Developmental language disorders: Organization and

Developmental language disorders: Organization and management in

Belgium

Prof.dr.PhilippeF.Paquier Dr.StefanieKeulenUniversité LibredeBruxelles(ULB) Université LibredeBruxelles(ULB)VrijeUniversiteitBrussel(VUB) VrijeUniversiteitBrussel(VUB)UniversiteitAntwerpen(UA)

DNPS Annual MeetingHindsgavl Slot

3-4 November 2017

DEVELOPMENTAL LANGUAGE DISORDERS

Speech vs. LanguageSpeech• Themotorexecutionoforallanguagecommunication(theactof

speaking).• Speechisproducedthroughcomplexandcoordinatedrespiratory,

laryngeal,velopharyngeal,andarticulatorymovements(Sharp&Hillenbrand,2008):– Respirationprovidestheairpressuretoinitiatesoundproduction

throughvocalfoldvibrationatthelarynx;– Airflowandlaryngealsoundsaredirectednasallyororallybythe

velopharynx;– Articulators(e.g.,tongue,lips,teeth,jaw)shapelaryngealsoundsand

airflowtocreatevowelsandconsonants(phonemes).• Speechproductionencompassestheareasofvoice,fluency,and

intelligibility(articulation+resonance).


Language• Asociallyagreedon,rule-governedsystemofsymbolsthatisusedto

representideasabouttheworld(Sharp&Hillenbrand,2008).• Languageincludesthefollowinglinguisticcomponents:

– Phonology:theabilitytoanalyzewordsintoseparatewordsounds(phonemes)andtoassemblephonemestoformwords.

– Semantics:theknowledgeofwordmeaning.– Morphology:thecapacitytochangewordsbymeansofinflections,

conjugations,andderivations.– Syntax:rulesthatgovernwordorderinasentence.– Pragmatics:theuseoflanguageasasocialtool,andthecapacityto

dealwithlanguageinitssituationalcontext,includingtheinteractionsbetweenthespeaker’sandtheinterlocutor’sknowledgeandbeliefs(e.g.,theirinferredintents).

Speech vs. Language


Speech disorder vs. Language disorder

• Animpairmentofoneorseveralofthebasicspeechproductionmechanismsiscalledaspeech disorder.

• Animpairmentofoneorseveraloftheaforementionedlinguisticcomponents(phonology,semantics,morphology,syntax,pragmatics)iscalledalanguage disorder.


Factors influencing the acquisition of speech and language

• Speechandlanguageacquisition:anaturalandself-evidentprocess?

Yes,ontheconditionthat(a)thechildpossessestherequiredphysicalandintellectualabilities,and(b)his/herenvironmentissufficientlystimulating.

Learningbyimitatingiscruciallyinvolvedinthisprocess(roleofmirrorneurons?).



• Mirrorneuron:aspecifictypeofvisuo-motorneuronthatdischargesbothwhenamonkeyexecutesamotoractandwhenitobservesasimilarmotoractperformedbyanotherindividual.

• Inasense,amirrorneuronreflectsanotherprimate’sbehavior,andisequallyactiveasifexecutingitselfthesamemotoract.

• Inhumans,themirrorneuronsystemhasbeenidentifiedinpremotorandparietalcortices.

• In2010,mirrorneuronswerealsoreportedinthehumanhippocampus.

Giacomo Rizzolatti



• Mirrorneuronsplayakeyroleinperceiving,understanding,andinterpretingothers’actions,andinlearningnewskillsbyimitation.

• Mirrorneuronsarethoughttoplayaroleintheanticipationofactionoutcomesinothersandintheapprehensionofothers’intentions(theoryofmind),intheabilitytoenterintoothers’emotionalfeelings(empathy),andintheacquisitionoflanguage–morespecifically,theemergenceandfurtherdevelopmentoflanguageproduction(speech).



Languageacquisitionprocess=processofinteractionbetweenthechildandhis/hersocialenvironment,determinedby:

– Thechild’shealthandtemperament;– Materialcircumstances(e.g.,housingconditions,familycomposition);

– Thegeneralsocialandemotionalfamilyconditions.



• Medicalfactors

• Cognitivefactors

• Psychosocialfactors



Medicalfactors:

• Hearing• Morphologyofthespeechapparatus• Motilityofthespeechapparatus• Neurologicaland/orpsychiatricstate



Cognitivefactors:

• Globallearningability• Languagesensitivity(“talentforlanguages”)



Psychosocial factors:

• Stimulating familyand schoolenvironment(parent-childinteraction;homelanguage and schoollanguage)

• Housingconditions,familycompositionandconditions• Emotional and behavioral development


Classification of pediatric speech and language disorders

Childhoodspeechandlanguagedisorderscanbeclassifiedinto:

ü Developmental speechandlanguagedisorders

• specific (orprimary):noevident,detectablecause.• non-specific (orsecondary):resultingfroma

demonstrable,unfavorablefactor.

ü Acquired (neurological)speechandlanguagedisorders



DevelopmentalspeechandlanguagedisordersAdisorderofspeechproductionand/orlinguisticfunctionsresultingfromademonstratedorassumedpathologicalconditionalreadypresentbeforetheemergenceoflanguage.

Acquired(neurological)speechandlanguagedisordersAspeechand/orlanguagedisordercausedbyalesionthatissustainedafteronsetoflanguageacquisition,andthatdisruptsalreadydevelopedspeech/languageskills.Thepathologicalprocesswhichcompromisesthefunctioningofspeechand/orlanguageissustainedafteraperiodoflanguagedevelopment.



Primary (specific) Secondary (non-specific)

Speech • Verbal dyspraxia (childhood apraxiaofspeech)

• Developmental stuttering• Dyslalia (incorrectplacing ofphono-

articulatory organs)

Language







• Congenital /acquired dysarthria• Congenital /acquired apraxia ofspeech• Acquired stuttering• Articulation defects(speechapparatus

anomalies)

Language








anomalies)

Language • Dysphasia (SLI)








anomalies)

Language • Dysphasia (SLI) • Congenital /acquired aphasia• Other developmental language

disordersdue to identified causes:• Chromosomal anomalies• Neurodevelopmental disorders• Precarious physical condition• Detrimental environment• Hearing loss• …



ExamplesofsecondaryS/Ldisorders(resultingfromademonstrable,unfavorablefactor):

Pre-,peri- orearlypostnatalbraindamage(cf.congenitaldysarthria).

Jansen A, Andermann E. J Med Genet 2005: 42: 369-378.© 2005 by BMJ Publishing Group Ltd




Pre-,peri- orearlypostnatalbraindamage(cf.congenitalaphasia).

Pizzamiglio MR et al.Neurocase 2004: 10: 308-315.




Chromosomalanomaliesassociatedwithneurologicaldeficits.

Down Syndrome




Neurodevelopmentaldisorders.

J Commun Disord 2000: 33: 227-240.




Neurodevelopmentaldisorders,suchasautismandADHD.




Extremelyillphysicalcondition(anemia,metabolicdisorders).

In: Murdoch BE (ed.), Acquired neurological speech/languagedisorders in childhood. London: Taylor & Francis: 1990; 199-

215.

J Speech Lang Hear Res 2011: 54: 487-519.




Detrimentalenvironmentalfactors(deprivation,abuseandneglect,adversefamilyorsocialbackground).

Dev Med Child Neurol 1992: 34: 943-948.




Morphologyandmotilityanomaliesofthespeechapparatus.

Palatoschisis




Morphologyandmotilityanomaliesofthespeechapparatus.

Am J Speech Lang Pathol 2000: 9: 202-213.

Beckwith-Wiedemann Syndrome




Hearingloss.Auditoryprocessingdisorder.



Primary(specific)S/Ldisorders



• Delayedlanguagedevelopment:Thechild’slanguagesystemdoesnotmatchhis/herchronologicalage,butisconsistentwiththatofayoungerchild.

• Deviantlanguagedevelopment(specificS/Ldisorders):Thechild’slanguagesystemshowscharacteristicsthatdonotmatchanyphaseofnormallanguageacquisition.



Primary(specific)S/Ldisorders

Anomaliesinspeechand/orlanguageacquisitionanddevelopment,intheabsenceofanevident,detectablecause(i.e.,unfavorablefactorscannotbedemonstrated).

Ageneticpredispositiontopoorlanguageperformancemightbeinvolved.




Speech

Language





Language





• Developmental stuttering

Language







Language
















Classification of pediatric speech and language disorders: dysphasia

Dysphasia (synonyms:developmentalaphasia;SpecificLanguageImpairment[SLI])referstoabnormallanguageperformancethatdoesnotmatchanyexpectedagenorms,andhasnevershownanarrestatnoradeclinefromanearlierleveloflanguagefunctioning.

Thedisorderthathindersthenormaldevelopmentoflanguagefunctionsisnotadequatelyaccountedforby:- Intellectualdisability- Motororsensorydefects(e.g.deafness)- Frankneurologicalproblems- Severeemotionaland/orbehavioraldisturbances- Majorenvironmentaland/orlanguagedeprivation



“Theterminologyusedtorefertosuchchildrenhasvariedoverthepastfewdecades:‘developmentalaphasia’and‘developmentaldysphasia’(…)Moreneutraldiagnostictermswithfewermedicalovertones,suchas‘developmentallanguagedisorder’or‘specificlanguageimpairment’(SLI)arenowusuallypreferred.”(Bishop,1994).

Phil Trans R Soc Lond B 1994: 346: 105-111.



Prevalence

Morley (1972) 3-yr-old7-yr-old

± 10-20 %± 1.5-3 %

Silva (1980)

Beitchman et al. (1986)

3-yr-old

< 6-yr-old

± 8%

± 3-10%

• Dysphasiaisnotadelayedbutadeviant developmentoflanguage.• Isdifficulttodifferentiatefromadelayedlanguagedevelopmentata

youngerage.• Latetalkingtoddlers–whoerroneouslyreceivedadiagnosisofdysphasia

atayoungerage– naturallycatchupwiththeirpeersatalaterage(delayedlanguagedevelopment).



In: F. Plum (Ed.), Language, communication, and the brain. New York: Raven Press, 1988; pp. 57-75.

Updates:Rapin I.JChildPsychol Psychiat 1996:37:643-655.Rapin I.&DunnM.BrainDev2003:25:166-172.Rapin I.etal.DevNeuropsychol 2009:34:66-84.









Semanticpragmaticsubtype:• E.g.,autismspectrumdisorder(ASD),Aspergersyndrome,

Williamssyndrome,hydrocephalus+/- spinabifida(cocktailpartysyndrome),non-verballearningdisorder(+hyperlexia),…Ø butremember:primary vs.secondary S/Ldisorders!

• Fluent,verboseandscripted,grammaticallycomplexlanguage,butwithpoorsensitivitytothecommunicativesituation.

• Difficultyunderstandingironyandempathy.• Difficultycomprehendinginferentialmeaning.• PragmaticdeficitsmildinSLI,universalandoftenblatantin

ASD.


Classification of pediatric speech and language disorders: verbal dyspraxia


Verbaldyspraxia(synonyms:developmentalapraxiaofspeech;childhoodapraxiaofspeech) isaneurologicallybasedspeechdisorderthatcanbeunderstoodasadeficitinplanningandregulatingmotoractionsofvoluntaryandcomplexsequentialspeechmovements,intheabsenceofdysarthria,mentalretardation,hearingloss,receptivelanguageimpairments,andorofacialmalformation.Itsdefiningcharacteristicsare:unintelligiblespeechduetoalargenumberofconsonanterrors(especiallysubstitutionsandomissions),inconsistencyofspeecherrors,articulatoryabnormalitieslikegropingbehavior,andabnormalprosody.

Nijland L. Developmental apraxia of speech: deficits in phonetic planning and motor programming. Catholic UniversityNijmegen, PhD dissertation, 2003.



• Characterizedbydeficitsintimingandsequencingthemovementsrequiredforspeechproduction.

PhD dissertation, KU Nijmegen, 2003.


§ EarlyvisualprocessingÞ recognitionofthepicture;

§ Accessingthesemanticrepresentation(ormeaning);

Hillis AE, Course N° 2DS.008, American Academy of Neurology, 53rd Annual Meeting, 2001.

Structural Representation

Semantics

Auditory Word Form

Motor Planning

Articulation

« horse »





§ Accessingthephonological(orauditory)formoftheword;

§ Programmingthearticulatorymovements(lips,tongue,jaw,palate,etc)andtheirsequence;

§ Articulatingthewordbyimplementingtheplannedmovements.



Semantics

Auditory Word Form

Motor Planning

Articulation

« horse »










Semantics

Auditory Word Form

Motor Planning

Articulation

« horse »



Þ Apraxia of Speech








Semantics

Auditory Word Form

Motor Planning

Articulation

« horse »



Þ Dysarthria


Classification of pediatric speech and language disorders: dysphasia = SLI

“Specificlanguageimpairment (SLI)isdiagnosedwhenfornoobviousreasonachildfailstodevelopnormallanguagebuthasadequatenonverbalintelligence,physicalability,andhearing.”(Bishop&Adams,1992).



• Dysphasiaistypicallydefinedasadevelopmentallanguagedisorderthatisassociatedwithnoknownsensory,neurological,intellectual,oremotionaldeficits.

• Verbaldyspraxiaisaneurologicallybasedspeechdisorder(…)intheabsenceofdysarthria,mentalretardation,hearingloss,receptivelanguageimpairments,andorofacialmalformation.


Dysphasia (SLI): No (known) neurological disorder?





Electrical StatusEpilepticusduring slowSleep(ESES)Continuous Spikesand Wavesduring slowSleep(CSWS)



Epilepsia 2009:50(Suppl.7):21-24.



Epilepsy &Behavior 2010:19:550-558.

“Wesuggestaspectrumorcontinuumofnocturnalepileptiform activityandlanguageimpairmentthatrangesfromSLIatoneendtoLKSandESESatthemostaffectedend”.



Pediat Neurol 1994: 10: 20-26.

Pediat Neurol 1999: 21: 745-748.



Normal controls: Left-sided IFG > Right-sided IFG and Right-sided cerebellar lobule VIIIA > Left-sided cerebellar lobule VIIIA.

SLI subjects: opposite pattern = larger Right-sided IFG and Left-sided VIIIA → reversed asymmetry.


Verbal dyspraxia: No (known) neurological disorder?



• KEfamily,largethree-generationpedigree.

• Halfofthemembersareaffectedbyaseverespeech/languagedisorder.

• Transmittedasanautosomaldominantmonogenictrait.

• Responsiblegene(FOXP2)onlongarmofchromosome7(7q31).

Brain 2002: 125: 465-478.



Childhoodapraxiaofspeechisararemotorspeechdisorderthataffectstheproduction,sequencing,andtimingofsounds,syllables,andwords.Itisdistinctfromotherspeech(e.g.,stuttering)andlanguage(e.g.,SLI)disorders.

Theneedforamultidisciplinarydiagnosticandtherapeuticapproach:

• Medicalfactors:hearing;morphologyandmotilityofthespeechapparatus;neurologicaland/orpsychiatricstate.

• Cognitivefactors:globallearningability;languagesensitivity(“talentforlanguages”).

• Psychosocialfactors:stimulating familyand schoolenvironment(parent-child interaction;homelanguage and schoollanguage);housingconditions,familycompositionandconditions;emotional and behavioraldevelopment.

Management of pediatric speech and language disorders in Belgium


Referraltohealthandsocialcarestakeholdersvia:Management of pediatric speech and language disorders in Belgium


Parents >>

school;schooladvisoryservicesGP

School > schooladvisoryservicesGP;schooladvisoryservices >

>multidisciplinarydiagnostic center(pediatric)rehabilitationcenter

Multidisciplinarydiagnosticcenter;(pediatric)rehabilitationcenter

> multidisciplinaryteamintramuros

Healthandsocialcarestakeholdersinvolvedinthediagnosticwork-up(firstlineormultidisciplinaryteam):

• GP/schooldoctor(schooladvisoryservices)• ENT/audiologist• Childneurologist• Childpsychiatrist• Speech/languagepathologist• Neurolinguist /clinicallinguist(Netherlands)• Child(neuro)psychologist• Remedialeducationalist/orthopedagogist• Socialworker



Healthcarestakeholdersentitledtorefertorefundable*speech/languagetherapy:

• GP• ENTspecialist• Pediatrician• (Child)neurologist• (Child)psychiatrist

* Bythenationalhealthinsurance.



Healthandsocialcarestakeholdersinvolvedinthe(multidisciplinary)speech/languagerehabilitation:

• Speech/languagepathologist• Neurolinguist /clinicallinguist(Netherlands)• Child(neuro)psychologist• Remedialeducationalist/orthopedagogist• Remedialteacher



Organizationofspeech/languagerehabilitationforschool-agedchildren(typesrefertospecificspecialneeds):

• Regulareducation+remedialteaching(e.g.,type9:ASDwithoutintellectualdisability)

• Regulareducation+rehabilitationcenter(e.g.,mildformsofSLIorACA)• Specialneedseducation(9differenttypes,ofwhich7might(partially)

pertaintospeech/languageimpairments):– Types1&2:mildorseverementaldeficiency;– Type3:severeemotionalandbehavioraldisorderswithoutintellectualdisability;– Type5:protractedhospitalization,preventorium;– Type7:severehearingloss/severespeech/languagedisorderswithoutintellectual

disability;– Type8:severelearningdisabilitywithouthearingdeficitorintellectualdisability;– Type9(seeabove).



Concluding vignette: current research into verbal dyspraxia (VD) at VUB


• Investigation into feedbackdeficitsinverbal dypraxia:• DIVA-model(Tourville &Guenther 2011):role ofauditory and kinesthetic feedback• Investigation into intactness ofauditory and kinesthetic feedbackinchildren with VDà

therapeutic measures?

• Researchquestions/aims:• TowhatextentdoesarticulationofchildrenwithVDdeviatefrompeerswithnormal

speechdevelopment?(viarepetitionofaseriesofsyllablescontrolledforcomplexityandlength);

• Doauditory and kinesthetic feedbackmechanismsfunctionnormallyinVDchildren?(doescompensationresemblethatofhealthycontrols?);

• Doesthepresence/absenceofASDimpactonperformance?

• Participants (aged 8-17yrs;Dutch-speaking):• 10children with VDwithoutASD• 10children with VD+ASD• 20healthy controls



• Methods

Protocol3x15minute-run

1st:nofeedbackinterruption2nd:auditory feedbackinterruption3rd:kinesthetic feedbackinterruption

StimuliSeriesofrandomized syllables controlled for internal complexity and sequencecomplexity

Electromagneticarticulography

Ultrasound



Stimuluscode

Syllabletype Sequence type Example Amount

SS Simple Simple /ba-ba-ba-ba-ba-ba/ N=20

SC Simple Complex /fo-de-ro-fo-de-ro/ N=20

CS Complex Simple /kli-kli-kli-kli-kli-kli/ N=20

CC Complex Complex /bri-dre-klau-bri-dre-klau/ N=20

Documents

Developmental language disorders: Organization and