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Note regarding content: This article is not included here for its content as such. Anyone seeking treatment for the speech disorders mentioned here should seek the counsel of a speech pathologist, medical doctor, or other professional. Anyone doing academic research in the field will want to examine the publications since 1967. It is included because (1) it presumably represented Wendell Johnson's thinking in 1965 (when it was written), and thus can be compared with earlier writing, including his 1930 autobiography Because I Stutter, and (2) was the last thing he wrote -- indeed the piece he was literally writing at the moment he died. In that connection, it is my vague recollection that he had not, in fact, totally completed the entry -- that would make almost too good a story -- but that someone (alas, I cannot now recall who -- if, indeed, this memory is accurate at all) put the finishing touches on it later. -N.J.
1190 SPEECH DISORDERS
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SPEECH DISORDERS. Speech may be said to be disordered, and so to present a problem for the speaker, or his listeners, or both, when listeners pay uneasy attention to the manner of speech, have difficulty making it out, or are distracted from what is said by the way in which it is said. The major personal effects of speech disorders depend on the basic role of speech in human relationships. Insofar as such disorders interfere with ability to relate to others through speech, and so to achieve social and personal adjustment, they affect personality. Some authorities regard certain kinds of speech disorders as symptoms of emotional disturbance or personality maladjustment. Research evidence, however, indicates that while most persons with speech disorders have educational, vocational, social, and personal problems because of their impaired speech and because of their own and other people's reactions to it, as a group they are not significantly different in basic personality from persons without speech disorders.
So few estimates of prevalence of speech disorders in different countries are available that meaningful comparison is impossible. Further, available estimates reflect cultural differences in the value attached to quality of speech, especially in small children. Substantial data indicate that among the Ute, Bannock, and Shoshone Indians of North America, as well as in certain cultures in other parts of the world, lack of fluency in children is uncritically accepted and the problem of stuttering does not occur. On the other hand, in modern Western cultures, the strong trend toward "standard speech," enhanced by radio and television, encourages conformity and so directs attention to unusual or disordered speech. It seems likely that, other things equal, the more value a society attaches to "correct" or "normal" or "good" speech, the larger will be the proportion of its members regarded as having disordered or unsatisfactory speech.
The United States Office of Education has variously estimated that 3% to 4%, or roughly 2,500,000, of school-age children in the United States have speech disorders. For the rest of the population, an extremely conservative figure is 3%, or close to 5,000,000. This gives a national total of roughly 7,500,000 speech-handicapped persons. Office of Education statistics indicate further that speech impairment is the commonest handicap in U.S. school-age children: of the 105 out of every 1,000 that are handicapped in some way, 35 have speech disorders, 23 are mentally retarded, 20 are emotionally disturbed, 10 are physically disabled, 10 have handicapping illnesses, 6 have hearing problems, and 1 is blind or partially seeing.
Speech pathology and audiology have developed as a theoretical and clinical service field in the United States. Clinical work with speech disorders (usually in closer relationship to medicine than it is in the United States) is fostered also in Great Britain, the Scandinavian countries, most of the rest of continental Europe including the U.S.S.R., Japan, South Africa, South America, and such parts of the British Commonwealth as Canada, Australia, and New Zealand. There is promising evidence that as teachers, physicians, and parents learn more about how, for example, stuttering begins, its prevalence is decreasing; and that new modes of treatment of stuttering in its early stages, stressing counseling of parents and teachers, are increasingly effective. There is compelling
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evidence that most children who misarticulate speech sounds can be taught to form the sounds normally; that most voice problems yield to treatment; that most patients who undergo laryngectomy (surgical removal of the "voice box") can learn to speak again; that patients with aphasia recover useful language and speech. Such organic impairments as cerebral palsy, severe hearing loss, and cleft palate, however, even with all possible physical restoration, in some cases set limits to speech improvement. Nevertheless, persons without tongues have learned to speak, and the large numbers of persons with cleft palates who speak normally or nearly so reflect recent advances in surgery, prosthetic and orthodontic dentistry, and speech pathology and audiology.
DESCRIPTION, CAUSE, AND TREATMENT OF SPEECH DISORDERS
Classification Schemes. -- Disorders of speech are commonly classified as follows: (1) disorders of voice; (2) disorders of articulation; (3) stuttering (stammering); (4) aphasia (dysphasia); (5) retarded development of speech or language; and (6) speech disorders associated with hearing loss or deafness, cleft lip and cleft palate, cerebral palsy and other neuromuscular impairments, laryngectomy, facial or oral injury or deficiency, mental retardation, and emotional illness.
There are other classification schemes. Some speech pathologists add a category called cluttering, usually said to be distinguished by rapid rate, indistinct articulation, and some disfluency, but without the tension, anxiety, and blocking reactions that characterize stuttering. The definition and clinical significance of "cluttering" are in process of clarification. A controversial diagnostic category is "congenital" aphasia, referring to a condition said to be due to brain deficiency or to brain damage before, during, or after birth but before development of speech. "Congenital" aphasia is not universally accepted because some insist that there can be no aphasia if there is no developed language function to be lost. The controversy is complicated by the difficulty in most cases of clearly demonstrating brain damage. "Retarded speech or language development" is a more widely accepted diagnostic term.
The Total Speech Problem. -- In presenting, below, descriptions, causes, and treatments of the various speech disorders (see MOUTH; VOICE; and EAR, ANATOMY OF, for anatomical details mentioned), each disorder is considered to be one part of a total speech problem; each such problem has as participants not only the speaker but also his listeners. Some listeners contribute to solving or coping with the problem, others make it worse. Some even help to cause it in the first place, as, for example, in the beginning of stuttering, when the child's hesitations and repetitions appear to his parents to be a problem before they do to the child.
The total speech problem has three aspects: first, the speech characteristic that is regarded as a disorder; second, the listeners' reactions to the speech; and third, the speaker's reactions to the listeners' reactions and to his own speaking behaviour. Listeners' revealed feelings -- and in the case of children the most important listeners often are the parents -- about speech affect the speech, making it more or less hesitant, disfluent, or tense. The speaker's reactions to the listeners' reactions may thus either complicate the disorder or help in the direction of more acceptable speech.
The three aspects of the speech problem may be affected by various factors: the speech characteristic itself may be complicated by such organic conditions as cleft palate, dental malformations, or brain damage, or by such nonorganic factors as poor adult speech models and lack of stimulation and motivation. Listener and speaker reactions may be affected by level of education, intelligence, experience with and understanding of speech disorders, and personal and social adjustment. Listener and speaker reactions of course vary. What one listener hears as severe disfluency, another may regard as moderate and a third as normal for age and circumstance; likewise, the speaker may be unconcerned or moderately or deeply concerned about listener reactions and about the speech characteristic to which they are related.
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Diagnosis and Therapy. -- For any type of speech disorder, diagnosis involves: (1) detailed description of what the speaker does that makes his speech clinically significant; (2) identification of the times, places, listeners, and types of speaking in relation to which he does or does not do these things; and (3) determination of whether physiological or psychological factors are fostering the disorder.
Basic aspects of therapy include: (1) identifying the persons other than the speaker who are most concerned in the problem, counseling them, and enlisting their support; (2) making use of family, school, and community resources; (3) counseling the speaker as his age and maturity warrant; (4) speech retraining by individual or group methods that enable the speaker to hear, see, and feel what he does that interferes with his speech; to listen to the differences between disordered and normal speech patterns; to practice the normal patterns, or his best approximation of them, in drill sessions and increasingly in social situations. Tape recorders, mirrors, sound amplifiers, and other instruments and positive rewards and reinforcements are useful in facilitating the desired learning. In any case of impaired speech associated with physical or psychological factors -- as, for example, misarticulations related to mouth injury, cleft palate, or cerebral palsy, or speech impairment related to emotional illness or loss of hearing -- appropriate medical care or psychological counseling should precede or accompany speech therapy.
Disorders of Voice. -- The voice may be pitched too high or too low; may be too loud or too soft; may be distractingly nasal, hoarse, harsh, or breathy; or may lack expressive variation. The voice may be affected by enlarged tonsils and adenoids, throat infections, the common cold, vocal abuse, growths on the vocal cords, and paralysis. Most voice disorders, however, are associated not with organic pathology but with negative emotional reactions (resentment, hostility, anger, or shame), faulty models for learning speech, shyness and insecurity, or adolescent "change of voice." In speech therapy, ear training may be emphasized for monitoring pitch, loudness, quality, and flexibility. A change of pitch level may be prescribed to reduce tension and increase expressiveness.
Disorders of Articulation. -- About 80% of the children in public-school remedial speech programs in the United States have disorders of articulation. Often these result from faulty learning due to meagre speech stimulation or from inadvertent positive reward by parents through their acceptance of speech with such errors. It is an unresolved question whether many of these children, concentrated in the early grades, would learn to articulate correctly in the normal course of maturation. Practically all articulation errors are omissions of speech sounds (as in pay for play), distortions of sounds (slighting sounds or overarticulating them, as in the "whistling" s or in the "mushed" s that resembles sh), or substitutions of one sound for another (as wun for run or thum for sum). A speaker may misarticulate one or more sounds or sound blends (as st, pl) consistently or inconsistently.
Speech retraining is concerned chiefly with the defective sounds. If the speaker is a child still learning to speak and making the errors common for his age, he may need no speech instruction; the clinician works instead with the parents, teachers, and other listeners to encourage normal maturation of the child's speech.
Stuttering (Stammering). -- Stuttering, like all disorders of speech is not concerned with the speaker alone. The characteristic to which his listeners originally react is disfluency, as seen in repetitions, "uh uh," hesitations, and interruptions common in normal childhood speech and occurring also in normal adult speech. Half or more of all parents do not notice their young children's disfluencies. Most parents who do notice them regard them as normal. Roughly one parent in 100 reacts with serious concern. Sensing this reaction, the child may gradually come to doubt that he can speak well enough to please his parents, and to fear the consequences if he does not. As he tries harder to speak more fluently than he can, he becomes less spontaneous, more hesitant, tense, and uneasy. Straining to do better, he presses his lips together, holds his breath, and performs other actions that interfere with speech. He has more difficulty speaking; his parents become
still more concerned. They try to be helpful by urging him to relax, go slowly, start over; he feels more discouraged and becomes more tense and distressed. And so stuttering develops.
The single question "What causes stuttering?" therefore breaks down into four questions: (1) Why does one parent in a hundred make a serious issue of the child's disfluencies? (2) What causes the disfluencies? (3) How are they complicated by speech-disorganizing reactions? (4) Why does the speaker react negatively to his disfluencies and to his listeners' negative reactions to them -- and to him? With regard to (2), some speech pathologists hold that the disfluencies are caused by organic factors, including heredity, while others view them as symptoms of emotional disturbance, usually involving impaired parent-child relationships; but laboratory and clinical data do not firmly support these hypotheses. Another explanation is that simple disfluencies are part of the normal speech process, varying with such factors as age, language development, momentary excitement, and listener interest; the child learns speech-disruptive behaviour as he tries to keep from stuttering and so to gain approval.
For a young child, treatment is directed mainly to the parents and other listeners important to the child, who are counseled to increase their understanding of the factors, including their own reactions, that affect the child's disfluencies; to help them understand how the problem is compounded by the child's misguided efforts to speak more clearly; to encourage them to make it easy for him to talk to them; and to provide conditions favourable for his spontaneous attempts at speech. Older children and adults are given much the same sort of counseling as key listeners, being treated clinically as both listeners and speakers. They are trained to think about what they do that interferes with speaking rather than about what happens or what it is that prevents the words from coming out. Once the stutterer recognizes what he does that disrupts his speech, he works to increase his awareness of it and to contrast it with his normal speech. Therapy proceeds then toward learning or relearning to talk without exerting the tensions and doing the other things that disrupt speaking.
Retarded Development of Speech or Language. -- Development of speech or language may be retarded in respect to: (1) amount of vocalizing during infancy, (2) age at which first words and sentences are spoken, (3) articulation of speech sounds, (4) length and complexity of speech response, (5) amount of speaking, and (6) vocabulary. A child's speech development is to be compared not with any average (though speech development norms have been presented) but with that of the majority of children and with his own past performance. Generally speaking, a child may be a year behind the majority without being considered retarded. In the United States, for example, where most children have begun to say words at the age of 12 to 15 months, a child would not be judged retarded until he had passed 24 months without doing so. Factors commonly associated with retarded speech development include lack of speech stimulation in the home; inadequate or inconsistent rewards and punishments; isolation and inactivity, as in prolonged illness; impairment of muscles used in speech; damage to the brain, and loss of hearing.
Aphasia (Dysphasia). -- Aphasia, or more appropriately dysphasia, is the impairment of language function due to brain damage. Loss of language function may be slight to total and is likely to be regained as, and in the measure that, the patient recovers from the condition that caused it. Recovery may be hastened or enhanced by speech therapy. Speech retraining is based on remaining functions and life experience with language. A patient relearns best the language concerning things with which he was once familiar and thus in all likelihood will make best progress in familiar surroundings. Objects and pictures are used, the patient repeating their names, pointing to them, then eventually talking about them in phrases and sentences.
Speech Disorders Associated with Other Physical or Mental Disorder or Impairment. -- Impaired Hearing. -- Hearing loss may be slight, moderate, or severe and varies in character. (See DEAFNESS AND IMPAIRED HEARING.) For a person with simple conductive hearing impairment, all voices are muted except his own, which sounds louder to him than it does to his
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listeners. His main or only speech problem lies in speaking loudly enough. Other types of hearing impairment may result in a variety of distortions of hearing: the person may hear his own and others' voices as muted, hear low-pitched sounds better than high-pitched, hear some things and not others. When two kinds of hearing loss occur together the associated speech problem usually reflects the combination. The speech and language difficulties of hard-of-hearing persons therefore may be complex. The afflicted person may have a limited vocabulary or may misarticulate certain sounds; his voice may be unusually loud, monotonous in pitch, and muffled in quality as if the mouth were full. Therapy emphasizes monitoring speech, training in the use of a hearing aid if the patient can benefit from it, practice in the recognition of sounds, training in lip-reading (or speech-reading, as it is more appropriately called), and vocabulary building. Young children with profound hearing impairment tend not to learn speech unless taught by special methods in schools for the deaf (see DEAF AND HARD OF HEARING, TRAINING AND WELFARE OF).
Cleft Lip and Cleft Palate. -- Clefts of the upper lip or the palate (roof of mouth), or both, are formed, for reasons not well understood, when normal growth is disrupted early in fetal life. A cleft may involve only the soft palate or both soft and hard; may extend through the front upper gum ridge; and may involve one or both sides of the upper lip. Cleft lip is usually repaired surgically shortly after birth, and if there is no other cleft no speech problem is likely to develop unless there remains a limitation of lip function that affects articulation of lip sounds. Cleft palate may be closed surgically or by means of an obturator (artificial palate). An obturator must be adapted periodically to the child's growth; surgery should wait until the age at which it will not interfere significantly with growth of the upper jaw and the face. After palatal closure, most children, at least in the United States, require speech training to counteract excessive nasality, misarticulations, inefficient regulation of air pressure within the mouth, and in some cases vocal monotony, low loudness level, indistinctness, and lack of spontaneity. Training to correct faulty jaw and tongue action may be started even before closure has been made.
Cerebral Palsy and Other Neuromuscular Impairments. -- Paralysis (q.v.) impairs speech when it affects muscles used in speaking. Cerebral palsy (q.v.) affects these muscles in about three out of four cases, producing laborious and slow speech, of uneven rhythm, with breathing irregularities, faulty articulation, and monotonous or erratic patterns of voice quality, pitch, and loudness. The speech problem is often only one of several associated with this condition. Treatment of cerebral palsy requires the resources of medicine, special education, physical and occupational therapy, psychology, social work, and speech therapy.
Laryngectomy. -- Laryngectomy, most commonly performed in later life as a means of controlling cancer, leaves the patient without vocal cords. Though he cannot vocalize, usually he can learn esophageal speech, drawing air into his esophagus, producing sound as he expels it, and articulating this sound into spoken words. An "artificial larynx" also may be used (see VOICE: Substitutes for the Larynx).
Facial or Oral Injury or Deficiency. -- Problems of articulation and occasionally of vocal resonance and quality may be associated with high and narrow hard palate, large or sluggish tongue, surgery of the tongue, cancer, and missing or misaligned front teeth. Following dental and medical treatment, speech therapy is indicated.
Mental Retardation. -- Learning difficulties of the mentally retarded extend to learning to speak, misarticulations being the main speech problem. Retraining methods are adapted to specific needs and abilities, with emphasis on simplicity, persistence, patience, and rewards for small gains.
Emotional Illness. -- The chief effects of emotional illness on speaking behaviour are restrictions or disturbances of speech, impairment of voice, and deviant use of language. Often the voice is high pitched, nasal, harsh, and monotonous; or the patient may not speak at all. Treatment usually begins with a psychological evaluation. Speech therapy and psychotherapy may then proceed together, in a relationship that depends on whether the speech
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problem preceded, is independent of, or is basic to the personality problem.
DEVELOPMENT OF SPEECH CORRECTION
Persons with speech disorders, like other handicapped persons, have traditionally known the scorn, ridicule, and even revulsion of their society. Attitudes toward handicaps have changed only slowly, and the change is still going on. Hippocrates (fl. 400 B.C.) was among the first to look at speech disorders scientifically, writing a treatise on the cause of stuttering. Other early scientists who were interested in speech and speech problems included Albertus Magnus, who in the 13th century wrote about voice pitch and articulation, Paracelsus, who in the 16th century referred to speech disturbance after injuries to the head; Hieronymus Mercurialis (Geronimo Mercuriale), who published (1584) on children's speech; and J. C. Ammann, whose Surdus loquens (1692) set down the oral method of training deaf children. By the 19th century a large European medical literature on speech was developing, and concurrently in the New World the work went on through activities of such men as T. H. Gallaudet, who had been schooled in London and Paris. The Spanish singing teacher Manuel Garcia at mid-century developed a method for examining the larynx; the French surgeon-anthropologist Paul Broca in 1861 published his pioneer work relating aphasia to brain lesions; H. Klencke, in Leipzig, was the first formally to suggest (1862) that effective speech correction must deal with the total speech problem; C. L. Merkel's Anthropophonik ("Human Phonetics") in 1876 and Adolf Kussmaul's Die Storungen der Sprache ("The Impediments of Speech") in 1877 stand as classics from which German logopedics grew.
By the early years of the 20th century, with the growth of knowledge about speech, with refinement of clinical techniques in speech correction, and with new appreciation of the human need to communicate, there emerged an interdisciplinary profession which in the United States went by the name of speech pathology and audiology and in Europe was called logopedics and phoniatrics. The contributing professions included medicine, psychology, dentistry, education, speech, psychiatry, engineering, and social welfare. All are represented in the membership of the International Association of Logopedics and Phoniatrics (IALP) and of the American Speech and Hearing Association (ASHA), two of the more inclusive organizations in the field. Both were founded in the 1920s; both are dedicated to support of high professional standards, encouragement of research, and improvement of clinical procedures.
Most countries of Western Europe have some kind of provision for speech correction, but programs and requirements for the training of speech correctionists vary. Much of the program is directed by medical doctors, often in hospital clinics or special schools. As compared with procedures in the United States, the initial evaluation of each case is considerably longer, use of speech stimulation techniques and motivational devices is considerably less.
Great Britain, with a long history of speech correction, officially recognized speech disorders as a handicap by the Education Act, 1944. The College of Speech Therapists, an organizing and examining body, was established in 1945; the first school for children with very severe speech handicaps was opened in 1947.
Japan, with schools for the blind since the 8th century and for the deaf since the 19th, is developing a school-connected program in speech correction with the assistance of therapists and clinicians who are largely self-taught and with the support of a research program.
In the U.S.S.R. speech correction is directed by the Department of Logopedics in the government Institute of Defectology of the Academy of Pedagogical Sciences. Children with speech disorders go to regular schools; each school has at least one logopedist, who works often with other specialists. Therapy may include repetition of sounds, long periods of silence, use of the logopedist's finger or a wire apparatus called a zond to place the tongue properly for a given sound. The child is encouraged to assume much responsibility in overcoming his handicap. ### In the United States, 200 colleges and universities offer degrees in speech pathology and audiology, 25% at the doctoral level. The M.A. degree is required by the American Speech and Hearing Association for membership and for clinical certification of speech correctionists. Many states, as well, set certification requirements. There are about 7,000 active speech correctionists, most of them in public schools, some in community clinics or with special health agencies, some staffing the 320 speech and hearing clinics associated with hospitals, colleges, and universities. About one-fourth of the children who have some kind of speech disorder are receiving special speech training.
BIBLIOGRAPHY. -- Foundations of Speech Pathology, series of 14 volumes (1964); Wendell Johnson, People in Quandaries (1946), Stuttering and What You Can Do About It (1961), Wendell Johnson and associates, The Onset of Stuttering (1959); Wendell Johnson et al., Speech Handicapped School Children, rev. ed. (1956); Wendell Johnson, Frederic L. Darley, and D. C. Spriestersbach, Diagnostic Methods in Speech Pathology (1963), Romaine P. Mackie, Harold M. Williams and Patricia P. Hunter, Statistics of Special Education for Exceptional Children, U.S. Office of Education (1963); Samuel D. Robbins, A Dictionary of Speech Pathology and Therapy (1963); Hildred Schuell et al., Aphasia in Adults (1964); Speech Foundation of America Series: Stuttering and Its Treatment (1960), Stuttering: Its Prevention (1962), Stuttering Words (1963); Lee Travis (ed.), Handbook of Speech Pathology (1957); Charles Van Riper, Speech Correction Principles and Methods, 4th ed. (1963), see also recent issues of these journals: Asha, dsh Abstracts, J. Speech Hearing Dis., J. Speech Hearing Res. (U.S.); Acta Otolaryng. (Stockholm); Folia Phoniat. (Basel); Speech Path. Ther. (London).
(W.A.L.J.)