Childhood Motor Speech Disorders

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Childhood Motor Speech Disorders

• Julie M. Liss, Ph.D.
• SHS 567

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Childhood vs. Adult MSD

• How does speech production (and language) develop
  in a physically impaired system?
• Localization is not so neat with kids.
  Classification is difficult
• Consider language, cognition, perception,
  feeding, and speech in kids.
• Many disorders stem from no obvious lesion.

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Where do we see childhood MSD?

• Schools
• hospitals
• private practice

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Our Role

• Diagnose if possible
• Treat, usually as part of a multidisciplinary
  approach
• Aim for maximum level of communication with least
  effort (verbal/vocal )

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Taste of the Controversy

• Speech--feeding relationship
• early intervention efficacy
• oral motor exercises
• drooling therapy
• biofeedback technology
• AAC

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Diagnostic Controversy...

• Does Developmental Apraxia of Speech exist?
• What does it look like?
• Why does it occur?
• Do we treat it differently than other speech
  disorders in childhood?

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What Constitutes Normal

• Before discussing diagnosis of motor speech
  disorders, lets examine normal development...

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Prespeech Assessment

• General Observations
• oral motor control
• gross and fine motor control
• Specific prespeech functions
• articulator assessment
• feeding assessment (nursing, transitional,
  modified adult form)
• vocalization assessment

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Motor Development Milestones

• Neonate (0-10 days)
• physiologic flexion
• reflexes prominent and strong
• prone head slightly to one side pelvis high
• supine head at 45 degrees to side flexor recoil
  of upper and lower extremities hand loosely
  fisted
• sitting no flexor control head lag and flop
  back rounded

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Milestones Continued...

• 1 Month
• decreased flexion throughout
• head lifting begins
• random extremity movements
• reflexes remain prominent and strong
• sitting makes fleeting attempts to control head
• smiles can visually fixate

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Milestones continued...

• 2 Months
• asymmetry prominent
• obligatory ATNR prominent
• decreased hip flexion
• tries to assist in sit but lacks head control
  back still rounded
• more smiles visual tracking begins

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Milestones continued...

• 3-4 Months
• beginning of symmetry
• head maintained in midline and aligned with trunk
  in supported sitting
• visual recognition of parents smiling laughing

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Milestones continued...

• 5-9 Months
• independent sitting and crawling begins
• primitive reflexes diminish and disappear
• trunk lateralization in sitting, standing,
  crawling
• visual interest in small objects stranger
  anxiety
• begins transitional stage of swallow

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Milestones continued...

• 10-18 Months
• trunk stability and refinement of upper extremity
  coordination
• walking with, then without support pinching
  grasp transfers object from hand to hand
• first words and phrases appear
• begins modified adult pattern of eating

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Normal Infant Oral Reflexes Present at Term

• Gag
• phasic bite
• tongue thrust
• rooting
• suckling
• Babinski
• ATNR

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Abnormal Movements and Reflexes not seen in the
Developing Infant

• Jaw thrust
• tonic bite
• lip retraction/pucker
• tongue retraction
• jaw clenching

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Assessment and Classification of MSD in Children

• Sensorimotor Programming
• DAS
• Neuromotor Execution
• UMN Spastic CP
• UMN BG Dyskinetic CP
• UMN CBM Ataxic CP
• UMN meningitis, TBI

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Classification continued...

• LMN
• motor nuclei Moebius syndrome
• axons of cranial or spinal nerves Guillain-Barre
• neuromuscular junction myasthenia gravis
• muscle fibers muscular dystrophy

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DAS

• No known lesion or etiology
• neurologic soft signs language deficits oral or
  other apraxia
• awkward groping movements inconsistent
  articulatory errors syllable sequencing errors
  consonant and vowel distortions, substitutions,
  omissions hypernasality

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The Disagreements

• Etiology and pathology
• Signs, symptoms, or syndrome?
• The symptoms themselves

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UMN Spastic CP

• Hemiplegia paraplegia diplegia quadriplegia
• spastic dysarthria, dysphagia, especially with
  spastic quadriplegia decreased respiratory
  support breathy, strained strangled voice
  monopitch and loudness
• disturbances in cognition, perception, sensation,
  language, hearing, emotions, behavior, feeding
  seizures common

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UMN BG Dyskinetic CP

• Hyperkinetic dysarthria rapid, irregular
  breathing forced voice quality with weak
  intensity large jaw movements with gross tongue
  positioning unstable velum
• motor development slow failure to sit
  dysphagia cognitive deficits

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UMN CBM ataxic CP

• Ataxic dysarthria irregular articulatory
  breakdown errors of voicing inappropriate
  variation of pitch and loudness equal and even
  stress possible
• dyssynergia wide-based gait action tremor,
  hypotonia dysmetria nystagmus

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UMN Meningitis, TBI

• Spastic or mixed dysarthria
• profile varies with etiology

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LMN motor nuclei

• Flaccid dysarthria primarily articulation
  deficits secondary to facial or other paralysis
• in Moebius syndrome congenital bilateral CN VII
  paralysis feeding problems hearing loss
  language delays mental retardation

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LMN axons

• Flaccid dysarthria respiratory, phonatory,
  articulatory, resonance deficits possible speech
  may be severely affected, prohibiting oral
  communication
• Guillain-Barre symmetrical muscle paralysis
  following infection (CN VII, IX, X) dysphagia
  prognosis often good

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LMN neuromuscular junction

• Flaccid dysarthria hypernasality that worsens
  with fatigue
• myasthenia gravis classic symptom is muscle
  weakness after sustained contraction
  hypernasality secondary to CN X involvement
  ptosis dysphagia respiratory deficits

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LMN muscle fibers

• Flaccid dysarthria not common in the MD
  population may be very mild articulatory,
  phonatory, and respiratory deficits until late in
  the disease when alternative forms of
  communication are required
• X-linked inheritance onset between 2-5 years of
  age affects pelvis and trunk before limbs and
  head

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DIAGNOSTIC SUMMARY

• Differential dx difficult and not necessary in
  kids (especially young ones)
• primary goal is to determine best modes of
  communication in short and long term
• think functional--think whole kid

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Video Handling Children with tone problems
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Continua of Sensory Input

• Rhythm slow -- fast
• Pressure firm -- light
• Reps consistent -- intermittent
• nature palm -- finger pads
• area proximal -- distal
• orientation midline -- lateral
• mouth closed -- open
• effects calming -- stimulating