Speech & Language Disorders Explained
There are various types of Speech and Language Disorders. In this article Speech Therapist Mary Pat O’Malley goes through different speech and language problems that you may encounter with your children, and gives advice on how you can help your child with speech therapy.
What is the difference between speech and language?
Before I get into the different kinds of Speech and Language Disorders, let’s refresh the difference between speech and language.
When I say speech, I’m talking about pronunciation- how your child says their words. (Speech can also include how their voice sounds and stuttering but I’m not including them here today)
When I talk about language, I’m talking about what their first words are, their sentences, their grammar, and vocabulary.
A speech problem and a language problem are not the same thing.
Now of course your child can have both a speech and a language problem at the same time but to keep things clear, I’m going to focus on one at a time.
It’s also important to remember that speaking two languages or more doesn’t cause any of these problems or make them worse.
Bilingual Children and Language Development
Often when it comes to speech and language problems, there’s no known cause so it isn’t something that you did that made this happen.
What is a speech disorder?
So what exactly is a speech problem? Having a lisp or saying tar when you mean car. Or speech that sounds slurred or strained. There’s a lot of discussion in speech and language therapy about how to classify the different types of speech sound problems.
There’s no universally agreed upon system yet. I’m sharing with you the one I use to teach speech and language therapists in training. The idea is that any child’s speech sound problem should be able to fit into the system.
Essentially there are 7 possibilities and 1 exception when it comes to children’s speech sound disorders. So let’s get started!
1.Articulation Impairment- in the mouth
This is where your child has trouble producing particular sounds, usually /s/ or /r/. For English speakers this can be a lisp (technically called an inter-dental /s/). Usually /s/ is made with the tip of your tongue up behind your front teeth.
I had a lisp until I was 17 and had no idea I had one until I visited a local speech & language therapist to find out about training to be one!! I couldn’t make a /s/ with my tongue tip behind my front teeth. So I make my /s/ with my tongue tip behind my lower teeth.
My little girl has a lisp too. I think it’s really cute for now! Her permanent front teeth have just come in now and the lisp comes and goes. She’s not aware though so I’m leaving it for now.
For /s/, the air is directed out of the centre of your mouth. Make one and see if you can put your focus on where is your tongue when you do.
Another articulation impairment affecting the /s/ sound is when the air comes out the sides of the tongue- often called a lateral lisp. Both of these sounds are not speech sounds in English which can be another way of working out that your child has an articulation impairment.
An articulation impairment can also affect /r/ so your child might say wed when they mean red. If you ask them to say /r/, they can’t do it. Same applies for the /s/.
A general rule of thumb is that articulation impairments are in the mouth- a problem with the physical articulation of sounds. The meaning of words is generally not affected so it won’t necessarily be harder to understand your child because their meaning will still be clear. (This does depend on how many sounds are affected though and how frequent they are in speech- I know- it’s complicated!!)
Problems with /r/ are a little more complex in that meaning is affected. Wed and red do not mean the same thing. So I tend to think of problems with /r/ as an articulation impairment with phonological consequences. Bear with me- I’ll explain more about phonology in # 2 below!
Speech Therapy for Articulation Impairments
Speech therapy for articulation impairments is basically showing your child how to produce the sound by itself. This involves explaining how to make the sound. Then the sound is combined with a vowel. Either a vowel first followed by the /s/ for example, ee-s. Or the /s/ first followed by the vowel, s-ee. Then the sound in words- either at the beginning (son) or the end (house). Then in phrases and sentences and ultimately in spontaneous speech when it has become automatic.
I got rid of my lisp by saying the prayers at Mass out loud until I could do it without thinking about it!! Some researchers say that your child would need to be at least age 7 and really committed to changing their speech for therapy to work. It’s a lot of drill work and practice so motivation is important.
2.Phonological Delay: in the mind
Big word phonology! ‘What is that?’ you may be wondering. Think of words like telephone, megaphone, microphone, phonics and so on. They all have something to do with sound right? Well, phonology is about the organisation of speech sounds and meaning. It’s about rules.
So for example knowing that in English you can have str at the beginning of words like strawberry but not nd at the start of words. If you do crosswords a lot, you’ll recognise patterns like this and use the knowledge to work out what the answer might be.
Sounds are organised in classes with shared features so we have long sounds like /s/ /z/ /f/ /v/ and short sounds like /t/ /d/ /p//b/. If you say them yourself, you’ll feel the difference.
There are front sounds /t/ /d/ /n/ and back sounds /k/ /g/ and the sound at the end of words like sing.
There are quiet sounds like /p/ and /t/ and loud sounds like /b/ and /d/. To feel this difference, put your hand on your throat and say a long /s/. Then say a long /z/. You should be able to feel a difference with some slight vibration on the /z/.
Children who have a phonological impairment might say deben instead of seven. Or tar when they mean car. Or boon when they mean spoon. If your child has a phonological impairment, this means that they have trouble with learning the rules of their language. (This learning the rules is happening unconsciously).
In a way, it’s a language problem that affects the organising of speech sounds into a system of sound contrasts. The contrast is important because that’s connected to the meaning of words. If you want tea, you need to be able to say tea and not have key come out instead.
There are 2 kinds of phonological impairment
The first one is phonological delay. So for children who speak English as their only language, the ages and stages of speech development are fairly clearly mapped out. When they’re on their journey to speaking like an adult, they make predictable and acceptable errors. (This takes up until about age 5 and possibly up to age 8 for some sounds) For example aminal instead of animal, hopsital instead of hospital.
We expect them to make errors like leaving out the last consonant in a word when they are between 18 and 24 months. In fact in this time period they may be making all of the following errors at the same time:
leaving out one of the consonants where two come together: boon for spoon.
saying tat when they mean cat. Saying tar when they mean car.
saying dit when they mean fish.
saying wed when they mean red.
saying door when they mean tore and
saying gog when they mean dog.
And that’s typical development! No need to correct them. The best thing to do is to repeat the words correctly after them in a natural sounding way. Here is a very quick video I’ve made to show you how to do this.
A phonological delay then is when these kinds of errors don’t go away at the ages you’d expect them to. (There’s a lot of individual variation in early child speech and language development so it’s important to think of the ages and stages in a flexible way). So if your child’s 3 and a half and is still leaving out the consonants at the ends of words. Or they’re 6 and saying sip when they mean ship.
3.Consistent Phonological Disorder
Some errors that children make are not found in typical development. (I’m talking about monolingual English speakers here. It’s slightly different when you speak two or more languages)
Things like leaving out the first sound in a word or the middle sounds in words or using a back sound instead of a front sound. That would be saying kar when they mean tar. This is called a phonological disorder.
There are 2 kinds of phonological disorder:
The first one is a consistent phonological disorder where your child says the word wrong the same way each time. So it’s always kar for tar. There’s still a consistent pattern in the errors. (I’ll get on to the 2nd one in a minute!)
Speech Therapy for Phonological Delay and consistent Phonological Disorder
Speech therapy for phonological delay and consistent phonological disorder focuses on helping children organise their speech sound system and learn the rules.
So it would mean talking about long sounds and short sounds for example. Having your child listen and identify long and short sounds and then producing long and short sounds.
They would play games where they pick a picture from a pile of pictures with word pairs such like sick (long sound at the start) and tick (short sound at the start). The therapist can’t see which picture. Your child says the name of the picture and the therapist points to the one she hears.
The idea is that if your child says tick and the therapist points to tick, but your child meant sick, they realise that they need to use a short sound instead.
4.Inconsistent speech disorder
The other type is an inconsistent phonological disorder. The problem here is with selecting and sequencing speech sounds correctly. It means that your child will say the same target word (the word they’re trying to say) differently each time they say it. So seven might be teben, deben, seben.
You can see how this makes it hard to understand your child because there’s no predictable pattern in their speech. Things change constantly.
Speech therapy for Inconsistent Speech Disorder
The therapy for an inconsistent speech disorder is called. It the core vocabulary approach works like this.
The therapist together with you, your child, and your child’s teacher make a list of 50-70 words that are meaningful to your child and that they’ll have an opportunity to use in day to day interactions.
Words like people’s names, pets’ names, foods, favourite things, words like sorry and please and thank you. Generally, your child attends for 2 thirty minute sessions in a week over the course of 6-8 weeks. The first goal is to get their best production. It doesn’t have to be the same as yours. It just has to be consistent so that they’re always saying a word the same way. That will make it easier to understand them and for them to experience successful communication.
5.Childhood Apraxia of Speech (previously known as Developmental Verbal Dyspraxia or developmental dyspraxia.
This is a difficult speech disorder to explain. The technical description says it’s a difficulty planning and programming movement sequences resulting in errors in speech sound production and prosody.
I know! What would that sound like though?
Well if your child is very hard to understand, has trouble producing many consonant and vowels, has trouble saying long words, and has unusual sounding speech, then they may have childhood apraxia of speech.
It affects 1-2 children per 1000.
There are a range of interventions for children with CAS. Two that I have used are the Nuffield Centre Dyspraxia Programme and the Kaufman Speech to Language Protocol which is a little like Core Vocabulary. One early aim is to get consistent production of your child’s best attempt at the words they’re aiming to say. There’s unpublished case study data on the website to show it works. As for the Nuffield programme, there’s published and unpublished evidence about it.
This means weakness or slowness or poor coordination of speech movements. It can affect your child’s breathing, vocal quality, muscle tone, nasal-sounding speech or, slurred-sounding speech.
It’s not as common as the other types. It’s caused by neurological impairment which could occur during or after birth like cerebral palsy. Intervention for children with childhood dysarthria depends on the type of dysarthria, how severe it is, and on what aspects of speech are involved.
7.A combination of issues
Children’s speech may fit neatly into one category. For example, your child has a lisp or articulation impairment and that’s it. But they may have trouble in other areas too.
So for example, if your child has dysarthria related to cerebral palsy and trouble with the physical production of speech sounds, they may also have a phonological impairment.
While I’ve presented the types separately, it’s not as simple as that in reality. The idea is that SLTs need a system to explain your child’s speech symptoms so they can plan intervention according to their understanding of the type of speech problem it is. So if your child has a lisp, they need articulation intervention. And so on.
There’s another category called speech difference. And this is an important one for families who speak two languages or more. If you’ve read my post on what you need to know about speech development for multilingual families, then you’ll know all about languages interacting and how ultimately with high quality input and opportunities to use all of their languages, the speech of most multilingual children develops without problems.
Language Development in Bilingual Children
What can make it a little more challenging to identify one of the speech problems above is that the languages interact in ways that can produce errors that would be considered a disorder in monolingual English speakers.
For example, leaving out the first sounds in words is unusual in monolingual English speaking children but not unusual for French speaking children. That’s why multilingual children need to be assessed in all of their languages and why SLTs need to find out about the different sounds in the different languages they try to work out if there is a problem or not.
They call this difference vs disorder in the literature.
Accents are NOT speech problems
Lastly, accents are not speech problems. Everyone has an accent whether they think they do or not! The fancy word for it is idiolect and it includes language as well as speech.
So, for example I say I do be talking to her. Or I’m after burning the dinner. These are common for some Irish English speakers and artefacts from the Irish language. It’s also common for Irish English speakers to sound like they’re saying dis, dat, dese, and dose for this, that, these, and those .
If you live in South London, you might say souf for south and it’s dialect not a diagnosis!
In the US, for Tuesday you say toosday. In Ireland we say chewsday! Tomayto, tomato!
Accent is not a speech sound problem. And no accent is better or worse than any other.
Now, if you’re an adult who learned a second language later in life and you feel that your accent is interfering with getting your message across, then a speech and language therapist can help you. It’s important to know though that this an area that is only beginning to emerge in speech and language therapy practice and can be controversial.
Inspired by: Barbara Dodd (2005) Differential diagnosis and treatment of children with speech disorders. London: Whurr. McLeod & Baker (2017) Children’s Speech: An Evidence-Based Approach to Assessment and Intervention. London: Pearson
Next up are language problems and it gets even more complicated!! There is no universally agreed for describing language problems in childhood.
Language delay, language disorder, developmental language disorder, primary language impairment, specific language impairment. What the??!!!
There is a LOT of discussion about this in SLT. So to keep it simple, remember that language has to do with things like vocabulary (knowing and using words), grammar (using the past tense correctly, using plurals, having words in the right order in sentences), being able to find the word you’re looking for when you want to say it (called word retrieval or word finding), giving the right amount of information when answering a question, staying on topic, memory, and so on.
Language can be spoken, written, or signed.
And children can have problems in any of these areas of language. Between 7-16% of five year olds have poor language development and that number can be higher for children in socially-disadvantaged groups.
Children who have poor language ability at age 5 are likely to struggle with language in the long term. There isn’t agreement about how to identify and categorise language problems in children but there are a lot of people working on it to try and make things clearer.
One project which involved 59 experts (including families) from around the world in the field tried to come to some consensus on the topic. They concluded that language disorder was the preferred term to mean children who have severe language problems that interfere with their lives and schooling. And the language problems they have are not likely to resolve spontaneously but will most likely persist over time.
For some children, the language disorder can be associated with another biomedical condition such as Down syndrome or autism. For many children though, their language problems occur without any additional conditions or obvious explanation. For these children, the term Developmental Language Disorder is now the preferred term. It’s not one single condition where everyone is the same.
Here are 4 important conclusions that they came to:
- Many children who limited expressive vocabulary at 18–24 months (also known as Late Talkers) do catch up to their peers without any specialist help. But it’s difficult to accurately predict which children will go on to have problems in the long-term.Risk factors for persistent problems are: children who are late-talkers with poor language comprehension/understanding, poor use of gesture, and/or a family history of language impairment. Even then, predictions of language outcomes are unreliable. They recommend reassessment after 6 months in these cases.
- There are some things that were agreed as signs of atypical development by the panel. For example: if by 1-2 years of age a child wasn’t babbling, responding to speech or sounds or was making few attempts to communicate. In that situation, they recommend referring the child for expert assessment.
- If between the ages of 2 and 3 years, a child was showing any of the following features: very little interaction, not showing an intention to communicate like ask for something or wave bye-bye, had no words, didn’t react to spoken language or regressed in their language development, then the child should be referred for assessment.
- Between 3 & 4 years of age, the following features are signs that a child needs to be assessed: using only two word utterances like mama gone, not understanding simple commands, and close relative can’t understand much of what they say.
Language development is complex
Language development is complex and affected by interactions between your child’s biological make-up, their family, school, community, and social and cultural context. It’s important to remember that in early child language development, there’s a lot of individual variation and especially so for bilingual and multilingual families.
There are three things that are really important to remember about your multilingual child’s language development.
- It’s normal for them to have uneven ability across languages at different points in time. This is because they use their languages for different purposes (reporting on a science experiment, planning a party, explaining the rules of a game) with different people (parents, grandparents, peers, siblings, teachers) in different contexts (home, school, playground, speech and drama club).Some skills are present only in one language and not the other. So if your child’s language development is being tested, all languages need to be tested and a range of settings need to be taken into account.
- The languages interact with each other. So the languages are stored separately but not totally cut off from each other. An obvious example is accent which is simply where your child is applying the intonation rules and speech sound rules from one language when using the other. This can give rise to speech errors that would look like a disorder if you were only thinking with an English language monolingual mindset.Your SLT needs to know about the different features of your different languages so he or she can make sense of errors.
- There’s a lot of individual variation in the research both within carefully selected groups of multilingual children at all ages and stages of development and between groups of multilingual children.This is because of the diverse range of factors affecting multilingual children’s language development from individual styles of learning, motivation, quality and quantity of their exposure to the languages and opportunities to use the languages. So what’s true for a group in the research may not be true for your child.
So what can you do?
If you’re concerned about your child’s speech and language development, then get in touch with your local services for a referral to see a speech and language therapist.
Be certain that if there is a problem, being multilingual is not a cause.
If you’re advised to drop a language, ignore that advice. It’s not best practice and can be considered a form of cultural destruction. If your child needs two languages to operate in their world, they need two languages and any assessment and intervention needs to take that into account.
It’s the together part that’s important because you build their language in the conversations you have about plot structure, font size, character’s feelings, predicting what might happen next and discussion your predictions when you know where the story ended.
Inspired by Bishop, D., Snowling, M., Thompson, P. and Greenhalgh, T. (2016) CATALISE: A multinational and multidisciplinary Delphi consensus study. identifying language impairments in children. PLOS ONE. | DOI:10.1371/journal.pone.0158753 Bishop, D. (2014). Ten questions about terminology for children with unexplained language problems. International Journal of Language and Communication Disorders 49(4): 381-415. Kohnhert, K. (2010) Bilingual children with primary language impairment: issues, evidence and implications for clinical actions. Journal of Communication Disorders 43(6):456-73. McKean, C., Mensah, F., Eadie, P., Bavin, E. Bretherton, L., Cini, E., and Reilly, S. (2015) Levers for Language Growth: Characteristics and Predictors of Language Trajectories between 4 and 7 Years. PLOS ONE. https://doi.org/10.1371/journal.pone.0134251 Reilly, S., Bishop, D., and Tomblin, B. (2014) Terminological debate over language impairment in children: forward movement and sticking points. International Journal of Language and Communication Disorders 49(4): 452-462.
If you would like to read more about Speech and Language Disorders, or other general information about the language development of bilingual kids, see Mary-Pat’s Website, or Facebook Page. You can also find a wealth of resources in our Expert Advice section or Language Resources section on the website.