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Common Disorders of Speech in Children by T Arch Dis Child: first published as 10.1136/adc.34.177.444 on 1 October 1959. Downloaded from A DESCRIPTION AND CLASSIFICATION OF THE COMMON DISORDERS OF SPEECH IN CHILDREN BY T. T. S. INGRAM From the Department of Child Life and Health, University of Edinburgh and the Royal Hospitalfor Sick Children, Edinburgh (RECEIVED FOR PUBLICATION MARCH 9, 1959) The full assessment of children suffering from speech defects, speech therapy is rarely provided. speech defects requires a team consisting of speech Children with speech defects attending these schools therapist, paediatrician, psychologist and otologist. were frequently referred to the Speech Clinic in the The additional services of a phonetician, neurologist, Hospital. orthodontist, plastic surgeon, radiologist, social Detailed family, birth and developmental histories worker or psychiatric social worker and child were taken, with particular emphasis on the rate, and psychiatrist are often helpful. any abnormalities, of speech development. The Unfortunately the majority of descriptions and children were subjected to a detailed paediatric and classifications of speech disorders in childhood are neurological examination, and behaviour in play by speech therapists working without much medical was observed for as long as possible in each case. co-operation and advice. With honourable excep- The child's speech was studied jointly by the by copyright. tions, they tend to regard speech disorders as rather paediatrician and the speech therapist, and detailed isolated phenomena, dissociated from the other notes were made of its intelligibility and of the behavioural and psychological characteristics of the particular defects which were observed. In many child. In the present paper an attempt is made to cases tape recordings were made, though it is always describe and classify the disorders of speech most easier, in fact, to examine speech for defects of frequently encountered in a hospital speech clinic articulation in the presence of the patient. Speech from the point of view of the paediatrician of a was studied from the points of view of level of diagnostic team. language ability and defects of articulation. Attempts were made to assess the child's ability http://adc.bmj.com/ Case Material and Methods of Examination to understand what was said to him by his parents The descriptions of speech disorders are based largely on experience in the Speech Clinic of the TABLE 1 Royal Hospital for Sick Children, Edinburgh, in the DISTRIBUTION OF 189 PATIENTS WITH SPEECH last three years. During this time a total of 348 DISORDERS BY AGE AND SOCIAL CLASS patients were referred, though for various reasons Social Class it was possible to investigate only 189 of them fully. Age Total on September 25, 2021 by guest. Protected The patients are not representative of an unselected II III IV V sample of children in the community as judged by Under 3 .. 1 15 3-5 .. 25 16 48 13 9 111 the figures for all live births given by the Registrar 5-10 12 I11 20 5 2 50 General for Scotland (1951). There is an excess 10+ .. 3 3 3 2 2 13 of patients in Social Classes I and lI, possibly because All ages 41 31 81 22 14 189 of the greater attention paid to speech defects in Under 5 . 43 58 25 126 these classes (Table 1). The greater excess of Over5 29 23 11 63 patients in Social Classes I and 11 over the age of 5 All ages .. 72 81 36 189 than under the age of 5 is probably the result of the Approx. % 39 42 19 100 fact that children in the lower social classes attend Registrar corporation schools where there is a very compre- General Scotland hensive speech therapy service. In private fee-paying 1951 ..12-5 58 3 29-2 100 schools, where more attention is usually paid to 444 Arch Dis Child: first published as 10.1136/adc.34.177.444 on 1 October 1959. Downloaded from CLASSIFICATION OF SPEECH DISORDERS IN CHILDREN 445 and by other people. Any apparent tendency for the of the articulatory organs can be demonstrated the child to rely unduly on gesture, or on watching disorder is considered to be 'dysarthric'. When the people talking to him, was noted. Rough tests of abnormalities of articulation are part of a more hearing were used during the general examination of general disorder and no direct interference with the the patient, his responses to whistles of various function of the articulatory organs can be demon- pitches, bells, the rustling of paper, vibration forks, strated they are considered to be 'secondary'. When whispering, talking and shouting being observed. disorders apparently confined only to the functions Full audiometry was performed on all children as of speech are present, unassociated with direct soon as they were co-operative enough for this interference with the articulatory organs, they are examination to be performed. Handedness was classified as 'specific developmental' or 'functional tested rather unscientifically by noting the hand speech disorders' (Table 2). which the child used in each of four performance tests carried out three times. Each patient was asked TABLE 2 CLASSIFICATION OF SPEECH DISORDERS FOUND IN to turn a door handle, break a stick, throw and catch 189 CHILDREN a ball. Patients not using a single hand for nine or more of the total of 12 tests were classified as being (1) Disorders of Voicing (Dysphonia) (4) a. With demonstrable disease of the larynx .... ambidextrous. Eyedness and footedness were also b. Without demonstrable disease of the larynx 3 tested (2) Disorders of Rhythm (Dysrhythmia) (29) (Ingram and Reid, 1956). a Clutter . ..3 A psychiatric social worker, seconded to the b. Stammer . .26 (3) Disorders of Articulation with Demonstrable Dysfunction Clinic, was asked to investigate the home situation of Articulatory Apparatus (Dysarthria) (30) in a. Due to neurological abnormalities . ..7 of 41 patients whom psychological stress appeared b. Due to local abnormalities .... .. ..23 to be important. Thirty-one patients were further (4) Disorders of Articulation without Demonstrable Dys- function of Articulatory Apparatus (Secondary Speech assessed in the Department of Psychological Disorders) (41) a. Secondary to hearing defect. ..... 8 Medicine. The opinion of an otolaryngologist was b. Secondary to mental retardation . ... 29 asked in 34 cases, of a plastic surgeon in five, and of c. Secondary to psychogenic disorders .. 3 d. Secondary to aphasia due to brain damage .. 1 an orthodontist in eight. Eleven patients were (5) Specific Developmental Speech Disorders (Functional by copyright. Speech Disorders) (80) admitted to hospital on account of physical condi- a. Involving language development and articulation 40 tions noted at the time of assessment. These b. Involving articulation only .... .. .. 40 (6) Mixed Cases (4) .. ... 4 included patients suffering from cretinism, epilepsy, (7) Unclassified and Other (1) ......I enuresis, phenylketonuria, fibrocystic disease of ............189 the pancreas and Sj0gren's syndrome. Classification In some cases there are contributory causal factors The classification is by clinical findings. Categories in the speech disorder. For example, a child with are defined in the first place by the form of the major brain damage secondary to encephalitis or trauma http://adc.bmj.com/ speech defect. Thus distinctions are made between may have a disorder of articulation which is partly disorders affecting the voice predominantly (dys- secondary to aphasia and partly the result of phonia), those whose main effect is to alter the inco-ordination of the organs of articulation. Such rhythm of speech (dysrhythmia) and those in which patients may conveniently be placed in the category abnormalities of articulation are the presenting of 'mixed cases'. They are relatively few. feature. It must be admitted that classification on the basis Categories of the major defect of speech is somewhat arbitrary Disorders of Voicing. Disorders of voicing are on September 25, 2021 by guest. Protected and crude (as are most classifications), and it is relatively uncommon in childhood, amounting to no necessary to ignore a number of significant clinical more than 4 % in most large series of patients with findings in many cases for the purpose of giving speech defects. In the present series there were the speech condition a name. For example, many four patients with disorders of the voice (approxi- patients suffering from a stammer will have minor mately 2 % of the series). abnormalities of articulation; some patients with The only disorder of voicing considered in the 'specific developmental speech disorders' will have present classification is chronic lack of voice, which minor stammer (speech dysrhythmia). It is impos- makes the child sound as if he is hoarse. This is sible to take account of these subsidiary defects in similar in quality to the 'loss of voice" suffered by the major categories. adults with laryngitis. It must be distinguished from Further classification is by associated clinical the effects of excessive nasal escape (hyperrhino- findings. When direct interference with the function phonia) or nasal obstruction (hyporhinophonia). In Arch Dis Child: first published as 10.1136/adc.34.177.444 on 1 October 1959. Downloaded from 446 ARCHIVES OF DISEASE IN CHILDHOOD these conditions difficulty of articulation is the Many children aged between 2 and 4 years may striking abnormality. They have therefore been show clutter transiently for a period of weeks or included under the heading of 'dysarthria'. months without any associated or subsequent Dysphonia affects girls rather more frequently abnormality of speech. When clutter occurs after than boys, or at any rate is complained of more the age of 5 it is more often associated with stammer frequently by the parents of girls. It may occur at or hesitation (Van Riper, 1947). any age and has been observed in a child of 6 months, Involuntary temporary arrest of the flow of speech but more commonly it begins between the ages of 2 may be manifest as hesitation, a transient inability and 8 years.
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