Dysarthria in Children | Symptoms, Causes & Treatments - ASLPclick

DYSARTHRIA  In  CHILDREN

•  Dysarthria is a Motor Speech disorder in which the muscles that are used to produce speech are damaged, paralyzed or weakened.

The person with Dysarthria can not control tongue or voice box    and may slur words 

• Common causes of Dysarthria include – Nervous system disorders & conditions that cause Facial Paralysis & Tongue or Throat Muscle weakness.

•  Difficult or unclear articulation of speech that is otherwise linguistically normal.
•  Dysarthria is a speech disorder caused by muscle weakness. People may have trouble understanding what you say.

Speech-language pathologist or SLPs can help. 

Dysarthria: Speech that is characteristically slurred, slow, and difficult to understand. A person with Dysarthria may also have problems controlling the pitch, loudness, rhythm, and voice qualities of his or her speech. Dysarthria is caused by Paralysis, Weakness, or Inability to Coordinate the Muscles of the Mouth. Dysarthria can occur as a Developmental Disability. It may be a sign of a Neuromuscular disorder such as Cerebral Palsy or Parkinson's disease. It may also be caused by a Stroke, Brain injury, or Brain tumor. Treatment of dysarthria includes intensive Speech Therapy with a focus on Oral-Motor Skill Development.

Ø Types of Dysarthria –

> Spastic

> Flaccid

> Ataxic

> Hyperkinetic

> Hypokinetic

> Mixed

1.      Spastic Dysarthria

-         Harsh vocal quality

-         Reduced Stress

-         Monopitch

Bilateral damage to the pyramidal & extrapyramidal systems.

Common causes include – Stroke, ALS, Traumatic Head Injury & MS

2.     Flaccid Dysarthria

-         Hypernasality

-         Breathy Voice

-         Imprecise Consonants

Damage to the Lower Motor Neurons used in speech.

Common causes include – Physical Trauma, Brainstem Stroke, Myasthenia Gravis & Polio

3.     Ataxic Dysarthria

-         Regular articulatory breakdown

-         Imprecise consonant production

Damage to the Cerebellum or the Cerebellar control circuits.

Common causes include – Degenerative disease, Stroke, Toxic conduction, Traumatic head injury

4.     Hyperkinetic Dysarthria

-         Depending on associated movement disorder

-         Typically involuntary movements

It may cases, damage to the Basal Ganglia; however some disorders have no known causes.

Common causes include – Chorea, myoclonus, Ties, Essential tremor & Dystonia  

5.     Hypokinetic Dysarthria

-         Tremor

-         Muscular rigidity

-         Akinesia

-         Postal reflex disturbances

Damage to Basal Ganglia.

Common causes include – Parkinson’s disease, Neuroleptic-induced Parkinsonism, Traumatic head injury & Stroke

Ø Aphasia   v/s   Dysarthria –

Language Disorder

Aphasia                               Understanding-Expansion Problem

                                                          No Muscle Weakness

 

 

 

                                                          Speech Disorder

Dysarthria                              Muscular Weakness

                                                          Language Not Affected

Ø Causes of Dysarthria –

 

1.     Developmental Causes

-         Cerebral Palsy

-         Down Syndrome

 

2.    Acquired Causes

-         Brain injury

-         Tumor

-         Stroke

-         Infection Diseases

-         Atrophy

-         Toxic/Metabolism Diseases

Dysarthria occurs when damage to the nervous system weakens the muscles that produce speech sounds. It may affect the muscles in one or more of the following areas:

• Face
• Lips
• Tongue
• Throat
• Upper Respiratory Tract

The neurological damage that causes dysarthria can occur due to:

• Neurological conditions, such as Epilepsy, Amyotrophic Lateral Sclerosis (ALS), and Parkinson’s Disease
• Brain Tumors
• Trauma from injuries to the head or neck, as well as repeated blunt force impacts to the skull
• Inflammatory conditions, such as autoimmune diseases, encephalitis, and meningitis
• Vascular conditions, such as stroke or Moya-Moya disease
• Exposure to toxic substances, such as alcohol, heavy metals, or carbon monoxide

Ø Sign & Symptoms of Dysarthria –

According to the American Speech-Language-Hearing Association, dysarthria can affect one or more of the following five systems that speech involves:

• Respiration: Respiration moves air across the vocal cords, creating sounds that the mouth and nose shape into words.

• Phonation: This system uses airflow from the lungs plus vocal cord vibrations to produce speech sounds.

• Resonance: Resonance refers to the quality of speech sounds that the vocal tract produces.

• Articulation: This term means shaping sounds into recognizable words, which involves forming precise and accurate vowels and consonants.

• Prosody: The rhythm and intonation of speech that give words and phrases their meaning.

The five speech systems work together, meaning that impairment in one system can affect the others.

People who have dysarthria may experience one or more of the following symptoms:

• Abnormally quiet or loud speaking voice
• Monotonous tone
• Rough, scratchy, or hoarse voice
• Stuffy or nasal-sounding voice
• Vocal tremors
• Speech that is too fast or too slow
• Distorted consonant and vowel sounds

As conditions that cause dysarthria also affect the nerves that control muscles, people with dysarthria may experience physical symptoms, such as:

• Tremors or involuntary movements of the jaw, tongue, or lip
• Overly sensitive or under-sensitive gag reflex
• Muscle wasting
• Weakness

Ø Screening of Dysarthria –

Screening for dysarthria is pass/fail. It does not provide a diagnosis, or a detailed description of the severity and characteristics of speech deficits associated with dysarthria but, rather, identifies the need for further assessment.

Screening may result in recommendations for

• dysarthria assessment and/or
• referral for other examinations or services.

Ø Dysarthria Assessment –

Assessment of individuals with suspected dysarthria should be conducted by an SLP using both standardized and non-standardized measures.

The goal of the dysarthria assessment is to

• Describe perceptual characteristics of the individual's speech and relevant physiologic findings.
• Describe speech subsystems affected (i.e., articulation, phonation, respiration, resonance, and prosody) and the severity of impairment for each.
• Identify other systems and processes that may be affected (e.g., swallowing, language, cognition); and
• Assess the impact of the dysarthria on speech intelligibility and naturalness, communicative efficiency and effectiveness, and participation.

 

The severity of the disorder does not necessarily determine the degree of disability. Speech-related disability will depend on the communication needs of the individual and the comprehensibility of his or her speech in salient contexts.

Consistent with the World Health Organization's (WHO) International Classification of Functioning, Disability, and Health (ICF) framework (ASHA, 2016b; WHO, 2001), the assessment identifies and describes

• Impairments in Body Structure & Function, including underlying strengths and weaknesses in speech production and verbal/nonverbal communication.
• The individual's Limitations in Activity & Participation, including functional status in communication, interpersonal interactions, self-care, and learning.
• Contextual (Environmental & Personal) Factors that serve as barriers to, or facilitators of, successful communication and life participation; and
• The impact of communication impairments on Quality of Life and functional limitations relative to the individual's premorbid social roles and abilities and the impact on his or her community.

Ø Typical Components of The Dysarthria Assessment

The assessment process includes consideration of the individual's hearing and vision status. This may include hearing screening, inspection of hearing aids, and provision of an amplification device, if needed. If the individual wears corrective lenses, these should be worn during the assessment.

The assessment section below is not prescriptive—it outlines the components of a very thorough exam. Some components may not be applicable in all clinical settings.

 

1.     Case History

• Medical diagnosis and history
• Onset and course of symptoms
• Associated deficits (e.g., language, cognitive-communication, and swallowing, problems)
• Medical procedures, hospitalizations, prior treatments and their outcomes
• Other medical and rehabilitation specialty referrals and interventions and their outcomes
• Medications and potential side effects/symptoms
• Review of auditory, visual, motor, cognitive, language, and emotional status (if not included as part of the assessment)
• Education, vocation, and cultural and linguistic backgrounds
• Patient and family report
• Awareness, observations, and perspectives
• Person-specific communication needs
• Impact of the presenting problem on activities and participation
• Identification of facilitators of and barriers to communication
• Extent to which the level of effort for speaking changes in different contexts (e.g., when fatigued, at different times of day, relative to medication schedule)
• Adaptability in different communication contexts (e.g., in noisy environments, with distractions, with multiple communication partners, with unfamiliar listeners) 

2.    Nonspeech Examination

• Assessment of speed, strength, range, accuracy, coordination, and steadiness of nonspeech movements and assessment of the speech subsystems using objective measures, as available. The following are typically included:
• Completion of a cranial nerve exam (CN V, VII, IX, X, XI, XII)—to assess facial, oral, velopharyngeal, and laryngeal function and symmetry
• Observation of facial and neck muscle tone—at rest and during nonspeech activities
• Assessment of sustained vowel prolongation—to determine if there is adequate pulmonary support and sufficient laryngeal valving for phonation
• Assessment of alternating motion rates (AMRs) and sequential motion rates (SMRs) or diadochokinetic rates—to judge speed and regularity of jaw, lip, and tongue movement and, to a lesser extent, articulatory precision

3.    Speech Production

• Vocal quality and ability to change loudness and pitch—to assess laryngeal/phonatory function.
• Stress testing—2 to 4 minutes of reading or speaking aloud to assess deterioration over time (can use spontaneous conversation, reading text aloud, or counting)
• Motor speech planning or programming—repetition of simple and complex multisyllabic words and sentences to determine if apraxia of speech (AOS) is present.

Prosody—use of variations in pitch, loudness, and duration to convey emotion, emphasis, and linguistic information (e.g., meaning, sentence type, syntactic boundaries); speech naturalness reflects prosodic adequacy

• Recommendations for speech sampling include the following:
• Use connected speech (reading and spontaneous speech) to observe variations in pitch, loudness, and duration.
• Use targeted prosodic tasks, including asking and answering questions; contrastive stress tasks; and reading statements using prosodic variation to express different emotions.

Speech Intelligibility—the degree to which the listener (familiar/unfamiliar) understands the individual's speech; typically reported as a percentage of words correctly identified by a listener

• Recommendations for speech sampling include the following:
• Use material unknown to the listener and with low semantic predictability.
• Include words that provide a sampling of most of the phonemes.
• Tasks include single-word production and sentence production (recorded and later transcribed by a judge).

Comprehensibility—the degree to which the listener understands the spoken message, given other information or cues (e.g., topic, semantic context, gestures) to enhance communication; typically reported as percentage of words correctly identified by a listener

• Materials and tasks are similar to those used to assess speech intelligibility.
• Various cues (e.g., auditory, visual, contextual) are provided to the listener.
• The speaker's use of comprehensibility strategies or the potential to adopt these strategies can also be assessed during these tasks.

Efficiency—the rate at which intelligible or comprehensible speech is communicated; typically reported as the number of intelligible or comprehensible words per minute

• Sentence-level materials and tasks are similar to those used to assess speech intelligibility and comprehensibility.
• Sentences are transcribed by a judge, and the number of correct words per minute are computed.

Other components of the assessment may include a review of the following, which may lead to further, in-depth assessment of these areas:

• Language—assess receptive and expressive language skills in oral and written modalities to help distinguish between dysarthria and aphasia.
• Cognitive-Communication—identify aspects of verbal or nonverbal communication that may be affected by disruptions in cognition (e.g., attention, memory, organization, executive function).
• Swallowing—assess swallowing function.

Assessment May Result in The Following Outcomes:

• Diagnosis of dysarthria and classification of dysarthria type.
• Clinical description of the dominant auditory-perceptual speech characteristics and the severity of the disorder.
• Presence of co-morbid conditions, including apraxia of speech, aphasia, cognitive-communication disorder, or swallowing disorder.
• Statement of prognosis and recommendations for intervention that relate to overall communication adequacy.
• Development of an intervention or management plan (in collaboration with patient, family, and rehabilitation team), including (a) prosthetic or surgical management or (b) augmentative and alternative communication (AAC), as appropriate.
• Identification of relevant follow-up services, including support for individuals with dysarthria.
• Referral to other professionals as needed (e.g., neurologist, psychologist).

Ø Treatment of Dysarthria –

v Treatment Approaches

Treatment can be restorative (i.e., aimed at improving or restoring impaired function) and/or compensatory (i.e., aimed at compensating for deficits not amenable to retraining).

·        Restorative approaches focus on improving

·         Speech intelligibility,

·         Prosody and naturalness, and

·         Efficiency.

·        Compensatory approaches focus on

·         Improving comprehensibility by

o    increasing the speaker's use of communication strategies,

o    improving listener skills and capacity, and

o    altering the communication environment

·         Increasing effective use of AAC options; and

·         Increasing use of non-AAC devices

Ø Treatments That Target Speech-Production Subsystems

·       Respiration

• Making postural adjustments (e.g., sitting upright to improve breath support for speech)
• Inhaling deeply before onset of speech utterance (known as preparatory inhalation)
• Using optimal breath groups when speaking (i.e., for each breath, speak only the number of syllables that can be comfortably produced)
• Using expiratory muscle strength training to improve strength of the expiratory muscles (the individual blows into a pressure threshold device with enough effort to overcome a preset threshold)
• Using inspiratory muscle strength training to improve strength of the inspiratory muscles to permit better sustained or repeated inspirations (the individual uses a handheld device that is set to require a minimum inspiratory pressure for inspiration to continue)
• Using maximum vowel prolongation tasks to improve duration and loudness of speech
• Using controlled exhalation tasks (air is exhaled slowly over time) to improve control of exhalation for speech
• Using nonspeech tasks to improve subglottal air pressure and respiratory support (e.g., blowing into a water glass manometer)

·         Phonation

• Lee Silverman Voice Treatment
• Pitch Limiting Voice Treatment
• Effort closure techniques to increase adductory forces of vocal folds (e.g., pulling upward on chair seat; squeezing palms of hands together)
• Improved timing of phonation (e.g., initiating phonation at beginning of expiration) 

·         Articulation

• Phonetic placement techniques (e.g., hands-on, descriptive, pictures) to work on positioning of the mouth, tongue, lips, or jaw during speech.
• Phonetic derivation techniques (nonspeech to speech tasks such as "blowing" to /u/).
• Exaggerated articulation (over-articulation) to emphasize phonetic placement and increase precision, sometimes called "clear speech."
• Minimal contrasts to emphasize sound contrasts necessary to differentiate one phoneme from another.
• Intelligibility drills in which the individual reads words, phrases, or sentences and attempts to repair content not understood by the listener.
• Rate modification to facilitate articulatory precision—strategies include
• pausing at natural linguistic boundaries (e.g., using printed script marked at natural pauses);
• using external pacing methods such as pacing boards, hand/finger tapping, and alphabet boards;
• using auditory feedback (e.g., delayed auditory feedback or metronome);
• using visual feedback (e.g., using computerized voice programs); and
• using approaches that reduce speech rate without directly targeting it (e.g., increasing loudness, altering pitch variation, altering phrasing or breath patterns). 

·         Resonance

• Prosthetic management in collaboration with other disciplines (e.g., dentists, prosthodontists)—examples include
• palatal lift prosthesis and
• nasal obturator to occlude nasal airflow.
• Resistance training during speech using continuous positive air pressure.

·         Prosody

• Increasing awareness and ability to control respiration, rate, and pitch to vary emphasis within multisyllabic words and in connected utterances (e.g., using scripts, marked and unmarked passages)
• Improving intonation by signaling stress with loudness, pitch, or duration
• Extending breath groups to better align with syntactic boundaries
• Using contrastive stress tasks to improve prosody and naturalness (e.g., repeating sentence with stress on different word[s])

Other Treatment Options

Ø Communication Strategies

A variety of communication strategies can be used by the individual with dysarthria (speaker) and his or her communication partner to enhance communication when speech intelligibility or efficiency is reduced. These strategies can be used before, during, or after other treatment approaches are implemented to improve or compensate for speech deficits (see, e.g., Duffy, 2013).

Speaker Strategies include

• maintaining eye contact with the communication partner;
• preparing the communication partner by gaining his or her attention and introducing the topic of conversation before speaking;
• pointing and gesturing to help convey meaning;
• looking for signs that the communication partner has or has not understood the message; and
• effectively using conversational repair strategies (e.g., restating message in different words; using gestures to help clarify message).

Ø Communication-partner Strategies include

• maintaining eye contact with the speaker;
• being an active listener and making every effort to understand the speaker's message;
• asking for clarification by asking specific questions;
• providing feedback and encouragement; and
• optimizing the ability to hear the speaker and to see the speaker's visual communication cues (e.g., by wearing prescribed hearing aids and glasses during conversations).

Ø Environmental Modification

Environmental modification involves identifying optimal parameters to enhance comprehensibility.

These parameters include

• reducing background noise (e.g., choose a quiet setting for conversations; turn off TV, radio, and fans);
• ensuring that the environment has good lighting
• improving proximity between the speaker and his or her communication partner; and
• using face-to-face seating for conversations.

Augmentative and Alternative Communication (AAC)

AAC involves supplementing or replacing natural speech and/or writing.

The two forms of AAC are

• unaided (e.g., manual signs, gestures, and finger spelling) and
• aided (e.g., line drawings, pictures, communication boards, tangible objects, speech-generating devices).

Other augmentative supports include voice amplifiers, artificial phonation devices (e.g., electrolarynx devices and intraoral devices), and oral prosthetics to reduce hypernasality.

Ø Medical/Surgical Intervention

SLPs may refer the individual to a medical specialist to assess the appropriateness of, or need for, medical interventions.

These interventions can include, for example,

• pharyngeal augmentation, pharyngeal flap, or palatal flap to treat velopharyngeal incompetency and improve resonance
• laryngeal (vocal fold) augmentation (e.g., autologous fat or collagen), laryngoplasty, or recurrent laryngeal nerve sectioning to improve phonation; and
• pharmacological management to relieve symptoms of the underlying neurologic condition (e.g., spasticity, tremor) associated with underlying neurologic disease.