Features of differential diagnosis of speech disordersmaterial on speech therapy
Features of differential diagnosis of speech disorders
Diagnostics is an activity aimed at making a diagnosis.
“Developmental diagnosis,” as L. S. Vygotsky presented it, is an integral concept that includes an assessment of the level of development of different body systems (both psychological and physiological), considered in their systemic interaction.
The basic principles for diagnosing abnormal development were laid down in the works of L. S. Vygotsky: an integrated approach; the principle of a holistic systemic study of the child; principle of dynamic learning; the principle of qualitative analysis of data obtained in the process of psychological diagnostics.
Diagnosis is the first and most important stage of the process of providing speech therapy assistance.
When starting to diagnose a child’s speech development, a teacher can use one of the previously presented classifications of speech disorders. These classifications are based on the causes, mechanisms, and structure of each of the possible speech disorders.
The difficulty of diagnosis comes from differentiating not only the dysantogynosis itself, but also the symptoms within the disorder, and limiting similar conditions of abnormal development of various origins from each other, since many syndromes have a number of similar symptoms. Knowledge of the structure of the disorder allows us to identify primary and secondary disorders. The conclusion of differential diagnosis makes it possible to predict the paths of further development and training and means of correctional and developmental work.
And so, in order to perform a differential diagnosis, the teacher needs to understand the causes, mechanisms, leading symptoms, structures of each disorder, similarities and differences.
Let's take a closer look at the similarities and differences of the most common speech disorders.
Alalia is the absence or underdevelopment of speech due to organic damage to the speech areas of the cerebral cortex in the prenatal or early period of a child’s development.
Alalia is characterized by the fact that it manifests itself in the absence of speech or its extremely small volume in children during the period of ontogenesis when it should appear.
The systemic nature of alalia means that it affects not just one, but almost all aspects of speech - phonetic-phonemic, lexical-grammatical, and syntactic. This follows from the systemic structure of the speech function itself and the systemic relationship of its parts.
The fact that alalia is determined by the pathology of the central nervous system in the pre-speech period indicates that alalia is a consequence of some early pathological influences on the child’s brain.
With alalia, in the structure of a speech defect, speech underdevelopment is primary, and cognitive impairment is secondary.
Impressive speech is relatively preserved and may be close to normal; severe impairment of expressive speech. Polymorphic disturbances in sound pronunciation, confusion, and substitution are characteristic. Difficulties in choosing a phoneme in the process of word realization. The phonemic aspect of speech, the grammatical structure of speech, and coherent speech are grossly impaired. The sound-syllable structure of the word is grossly violated. A large gap between the level of passive and active vocabulary; variability of verbal paraphasias, word searches.
Usually alaliks are inactive, less often impulsive or balanced. They are not critical of their speech impediments. They are distinguished by clumsiness and clumsiness of movements, incoordination. The motor skills of the fingers are grossly impaired, small precise actions are difficult to perform. In the cognitive sphere, inertia of thinking, a small amount of memory, perception disorders, and instability of attention are revealed. Children are whiny, suffer from frequent mood swings, sleep and appetite disturbances.
Alalia is fundamentally different from other types of speech disorders in children - dysarthria, speech disorders due to deafness and hearing loss, mental retardation, autism.
What distinguishes alalia from intellectual impairment is that in intellectual impairment, the primary impairment is cognitive activity, and speech impairment is secondary. The causes are considered to be harmful effects on the central nervous system during pregnancy; the influence of various factors that led at an early age to cerebrasthenic and asthenic conditions of the body. In children with mental retardation, the intellectual defect affects all types of mental activity and, first of all, verbal and logical thinking. Understanding speech is difficult. Impressive speech is grossly impaired and lags significantly behind the norm, both in terms of the volume of the passive vocabulary and in distinguishing grammatical forms. Frequent use of diffuse words, no word search.
What distinguishes alalia from mental retardation is that in alaliks, as speech develops and under the influence of special training, the intellectual retardation gradually disappears. Unlike the mentally retarded, they demonstrate reasonable behavior: they adequately navigate their surroundings, in everyday life, understand everyday speech and gestures, correctly carry out tasks that are feasible and accessible to them, and simple tasks.
The main difference between mental retardation and alalia is that it is a lag in the development of mental processes and immaturity of the emotional-volitional sphere in children, which can potentially be overcome with the help of specially organized training and upbringing. Mental retardation is characterized by an insufficient level of development of motor skills, speech, attention, memory, thinking, regulation and self-regulation of behavior, primitiveness and instability of emotions, and poor school performance.
What distinguishes delayed speech development from alalia is that the causes can be not only congenital or acquired disorders in the body’s functioning or unfavorable psychological conditions of the child’s life: pathologies of intrauterine development; birth injuries; mental disorders; physical injuries; hearing loss; brain diseases; underdevelopment of the muscles of the mouth and face, but the reason may be little communication between adults and the child. Speech understanding with delayed speech development is usually intact. All aspects of speech development are impaired.
Children with mental retardation development have a developed motive for activity, no speech negativism, and no structural disorders. In children with speech delay, the development of fine motor skills lags behind the norm.
In contrast to alalia, with mental retardation, speech is often spontaneous, without special training, children fully master the language and can study in a public school.
If a child’s understanding of spoken speech is impaired, the question often arises of differentiating sensory alalia from hearing loss.
Unlike alaliks, in children with hearing loss, increasing the volume of spoken speech improves its understanding. Children with hearing loss exhibit behavioral characteristics in the form of increased mental exhaustion, emotional excitability, and motor disinhibition. The function of active attention is reduced, the impressive vocabulary is insufficient. But they actively use nonverbal means of communication. Facial expressions and plasticity change when reacting to an impression; a reaction to pronounced affective states is noted. A good reaction is observed to iconic stimuli. The most informative thing is that children try to peer into the face of the speaker. Objective research is difficult, but it is noted that the development of the psyche proceeds with deviations from the norm, and all components of the language system are impaired. Children must be examined by an otolaryngologist and audiologist. Speech impairment in these cases is diagnosed as absence of speech due to hearing impairment. People who are hard of hearing cannot pick up words and phrases from their surroundings. The voice of such children lacks sonority and may be muffled, dull, metallic, wooden, or creaky. Speech is insufficiently intonated and lacks emotional expressiveness.
With this diagnosis, speech does not appear outside of special training; prosody is impaired; there is no accompaniment of facial-gestural speech with words and non-verbal vocalizations.
Alalia has similar external manifestations to autism spectrum disorder (ASD).
In autism, speech can develop normally in the very early stages, and the child sometimes even outpaces his healthy peers in terms of the pace of its development. Then, usually before the age of 30 months, speech is lost: the child stops speaking to others, although sometimes he can talk to himself or in his sleep. In early childhood autism, there is often a lack of babbling and poor development of imitation function. Autistic children rarely have full speech. In older preschool age, they usually speak poorly outside their usual environment, they exhibit persistent agrammatism, and they almost never use the personal pronoun “I” and the affirmative word “yes.” Children with this disorder do not respond to addressed speech, are non-communicative, there is no speech initiative, there is no need for communication, their facial expressions and gestures are quite developed and are used instead of verbal speech. There are disturbances in the motor sphere, both in general and fine motor skills: rotation of the hands, shaking of the arms, swaying of the body. Children become afraid to look into a person's face when communicating with him. Anxiety, fear and aggression may increase.
Factors that can lead to the development of autism in children have not yet been clarified. These include: genetic predispositions, disorders of the development of the nervous system (autism is considered as a disease caused by disorders of brain development in the early stages of a child’s growth), the influence of external factors: infections, chemical effects on the mother’s body during pregnancy, birth injuries, congenital metabolic disorders substances, the influence of certain medications, industrial toxins.
When diagnosing speech disorders, knowledge of the similarities and differences between alalia and dysarthria is required. The differential diagnosis between dysarthria and alalia is based on the absence of primary disorders of language operations.
In children with alalia, the motor level of speech production is completely or relatively preserved and potentially allows them to carry out an articulatory act. In children with dysarthria, a violation of the articulatory component of speech is the essence of their pathology. With alalia, the entire language system is upset; with dysarthria, only one of its subsystems, phonetic, is upset (this does not exclude the possibility that some of these children may also have alalia at the same time). In alalia, disorders of the pronunciation of sounds are the result of a violation of the production of phonemic operations - the selection and combination of units. In children with dysarthria, sound pronunciation disorders are caused primarily by disturbances in phonetic (motor) operations.
With alalia, many sounds that are subject to violations (distortions, substitutions, omissions, repetitions and rearrangements) simultaneously have correct pronunciation; with dysarthria, only single sounds have the correct pronunciation at the same time. With alalia, different types of disturbances in the pronunciation of sounds predominate; with dysarthria, the same type of disturbances predominate. With alalia, distortions of a small number of sounds are observed, with erased dysarthria, distortions of sounds predominate.
With alalia, the pace of mastering speech is slow, and with dysarthria, the pace of mastering the semantic side of speech is not impaired. Impressive speech with alalia also has disturbances, which are manifested in a violation of the understanding of the meanings expressed by the morphological elements of words; it is difficult to understand words that are similar in sound composition. With dysarthria, impressive speech does not have pronounced impairments.
Despite their differences from each other, both of these disorders have similarities in the manifestation of accompanying defects - general underdevelopment of speech, impaired phonemic hearing, and distortion of sounds.
In speech therapy, dysarthria is one of the three most common forms of oral speech disorders, second only to dyslalia in frequency and ahead of alalia.
The greatest difficulty in making a differential diagnosis is the distinction between erased pseudobulbar dysarthria and dyslalia.
It should be remembered that Dysarthria is a disorder of the pronunciation organization of speech associated with damage to the central part of the speech motor analyzer and a violation of the innervation of the muscles of the articulatory apparatus. The structure of the defect in dysarthria includes violations of speech motor skills, sound pronunciation, speech breathing, voice and prosodic aspects of speech; with severe lesions, anarthria occurs. With dysarthria, the presence of paresis, various changes in muscle tone are noted, sometimes unexpressed hyperkinesis in the facial muscles is detected, and pathological reflexes can be detected.
Unlike dysarthria, dyslalia does not involve damage to the central nervous system. Children with dyslalia do not exhibit any significant focal neurological microsymptoms. With dyslalia, disturbances in the motor sphere are not detected, the detectable reflexes are uniform, and there are no pathological reflexes. Children with dyslalia have no breathing problems; diaphragmatic speech breathing corresponds to the norm, whereas with dysarthria, diaphragmatic speech breathing is unformed. Dyslalia is characterized by the absence of impairment of non-speech motor skills, so children are active, mobile, and easily learn hygienic skills. With dysarthria, multiple motor disorders occur, as a result of which such children are slow, inactive and inactive, switching from one type of activity to another is accompanied by significant difficulties.
From the side of speech manifestations, it should be noted that the main difference between dyslalia and dysarthria is that with dyslalia only sound pronunciation is impaired, while with dysarthria the spectrum of damage is wider and covers the entire phonetic side of speech.
In children with dyslalia, the characteristics of the voice remain unchanged; the voice is loud, with complex modulations; the speech activity of such children, as a rule, is even increased, while criticism remains of their own speech defect. With dyslalia, mental disorders are quite rare. And also the nature of sound pronunciation disorders is more diverse, so several types can occur - distortions, substitutions, and omissions.
Stuttering differs from dysarthria in other manifestations: disturbance of the rhythm of speech (snatches of words, phrases, repetition of syllables, stretching of certain sounds); difficulties and hesitations at the beginning of speech; attempts to cope with stuttering with the help of side movements (grimaces, tics). Stuttering is convulsive movements of the articulatory and laryngeal muscles, occurring more often at the beginning of speech (less often in the middle), as a result of which the patient is forced to linger on any sound (group of sounds).
The causes of stuttering include: increased tone and periodically occurring convulsive readiness of the motor endings of the speech centers of the brain; consequences of acute and chronic stress in childhood; genetic predisposition (some types of stuttering are inherited); consequences of perinatal damage to the central nervous system; tendency to have a convulsive reaction; various brain injuries; injuries, consequences of infectious and endocrine diseases; disruption of normal speech development in children (early speech development and delayed psychomotor development); children can imitate a person who stutters, but after a while they will develop a stable defect; when trying to retrain left-handedness in childhood; lack of affection, love, and understanding in a child. Stuttering in children can occur as a result of strict upbringing and increased demands on the child.
Breathing during stuttering is irregular, shallow, thoracic or clavicular; Discoordination of breathing and articulation is noted: children begin to speak while inhaling or after a full exhalation. The speech of children with stuttering is often accompanied by involuntary accompanying movements: twitching of the facial muscles, flaring of the wings of the nose, blinking, swaying of the body, etc. Quite often, people who stutter use motor and speech tricks aimed at hiding stuttering (smiling, yawning, coughing, etc.). Difficulties in speech communication cause logophobia in children who stutter. Due to the desire to hide the defect from others, unclear articulation occurs, and consonants become heavier, and vowels seem to be “squeezed” through teeth. The dome practically ceases to be used as a resonator cavity, and in general speech creates the impression of “porridge in the mouth.” In the speech of people who stutter, as a rule, a low voice with a chest sound, as well as a middle voice with a well-developed head and chest sound, are not sufficiently represented. In children who stutter, essentially all characteristics of the musicality of speech are impaired.
For all child development disorders, differentiating criteria are required that will help distinguish between variants of speech development disorders. Which in turn will lead to an accurate diagnosis and determine the correct direction, content and organization of correctional work with children.
Many outstanding speech pathologists contributed to the development of speech therapy in Russia in the second half of the 20th century. Prominent representatives among them were scientists who were involved in the development of differential diagnostic methods: R.E. Levina, T.B. Filicheva, G.V. Chirkina, O.E. Gribova, R.I. Lalaeva, G.A. Volkova and others. Let's consider some of them.
Gribova O. E. identifies 5 stages of speech therapy examination:
Stage 1. Approximate stage. Its tasks are: collection of anamnestic data; clarifying the parents' request; identification of preliminary data about the individual characteristics of the child. At this stage, medical and pedagogical documentation is studied; studying the child’s work (drawings; creative crafts); conversation with parents (parental complaints about the child’s speech, parents filling out a questionnaire; recommendations for parents).
Stage 2. The diagnostic stage is a direct examination of the child’s speech. This clarifies the following points: the formation of linguistic means at the time of the examination. In addition, the teacher must determine in what types of speech activity the deficiencies are manifested, what reasons influenced the manifestation of the speech defect.
The selection of didactic material is individual and will depend on: the age of the child; on the level of speech development; on the level of mental development of the child; depending on the child’s level of learning.
The examination takes place in the following areas: the state of coherent speech; state of vocabulary; the state of the grammatical structure of speech; state of sound pronunciation; examination of the syllable structure of a word; state of the articulatory apparatus; phonemic awareness examination.
Stage 3. The analytical stage, the task of which is to interpret the received data and fill out the speech card, which is a mandatory reporting document for the speech therapist, regardless of his place of work.
The speech card must contain sections: passport part, including the age of the child at the time of the examination; anamnestic data; data on the child’s physical and mental health; section devoted to the characteristics of speech; speech therapy report. The conclusion must indicate the structure of the defect, i.e. which aspects of the child’s language and speech systems turned out to be unformed. It is further indicated whether, in the opinion of the speech therapist, the primary or secondary disorder is speech defects, and, if possible, the clinical basis of the speech deficiency (medical diagnosis) is determined.
Stage 4. Prognostic. At this stage, based on the results of an examination of the preschooler by a speech therapist, a prognosis for the child’s further development is determined, the main directions of correctional work with him, and an individual work plan is drawn up.
This stage is very important during a speech therapy examination. Identification of primary and secondary factors in the structure of a defect makes it possible to organize correctional and developmental training that is adequate to the child’s capabilities with the goal of his most complete socialization. Often during the examination of a child, certain doubts arise about the validity of a particular conclusion. Therefore, it is possible for a speech therapist to decide to re-examine the child’s speech after a certain period of training, in order to identify the dynamics of his development and determine future prospects.
Stage 5. Informing parents is a delicate and difficult stage of examining a child. It is carried out in the form of a conversation with parents in the absence of the child.
The sequence of conducting a survey using this methodology is based on general principles and approaches: the principle of an individual and differentiated approach; the examination is carried out in the direction from general to specific; the material is given from complex to simple; from productive types of speech activity - to receptive ones.; First, examine the volume and nature of the use of linguistic and speech units, and only if there are difficulties in their use, proceed to identifying the features of their use in the passive. During the examination, methods such as a pedagogical experiment, conversation with the child, observation of the child, and play are used.
According to G.A. Volkova, before starting an examination of a child’s speech, it is necessary to find out his development in the early stages of ontogenesis, using anamnesis data, since the examination of a child is considered in the context of the social situation of development, the hierarchy of activities, taking into account the psychophysical characteristics of children, the patterns of ontogenesis in in general. During an individual examination, it is important to identify behavioral characteristics and those main deviations or speech disorders that will justify a speech therapy conclusion.
The examination of the anamnesis should take place in several stages.
1. Prenatal period: during a conversation with the mother or both parents, some hereditary factors are clarified: the health status of the parents before the birth of the child, the presence of neuropsychiatric disorders, speech pathology, the age of the mother, diseases of the mother during pregnancy, unfavorable factors in the intrauterine development of the child.
2. Natal period: birth of a child prematurely, at 8 months; duration of labor; the use of pharmacological agents to stimulate labor; birth of a child with asphyxia; weight less than 1500 g; presence of injuries; Rh factor.
3. Postnatal period: after what time was the first feeding; deviations in the baby’s behavior; illness during the first month; illnesses in the first year of life; illness from 1 year to 3 years; injuries; insufficient speech and intellectual contacts with the child; bilingualism.
After a thorough examination of the child's medical history, they begin to examine the child.
At the first stage, non-speech functions are studied: the study of sociability, the study of psychomotor skills, the study of gnosis, the study of optical-spatial praxis, the study of dynamic praxis, the study of thinking.
In the second stage, they move on to the study of impressive speech: understanding coherent speech; understanding sentences/carrying out instructions; understanding different grammatical forms; understanding of constructions with different case forms; differentiation of singular and plural nouns and understanding of other grammatical norms.
At the third stage, the study of phonemic analysis, synthesis and phonemic representations occurs. The ability to isolate a sound against the background of a word is determined; extract a sound from a word; determine the place of a sound in a word; determine the number of sounds in a word; differentiate sounds by contrast. The ability to form words from sequentially given sounds is determined; the ability to form words from sounds given in a broken sequence; come up with a word for a certain sound.
At the fourth stage, the study of expressive speech occurs: the structure and mobility of the articulatory apparatus; state of sound pronunciation; study of the vocabulary of the language; examination of the grammatical structure of speech.
At the fifth stage, the state of written speech is examined.
In the speech therapy report, it is recommended to take into account: the mechanism of the speech disorder, the form of the speech disorder, and the symptoms of the disorder.
R.I. Lalaeva, when developing a method of differential diagnosis, was based on a psycho-linguistic approach. The scientific and theoretical prerequisites for the methodology are modern psycholinguistic ideas about the structure of speech activity. Thus, in accordance with the psycholinguistic approach, when researching using this methodology, it is not an isolated utterance, a text as finished products of speech production, that is analyzed, but these processes themselves.
The technique is designed to study the process of producing speech utterances in children 6-10 years old with speech pathology of various origins, having both relatively intact intelligence and intellectual disability. This technique allows you to more accurately diagnose the nature of primary and secondary speech underdevelopment in children.
This research methodology involves studying in children “deep” syntactic structures, various semantic relations characterizing the structure of an utterance (predicativity, “subject-object” relations, location, etc.), as well as the possibility and nature of the transition to “surface” syntactic structures.
Taking into account brief data on the multi-level structure of the process of producing speech utterances, a methodology for studying speech disorders in children with speech pathologies of various origins was developed. It includes the following sections: study of internal programming of coherent speech utterances, study of internal programming of individual speech utterances, study of lexical operations and grammatical structuring, study of sensorimotor operations for generating speech utterances, study of language analysis and synthesis.
The study of internal programming of coherent speech utterances occurs in two stages: 1. Study of dialogic speech; 2. Study of monologue connected speech;
The material for studying the internal programming of individual speech utterances are plot pictures that make it possible to structure various types of utterances: the child’s inventing a sentence; selection of proposals for the scheme; under the picture, chips are laid out according to the number of words in the sentence, the child is asked to come up with a sentence based on the picture, which would have the same number of words as chips.
The study of lexical operations and grammatical structuring includes the study of lexical operations, the study of word formation, the study of inflection, and the study of syntactic structure of sentences.
The sequence of studying sensorimotor operations of generating speech utterances: 1. Study of the sensory-perceptual level of speech perception (imitation of syllables); 2. Study of articulatory motility; 3. Study of motor implementation in external speech (study of the state of sound pronunciation, sound-syllable structure of the word).
The study of language analysis and synthesis passes through the analysis of sentences into words, syllabic analysis and synthesis, phonemic analysis, synthesis and representations.
In drawing conclusions, I would like to note that in the differential diagnosis of speech disorders in children, the organization of an integrated approach is of great importance. Having complete and reliable information about the child’s development, it is possible to differentiate between one or another speech disorder, which in turn makes it possible to reduce the possibility of diagnostic error and determine the optimal educational route for the child’s development.
Differential signs of clinical forms of dysarthria
Bulbar dysarthria
Characterized by flaccid paralysis of the muscles of the pharynx, larynx, soft palate, tongue, lips, cheeks. Atony and atrophy of these muscles. The tongue is sluggish, flabby. Dysphagia or aphagia. Choking and coughing while eating and drinking. Dysphonia or aphonia. The voice is weak, dull, exhausted, nasal. Indistinct, blurry articulation. Speech is slow and monotonous. Involuntary and voluntary muscle movements are impaired. The pharyngeal and mandibular reflexes are reduced.
Pseudobulbar dysarthria
Spastic paralysis of the muscles of the speech apparatus is characteristic. Hypertension of these muscles. The tongue is tense and pushed back. The voice is dull, nasal (like closed nasality), hoarse, hoarse. Articulation of sounds is difficult. When the patient tries to overcome articulation disorders under the control of hearing, muscle hypertension increases and pronunciation defects, nasal sound, and not saying the end of words become even more pronounced. The rate of speech slows down. Voluntary movements are disrupted, including the most subtle movements of the tongue, but involuntary movements may persist. The pharyngeal and mandibular reflexes are strengthened. There are reflexes of oral automatism. Violent laughter or crying is common.
Extrapyramidal dysarthria
Characterized by a disorder of muscle synergies and muscle tone with the appearance of hypo- and hyperkinesis (they can weaken or disappear when performing voluntary movements). Speech is tense and unfluent. The pace of speech either speeds up or slows down. Sudden or gradually developing stops in speech production, stereotypy and perseveration of individual sounds, syllables, and words may be observed. The pitch and timbre of the voice changes: it can be weak, dull or with fluctuating sonority. Articulation can be either slurred or intelligible against the background of pronounced speech prosody disorders.
Cerebellar dysarthria
Static and dynamic ataxia of speech movements of the hyper- and hypometria type is characteristic. In speech, this is manifested by difficulty, slowness and jerkiness, lack of correct modulation of the voice, uniform, but independent of the meaning, accentuation of speech, i.e. scantiness.
Cortical dysarthria
Characteristic are motor speech disorders caused by apraxic disorders of the kinetic and kinesthetic type. Accordingly, cortical premotor and cortical postcentral dysarthria are distinguished. We can talk about this pathology only if the patient fully understands spoken speech, there are no impairments in writing or understanding written speech, and there is no agrammatism.
Mesencephalic-diencephalic dysarthria
Characterized by a decrease in speech activity, from transient to complete akinetic mutism. Speech becomes more and more laconic, less and less intelligible and articulate. At the same time, there are no disorders in the state of the direct motor mechanisms of speech. Articulation and voice disorders disappear with emotional stimulation and the patient’s increased attention to his speech. Other types of dysarthria cannot be overcome with emotional stimulation.
Various forms of dysarthria can be combined with each other. Bulbar and pseudobulbar dysarthria are especially often combined.
