy and are defined as "developmental dysarthria".

What are the diseases in which dysarthria can be observed?

1. Cerebrovascular events
2. Traumatic brain injuries
3. Tumors
4. Cerebral palsy
5. Progressive supranuclear palsy
6. Parkinson's
7. Huntington's disease
8. Amyotrophic lateral sclerosis
9. Multiple sclerosis
10. Myastania gravis

What are the types of dysarthria?

1. Spastic dysarthria: It is a type of dysarthria in which decreased vital capacity, scratchy, tense, harsh voice, low pitch, hypernasality, unclear consonant production, decreased emphasis, sometimes excessive or the same emphasis and slow speech are observed as a result of upper motor neuron (UMN) lesion (in degenerative diseases such as Cerebrovascular Events, Trauma, Progressive Supranuclear Palsy).

2. Fluxide dysarthria: As a result of lower motor neuron (AMN) lesion (Bulbar palsy, Myasthenia Gravis, V., VII, XII. cranial nerve lesions) secondary to muscle weakness, decreased respiratory support, difficulty breathing, breathless voice in bilateral lesions, audible breathing, diphosphonia, decreased pitch and intensity level, aphonia, hypernasality and nasal emission, unclear consonant production, unclear double lip, tooth-lip, tooth-lip, tooth-back tongue tip consonants or inability to produce these sounds, prosodic inadequacy, monotone speech.

3. Ataxic dysarthria: It is a type of dysarthria in cerebellar system lesions in which speech characteristics such as low breathing, normal phonation or excessive variability in loudness, sudden bursts, cracking, scratching sound, monotony/monotony, unclear consonant production, disturbances in vowel production, irregular vocalization, slow but exaggerated emphasis on almost every syllable, prolonged syllables, pauses after each syllable are observed.

4. Hypokinetic dysarthria: In basal ganglia lesions (Parkinson's Disease), this type of dysarthria is characterized by decreased respiratory support, breathlessness in phonation, stiffness, tremor, decreased voice intensity, hypernasality in some cases, change in vocalization pattern, palilalia, single pitch, monotonous voice intensity, and short, clipped speech.

5. Hyperkinetic dysarthria: In basal ganglia lesions; Myoclonia, Tourette Syndrome, Infection, Ballismus, Athetonia, regular tremor in pitch and volume, single pitch and pitch breaks, phrases at long intervals, variable ranges and monotony are observed. In dystonia and athetosis; weak respiratory support, scratchy, tense voice, audible inspiration, monotonous voice, variable and decreasing emphasis, long pauses in speech, inappropriate silence are observed, while in Chorea, sudden forced inhalation and exhalation, excessive variability in voice volume, panting, voice pauses due to involuntary movements, long pauses in speech, speech with short phrases and monotony are observed. In addition, hypernasality, variable vocalization, unclear consonant production and vowel distortion are other features of hyperkinetic dysarthria.

6. Complex type dysarthria (Spastic-Flaxid): In diseases such as Amyotrophic Lateral Sclerosis in which upper and lower motor neuron lesions can be seen; poor respiratory support, hypernasality, unclear consonant production, prosodic inadequacy, decreased emphasis, monotony, UMN: single pitch, scratchy, tense voice with wet voice; AMN: faintness, monotonous voice intensity.

7. Complex type dysarthria (Spastic-Athaxic): Poor respiratory support, impaired pitch control, harsh, breathy voice quality, sometimes hypernasality, impaired intonation, inadequate prosody, decreased emphasis and impaired pitch control in UMN and cerebellar lesions (Multiple Sclerosis).

How is dysarthria assessment performed?

The aim of the evaluation is to screen and detect, diagnose and plan the intervention method. The evaluation is based on the identification of damaged structures and their functions by imaging methods, direct observation of the movement and functions of speech-producing structures with devices, and perceptual evaluation of speech production. In order to make more objective judgments, computerized voice analysis systems (CSL), video and voice recorders are used to evaluate the acoustic properties of speech.

What are the main goals of dysarthria therapy?

The overall goal of therapy is to enable the patient to participate in lifelong communication activities by maximizing language use, speech intelligibility, rate, duration, naturalness, melody and prosodic features.

When are alternative and supportive communication systems (ASCS) needed?

In non-progressive and acute dysarthria, ADCS can be used until the patient can communicate again in intelligible speech. Chronic non-progressive dysarthric individuals may require long-term use of ADIS. In degenerative disorders, it can be used to support speech and then as the sole means of communication.

APRAKSİ

What is apraxia?

It is the inability to perform movements that require skill, except for any weakness, akinesia, abnormal tone or posture, impairments in cognitive functions, decreased comprehension, and inability to cooperate. It is a form of motor agnosia.

What are the types of apraxia?

1. Motor Apraxia: The kinetic formula gained through experience is impaired.

2. Limb-Kinetic Apraxia: The speed, fluency and fineness of movement are lost. Left frontal-anterior parietal/supplementary motor area lesions or premotor area lesions are responsible. It is unilateral and manifests in the extremity across the lesion.

3. Ideomotor Apraxia: The ability to activate the motor apparatus in response to an idea, a sequence of actions is impaired. It is caused by inferior parietal lobe lesions. Patients perform the movement sequence incorrectly, especially when commanded. When the real object is handed to them, they perform it better than when shown by imitation. They have difficulties in performing movements independently of the object. It is seen in left side lesions. In this type of apraxia, the patient's perception of impaired motor performance by himself or others is also impaired.

4. Ideatory Apraxia: The mental schema of how to perform the action and the associated plan is impaired. Therefore, the sequence of a complex series of movements is disrupted, they are performed one by one, but cannot be performed when asked to be performed one after the other.

5. Apraxia of Gait: It occurs in medial frontal cortex lesions. It may occur as a result of bilateral subcortical infarction and stretching of the fibers projecting from the medial part of the frontal lobe due to hydrocephalus while passing in front of the ventricle.

6. Apraxia of speech (Verbal Apraxia): The dominant inferior frontal region is responsible.

What is apraxia of speech (verbal apraxia)?

It is a motor disorder related to the programming of speech in adulthood and childhood. The adult form occurs after normal speech and language development. Childhood apraxic speech occurs as a result of structural brain damage. It is also defined as sensory motor speech disorder. It is a disorder of motor planning in the center necessary to produce words and voluntary muscle movements.

What are the characteristics of apraxic speech?

Pronunciation problems are frequently observed. In addition, phonation coordination, frequency and/or emphasis are effective. The patient is aware of his/her inability, the problem increases as the word length increases. Pronunciation disorders are not consistent; repetitions, prolongations or variations in word changes are seen. Consonants are more difficult to articulate than vowels, initial consonants are more difficult than final consonants. Perfectly voiced parts of speech are common, especially in automatic and frequently used words.

What is the overall goal of apraxia therapy?

The main goal of apraxia therapy is to increase the patient's voluntary control of the articulatory movements necessary for speech production. If apraxia is very severe, intelligible speech may not be a realistic goal. For these people, developing an alternative and supportive communication system may be a more meaningful goal.

Pronunciation and Phonological Disorders

What is articulation?

Articulation is the ability of an individual to correctly pronounce the speech sounds of a particular language with consecutive, harmonious movements of the organs involved in speech.

What is an articulation disorder?

Pronunciation disorders are problems based on the faulty production of the location, form, speed, timing and pressure of speech sounds.

What causes pronunciation disorders?

Pronunciation disorders can be of structural origin or they can be seen without any cause. Among the causes that may cause vocalization problems; cleft lip-palate and oral-facial anomalies, orthodontic anomalies, hearing loss, mental disability, neurological disorders (cerebral palsy and other).

In pronunciation disorders, errors can be observed in the following forms:

• Substitution of /k/ and /t/ sounds: /dog/ for /dog/,
• Substituting other sounds for /r/, /y/, /l/, /ç/
• Use /t/ and /d/ instead of /k/ and /g/ sounds

What is phonological competence?

Phonological competence is the ability to use speech sounds appropriately in the context of language.

What is a phonological disorder?

Phonological disorders are difficulties in acquiring knowledge of the rules of language (phonology/phonology) that form the basis of speech. The child cannot produce easily understandable speech patterns. For example, the child has not learned to use the /s/ sound at the beginning of a word. Developmental phonological disorders can be a factor in children's later reading and writing difficulties.

Are all sounds learned at the same time?

No, they are not. Sounds are acquired in a certain order. Some sounds are acquired around the age of 3 (/p/, /b/, /m/), while others may not be fully acquired until school age (/s/, /r/, /l/).

Is it important to correct pronunciation disorders?

It becomes more important when it affects social, emotional, academic and/or work life. Therefore, pronunciation problems should be addressed urgently.

Are pronunciation problems like baby talk?

When young children misuse sounds, syllables and words, their speech may be perceived as "baby talk". However, the speech of children and adults with serious pronunciation problems is quite different from baby talk.

How can I help my child produce sounds correctly?

You need to be the right model for your child. Do not interrupt or constantly correct your child's speech. Your child's vocal mistakes should not be ridiculed or treated as cute and reinforcing by both you and your close environment. The best behavior you can do is to be the right model. The mispronounced word should be expressed correctly. When your child says "number sun", give correct feedback by repeating "yes, yellow sun, big yellow sun warms us".

Traumatic Brain Injury

What is Traumatic Brain Injury?

Traumatic brain injury (TBI) is a brain injury that occurs when the head suddenly and violently hits an object (such as a car window, radiator, concrete) or when an object pierces the skull and damages the brain tissue (such as a bullet, nail).

What are the types of Traumatic Brain Injury?

Depending on the condition of the skull, it can be divided into two as closed and open head injuries. In open head injuries, a skull fracture occurs, while in closed traumas no fracture occurs.

How does the severity of Traumatic Brain Injury affect individuals?

TBI is graded as mild, moderate and severe in terms of symptoms depending on the extent of damage to the brain. In mild damage, there may be no loss of consciousness or a brief loss of consciousness of a few seconds/minutes. There may be headache, confusion, dizziness, blurred vision or eye strain, tinnitus, bad taste in the mouth, fatigue, disturbed sleep patterns, changes in behavior or mood, and minor problems with memory, concentration, attention and thinking. Most people with mild head injuries recover well.

Moderate or severe injuries may also have these symptoms, but may also include worsening or persistent headaches, recurrent vomiting or nausea, convulsions or seizures, inability to wake from sleep, dilated pupils, slurred speech, weakness or numbness in the limbs, loss of coordination and increased confusion, restlessness, agitation, anxiety, worry, nervousness, and some injuries can be fatal.

What are the common causes of Traumatic Brain Injury?

The most common cause of TBI is traffic accidents (often car and motorcycle accidents). Other causes include falls, sports injuries, occupational accidents, violence and child abuse.

Are traumatic brain injuries related to age?

Males aged 15-24 are more likely to suffer from traumatic brain injuries due to their supposedly risky lifestyles. Individuals over 75 years of age are more likely to be exposed to fall-related trauma. For adolescents and adults, the most common causes are automobile and motorcycle accidents and violent crimes. Depending on the profession, bullet injuries are common in professions such as military and police.

In infants under one year of age, the most common cause may be physical abuse. In particular, very violent shaking for play or harm can cause brain damage. In slightly older preschool children, injuries from falls are common. After the age of five, pedestrian or bicycle injuries may increase.

What changes occur in people with traumatic brain injury?

Depending on the areas of the brain that are damaged, physical, behavioral or mental changes may occur. Most injuries can be limited to a small area of the brain. This small area of damage is often located where the head strikes the object or where the object enters the brain.

Especially in closed head injuries, widespread damage can also occur in which several areas of the brain are affected. These diffuse injuries are caused by the brain moving back and forth inside the skull. The frontal and temporal lobes, and thus the speech and language areas, are often affected in this way. Since the speech and language areas are often damaged, communication difficulties often arise. Other problems can be listed as follows: voice disorders, swallowing difficulties, inability to walk, balance, coordination, smell, memory and cognitive skills.

What are the linguistic and cognitive problems that occur as a result of Traumatic Brain Injury?

These problems vary from person to person. Individual differences are seen according to personality, pre-injury skills and the severity of the brain injury. The impact of brain injury is greatest immediately after the injury. Nevertheless, some effects of TBI can be misunderstood. Newly damaged brain tissue is often swollen (edema), bruised and scarred. This type of damage is usually not permanent; the function of these areas can be restored once the swelling and scarring have gone. Therefore, it is difficult to accurately predict long-term problems in the first weeks after TBI. However, even a minor injury can cause permanent, long-term problems. Development can be observed as the undamaged areas of the brain learn and begin to perform the functions of the damaged areas. Children's brains are more prone to this plasticity than those of adults. For this reason, children with the same damage may progress better than adults.

Cognitive problems

Possible cognitive problems in conscious patients can be listed as follows: Decreased attention span, difficulty organizing thoughts, forgetfulness, confusion, sometimes difficulties in learning new information, inability to interpret other people's actions, inappropriate behavior in social situations, difficulty in problem solving, decision making and planning.

Language problems

Language problems, like cognitive problems, show individual differences. Some of the language-related problems include: Difficulty finding words; inability to form proper sentences; long and often inaccurate narratives or explanations; difficulty in understanding words; inability to understand different usages, idioms, innuendos in jokes or jokes; sometimes not being aware of one's own mistakes and thus becoming irritable; decline in reading and writing skills; deterioration in math skills.

Problems with speech

There are also problems with speech intelligibility that can occur in people with TBI. Slower than normal, unintelligible, slurred speech may be heard. This is due to damage to the areas of the brain that control the muscles in the speech organs. This type of speech disorder is called dysarthria. More detailed information about dysarthria is given in the section "Motor Speech Disorders".

What kind of interventions are performed in Traumatic Brain Injury?

People with TBI first need medical attention. The priority is to provide oxygen support and adequate blood flow to the brain and the rest of the body, and to control blood pressure. Imaging techniques such as X-rays, tomography and MRI are very important in determining the diagnosis and treatment of a patient with TBI. After imaging and diagnosis of the damage, necessary medical and surgical interventions are performed.

In the following periods, individual therapy programs suitable for the patient are organized. These programs may include physiotherapy, occupational therapy, speech and language therapy, psychological and social solidarity.

What is the role of a speech and language therapist in traumatic brain injuries?

The speech and language therapist primarily performs speech and language assessment in order to determine the areas where the current situation is sufficient and insufficient and to plan appropriate therapy programs. If necessary, a cognitive assessment may also be carried out.

If there is a speech and language therapist working in the hospital, therapies can be started while the person is hospitalized. In early therapies, work on alertness and attention is included. Skills that are essential for communication, such as noticing and recognizing people, place and time, and understanding what is said to them, can be practiced. If the person has problems with speech intelligibility or swallowing, oral-motor exercises can be performed.

The main goal of rehabilitation in the period after leaving the hospital is to enable the person to continue living as independently as possible. With regard to language skills, the speech and language therapist determines and elaborates on goals such as expressing requests appropriately (through speech, gestures or pictures), understanding what is said, remembering and using appropriate words in speech, reading and writing as much as necessary.

The speech and language therapist also deals with cognitive problems. The most common problem with people with TBI is memory problems called "forgetfulness". The problems with forgetfulness and how long it takes to recover depend on the degree of brain damage. Memory-related activities include remembering people's names (such as spouse's name, parents' names, names of famous people), remembering the names of frequently used objects (such as cups, beds, phones, money), remembering the sequence of events (such as first I got up, then I washed my face, then I had breakfast), remembering general information (such as where is the capital of Turkey, who is the President of the Republic, what is April 23rd, what is the holiday), remembering personal information (such as address, telephone, occupation).

Swallowing Disorders

What is a swallowing disorder?

A swallowing disorder (dysphagia) is swallowing difficulties during eating and drinking. Swallowing disorders can occur in three different swallowing phases:
Oral phase: Problems with sucking, chewing or moving food or drink from the mouth to the throat
Pharyngeal phase Problems that can be seen in sending food or drink into the esophagus, that is, in closing the trachea to prevent food and drink from going in the wrong direction and escaping into the windpipe
Esophageal phase Problems in the transfer of food and drink from the esophagus to the stomach

What causes swallowing disorders?

Swallowing disorders can be caused by damage to the nervous system, various problems or diseases involving the head and neck region:

• Stroke
• Brain trauma
• Parkinson's disease
• Multiple sclerosis
• Cerebral palsy
• Alzheimer's disease
• Cancers of the mouth, throat or pharynx
• Head and neck surgery
• Oral hygiene problems (missing teeth, decay or use of inappropriate dentures)

What are the symptoms of swallowing disorders?

There are many symptoms of swallowing disorders:

• Coughing during or immediately after eating or drinking
• "Wet" sound during or immediately after eating or drinking
• More effort or time spent chewing or swallowing
• Weight loss and dehydration (dehydration) due to malnutrition
• Recurrent pneumonia or tightness when breathing after eating
• Food or liquid flowing from the mouth or accumulation of food in the mouth

How is swallowing disorder diagnosed?

A speech-language pathologist specializing in swallowing disorders evaluates people with eating and drinking problems. During the evaluation, the speech-language pathologist performs the following assessment

• Learning about the patient's medical condition and information about the swallowing disorder
• Evaluation of the strength and movements of the muscles and structures (such as lips, tongue, jaw, palate) that play a role in swallowing
• Evaluation of the patient's posture and mouth movements during eating and drinking
• Instrumental assessment of swallowing disorder

How is swallowing disorder treated?

The treatment of swallowing disorder is planned by a specialized speech and language therapist depending on the cause, symptoms and type of swallowing disorder. During treatment

• Performing customized exercises to strengthen and coordinate the muscles responsible for swallowing or to stimulate the nerves that can activate the swallowing reflex
• Applying various positions and swallowing strategies to help the person swallow more comfortably
• Feeding food and drink of different consistency so that it is safe and easy for the person to swallow

How does a swallowing disorder affect a person's life?

Swallowing disorders can affect a person's life in different ways:

• malnutrition and dehydration
• Less enjoyment of eating and drinking
• Avoidance of social situations with meals, embarrassment or withdrawal in such situations
• Risk of aspiration (food or drink getting into the windpipe) leading to pneumonia or chronic lung disease

Bibliography:

Speech and Language Disorders Education Application and Research Center, Eskişehir-TURKEY