Speech and Language Difficulties is a term generally applied to children who have difficulty with expressive or receptive language, or both, without having any other disability such as autism or general developmental delay. There are many different profiles in speech and language difficulties, depending on the nature of the underlying causes. Speech dyspraxia is considered separately. There are a number of possible difficulties which go together to form a child’s particular profile and it is helpful to consider them first as separate issues:
A difficulty in discriminating the sounds which make up language, either due to a history of glue ear or other issues which would affect hearing, or as a result of a central auditory processing difficulty. This results in a difficulty with producing the appropriate sound, so for example a child may confuse consonant sounds such as ‘b’ and ‘d’, ‘’j’ and ‘d’ in words, substitute one vowel sound for another or have difficulty with consonant blends.
A difficulty in forming the sounds which make up language as a result of problem with making the movements which produce speech. This usually results in a clear difficulty with producing certain sounds.
A speed of auditory processing difficulty, which means that children cannot process sounds quickly enough. The next sound comes along before they have fully processed the previous one so they have to concentrate really hard to follow what is being said. They may find listening very tiring, and ‘switch off’ quite often.
A difficulty in distinguishing speech sounds from background noise, so that they cannot listen effectively. This is sometimes known as cocktail party effect.
A severe hypersensitivity to sound which causes the child to shut down and become effectively deaf.
A difficulty in learning a verbal label for something in the first place, which would result in delayed speech development, use of substitute words such as ‘thingy’ and ‘whatsit’ and a limited range of vocabulary. These children will also have word finding difficulties.
A sequencing difficulty, which makes it hard for a child to order their words correctly and link them together properly.
A short-term memory problem which prevents a child from remembering phrases and sentences accurately and developing their own complex sentences.
A motor planning difficulty, which results in the child knowing what they want to say, but saying something slightly different because the processing which leads to the motor output – saying what they intend – is disrupted.
A difficulty with semantics, which has to do with understanding the meanings of words, phrases and sentences and using the right words in speech. They may find it hard to process abstract words, time, words expressing emotions, idioms and slang expressions. They may seem to miss the point in conversation and can be very literal in their interpretation. They may be inappropriate in their responses and comments.
A difficulty with pragmatics, which involves being aware of the social context, using language appropriately, taking turns in conversation, picking up on non-verbal cues, using proper eye contact, understanding what the listener may already know and what they may want to hear.
An inability or refusal to speak at all in certain circumstances, for example at school or with strangers. This is known as selective mutism.
Children diagnosed with speech and language difficulties will generally have a number of the above issues. They will often have difficulty with social interaction at the pre-school stage. Once they get to school they may find it hard to acquire literacy skills, the school day may be very tiring for them and friendships may be difficult. It is not unusual for behaviour problems to develop as a result of their frustration and isolation. Some children benefit from a gluten/casein free diet, particularly if they suffer from constipation.
Case Histories
JOSEPH
Presenting problems
Joseph was five years old and had been assessed as having speech and language difficulties, but no one-to-one support had been offered. He had a specific difficulty in understanding and processing auditory information and following complex instructions. He was beginning to get very frustrated and could be quite disruptive in school. There was a history of glue ear and dyslexia in Joseph’s family. He did not suck well as a baby, which could affect his oral motor development and brain integration and he suffered a number of ear infections in his first year. Tests indicated a mild hearing loss. His speech was not clear and he was late putting sentences together. Joseph was over-sensitive emotionally, hypersensitive to touch, and also reacted to bright light and loud noises.
Recent assessment by a speech therapist had identified a number of problems. He had great difficulty with linguistic concepts such as either/or, next to, after, a, when, and could not handle more than three instructions; he had problems with basic concepts such as ‘large’ and different’; he found it hard to process long, complex sentences, and any which included negatives; he found it hard to use appropriate grammar; he had difficulty in forming certain sounds, particularly ‘k’, ‘l’ and ‘ch’; he found it hard to ‘name’ pictures of objects.
Assessment
Joseph cooperated really well with the assessment and tried very hard, but he had problems in every area of visual and auditory processing and brain integration. Hand and eye dominance were not properly established, and balance, muscle tone and differentiation were poorly developed, so he would find it very hard to keep still. On our computerised tests he had great difficulty in every dyslexia-sensitive area except rhyme. Speech and language difficulties and behavioural issues were on the surface, but beneath that was a more generalised neuro-developmental delay. Joseph was a very bright little boy, however, with an average IQ despite his processing difficulties, but he was not ready to sit down in the classroom and apply himself to literacy skills and maths.
Progress
Joseph responded to the programme quite quickly. Within a month his speech was clearer, his drawing had improved, his concentration was much better and he was much less frustrated. Two months into the programme he was much more involved in things, wanting to read books, able to relate what had happened at school and much more loving and helpful. He had learnt to skip and was balancing better on his bike. He was now having speech therapy sessions at school every two to three weeks and could say the ‘k’ sound for the first time. His memory for numbers was better too, and he was beginning to recognise letters of the alphabet. He could hear the sounds better and was starting to blend them together. He had got interested in time, too, and he could now understand ‘tomorrow’, ‘yesterday’, ‘o’clock’ and ‘half-past’. He was coming home with ‘well done’ stickers in his book for the first time.
Six months into the programme Joseph had a speech therapy review which showed an amazing improvement, particularly in short-term memory and phonic ability. He was picking up songs and lyrics very well too. A couple of months later he was starting to really love dancing and singing, something he had never been able to do before, and his rhythm and coordination was very good for his age. He was also asking a lot of questions for the first time. His numeracy was up with everyone else in the class, so he needed no more extra help and his listening skills were much improved. Drawing was much better and his reading was coming on in leaps and bounds. He could still be easily distracted, however.
A review twenty months after the start of the programme showed Joseph to be doing extremely well. He had recently managed the transition to a new school as a result of a family move without trouble, and in fact seemed a lot happier in his new environment. He had already made friends and was seeing the children outside school. He always wanted to do his homework well and was getting full marks on his spellings. His writing had improved hugely. He had been discharged by the speech therapy service after eighteen months on the programme because there appeared to be no more problems.
There seemed to be a few issues with the application of phonics still at school and his new school were investigating whether he still needed any extra help. Reading was coming on nicely, but he needed to work at it. He had become a bit of a perfectionist, and would become frustrated if he did not get things right first time. He was a little slow on picking up on instructions still and needed a little more time than others to process language. There was also still evidence of word finding difficulties and his auditory memory was still below average. In spite of this his verbal IQ had risen by 25 standard points and was now considerably above average, which confirmed our observations that he was a bright little boy. The symptoms he presented at this stage were more in line with a dyslexic profile.
SEBASTIAN
Presenting problems
Sebastian was five when he was assessed and had very little speech. He had been educated in a specialist language unit for the past eighteen months. He had suffered from hearing loss as a young child and had severe glue ear for a prolonged period. Grommets had been inserted and his adenoids removed, but this did not prevent the development of severe speech and language difficulties. There were also significant difficulties with general motor coordination and the fine motor skills needed for colouring and writing and he was physically weak. He found it very hard indeed to pay attention and had great difficulty following instructions. He was very under-confident, needed constant reassurance and when he did speak he spoke so quietly that it was often very difficult to understand him. He found it hard to make friends and tended to be pushed around by other children.
Sebastian had a significant degree of hypersensitivity to sensory stimuli. He used to be very frightened of loud noises and would put his hands over his ears in noisy situations. He also had a marked sensitivity to light and his unwillingness to put his thumb on his pencil indicated a sensitivity to touch. He was also sensitive to odours and would not eat any fruit or vegetables. He had a tendency to constipation and found it very painful to pass stools.
Assessment
Sebastian’s balance was so bad that he was unable to stand on one leg at all. His auditory processing ability was very poor indeed. Audiometric testing indicated that his hearing was impaired, and he had a very slow speed of auditory processing so that he had great difficulty in discriminating fast speech sounds. He had no ability to integrate the information coming through each separate ear and an exceptionally poor, almost non-existent memory for what he had just heard. His auditory processing ability had not developed well enough for him to analyse a stream of language, extract meaning from it and hold that meaning in mind.
Sebastian had almost as much difficulty with his visual processing as he did with his auditory processing, so he could not support weak auditory skills with stronger visual processing. He had very little control over his eye movements, no eye dominance at near-point, a very slow processing speed and little ability to integrate the information from each eye. His visual motor skills were also very delayed.
With very poor auditory, visual and motor processing and little brain integration Sebastian did not have a reliable channel for learning, and it is not surprising that his parents were seeing little progress in spite of the extra attention he was receiving in a specialist school environment. He was also so fearful in any interaction requiring him to respond that any one to one teaching situation tended to be in a climate of extreme fear.
Progress
To begin with, visible progress was slow, which is normal when there are so many issues and such a significant degree of difficulty. He had suffered from constipation and this disappeared after about four months, indicating that the underlying metabolic issues were being addressed. Then visual improvements were noticed - he could follow all the shapes and instructions to make his star wars figures, for example. Then use of language improved in school and he got the concept of 1st, 2nd, 3rd. His speech became slower and clearer, although he would sometimes leave a word out of a sentence. He became more confident in social situations, to the point where there were no issues at all on a one-to-one with adults unless he was put on the spot. He took an interest in football, learned to control a ball and began to love tennis. His running was getting better, less on his toes. His appetite was building, he would try new foods and was eating more vegetables.
A speech and language assessment after eighteen months on the programme indicated that Sebastian was flying. He was now very sociable and aware, and remembered things much better. He was put into the mainstream for literacy, but there were still major issues with maths. After just a month in mainstream literacy classes his use of language was wider and more appropriate and there was much greater depth and roundedness. He could engage in proper conversations and give good descriptions. His reading was very good and he got most of his spellings right.
A few months later Sebastian was continuing to make progress and had become very chatty – making up for lost time! He was in mainstream for everything except maths and he did extremely well in his SATS test, achieving level 2 in all subjects. Numeracy was weak but getting better. All his other subjects were good. He was a lot more observant, his memory skills were much better and his communication was generally more sophisticated. Reasoning, conversation and conceptual thinking had improved. There were no more letter reversals. The only remaining issues were self-esteem and sociability.
Sebastian then moved to a mainstream school and settled very well. He was constructing lovely creative sentences with his spelling words and his memory had taken a leap forward. His reading was excellent, but comprehension not so good. By the end of his first term in his new school his teacher could not see any major issues and he seemed much happier in the busy environment of a normal school.
One year on Sebastian was happily settled and really enjoying school. Self-esteem and sociability were no longer a problem. He had plenty of friends, and although he was not very assertive in the play ground, it did not seem to worry him. He was still very fearful in a testing situation, which made it hard to assess progress in some areas, and there were still issues with expressive language. He was very slow in formulating his thoughts, and kept everything as brief and simple as possible. He had begun to enjoy reading at bedtime, however, and scored four years ahead of his age in a passage reading test, and two and half years ahead in comprehension. Maths was still a bit of a mystery and testing showed that the visual processing systems that underlie maths concepts were still immature. He had just started to become really interested in constructing with Lego, however, which would help to build the visual spatial skills he still lacked.
Sebastian had severe problems when he started the programme, and three and a half years on his systems were not fully mature. There was still work to be done. However, he was now a very happy, normal little boy in a mainstream school with plenty of friends and there was every reason to believe that he would continue to catch up.