Management of Motor Speech

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 Management of

Motor Speech
Disorders
in Children and Adults

Kathryn M. Yorkston

David R. Beukelman

Edythe A. Strand

- - jMw
Mark Hakel
 NLM duplicate

Management of Motor Speech Disorders

in Children and Adults

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Management of Motor Speech
Disorders in Children
and Adults

Third Edition

national institutes of Kathryn M. Yorkston

NIH LIBRARY health
David R. Beukelman
AUG 0 7 2010 EdytheA. Strand

8ETHESOA MnCeWT£R DR
Mark Hakel
tRDA, MD 20892-ii50

8700 Shoal Creek Boulevard

Austin, Texas 78757-6897
800/897-3202 Fax 800/397-7633
www.proedinc.com
 pro-ed
I An International Publisher

© 1988,1999, 2010 by PRO-ED, Inc.

8700 Shoal Creek Boulevard
Austin, Texas 78757-6897
800/897-3202 Fax 800/397-7633
www.proedinc.com

All rights reserved. No part of the material protected by this

copyright notice may be reproduced or used in any form or by
any means, electronic or mechanical, including photocopying,
recording, or by any information storage and retrieval system,
without prior written permission of the copyright owner.

Library of Congress Cataloging-in-Publication Data

Management of motor speech disorders in children and adults / Kathryn M. Yorkston

[et al.].—3rd ed.
p. ; cm.
Includes bibliographical references and index.
ISBN-13: 978-1-4164-0434-7
1. Speech Disorders. I. Yorkston, Kathryn M., 1948-
[DNLM: 1. Dysarthria. 2. Speech Disorders—diagnosis. 3. Speech Therapy.
WL 340.2 M2665 2010]
RC423.M275 2010
616.85'5—dc22
2009005014

Art Director: Jason Crosier

Designer: Vicki DePountis
This book is designed in Minion and Charlotte.

Printed in the United States of America

1 2 3 4 5 6 7 8 9 10 18 17 16 15 14 13 12 11 10 09
 To the speech-language pathologists of the University of Washington Medical Center,
Harborview Medical Center, the Madonna Rehabilitation Hospital, and the Munroe-
Meyer Institute for Genetics and Rehabilitation, whose commitment to clinical service has
created wonderful settings in which to learn about motor speech disorders.

To our families, who have understood and supported our personal commitments to
persons with severe communication disorders.
 Contents

List of Video Segments ix

Preface xi

CHAPTER 1

Perspectives on Motor Speech Disorders:

A Clinical Point of View 1

CHAPTER 2

Clinical Examination of Motor Speech Disorders 25

*

CHAPTER 3

Differential Diagnosis 81
a

CHAPTER 4

Treatment Planning in Motor Speech Disorders 113

CHAPTER 5

Management of Respiration Impairment 141

CHAPTER 6

Management of Laryngeal Impairment 175

CHAPTER 7

Management of Velopharyngeal Impairment 203

CHAPTER 8

Management of Speech Rate 237

CHAPTER 9
Articulation and Prosody: Segmental
and Suprasegmental Aspects of Dysarthric Speech 267
viii © Contents

CHAPTER 10

Interventions for Participation Restrictions:

Enhancing Social Function in Motor Speech Disorders 307

CHAPTER 11

Childhood Dysarthria: Cerebral Palsy 359

Katherine C. Hustad

CHAPTER 12

Treatment of Childhood and Acquired Apraxia of Speech 385

CHAPTER 13

Conditions Associated with Motor Speech Disorders 435

Appendix A: Descriptions of Video Segments and Case Histories

of Individuals Shown on DVD 517

About the Authors 533

Author Index 535

Subject Index 549

 Video Segments

Dysarthria (Adult)

D.la Word intelligibility test

D.lb Sentence intelligibility test

D.lc Repetition of sentences, no supplementation

D.ld Alphabet supplementation

D.le Topic supplementation

D.2 Physical and motor speech examination

D.3a Clinical examination

D.3b Endoscopic assessment of phonation

D.3c, Endoscopic evaluation of velopharyngeal function

D.4a Clinical examination

D.4b Endoscopic evaluation of velopharyngeal function

D.5a Speech evaluation

D.5b Speech with nasal obturation

D.6 Aerodynamic and endoscopic assessment of velopharyngeal function

Dysarthria (Childhood)

DC.l Word and sentence repetition

DC.2 Word and sentence repetition

Apraxia of Speech (Adult)

AOS.la Conversation

AOS. lb Sentence repetition

IX
X 0 Video Segments

Childhood Apraxia of Speech

CAS.la Conversation

CAS. lb Physical examination of oral mechanism

CAS.2 Treatment session

CAS.3 Treatment session

Demonstrations

DEMO 1 Blow-bottle training

DEMO 2 Endoscopic assessment of phonation

DEMO 3 Endoscopic assessment of velopharyngeal function

DEMO 4 Interview with prosthodontist

DEMO 5 Interview with speech-language pathologist about nasal obturation

 Preface

Management of Motor Speech Disorders in Children and Adults was written for gradu¬
ate students and practicing speech-language pathologists interested in serving children
and adults with neurologic communication disorders. The third edition of this book
contains several noteworthy modifications. First, a DVD containing 27 video segments
has been added (see inside back cover). These segments show children and adults with
dysarthria and apraxia of speech engaged in a range of speaking tasks. Intelligibility,
aerodynamic, and endoscopic assessments of speech performance are illustrated; also
included are brief demonstrations showing equipment and procedures, as well as two
interviews, one with a prosthodontist and the other with a speech-language pathologist
involved in respiratory, palatal lift, and nasal obturation interventions. Brief descrip¬
tions of the video segments as well as case histories of the people with neurologic com¬
munication disorders who appear in the videos are provided in Appendix A. Second,
the content from eight recently published practice guidelines developed by the Academy
of Neurologic Communication Disorders and Sciences (ANCDS) for the motor speech
disorders field has been integrated into this edition. Third, the terminology and con¬
cepts of the International Classification of Functioning, Disability and Health (ICF)
model have been integrated throughout the book, reflecting the continuing emphasis in
medical education on clinical decision making. Finally, a chapter describing conditions
associated with motor speech disorders has been added to the book (Chapter 13). In this
chapter, readers are directed to appropriate websites for up-to-date information.
Like the field of medical management more generally, the field of motor speech dis¬
orders can be characterized as having gone through a series of phases. The first era, cul¬
minating in the mid-1970s with the classic Mayo Clinic studies, was the era of diagnosis;
disorders were described and differentiated from other disorders. This phase was fol¬
lowed by an era of treatment, during which a repertoire of interventions was developed
and tested. The field is now entering the era of clinical decisions—a more sophisticated
phase in which a rubric is provided to the clinician for the selection and timing of the
various interventions. Readers will note that many of the descriptions of populations
are organized into levels, or stages, in which speakers are characterized across a con¬
tinuum of severity. Similarly, approaches to intervention are organized by stages of the
disorders, so that clinical decisions can be guided by the level of functional limitation.
The organization of the book reflects this emphasis on clinical decision making.
The first chapter, “Perspectives on Motor Speech Disorders: A Clinical Point of View,”
reviews the perspectives from which motor speech disorders can be viewed, including
the viewpoints of the neurologist, the speech physiologist, the rehabilitationist, and the
xii S Preface

people experiencing the disorder. Motor speech disorders are defined within the frame¬
work of the ICF model.
Chapters 2, 3, and 4 deal with clinical decision making and assessment. In Chapter
2, “Clinical Examination of Motor Speech Disorders,” the components of the clinical
examination are described, including the history, the physical examination, and the
motor speech examination. Chapter 3 focuses on differential diagnosis of the various
motor speech disorders, including apraxia and dysarthria. The Mayo Clinic model of
differential diagnosis of the dysarthrias is presented. Chapter 4 discusses treatment
planning.
Chapters 5 through 12 provide detailed discussion of specific areas of intervention.
Chapter 5, “Management of Respiration Impairment,” outlines approaches for assess¬
ment and training of the respiratory aspects of speech: establishing respiratory sup¬
port, stabilizing the respiratory pattern, and increasing respiratory flexibility. Chapter
6, “Management of Laryngeal Impairment,” reviews such management topics as estab¬
lishing voluntary phonation, increasing loudness, reducing hyperadduction of the vocal
folds, and improving laryngeal coordination. Chapter 7, “Management of Velopharyn¬
geal Impairment,” reviews the assessment of and intervention for velopharyngeal dys¬
function in dysarthria, including behavioral, prosthetic, and surgical methods. Chapter
8, “Management of Speech Rate,” addresses candidacy for rate control and selection
of appropriate techniques. Included is a discussion of the rigid rate control techniques
used with speakers who have severe impairment as well as those techniques that attempt
to preserve prosody. Chapter 9, “Articulation and Prosody: Segmental and Supraseg-
mental Aspects of Dysarthric Speech,” presents management techniques designed to
improve the production of speech and sounds and also techniques that focus on the
prosodic aspects of speech, including stress patterning, intonation, and rate-rhythm.
Chapter 10, “Interventions for Participation Restrictions: Enhancing Social Function
in Motor Speech Disorders,” describes strategies designed to compensate for residual
speech limitations by integrating supplementation and augmentative communication
techniques; these strategies serve to enhance the social functioning of people with mo¬
tor speech disorders. Chapter 11, authored by Katherine C. Hustad, discusses the com¬
munication characteristics, assessment, and intervention associated with childhood
dysarthria stemming from cerebral palsy. Chapter 12, “Treatment of Childhood and
Acquired Apraxia of Speech,” summarizes treatment approaches for children and adults
with apraxia. Principles of motor learning are reviewed as they relate to a variety of
clinical decisions associated with treatment planning. Finally, Chapter 13 summarizes
the medical conditions and speech symptoms associated with motor speech disorders.
A project such as Management of Motor Speech Disorders in Children and Adults
reflects the contributions of many people. The work of numerous colleagues is refer¬
enced throughout the text. We are indebted to those clinicians and researchers who have
been disciplined enough to record their observations, insights, and conclusions. Unfor¬
tunately, space and confidentiality do not permit a listing of clients who have served as
our “teachers.” We also acknowledge the pervasive influence of the speech pathology
staff of the University of Washington Medical Center, Seattle; the Harborview Medi¬
cal Center, Seattle; the Barkley Memorial Center, Lincoln; the Madonna Rehabilitation
 Preface i : XIII

Hospital, Lincoln; and the Munroe-Meyer Institute for Genetics and Rehabilitation at
the University of Nebraska Medical Center, Omaha. Although their contributions are
rarely referenced directly in this text, these colleagues have encouraged us, challenged
us, listened to seemingly endless audio recordings of speakers with dysarthria, critiqued
early versions of tests and software, and provided wonderful settings in which to learn
about dysarthria. We would also like to acknowledge Julie Marshall, DDS, MA, for
the informative interview she gave related to prosthetic management of velopharyn¬
geal dysfunction. Finally, we wish to thank Katie Hustad for contributing Chapter 11,
“Childhood Dysarthria: Cerebral Palsy,” and Vicki Philippi for filming and editing the
video segments included on the DVD. Vicki managed this task while providing ongoing
multimedia support to the education programs of Madonna Rehabilitation Hospital.

KMY
DRB
EAS
MH
 CHAPTER

Perspectives on Motor Speech Disorders

A Clinical Point of View

Clinical Issues: Family conferences in which the patients and their families have the op¬
portunity to meet with the entire team are frequent occurrences in our rehabilitation
unit. After one such conference, which began on a particularly discordant note, a stu¬
dent asked, “How do you prepare yourself for such a confrontation?” Our advice was to
try to understand the interaction from the viewpoints of the various participants. In this
particular case, Sam had been diagnosed over 12 years ago as having Parkinson’s dis¬
ease. He was being discharged from a hospitalization for adjustment of his medication.
The physician considered the hospitalization a success in that Sam’s rigidity, as well as
the excessive movements that were a side effect of his former medication schedule, was
reduced. The occupational therapist also considered it successful because Sam could
more safely perform some activities of daily living. His speech was considered functional
if the family modified their communication style. This required that his partners be face
to face with Sam when he was attempting to speak, that they clearly signal when they
were not understanding, and that they take an active role in resolving communication
breakdowns. However, Sam’s wife and son were less positive. They concluded that Sam
had not changed in any important ways and that the hospitalization had been a waste of
time and money. Sam still required a wheelchair for mobility, he needed some supervi¬
sion when carrying out many activities of daily living, and his speech was still extremely
difficult to understand by those outside the immediate family. The family’s disappoint¬
ment with the intervention was clear. Sam could not return to work or even to an inde¬
pendent lifestyle.

• How could people observe the same events and interpret them so differently?
• Was the family less observant than the rehabilitation staff?
• Was the rehabilitation staff exaggerating the changes that had occurred?

1
2 Chapter i

Perspectives are standpoints from which a problem or a condition may be viewed. They
provide a means for understanding or judging observations and for showing those ob¬
servations in relationship to one another. This chapter presents a number of perspec¬
tives from which the speech-language clinician can view and understand motor speech
disorders. Each perspective is valid for its own purposes. Before these perspectives are
presented, an introduction to the characteristics of motor speech disorders is provided,
followed by a discussion of the framework developed by the World Health Organization
(WHO). This framework provides an overview of the components of health and dis¬
ability; its terminology will be used throughout this text. Next, various perspectives on
motor speech disorders are presented, along with a discussion of the role of the speech-
language pathologist in differential diagnosis and intervention.

Characteristics of Motor Speech Disorders

Speech production occurs because of a complicated interaction of cognitive, linguistic,

and motor processes. A brief review of a basic model of how speech is produced helps
one understand the processing deficits that result in motor speech disorders. Figure 1.1
illustrates a simple example of such a model that will be referred to throughout this
book. The act of speaking begins with the intent to communicate a particular idea or
message. This ideation leads to the linguistic level, where a variety of language pro¬
cesses occur. Speakers must retrieve words from some storage mechanism, perform
the appropriate phonologic encoding, and assemble the words into syntactic frames.
Interactive with this linguistic processing, the speaker assembles and retrieves motor
plans before executing them. Execution involves contraction of muscle fibers, causing
the movements of structures responsible for modulating the airstream and the acoustic
speech signal. Although this discussion will focus primarily on the two motor levels
of this basic model, it is important to realize that speech motor control processes are
influenced by and interactive with the cognitive and linguistic levels of processing that
occur when people talk.
Motor planning (or motor programming) is the term most frequently used to desig¬
nate the “translation” between language forms and the movement that occurs to cre¬
ate the sounds that are understood by the listener. Although specific aspects of motor
planning are still open to debate, it is clear that some mechanism is at work to specify
movement parameters. That is, certain areas of the brain must specify how far, how
fast, in what direction, and with how much muscle contraction each muscle must move.
Also, each muscle must move in a temporal relationship with all of the other muscles.
The term apraxia of speech is used to designate a problem at this level of processing—the
ability to program the movements that must occur for a particular acoustic result.
Motor execution refers to the complex processes by which the motor plan results in
actual muscle contractions. It is overly simplistic to view the execution phase of motor
control as a system of “neuroelectrical lines” in which the motor control signals pass
from the primary motor cortex to the lower motor neuron pool, activating peripheral
 Possible Disorders

Execution
Domain
Function

Figure i.i. A model of expressive communication for children and adults.

4 fli Chapter!

nerves in such a way that peripheral fibers wrap around one or more muscle fibers and
release acetylcholine, causing the muscle fibers to contract. Motor execution also in¬
volves a sophisticated system for refining the neuromotor signal with a variety of feed¬
back and coordinative networks. These include proprioceptive and tactile sensory sys¬
tems, extrapyramidal descending tracts, and the basal ganglia and cerebellar circuits. A
pathology in the central or peripheral nervous system involved in motor execution can
cause a communication disorder that is called “dysarthria.”

^ Question: Isn’t the model presented in Figure 1.1 simplistic, given that it attempts to
represent cognitive, linguistic, and motor functions?

Yes. We develop models to help us understand concepts that in reality are very
complex and interrelated. We are aware that speech—that is, the expression of
ideas—is a complicated process or a series of complicated processes, depending on
how one chooses to think about it. In an effort to understand a complicated process
like speech production, we attempt to categorize it into “manageable chunks.”
While our categorization efforts—such as language, motor programming, and motor
execution—aid our understanding in some ways, they often cause controversy as
well. For example, later in this book we will discuss the long-standing argument as to
whether or not apraxia of speech is a linguistic disorder or a motor disorder.
Keep in mind, too, that a simplified model is useful for patient and family
education, such as helping adult children understand why their dad can understand
them, but cannot talk. The model is also useful in pediatric populations. For example,
the pediatrician or speech-language pathologist may have given the label “childhood
apraxia of speech” to a child with severe articulatory problems. Parents would ask,
“What is that? Does that mean he has a problem with his brain?” The model can be
helpful in explaining that there are different levels of processing, and that the child
might be experiencing deficits at certain of those levels (i.e., phonologic or motor
planning).

The Dysarthrias

Dysarthria is a neurologic motor speech impairment that is characterized by slow, weak,

imprecise, or uncoordinated movements of the speech musculature. Literally, the term
comes from the Greek dys arthroun, which means “inability to utter distinctly.” The
dysarthrias form a group of disorders marked by impaired execution of the movements
of speech production. Rather than being described by a single set of characteristics, dif¬
ferent types of dysarthria vary along a number of dimensions:

• Age of onset—The dysarthrias can be congenital or acquired at any age.

• Cause—The origin of the underlying neuromotor problem can be vascular,
traumatic, infectious, neoplastic, metabolic, and so on. Any trauma, lesion, or
 Perspectives on Motor Speech Disorders 5

disease that causes central or peripheral nervous system damage may result in
dysarthria.
• Natural course—The course of the dysarthria may follow a number of patterns, in¬
cluding developmental (as in cerebral palsy in children), recovering (as in early
post-onset traumatic head injury and stroke), stable (as in cerebral palsy in adults),
degenerative (as in amyotrophic lateral sclerosis), or exacerbating-remitting (as in
some cases of multiple sclerosis).
• Site of lesion—The neuroanatomic site of lesion may be either the central or the pe¬
ripheral nervous system or both, including the cerebrum, cerebellum, basal ganglia,
brain stem, and cranial nerves.
• Neurological diagnosis of disease—A number of diagnoses may be associated with
dysarthria, including cerebral palsy; Parkinson’s disease; multiple sclerosis; amyo¬
trophic lateral sclerosis; and unilateral, bilateral, or brain stem stroke. See Table 1.1
for a more complete listing.
• Pathophysiology—One or a combination of pathophysiological processes may be
involved, including spasticity, flaccidity, ataxia, tremor, rigidity, dysmetria, and in¬
voluntary movements such as tremor.
• Speech subsystems involved—All or several of the speech subsystems may be in¬
volved to varying degrees. These include the respiratory, phonatory, velopharyngeal,
and oral articulatory (lip, tongue, and jaw) subsystems.
• Perceptual characteristics—The various dysarthrias have unique perceptual
features.
• Severity—Dysarthria may range in severity from a disorder so mild that it is barely
noticeable during connected speech to a disorder so severe that no functional
speech is present.

Differences among the dysarthrias have an impact on nearly every aspect of clinical
management; for example, different medical courses influence sequence for treatment.
In recovering or developmental dysarthria, an extended period of intervention may be
appropriate. Degenerative disorders, on the other hand, usually warrant a different ap¬
proach, involving short, intensive periods of intervention at critical points during the
course of the disorder. Different underlying pathophysiological problems may dictate
quite different intervention techniques. For example, the reduction of habitual speak¬
ing rate, which brings about an important increase in intelligibility for certain ataxic
or hypokinetic dysarthric speakers, may not be appropriate for individuals with flaccid
dysarthria. Strengthening exercises may be contraindicated for individuals with amy¬
otrophic lateral sclerosis but appropriate for individuals with brain stem stroke. Bio¬
feedback programs designed to reduce overall muscle tone may be appropriate for those
dysarthric individuals with increased spasticity but contraindicated for those with
weakness. Knowing the pattern of speech component breakdown is critical in knowing
where to intervene. For example, in the development of a management program
for velopharyngeal incompetency, the appropriateness of palatal lift may be depen¬
dent on the level of function of other speech components, including respiration and
oral articulation. Thus, appreciation of the diversity of the dysarthrias is critical for
6 J Chapter i

Table 1.1
Characteristics of the Dysarthrias and Apraxia of Speech

Type Etiology Location Neuromuscular Condition

Dysarthria
Flaccid dysarthria Poliomyelitis Lower motor Flaccid paralysis
Stroke neuron Weakness
Congenital conditions Hypotonia
Myasthenia gravis Muscle atrophy
Bulbar palsy Fasciculations
Facial palsy
Trauma
Spastic dysarthria Stroke Upper motor Spastic paralysis
Tumor neuron Weakness
Encephalitis Limited range of motion
Trauma Slowness of movement
Spastic cerebral palsy
Ataxic dysarthria Stroke Cerebellar system Inaccurate movement
Tumor Slow movement
Trauma Hypotonia
Ataxic cerebral palsy
Friedreich’s ataxia
Infection
Toxic effects (e.g., alcohol)
Hypokinetic Parkinson’s disease Extrapyramidal Slow movements
dysarthria Drug induced system Limited range of movement
Immobility
Paucity of movement
Rigidity
Loss of automatic aspects
of movements
Hyperkinetic
dysarthria
Predominantly quick Chorea Extrapyramidal Quick involuntary
Infection system movements
Gilles de la Tourette’s Variable muscle tone
syndrome
Ballism

Predominantly slow Athetosis Extrapyramidal Twisting and writhing

Infection system movements
Stroke Slow movements
Tumor Involuntary movements
Dystonia Hypertonia
Drug induced
Dyskinesia
 Perspectives on Motor Speech Disorders §9 7

Table 1.1 (continued)

Type Etiology Location Neuromuscular Condition

Mixed dysarthria
Spastic-flaccid ALS Upper and lower Weakness
Trauma motor neuron Slow movement
Stroke Limited range of
movement

Spastic-ataxic- Wilson’s disease Upper motor Intention tremor

hypokinetic neuron, cerebellar, Rigidity
and Spasticity
extrapyramidal
Slow movement

Variable Multiple sclerosis Variable Variable

(spastic-ataxic-
flaccid)

Apraxia of Speech
Stroke Dominant Reduced ability in
S

$■ Tumors hemisphere lesion programming the

Trauma sequence of speech
movements

Note. Adapted from Motor Speech Disorders, by F. L. Darley, A. E. Aronson, and J. R. Brown, 1975, Philadelphia:
W. B. Saunders.

management. Rather than developing a generic dysarthria treatment, the field is very
rightfully developing specific interventions for specific patterns of impairment.

Apraxia of Speech

Apraxia of speech is a motor speech disorder caused by a disturbance in motor plan¬

ning, or programming of sequential movement for volitional speech production. Al¬
though the musculature itself is not impaired, individuals with apraxia of speech will
have difficulty completing sequences of movements for sound production (McNeil,
Doyle, & Wambaugh, 2000). Apraxia of speech often occurs concomitantly with apha¬
sia or language delay and less frequently with dysarthria. The perceptual characteristics
of apraxia of speech include disturbances in articulation, rate, and prosody, or in the
rhythm of the spoken utterance (Croot, 2002; Wambaugh, 2002; Wambaugh, Duffy,
McNeil, Robin, & Rogers, 2006a, 2006b). Articulatory errors consist primarily of vowel
and consonant distortions, although substitutions, additions, and omissions of sounds
may also occur. Articulatory errors are inconsistent. Some speakers with apraxia will
have great difficulty initiating utterances due to their inability to achieve initial articu¬
latory configurations. Transitions of movement out of one sound and into the next will
8 Chapter i

also be difficult, and these distorted transitions add to the perception of dysprosody.
In addition to slower rate, prosody is affected by the tendency to equalize stress across
syllables and words.
Articulatory errors are often perceived as approximations of target sounds as the
speaker produces effortful groping for accurate movement of articulators into a par¬
ticular position. Errors often increase as the length or phonetic complexity of the ut¬
terance increases. Speakers with apraxia exhibit more accuracy in well-practiced ha¬
bituated utterances, such as counting, than during spontaneous speech. Speakers with
apraxia are often aware of their errors and frequently attempt to correct error produc¬
tions. Oral apraxia (difficulty planning volitional movement of oral structures for non¬
speech movement tasks) may or may not be present with verbal apraxia.
Childhood apraxia of speech (CAS) is the term used for the developmental coun¬
terpart of acquired apraxia of speech. Many definitions of verbal apraxia in the devel¬
opmental form focus on difficulty with the ability to carry out purposeful voluntary
movements for speech, in the absence of a paralysis of the speech musculature (Ball,
Bernthal, & Beukelman, 2002; Caruso & Strand, 1999; Forrest, 2003; Shriberg, Aram,
& Kwiatkowski, 1997a, 1997b, 1997c). Most definitions also point out the articulatory
aspects and the inability to sequence speech movements. A problem with speech motor
planning and programming during the early stages of language and speech acquisition,
however, will necessarily affect the development of the child’s expressive phonologic
system. Consequently, it is sometimes difficult to determine how much of a severe delay
or deviancy in articulatory skill is due to motor planning problems versus phonologic
processing. Until recently, there has been controversy regarding the specific behavioral
markers that should be used to identify CAS. The American Speech-Language-Hearing
Association position statement concerning CAS now provides a definition of the disor¬
der (American Speech-Language-Hearing Association, 2007). That document defines
CAS as

a neurological childhood (pediatric) speech sound disorder, in which the precision

and consistency of movements underlying speech are impaired in the absence of neu¬
romuscular deficits (e.g., abnormal reflexes, abnormal tone). CAS may occur as a re¬
sult of known neurological impairment, in association with complex neurobehavioral
disorders of known or unknown origin, or as an idiopathic neurogenic speech sound
disorder. The core impairment in planning and/or programming spatio-temporal pa¬
rameters of movement sequences results in errors in speech sound production and
prosody, (p. 6)

Procedures for determining whether motor planning problems are contributing to de¬
lays or deviances in speech development will be discussed in Chapters 2 and 3. For now,
it is important to recognize that this term is useful for delineating a subgroup of chil¬
dren who present with severe articulatory performance deficits and who seem to have
a variety of associated characteristics in common. Developmental verbal apraxia may
be exhibited along with other deficits and strengths for a particular child. Our goal as
clinicians is to be as informed as possible regarding the nature of the motor planning
deficit so that we may make reasonable decisions as to the relative contribution of the
disorder to the child’s overall communicative performance.
 Perspectives on Motor Speech Disorders 0 9

Question: Are dysarthria and apraxia of speech medical diagnoses?

No, these terms are used to designate the type of communication disorder. The
medical diagnoses relate to the neuropathology that is causing the motor speech
disorders. For example, amyotrophic lateral sclerosis is a degenerative disease in which
the neuropathology is motor neuron degeneration, which results in the communicative
disorder of dysarthria. Stroke may result in a focal area of necrosis (brain death)—the
neuropathy that results in the communication disorder of apraxia of speech.

A Framework for the Components

of Health and Disability

Almost without exception, motor speech disorders are associated with health condi¬
tions that are chronic or long term. Therefore, it is useful to present a framework that
identifies the components of health and disability. The following is an introduction to
the World Health Organization (WHO) framework and a discussion of how the terms
in this framework can be used to describe motor speech disorders.

An Introduction to the World Health Organization Framework

In 2001, the WHO published a framework called the International Classification of

Functioning, Disability and Health (ICF; WHO, 2001). This is an interdisciplinary, in¬
ternational taxonomy that seeks to provide a comprehensive classification of the com¬
ponents of health and the consequences of health conditions. Its development spanned
over 20 years. The original version was called the International Classification of Impair¬
ments, Disabilities, and Handicaps (ICIDH; WHO, 1980); a later version was called
ICIDH-2 (WHO, 1999). The goal of this development effort was to move away from
a biomedical model and from a model in which the problem of disability was placed
within the individual rather than within the context of social and environmental do¬
mains. The resulting framework suggests that the consequences of health conditions
include a complex interaction of physical, social, and psychological components.
One of the major contributions of the ICF framework is that it provides a standard
language for the domains of health and disability (jette, 2006). As noted in Table 1.2,
each domain is defined and both a positive and negative term are provided. For example,
the domain of body structure and function is defined as “anatomical parts of body” and
“physiologic functions of body.” The phrase “functional and structural integrity” is
used to denote health and “impairment” to denote disability. The terminology derived
from the ICF framework has been adopted by many rehabilitation disciplines. For a
review see Bruyere, Van Looy, and Peterson (2005).
io m cHAPTER 1

Table 1.2
Dysarthria and Apraxia of Speech in the Context of Health and Disablement
Component Definition Motor Speech Disorder Measure of Problem

Body function Physiologic functions of Speech production

body process, including
respiration, phonation,
and articulation

Body structure Anatomical parts of body Respiration system,

larynx, soft palate,
tongue, and jaw

Impairment Problems in body Slow, weak, imprecise or Physiologic measures such as

function or structure uncoordinated respiratory support,
movements of speech phonatory or velopharyngeal
musculature or inability function, and oral
to plan sequences of articulation; integrity of
speech movements speech structures

Activity Execution of a task or Act of speaking

action

Activity Difficulties in executing Difficulty speaking Speech intelligibility, speaking

limitation activities rate, articulatory adequacy, or
naturalness

Participation Involvement in life Involvement in everyday

situations situations that involve
speaking

Participation Problems in involvement Problems in everyday Self-reported interference in

restriction in life situations speaking situations everyday communication
situations

Environmental Physical, social, and Environment in which Anecdotal reports of barriers

factors attitudinal environment speaking occurs, *

in which people live including noise, lighting,

and communication
partners

Applying the ICF Framework to Motor Speech Disorders

The ICF framework has recently received considerable attention in the speech-pathol¬
ogy literature (Threats, 2006) and has been applied to a number of clinical topics, in¬
cluding stuttering (Leahy, 2005; Yaruss & Quesal, 2004), aphasia (Howe, Worrall, &
Hickson, 2004), aging (Hickson, Worrall, Wilson, Tilse, & Setterlund, 2005), demen¬
tia (Bryne & Orange, 2005), laryngectomy (Eadie, 2003), speech disorders in children
(McLeod, 2004), deafness (Smiley, Threats, Mowry, & Peterson, 2005), and augmenta¬
tive and alternative communication devices (Bornman & Murphy, 2006). In addition
to these specific applications, the American Speech-Language-Hearing Association has
 Perspectives on Motor Speech Disorders fli 11

adopted this framework in several of its cardinal professional documents, such as its
Scope of Practice for Speech-Language Pathology (American Speech-Language-Hearing
Association, 2001). Speech functions are well represented in the ICF. See Table 1.2 for
definitions of dysarthria and apraxia of speech within the ICF framework. Each of these
parameters is also discussed further in the following paragraphs.

Functional and Structural Integrity—Impairment

In motor speech disorders, the anatomy of the speech production mechanism is normal;
however, the physiology of speech production is not. In ICF terms, there is structural,
but not functional, integrity. Dysarthria and apraxia of speech are neurologic speech
disorders characterized by abnormalities in movement rate, precision, coordination,
and sequencing of movements that can result in impairment of any combination of the
subsystems of the speech mechanism, including respiration, phonation, velopharyngeal
function, and articulation. Assessment and treatment targeted at each of these subsys¬
tems can be found in Chapters 5 through 9. In attempts to describe the impairment
of people with motor speech disorders, measures of physiologic control and support
are needed. These measures may include those that supply information about speech
mechanism subsystems as they function during speech and nonspeech tasks. Many of
the measures of impairment involve use of instrumentation to make physiologic mea¬
sures. However, certain aspects of the impairment, such as voice quality, may also be
measured perceptually using rating scales. To date, a large part of the research literature
in motor speech disorders has focused on impairment. Although it is beyond the scope
of this chapter to review this extensive literature, references to research focusing on the
underlying motor dysfunction of the various motor speech disorders are included in
many of the chapters that follow.

Activity—Activity Limitation
Activity in the ICF framework is defined as the execution of a task or action. Dysarthria
and apraxia of speech can also be defined as an activity limitation resulting from motor
impairment. In the case of motor speech disorders, the activity is speech. The activity
limitations are characterized by reduced speech intelligibility and rate and by abnormal
prosodic patterns. To describe the activity limitation, a number of overall measures
of speech performance are available. The majority of these measures are perceptually
derived, for example, speech intelligibility, judgments of overall articulatory adequacy,
and speech naturalness; however, certain aspects of rate and prosody lend themselves
to acoustic analysis. Measures at the activity level will be discussed in more detail in
Chapter 2.
Reduction or stabilization of limitation in speaking is the primary goal of speech
intervention for persons with motor speech disorders. Therefore, measures of activity
limitation are frequently considered in the outcome measures of dysarthria or apraxia
treatment, and also serve as an overall index of the severity of the disorder. The relation¬
ship between impairment and activity limitation is not always simple or straightforward.
For example, a preliminary report is available that examines the relationship between
impairment and functional limitations in speakers with amyotrophic lateral sclerosis
12 0 Chapter!

(Yorkston, Strand, & Hume, 1998). Our clinical experience suggests that relatively se¬
vere impairment of single subsystems of speech may not result in severe functional limi¬
tation. For example, severely restricted lip movement in the presence of adequate func¬
tioning of other speech components will not result in a severe disability. However, even
moderate impairment in multiple speech components may result in severe disability.
Clinical experience also suggests that severe impairment of certain speech components
may be particularly devastating in terms of impact on activity limitation. For example,
severe respiratory timing and coordination problems may result in severe disability.

Participation—Participation Restrictions
Participation in the ICF framework is defined as involvement in life situations. Thus,
communicative participation can be defined as taking part in life situations where
knowledge, information, ideas, or feelings are exchanged (Eadie et al., 2006). In this
definition, the term life situation suggests that the activity of speech or communication
occurs within a social context of what is being communicated, where, when, why, and
with whom. The presence of disability has been found to lead to participation that is
less diverse, is restricted more to the home setting, involves fewer social relationships,
and includes less active recreation (Law, 2002). If the disabling condition involves com¬
munication disorders, the potential for psychosocial restrictions is especially high. Dys¬
arthria and apraxia of speech are commonly associated with restrictions in participa¬
tion (Yorkston, Bombardier, & Hammen, 1994). These restrictions involve the reduced
ability to function in physical and social contexts that require understandable, efficient,
and natural sounding speech. Disability, then, involves not only speakers with motor
speech disorders but also their communication partners and their physical and social
environments. Restrictions in communicative participation have been described in in¬
dividuals living with multiple sclerosis (MS) (Yorkston et al., 2007; Yorkston, Klasner,
& Swanson, 2001) and spasmodic dysphonia (Baylor, Yorkston, & Eadie, 2005; Baylor,
Yorkston, Eadie, 8c Maronian, 2007).
It should be noted that there is not always a strong relationship between the level
of severity of the impairment and the level of restriction in communicative participa¬
tion. For example, persons with mild impairments in speech may experience severe
restrictions in participation if they are unable to fulfill valued roles such as working. In
a qualitative study, persons living with MS reported mild communication impairments
but major lifestyle changes (Yorkston et al., 2001). The restrictions in communicative
participation did not always come as a direct consequence of the communication im¬
pairment, but rather from other symptoms related to their condition. Fatigue, one of
the most common and distressing symptoms of MS, prevented participation in many
social situations. Participants felt that social relationships were difficult to maintain
because they couldn’t shop, go on short trips, or host dinner parties due to low energy.
Mobility limitations made maintaining friendships difficult. Participants indicated that
they “couldn’t keep up” with friends on outings.
In summary, communicative participation is a complex phenomenon that is influ¬
enced by the severity of the speech impairment, but also by environmental, social, and
personal factors. Measurement of communicative participation is a challenge. Perhaps
because the ICF has only recently been introduced, few standardized measures of par-
 Perspectives on Motor Speech Disorders 0 13

ticipation are available (Eadie et al., 2006). Clinicians must rely on activities such as
checklists and interviews regarding communication in natural settings.

Environmental Factors

The final construct described in the ICF framework includes the physical, social, and
attitudinal environment that may facilitate or impose barriers for the speaker with mo¬
tor speech disorders. The environmental barrier to communication in aphasia has been
reviewed in detail elsewhere (Howe et al., 2004). Barriers in the physical environment
may include noise, distance, lighting, and so on. Other physical barriers may not be
directly related to the speech disorder. For example, a woman with multiple sclerosis us¬
ing a wheelchair may not be able to fully participate in a lawn party because wheelchair
access is limited. An individual with a motor speech disorder may also be prevented
from participating in a desired role because of the biases and attitudes of individuals
in the society. For example, an intelligible speaker who does not sound natural might
not be hired as a receptionist, an occupation that demands excellent communication
skills, even though that speaker possesses other skills required for the job. A teenager
with a motor speech disorder may be excluded from a social group because of the at¬
titudes of the group. An individual can also be prevented from participating in desired
roles because of the severity of the disability. An unintelligible speaker cannot function
adequately in the role of a telephone operator.

^ Question: Can you give me an example of how a motor speech disorder might
be considered an impairment by one person and a function of social attitudes by
another?

We received a phone call from the parents of a 1 3-year-old child who was not socially
accepted in middle school. In their call, they indicated that they wanted a speech
evaluation for their son because they wanted him to become involved in speech
intervention again. The results of the assessment revealed that the young man’s
speech was 96% intelligible, yet his dysarthria, due to athetoid cerebral palsy, was
obvious. He had received speech intervention services since he was a toddler, and at
the time of the assessment was not interested in more intervention. Academically,
he was a strong student. Through the years, he had attended a local neighborhood
elementary school with two sections of each grade. His peers knew him, understood
his speech, and accepted him socially. A few months before his parents called us,
he had entered a regional middle school, and in that social environment his speech
was devalued by his fellow students, who excluded him from their social groups and
verbally abused him about the way he spoke. By requesting a speech evaluation to
encourage their son to “work on his speech," the parents were focusing on his speech
impairment or limitation. However, in our opinion, the societal limitation that he was
experiencing needed to be addressed by focusing on the attitudes, practices, and
policies of his school and its students rather than focusing primarily on his speech.
14 flP Chapter i

Perspectives on Dysarthria and Apraxia of Speech

Many people are interested in motor speech disorders. The reasons for this interest vary
depending on the person’s perspective. Like every complex phenomenon, motor speech
disorders may be viewed from a variety of perspectives. Although the point of view of
the rehabilitation team member is the focus of this text, other perspectives must also be
acknowledged because each perspective is useful for a different purpose.

The Medical Diagnostic Team

Neurologists, who play a prominent role in diagnostic teams, have historically viewed
the dysarthrias and apraxia of speech as signs or symptoms of a disease or condition.
For the speaker with dysarthria, the disease may be multiple sclerosis, Parkinson’s dis¬
ease, amyotrophic lateral sclerosis, cerebral palsy, or stroke. For apraxia of speech, the
disease is typically a left-hemisphere stroke. At times, these neurologic changes result
in signs and symptoms. The signs of a disease are those characteristics observed by oth¬
ers, including professionals examining the patient. The symptoms of a disease are those
characteristics perceived by the people with the disabilities.
For nearly 120 years, the characteristics of speech have been used to describe neuro¬
logic disease (Darley, Aronson & Brown, 1975). For example, in 1877 Charcot described
a triad of symptoms that were characteristic of disseminated sclerosis, now known as
multiple sclerosis. These symptoms included tremor, nystagmus, and scanning speech.
In 1929, Hiller studied the dysarthria of Friedreich’s ataxia and concluded that the pri¬
mary speech problem of patients with cerebellar lesion is one of respiratory control. In
1937, Zentay classified the dysarthric speech resulting from cerebellar lesions as ataxic
speech, adiadochokinesis, explosive speech, and scanning speech. Early descriptions
of dysarthria were associated with impairments of the nervous system that were diag¬
nosed by medical professionals. Therefore, the biomedical model, which is frequently
employed in the medical field, has been applied to the dysarthrias. According to this
model, the severity of the dysarthria is associated with the severity of the illness or
disease process, and the dysarthria is managed by treating the disease. Thus, dysarthria
has been used as an index of disease severity through the years, with little attention fo¬
cused on remediation of the speech disorder itself. The practice of describing neurologic
disease in terms of speech characteristics continued in a rather unsystematic fashion
until the late 1960s. It was then that Darley, Aronson, and Brown (1969a, 1969b, 1975)
at the Mayo Clinic studied the perceptual speech characteristics associated with a wide
variety of neurologic conditions. This work has been continued by Duffy (2005) and is
referenced throughout this text.

The Basic Scientist’s Point of View

Motor speech disorders can also be viewed from the perspective of those who study
the fundamentals of the speech process. For example, the neurolinguist may be inter-
 Perspectives on Motor Speech Disorders iS3 15

ested in apraxia of speech because it provides insight into the organization of language
processes, and the speech physiologist may be interested in dysarthria because it pro¬
vides insight into how speech movements are learned and executed. The viewpoints
adopted by scientists such as neurolinguists and speech physiologists are equally valid
but quite different from the one taken by the medical diagnostic team. Speech is a won¬
derfully complex phenomenon: Consider the rapid, precise, well-coordinated sequences
of movements required to produce understandable speech. Speakers use approximately
100 different muscles and produce recognizable sounds at a rate as high as 14 per sec¬
ond. Each of these sounds requires specific respiratory, laryngeal, and oral articulatory
postures. Sound productions are not based on fixed patterns; rather, speakers appear
to have the ability to produce a sound acceptable to the listener in a number of dif¬
ferent ways. Perhaps most remarkably, the speech motor activity is almost completely
automatic. Although speakers may be consciously aware of formulating a message, they
devote almost no conscious effort to planning motor speech activities. Given the com¬
plexity of motor speech, one would expect that impairment in motor control would
have negative consequences in the form of reduced intelligibility, naturalness, and ar¬
ticulatory adequacy.
During the 1960s a new, physiologic perspective on dysarthria appeared. Hardy
(1967) offered an early articulation of this position with his “Suggestions for Physi¬
ologic Research in Dysarthria,” in which he demonstrated the value of studying dysar-
thric speech using the principles of experimental phonetics. In developing this research
orientation, Hardy outlined principles that continue to guide dysarthria research. For
example, he suggested that the physiology of one mechanism (respiratory, phonatory, or
articulatory) interacts with the others to produce the speech signal. Study of physiologic
dysfunction of a single mechanism without regard to the role of the others will allow
only limited conclusions. Finally, he suggested that speech disorders could be profitably
studied as an aerodynamic, mechanical system. Readers will find discussions of aerody¬
namic assessment procedures in Chapters 5 through 7.
Focus on the physiologic aspects of speech production has contributed to the under¬
standing of many types of motor speech disorders. For example, individuals with Par¬
kinson’s disease have reported frequent problems with weak or hoarse voice, imprecise
articulation, and difficulty getting speech started (Adams, 1997). These problems have
been studied from a physiologic perspective. Respiratory contributions to parkinsonian
dysarthria have been evaluated (Murdoch, Chenery, Bowler, & Ingram, 1989; Solomon
& Hixon, 1993). Aerodynamic measures of laryngeal function, including maximum
flow declination rate and subglottal pressure, have been used to document treatment
effects (Ramig & Dromey, 1996). Articulatory kinematics have been used to compare
and contrast two types of treatment (loud speech and hyperarticulation) (Dromey &
Adams, 2000). Findings suggest that while both treatments increase displacement and
velocity of lip movement, loud speech results in less variability.
At times, especially when developing specific intervention plans, the speech-
language pathologist must take the speech physiologist’s viewpoint. A variety of in¬
strumental approaches are used to describe the aerodynamic, kinematic, and acoustic
properties of speech. This type of evaluation leads to questions quite different from
those posed from the neurologic perspective:
16 0 Chapter i

• How can aspects of speech mechanism performance be objectively measured during

speech production activities? Answers to this question have led to the development
of techniques for measuring physiologic aspects of speech and for comparing the
performance of the various aspects of speech production. In addition, this approach
has allowed for comparison of the performance of speakers with dysarthria with the
performance of individuals who have normal speech.
• Are there means of compensating for the abnormal performance of the speech
mechanism? Answers to this question have led to the development of a series of be¬
havioral and prosthetic approaches to intervention.
• What malfunctions of the speech mechanism contribute substantially to reduced
intelligibility? Answers to this question may form part of the strategy for sequenc¬
ing of intervention tasks.

The Rehabilitationist’s Point of View

Undoubtedly a speech-language pathologist who is part of a rehabilitation team and

managing a caseload of individuals with motor speech disorders must be familiar with
a number of perspectives in order to understand the disorder. Clinicians must be thor¬
oughly familiar with the viewpoint of the diagnostic team in order to participate in the
process of identifying the underlying condition. Understanding the diagnosis is neces¬
sary in order to plan intervention that is compatible with the underlying neuropathol¬
ogy and that is appropriate considering the natural course of the disorder. Likewise, the
clinician must have an understanding of the speech scientist’s viewpoint to be able to se¬
lect and sequence intervention tasks appropriately. The viewpoint taken by the speech-
language clinician planning rehabilitation programs is somewhat different from the
one taken by either the neurologist, who wishes to identify the disease or disorder and
to treat that condition, or the basic scientist, who wishes to understand both normal
and abnormal speech processes. The following are among the types of questions asked
by the clinician in the rehabilitation setting:
$

• How is the motor speech disorder affecting the person’s lifestyle?

• How can that effect be lessened?
• What are reasonable goals for intervention?
• What are important measures of successful intervention?
• How can these goals be achieved? Does this person need an augmentative commu¬
nication system, a palatal lift, a voice amplifier, and so on?

Before the role of the speech-language pathologist is described in more detail, a final crit¬
ical perspective—that of the speaker with a motor speech disorder—will be presented.

The Speaker’s Point of View

The viewpoint of speakers with motor speech disorders is variable and depends on
many different issues. Early in the course of a progressive condition such as Parkinson’s
 Perspectives on Motor Speech Disorders 9 17

disease, for example, people with the disorder are very focused on the perspective of the
neurologist as attempts are made to diagnose the symptoms that they are experiencing.
Once the diagnosis is made and confirmed, the speakers and their families become very
interested in what is known (the science) about the disease or condition. The search for
information often involves many family members and at times members of the larger
community. As speech function begins to deteriorate, people with disabilities become
increasingly focused on the rehabilitationist’s perspective as they strive to learn com¬
pensatory skills and maximize function. Eventually, the point of view of the speaker
with a disability shifts to a perspective that focuses on “living with the condition.” In
this phase, the speaker may be resistant to additional medical diagnostic or rehabili¬
tation-related activities. This description of the perspective of a person with a motor
speech disorder is brief and linear; however, life does not work that way. People with
disabilities may shift through this sequence of perspectives several times. In addition,
family members or others who are influential in the lives of these people may work their
way through this process according to different time lines.

Question asked at a presentation: I have listened today for the way you refer to
yourself and the persons with whom you work. In our rehabilitation center, we are
trying to use “people-first” terminology. What are you doing in your work settings?

Most of the time, we use people-first terminology and say “people with dysarthria” or
“speakers with dysarthria.” That works pretty well when we are referring to individuals
with a specific condition, such as “people with multiple sclerosis.” However, when
talking generally about people who are under current medical care, we refer to them
as “patients” or “clients.” You will notice that in the context of this text, in which we
are concerned about their ability to communicate, we often refer to them simply as
“speakers.” By the way, we refer to people in my profession as “speech-language
pathologists,” reserving the generic term clinicians to refer to persons from a variety
of professions who provide assessments and intervention services.

The Importance of Identifying Perspectives

The ICF framework provides a vocabulary for communicating with other professionals
and with speakers with motor speech disorders and their families. It allows the clinician
to identify the perspectives of others. In the introduction to this chapter, we described
a family conference in which there was an apparent disagreement about the outcome of
intervention. Reviewing that situation from the perspective of the ICF framework sug¬
gests that each participant in the family conference may have been viewing dysarthria
from a different perspective. The physician was viewing it as an impairment; thus, de¬
monstrable changes in rigidity were a signal of successful intervention. The rehabilita¬
tion clinicians, including the occupational therapist and the speech-language patholo¬
gist, viewed the dysarthria as an activity limitation; thus, the patient’s ability to perform
18 0 Chapter i

more activities of daily living signaled successful intervention. On the other hand, the
family viewed the dysarthria as a restriction in participation; thus, because the person
with Parkinson’s disease was no longer able to return to his former occupation or to
carry out his role as husband and father as he had before, the family felt that interven¬
tion had fallen short of its target. Recognizing the viewpoints of others might not have
changed the reality of the outcome, but the level of discontent might have been reduced
if communication had been clearer. The lack of close relationship between impairment,
activity limitations, and participation restriction makes it mandatory for professionals
to communicate clearly the point of view from which they are discussing the disorder.
Identification of the perspectives of others is also important when one is attempting
to read, understand, and interpret the literature in motor speech disorders. Students
given the task of reviewing research literature in this area are quickly impressed with
the diversity of approaches to measurement. Any number of physiologic, acoustic, and
perceptual measures have been used to understand the nature of the disorder. This di¬
versity may at first give the impression that there is little agreement as to the single best
way of understanding dysarthria, so writers simply choose the measures they prefer. We
do not believe that this is the case. Rather, the diversity of approaches to measurement
may simply reflect the differing perspectives from which the problem is being viewed.
The vocabulary used in the ICF model may enable the reader to critically evaluate the
adequacy of the measures employed in research, in other words, to determine whether
the measures are well suited to their intended purpose. For example, aerodynamic mea¬
sures of velopharyngeal resistance are frequently used as an indicator of velopharyn¬
geal impairment. However, these measures alone, without corroborating measures of
functional limitations such as speech intelligibility, may not be sufficient to document
the effectiveness of an intervention program. Because the ultimate goal of intervention
is more intelligible speech, and not better velopharyngeal performance, the measures
of change in functional limitation and disability must accompany the measures that
reflect a change in the impairment.

The Role of the Speech-Language Pathologist

For the speech-language pathologist, a clinical intervention may be thought of as a

process of observing behavior, gathering pertinent information, and making decisions
about the management of the communication problems of the individual with motor
speech disorders. Before the speech-language pathologist’s role is discussed, some basic
tenets of the clinical process are described.

Tenets of the Clinical Process

The decisions made by speech-language pathologists in the clinical setting can be char¬
acterized by three principles. First, they are individualized. Almost without exception,
the clinician is faced with decisions that relate to a single person who may or may not ex-
 Perspectives on Motor Speech Disorders 0 19

hibit a classic pattern of impairment, activity limitation, and restriction in participation

that is associated with a particular neurologic disorder. Typically in clinical manage¬
ment, complicating factors or special considerations make each person unique. Second,
there is almost always an urgency to make clinical decisions. Rather than waiting until
research has provided better measurement techniques or a more complete understand¬
ing of the disorder, the clinician is forced to do the best job possible with the knowledge
and tools available at the moment. Third, the clinician must make decisions based on
the broadest possible perspective. The researcher may quite rightfully choose to focus
on a limited aspect of this complex disorder and to study that aspect both systematically
and in great detail, but the clinician usually does not have this option.

Differential Diagnosis

At times, speech-language pathologists need to take the point of view that dysarthria or
apraxia of speech is a sign or symptom of a neurologic disease or condition. This role
frequently occurs in consultation with neurologists and other members of the medi¬
cal diagnostic team. The topic of differential diagnosis, which involves determining
which of a variety of conditions with similar symptoms a person is experiencing, is
discussed in detail in Chapter 3. Clinicians playing this role seek answers to specific
types of questions:

• Is dysarthria or apraxia of speech present, or are the signs and symptoms character-
istkrof some other communication problem? This line of questioning eventually
leads to a differential diagnosis of motor speech disorders; it is determined that the
patient has a motor speech disorder as opposed to some other type of neurologic
communication problem, including aphasia and dementia.
• If a motor speech disorder is present, are the features consistent with those typically
observed in speakers with the proposed diagnosis? This line of questioning leads to
a differential diagnosis among the motor speech disorders and may contribute
eventually to a differential diagnosis of the underlying neurologic disorder.
• How severe are the signs and symptoms, and are they changing? Answers to these
questions will eventually lead to an index of the severity of the neurologic disease
and a means of monitoring the course of the disease or response to medication.

Intervention

The primary role of the speech-language pathologist on the rehabilitation team is to

plan and carry out intervention, a process that helps a speaker with motor speech dis¬
orders to achieve and maintain the highest possible level of communicative function.

Identifying Treatment Candidates

The presence of motor speech disorders can be easily documented by listening to the
speaker or by obtaining any number of measures of motor performance of the various
20 HP Chapter i

speech components. However, merely knowing that the disorder is present does not help
the clinician decide how important it is to treat the individual. Placing motor speech
disorders within the ICF framework may provide some assistance in this area. Consider
the case of two speakers with dysarthria who have moderately severe impairment and
disability. The urgency of treatment for these speakers does not depend entirely on the
impairment or the activity limitation, but on the participation restriction. Suppose that
the first speaker is a retired person living at home with his wife. His intelligible but slow
speech may be sufficient to support his conversational needs. His level of activity limi¬
tation may be mild because he has occasion to speak only with those who are familiar
with him, and rapid, efficient, and natural sounding speech is not mandatory. However,
suppose the second speaker is a minister whose duties require extensive public speak¬
ing. Her speech must be intelligible, of course, but it must also be rapid, efficient, and
natural sounding. Even a moderate level of activity limitation would severely restrict
her participation. The severity of the impairment, activity limitation, and participation
restriction are not as closely correlated as they may first appear. A speaker with minimal
communication needs may experience a substantial impairment before participation is
restricted. For others, even the mildest of impairments may be of real concern.

Types of Intervention
Intervention may take many forms (see Chapter 4 for a more complete description).
Briefly, intervention may be focused on restoration. Using the terminology of the ICF
framework, the goal of this type of intervention would be to reduce the impairment. For
example, strengthening the muscles of expiration of a speaker with dysarthria (Jones
et al., 2006) has as its goal the “normalization” of the respiration subsystem. Although
the focus of this intervention is at the level of the impairment, outcome is measured
at several levels. Impairment is measured by means of maximum phonation duration,
activity by means of intelligibility scores, and participation by means of communicative
effectiveness. Intervention may also focus on compensation, where the goal is to reduce
the activity limitation through either behavioral or prosthetic strategies. An example
of behavioral compensation is the use of extra effort to increase the loudness of speech
in Parkinson’s disease (Ramig, Sapir, Fox, & Countryman, 2001). A case of prosthetic
compensation is the use of a palatal lift (Roth, Roburka, & Workinger, 2000) or nasal
obturator (Hakel, Beukelman, Fager, Green, & Marshall, 2004) to counteract the effect
of velopharyngeal impairment. Intervention focusing on supplementation of informa¬
tion provided to the listener (Hanson, Yorkston, & Beukelman, 2004) falls at the in¬
terface between activity and participation in the ICF framework. An example of such
intervention is the use of an alphabet board to indicate the first letter of each word as it
is spoken. Finally, when natural speech is profoundly affected, intervention may focus
on the addition of alternative types of communication to supplement residual natural
speech. Many types of electronic and nonelectronic devices are available (Beukelman,
Garrett, & Yorkston, 2007; Beukelman & Mirenda, 2005).
 Perspectives on Motor Speech Disorders 0 21

References

Adams, S. G. (1997). Hypokinetic dysarthria in Parkinson’s disease. In M. R. McNeil (Ed.), Clinical man¬
agement of sensorimotor speech disorders (pp. 261-286). New York: Thieme Medical.
American Speech-Language-Hearing Association. (2001). Scope of practice for speech-language pathology.
Rockville, MD: Author.
American Speech-Language-Hearing Association. (2007). Childhood apraxia of speech: Position statement.
Available from www.asha.org/policy
Ball, L. J., Bernthal, J. E., 8c Beukelman, D. R. (2002). Profiling communication characteristics: Chil¬
dren with developmental apraxia of speech. Journal of Medical Speech-Language Pathology, 10(4),
221-230.
Baylor, C. R., Yorkston, K. M., 8c Eadie, T. L. (2005). The consequences of spasmodic dysphonia on
communication-related quality of life: A qualitative study of the insider’s experiences. Journal of
Communication Disorders, 38, 395-419.
Baylor, C. R., Yorkston, K. M., Eadie, T. L., 8c Maronian, N. (2007). The psychosocial consequences of
BOTOX® injections for spasmodic dysphonia: A qualitative study of patients’ experiences. Journal of
Voice, 21(2), 231-247.
Beukelman, D. R., Garrett, K. L., & Yorkston, K. M. (Eds.). (2007). Augmentative communication strategies
for adults with acute and chronic medical conditions. Baltimore: Brookes.
Beukelman, D. R., 8c Mirenda, P. (2005). Augmentative and alternative communication: Management of
severe communication disorders in children and adults (3rd ed.). Baltimore: Brookes.
Bornman, J., 8c Murphy, J. (2006). Using the ICF in goal setting: Clinical application using TALKING
MATS. Disability and Rehabilitation: Assistive Technology, 1(3), 145-154.
Bruyere, S. M., Van Looy, S. A., 8c Peterson, D. B. (2005). The International Classification of Functioning,
Disability and Health: Contemporary literature overview. Rehabilitation Psychology, 50(2), 113-121.
Bryne, K., 8c Orange, J. B. (2005). Conceptualizing communication enhancement in dementia for family
caregivers using the WHO-ICF framework. Advances in Speech Language Pathology, 7(4), 187-202.
Caruso, A. J., 8c Strand, E. A. (1999). Motor speech disorders in children: Definitions, background, and
a theoretical framework. In A. J. Caruso 8c E. A. Strand (Eds.), Clinical management of motor speech
disorders in children (pp. 1-28). New York: Thieme.
Croot, K. (2002). Diagnosis of AOS: Definition and criteria. Seminars in Speech and Language, 23(4),
267-279.
Darley, F. L., Aronson, A. E., 8c Brown, J. R. (1969a). Clusters of deviant speech dimensions in the dysar¬
thrias. Journal of Speech and Hearing Research, 12, 462-496.
Darley, F. L., Aronson, A. E., 8c Brown, J. R. (1969b). Differential diagnostic patterns of dysarthria. Journal
of Speech and Hearing Research, 12, 246-269.
Darley, F. L., Aronson, A. E., 8c Brown, J. R. (1975). Motor speech disorders. Philadelphia: W. B. Saunders.
Dromey, C., 8c Adams, S. G. (2000). Loudness perception and hypophonia in Parkinson disease. Journal
of Medical Speech-Language Pathology, 8(4), 255-260.
Duffy, J. R. (2005). Motor speech disorders: Substrates, differential diagnosis, and management. St. Louis:
Mosby.
Eadie, T. L. (2003). The ICF: A proposed framework for comprehensive rehabilitation of individuals who
use alaryngeal speech. American Journal of Speech-Language Pathology, 12(2), 189-197.
Eadie, T. L., Yorkston, K, M., Klasner, E. R., Dudgeon, B. J., Deitz, J., Baylor, C. R„ et al. (2006). Measur¬
ing communicative participation: A review of self-report instruments in speech-language pathology.
American Journal of Speech-Language Pathology, 15, 307-320.
Forrest, K. (2003). Diagnostic criteria of developmental apraxia of speech used by clinical speech-
language pathologists. American Journal of Speech-Language Pathology, 12(3), 376-380.
22 fli Chapter i

Hakel, M., Beukelman, D. R., Fager, S., Green, J., 8c Marshall, J. (2004). Nasal obturator for velopharyngeal
dysfunction in dysarthria: Technical report on a one-way valve. Journal of Medical Speech-Language
Pathology, 12(4), 155-160.
Hanson, E. K., Yorkston, K. M., 8c Beukelman, D. R. (2004). Speech supplementation techniques for dys¬
arthria: A systematic review. Journal of Medical Speech-Language Pathology, 12(2), ix-xxix.
Hardy, J. C. (1967). Suggestions for physiologic research in dysarthria. Cortex, 3, 128-156.
Hickson, L. M., Worrall, L., Wilson, J., Tilse, C., 8c Setterlund, D. (2005). Evaluating communication for
resident participation in an aged care facility. Advances in Speech Language Pathology, 7(4), 245-257.
Howe, T. J., Worrall, L. E., 8c Hickson, L. M. (2004). What is an aphasia friendly environment? Aphasiol-
ogy, 18(11), 1015-1037.
Jette, A. M. (2006). Toward a common language for function, disability and health. Physical Therapy,
86(5), 726-734.
Jones, H. N., Donovan, N. J., Sapienza, C. M., Shrivastav, R., Fernandez, H. H., 8c Rosenbek, J. C. (2006).
Expiratory muscle strength training in the treatment of mixed dysarthria in a patient with Lance-
Adams syndrome. Journal of Medical Speech-Language Pathology, 14(3), 207-218.
Law, M. (2002). Participation in the occupations of everyday life. American Journal of Occupational Ther¬
apy, 56, 640-649.
Leahy, M. M. (2005). Changing perspectives for practice in stuttering: Echoes from a Celtic past, when
wordlessness was entitled to time. American Journal of Speech-Language Pathology, 14(4), 274-283.
McLeod, S. (2004). Speech pathologists’ application of the ICF to children with speech impairment. Ad¬
vances in Speech Language Pathology, 6(1), 75-81.
McNeil, M. R., Doyle, P., 8c Wambaugh, J. L. (2000). Apraxia of speech: A treatable disorder of motor
planning and programming. In S. Nadeau, L. Gonzalez-Rothi, 8c B. Crosson (Eds.), Aphasia and
language: Theory to practice (pp. 221-266). New York: Guilford Press.
Murdoch, B. E., Chenery, H. J., Bowler, S., 8c Ingram, J. C. L. (1989). Respiratory function in Parkin¬
son’s subjects exhibiting a perceptible speech deficit: A kinematic and spirometric analysis. Journal of
Speech and Hearing Disorders, 54, 610-626.
Ramig, L. O., 8c Dromey, C. (1996). Aerodynamic mechanisms underlying treatment-related changes in
vocal intensity in patients with Parkinson disease. Journal of Speech and Hearing Research, 39(4),
798-807.
Ramig, L. O., Sapir, S., Fox, C., 8c Countryman, S. (2001). Changes in vocal intensity following intensive
voice treatment (LSVT®) in individuals with Parkinson disease: A comparison with untreated pa¬
tients and normal age-matched controls. Movement Disorders, 16(1), 79-83.
Roth, C. R., Roburka, B. J., 8c Workinger, M. S. (2000). The effects of a palatal lift prosthesis on speech
intelligibility in amyotrophic lateral sclerosis: A case study. Journal of Medical Speech-Language Pa¬
thology, 8(4), 365-370.
Shriberg, L. D., Aram, D. M., 8c Kwiatkowski, J. (1997a). Developmental apraxia of speech: I. Descriptive
and theoretical perspectives. Journal of Speech, Language, and Hearing Research, 40, 273-285.
Shriberg, L. D., Aram, D. M., 8c Kwiatkowski, J. (1997b). Developmental apraxia of speech: II. Toward a
diagnostic marker. Journal of Speech, Language, and Hearing Research, 40, 286-312.
Shriberg, L. D., Aram, D. M., 8c Kwiatkowski, J. (1997c). Developmental apraxia of speech: III. A subtype
marked by inappropriate stress. Journal of Speech, Language, and Hearing Research, 40, 313-337.
Smiley, D. F., Threats, T. T., Mowry, R. L., 8c Peterson, D. B. (2005). The International Classification of
Functioning, Disability and Health (ICF): Implications for deafness rehabilitation education. Reha¬
bilitation Education, 19(2-3), 139-157.
Solomon, N. P., 8c Hixon, T. J. (1993). Speech breathing in Parkinson’s disease. Journal of Speech and Hear¬
ing Research, 36, 294-310.
Threats, T. T. (2006). Towards an international framework for communication disorders: Use of the ICF.
Journal of Communication Disorders, 39, 251-265.
 Perspectives on Motor Speech Disorders 0 23

Wambaugh, J. L. (2002). A summary of treatments for apraxia of speech and review of replicated ap¬
proaches. Seminars in Speech and Language, 23, 293-308.
Wambaugh, J. L., Duffy, J. R., McNeil, M. R., Robin, D. A., 8c Rogers, M. A. (2006a). Treatment guidelines
for acquired apraxia of speech: A synthesis and evaluation of the evidence. Journal of Medical Speech-
Language Pathology, 14(2), xv-xxxii.
Wambaugh, J. L., Duffy, J. R., McNeil, M. R., Robin, D. A., & Rogers, M. A. (2006b). Treatment guidelines
for acquired apraxia of speech: Treatment description and recommendations. Journal of Medical
Speech-Language Pathology, 14(2), xxxv-lxvii.
World Health Organization. (1980). International Classification of Impairment, Disabilities, and Handi¬
caps. Geneva, Switzerland: Author.
World Health Organization. (1999). ICIDH-2: A manual of dimensions of disablement and health. Re¬
trieved May 6, 1999, from http://www.who.int/msa/mnh/ems/icidh/
World Health Organization. (2001). International Classification of Functioning, Disability and Health
(ICF). Geneva, Switzerland: Author.
Yaruss, J. S., 8c Quesal, R. (2004). Stuttering and the International Classification of Functioning, Disabil¬
ity and Health: An update. Journal of Communication Disorders, 37, 35-52.
Yorkston, K. M., Baylor, C. R., Klasner, E. R., Deitz, J., Dudgeon, B. J., Eadie, T. L., et al. (2007). Satisfac¬
tion with communicative participation as defined by adults with multiple sclerosis: A qualitative
study. Journal of Communication Disorders, 40, 433-451.
Yorkston, K. M., Bombardier, C., 8c Hammen, V. L. (1994). Dysarthria from the viewpoint of individu¬
als with dysarthria. In J. A. Till, K. M. Yorkston, 8c D. R. Beukelman (Eds.), Motor speech disorders:
Advances in assessment and treatment (pp. 19-36). Baltimore: Brookes.
Yorkston, K. M., Klasner, E. R., 8c Swanson, K. M. (2001). Communication in context: A qualitative study
of the experiences of individuals with multiple sclerosis. American Journal of Speech-Language Pa¬
thology, 10(2), 126-137.
Yorkston, K. M., Strand, E. A., 8c Hume, J. (1998). The relationship between motor function and speech
function in amyotrophic lateral sclerosis. In M. P. Cannito, K. M. Yorkston, 8c D. R. Beukelman
(Eds.), Neuromotor speech disorders: Nature, assessment, and management (pp. 85-98). Baltimore:
Brookes.
 Clinical Examination
of Motor Speech Disorders

Clinical Issues: We regularly provide clinical training opportunities for student interns
in speech pathology, medical students, and resident physicians in neurology and re¬
habilitation medicine. The impetus for this book has come at least in part from our at¬
tempts to help our students make the transition from being students to being practicing
clinicians, from readers of research literature to individuals responsible for making deci¬
sions about management of communication problems. Typically, our speech-pathology
interns come to us well versed in the normal aspects of speech production. Students in
speech-language pathology have read research literature related to motor speech dis¬
orders. If we were to ask them to list all the aspects of speech production in individuals
with dysarthria or apraxia that can be measured, their lists would be long. Students, if
asked, would typically have much more difficulty selecting those aspects of speech that
they would measure given only a 1-hour evaluation time. The goal of this chapter is to
provide a framework for deciding what aspects of speech are important to measure
within typical clinical time limitations. In Chapter 1, we introduced the International
Classification of Functioning, Disability and Health (ICF) (World Health Organization,
2001). This framework provides a terminology and structure for describing dysarthria
and apraxia of speech. This framework will serve as the structure for assessment. In this
chapter, we will address the following questions:

• What is the nature and severity of underlying motor impairment?

• What are the consequences of those impairments for the activity of speech?
• Is participation in valued roles or situations restricted by the dysarthria or apraxia
of speech?

25
26 Si Chapter 2

This is the first of three chapters on the topic of assessment. In the present chapter, the
process of gathering relevant information is described. In the next chapter, “Differential
Diagnosis,” strategies to distinguish among the various neurologic communication dis¬
orders are illustrated. The third chapter on assessment, entitled “Treatment Planning
in Motor Speech Disorders,” outlines the process by which clinical decisions are made
about candidacy and treatment design.

Purposes of the Clinical Examination

While the clinical examination of speech is a process of observation and fact-finding,

it must go beyond description to include synthesis of information, dynamic analysis,
and initial intervention planning. Adequate treatment plans can only be developed out
of assessments that probe the nature of the condition and the speaker’s response to it.
Because clinical hypotheses are formed and tested, the examination will proceed in
different directions based on initial findings. In other words, the clinician changes the
assessment strategies based on what he or she has already seen. The specific goals and
outcomes of the examination may vary from situation to situation. Although each ex¬
amination does not address every issue, the following list contains potential reasons for
assessing speakers with motor speech disorders (McNeil & Kennedy, 1984, p. 337):

• to detect or confirm a suspected problem

• to establish a differential diagnosis
• to classify the problem within a specified disorder group
• to determine site of lesion or disease process
• to specify the degree or severity of involvement
• to establish a prognosis
• to specify more precisely the treatment focus
• to establish criteria for treatment termination
• to measure any change in the patient that accompanies treatment, lack of treatment,
or exacerbation of the original etiological factor

Site of Practice

The purposes of the clinical examination may vary depending on such factors as site
of practice and phase of intervention. For example, the site of practice may be an out¬
patient diagnostic clinic within a department of neurology, an inpatient rehabilitation
service, or a community-based rehabilitation program. In each of these sites, the clini¬
cal examination may have different goals. In the neurology clinic, contribution to a
differential diagnosis and documentation of current severity may be the tasks at hand.
 Clinical Examination of Motor Speech Disorders W 27

For example, the speech-language pathologist may be asked to give an opinion about
which cranial nerves are impaired. In an inpatient rehabilitation service, establishing
the prognosis for improvement and developing a plan of intervention may be the goal.
In a community-based rehabilitation program, the examination may have a number of
goals, including understanding the pattern and severity of the impairment as well as the
functional limitation and disability. A primary care team in a community-based set¬
ting may be responsible for multiple aspects of the condition. Increasingly, health care
is being delivered in a variety of venues, and clinical examination must be tailored to
the specific needs of each.

Critical Periods of Intervention

The phase of intervention may also influence the range of possible assessment questions
and thus the conclusions of the clinical examination. For example, a number of criti¬
cal points in the management of individuals with amyotrophic lateral sclerosis (ALS)
may dictate the focus of the clinical examination. Assessment may occur at four critical
points. The first occurs when the diagnosis is made. At that time, the speech-language
pathologist determines the presence or absence of dysarthria and verifies that the pat¬
tern of dysarthria is consistent with the proposed medical diagnosis. The clinician con¬
ducts the assessment in a way that will enable him or her to discuss with the speaker and
the family the nature of the problem, and to verify whether or not the dysarthria is cur¬
rently restricting participation in valued communicative situations. The second critical
point occurs after the individual has achieved some psychological acceptance of the
presence of the disease. Here the general goal of assessment is to stage treatment, that is,
to prepare speakers and their families for the next steps if the symptoms become more
severe. Based on this assessment, the clinician also makes some initial judgments about
the rate of progression of the disease. At this point, the person with ALS is involved in
an information-gathering phase regarding services available, including augmentative
communication options. Guidelines are provided for a reevaluation schedule. These
guidelines are general and suggest the need for reassessment when speech problems
begin to interfere with any aspect of daily activities. In most cases, this occurs when
intelligibility is compromised in some situations. Thus, the third critical assessment
point occurs when the dysarthria becomes severe enough to limit the activity of speak¬
ing or to restrict participation in communication situations. At this time, assessment is
carried out to establish candidacy for treatment and to specify the treatment focus. For
example, the outcome of the evaluation may be identification of strategies to supple¬
ment the speaker’s highly distorted speech with semantic or other types of cues. This
assessment may be followed by a brief period of training in an effort to maximize intel¬
ligibility and participation. The fourth critical point occurs when speech is so severely
involved that it must be replaced by other communication approaches. As an outcome
of this assessment process, an augmentative communication system may be selected.
The case of an individual with a degenerative dysarthria serves to illustrate the varying
28 0 Chapter 2

purposes of assessment. Purposes of assessment also vary over time in children with de¬
velopmental motor speech disorders. Parents’ and children’s needs, roles, and expecta¬
tions are different when the child is an infant or toddler compared with when he or she
enters school. Assessment is sometimes done to confirm the presence of the disorder,
and at other times to measure its severity. Still other times, clinicians assess to direct
the treatment, to identify the intervention approaches that may be effective, or to make
recommendations about alternatives to verbal communication.

Principles of the Clinical Examination

The following sections provide an overview of principles that form the foundation
for the clinical examination of motor speech disorders, including the knowledge base
needed, terminology, and procedures.

Establishing a Knowledge Base

“What one knows, one sees” (DeGowin, 1987, cited in Miller 8c Groher, 1990). This
maxim has two, quite different, meanings. On the one hand, the broader the knowl¬
edge base brought to the task, the more effective the examination will be. Therefore, it
is critical for the speech-language pathologist to have an understanding of the diseases
and conditions that may be associated with motor speech disorders, as well as their un¬
derlying neuropathologies, etiologies, natural courses, and associated symptoms. The
results of the clinical examination of speech must be viewed in the broad context of
other motor and cognitive signs and symptoms. For those clinicians evaluating a po¬
tential motor component to a speech or language delay in children, this broader context
includes knowledge of speech and language development. Clinicians need to pay par¬
ticular attention to how cognitive, language, and motor processes interact and influence
each other during development (Strand, 1992,1999). For example, children with severe
motor planning problems would not be expected to perform normally on articulation
tests or tests of phonologic processing. The clinician must ask, however, whether the
child’s poor performance on these tests is actually due to phonologic processing deficits
or to the impact of the motor planning deficit on normal acquisition of phonology.
On the other hand, the maxim “what one knows, one sees” should also be inter¬
preted as a caution. If clinicians see only what they expect to see, they may miss impor¬
tant findings. Care should be taken not to attribute all symptoms to a particular known
diagnosis. For example, the diagnosis of Parkinson’s disease does not preclude the oc¬
currence of other disorders with consequences for communication. A person with Par¬
kinson’s disease and dysarthria may also experience any number of problems unrelated
to the primary diagnosis. For example, the person may experience a hearing loss that
compromises his or her ability to speak at the appropriate loudness levels. If clinicians
 Clinical Examination of Motor Speech Disorders H 29

see only what they expect to see, they may fail to identify complicating and potentially
treatable problems.

Speech Assessment as Part of the Neurologic Examination

Assessment of speech is an important part of the neurologic examination. A neurology

colleague of Duffy’s (2005) said that “nearly all clinical neurologic diagnosis is based
on speech, either its content or its manner of expression” (p. 71). Consider how much
information about neurologic status a skilled clinician can obtain by appraising the
way a person communicates. Considering the following questions can yield a wealth of
information about a speaker’s cognitive status:

• What is the speaker’s level of consciousness—alert, drowsy, lethargic, and so on?

• What is the speaker’s level of cooperation?
• What is the speaker’s affect—depressed, anxious, labile, and so on?
• Can the speaker respond to questions?
• Is the speaker oriented to time, person, and place?

Skilled clinicians also form impressions about the speaker’s language skills:

• Does the speaker appear to have word-finding and sentence formulation problems?
• Does the speaker appear to understand what is being said?

Question: What is involved in a neurologic examination?

The neurologic examination attempts to answer the following six Wh- questions
(Mumenthaler, 1 983):

• When was the onset and what were the symptoms at onset (case history)?
• What can be found (physical examination)?
• Where is the lesion situated, producing this clinical picture (topical diagnosis)?
• Why is the patient ill (etiologic diagnosis)?
• What is the course of the illness (prognosis)?
• What is the management (treatment)?

Expressive communication, specifically speech, requires not only cognitive and linguis¬
tic processing, but also precise, rapid, and coordinated movements. Therefore, an im¬
pression of problems in movement and the control of movement can also be formed.
The clinical examination outlined in this chapter focuses to a large extent on motor
speech abilities. However, motor speech is affected by other factors, including, among
others, cognition, language abilities, somatosensory function, and level of hearing.
Another random document with
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doing they may be considered in connection with the remarks of their
critics and a just comparison made. In presenting the views of
Quaker educators reference may be made to salient points in the
criticism, which seem out of keeping with the ideas set forth and
without foundation as matters of fact.
There are quite a number of men, in the brief [Sidenote: Only a
period studied, who stand out clearly and express few of the leaders’
themselves definitely in favor of education, though statements to be
considered]
they do not consider it the first requisite for a
minister of the gospel.[76] From this number it will be feasible to
select only a few for the chief consideration, relegating the remainder
to a place of comparative unimportance and incidental notice. The
work of George Fox, though he was poorly educated, had a
remarkable effect on the educational work of the society. But it is not
necessary to review that in the present chapter as it has been
presented in the first.[77]
By far the most familiar of all characters in Quaker history is that of
William Penn. And to his influence must be attributed largely the
hearty interest in education shown, not only in Philadelphia, but also
in the surrounding communities. He was well educated, but it is not
desired to make a case for or against him on the basis of his
education; let us judge by his written or spoken expression and
actual procedure in practice. No attempt is made to prove or
disprove his contentions as to what was right or wrong, necessary or
unnecessary in education. The questions asked in his case and the
others that follow is: What did they approve or disapprove of in
education?
Not only in works that might be called strictly [Sidenote: Penn
educational did Penn give educational advice, recommends
valuable alike to youth and to parents, the directors practical virtues]
of youth. His advice to his children on the value of
diligence and its necessity for success, and the propriety of frugality,
even in the homes of the rich, embodies many of the most essential
principles in education at any time. It is especially applicable to the
education of the man of business, emphasizing the importance of the
practical duties in life. Some pointed statements are especially
worthy of repetition.
[Sidenote:
Diligence ... is a discreet and understanding Diligence]
application of onesself to business; ... it loses
not, it conquers difficulties.... Be busy to a [Sidenote:
Frugality]
purpose; for a busy man and a man of business
are two different things. Lay your matters and diligence
succeeds them, else pains are lost.... Consider well your end,
suit your means to it, and diligently employ them, and you will
arrive where you would be....[78] Frugality is a virtue too, and
not of little use in life, the better way to be rich, for it hath less
toil and temptation.... I would have you liberal, but not
prodigal; and diligent but not drudging; I would have you
frugal but not sordid.[79]

This bit of philosophy is educational in its bearing in very much the

same way as that of Benjamin Franklin.
In the letters to his wife and children, referring to the care for their
education, he is more specifically concerned with actual school
education.
[Sidenote: School
For their learning, be liberal. Spare no cost, education
for by such parsimony all is lost that is saved; recommended;
but let it be useful knowledge such as is the useful
emphasized]
consistent with truth and godliness, not
cherishing a vain conversation or idle mind; but ingenuity
mixed with industry is good for the body and the mind too. I
recommend the useful parts of mathematics, as building
houses, or ships, measuring, surveying, dialing, navigation;
but agriculture especially is my eye. Let my children be
husbandmen and housewives; it is industrious, healthy,
honest and of good example, ...[80]
 His preference, as might be expected from an [Sidenote: Private
Englishman of that time, was for a tutorial system tutors desired]
of education. His reasons therefore seem to have
been based chiefly on moral grounds.

Rather have an ingenious person in the house to teach

them, than send them to schools; too many evil impressions
being received there.[81]

The above quotation alone would seem to be adequate proof that

Penn did not oppose education, but urged it for others and in his own
family. But still more convincing and irrefutable evidence is found in
the preamble to this school charter, whence an extract is taken.
[Sidenote: Public
Whereas, the prosperity and welfare of any education
people depend in great measure upon the good essential for the
welfare of a
education of youth, and their early instruction in people]
the principles of true religion and virtue, and
qualifying them to serve their country and themselves, by
breeding them in writing and reading and learning of
languages, and useful arts and sciences, suitable to their sex,
age and degree; which cannot be effected in any manner or
so well as by erecting public schools for the purposes
aforesaid, therefore....[82]

If, as must be admitted, the previous statement [Sidenote: His

points out the lack of any opposition to the ordinary ideals expressed
rudimentary education that is necessary for the in action]
everyday walks of life, the last one certainly does [Sidenote: Yearly
the same in reference to his attitude towards a meeting
higher classical education. Moreover, this is not a recommend
French, High and
mere skeleton of words never clothed with the flesh Low Dutch,
of action. The principles set forth in the charter Danish, etc.]
were actually incorporated in the work of the
schools established in Philadelphia, and we find them maintaining a
classical school for languages and higher mathematics.[83] The
practical elements received the just emphasis which belonged to
them; it was necessary that the boys and girls be made able to earn
a living and be at least ordinarily intelligent citizens. The example of
Philadelphia was followed by other communities; practical needs
were given the first consideration and a higher classical education
offered when it became possible. Not only were these studies, which
we would term higher education, mentioned by Penn and other
writers among Quakers, but they were taken up and recommended
by the yearly meeting. For example, in 1737, the minutes
recommend that as opportunity can be found, children should be
privileged to learn “French, High and Low Dutch, Danish, etc.”[84]
This particular recommendation was made by the meeting because
of a felt need.[85] If then in case of a need for a particular subject,
they were willing to recommend that it be taught, can it be truly said
that they opposed all education?
It may be well to examine Barclay, since it is with [Sidenote:
him and his writings that Cox takes issue. In his Barclay’s position
Apology for Christian Divinity Vindicated is to be defined]
found a very clear statement of his position on the
subject, and he voices it as the principle of the whole society as well.
He seems to be answering some critic, who has taken him to task for
his educational views:
[Sidenote: In his
He goes on after his usual manner saying, I Apology]
inveigh against all human learning that has
been made use of any ways in Theology; but where he finds
this asserted I know not, whether the words he would declare
it from, to wit: that man hath rendered the plain and naked
truth obscure and mysterious by his wisdom, will bear such a
consequence is left to the reader’s judgment. But he thinks he
has found out our secret design of being against learning and
schools of learning, which is neither our affirmation nor our
principle, but his own false supposition. We would, saith he,
have all those banished, that we might more easily prevail
with our errors. But methinks the man should be more wary in
 venting his own false imaginations, unless he would bring
some ground for them; for his assertion is so far untrue, that if
he had been rightly informed, he might have known that we
have set up schools of learning for teaching of the languages
and other needful arts and sciences,[86] and that we never
denied its usefulness; only we denied it be a qualification
absolutely necessary for a minister, in which case alone we
have opposed its necessity.[87]

Another character of very great importance in [Sidenote:

this connection is Anthony Benezet. Born, 1713, at Benezet’s early
St. Quentin in France, of “an ancient and life and education]
respectable family” he spent his early years in
France and then in Holland, whither his father had fled for refuge.[88]
A few months were spent in Rotterdam and the family then moved to
London where the father entered into the mercantile business and
retrieved to some extent his fallen fortunes. This enabled him to give
Anthony sufficient education to qualify him for that business, for
which, however, he seemed to evince but little taste. Being of a very
religious nature, he became a member of Friends at about fourteen
years of age, and in that society found the field of his whole life’s
activity, which was chiefly educational.[89] Considerable space will be
devoted to his work in respect to the education of Negroes, so that
will be entirely omitted in this place.[90] He was a voluminous writer,
producing chiefly tracts and letters, and a great majority of these
have a definite educational bearing. Because of the great number of
them it is impossible really to do them justice, but an attempt will be
made to state a few brief theses for which he unchangingly stands.
First, education is a religious and social duty.[91] [Sidenote:
It is exceedingly interesting to notice that he looks Education a
function of
upon education as in the first place a governmental government, but
function, if the governments of this world were often neglected
influenced by true wisdom, they would make the as such; hence
individual effort
proper education of youth their first and special necessary]
care;[92] but since governments have neglected to
do this, it occurs to him that it is a service for which Quakers are
remarkably well fitted. It is a service for which the wage is very small
and which secures no return of special social favors for the laborer.
But they, being a quiet people, not wishing to gain great wealth or to
shine in social positions, can find their sphere of activity in the
education of the youthful members of society.
Second, a special care in the education of the [Sidenote:
poor is urged.[93] This should become the duty and Children
represent
secure the interest of the well-to-do public spirited “capital”; they
man, for if the upper class does not safeguard it, must be
they cannot be educated. The poor child educated]
represents so much unimproved property, the
owner being unable to improve it, which, if taken over by
philanthropists, may become of some consequence to himself and
perform great services for society at large. Such a movement would,
besides being a great aid to the poor and uneducated, be also a
worthy occupation for those who at present have nothing but time
and money to spend. It would help them to realize that there is
something real in the world, something greater than wealth and
broader than religious denominations. The heart of Benezet knew no
bounds; in his philanthropy he included all classes.
Third, a definite stand is made for higher standards for teachers.

I do not know how it is amongst you, but here any person of

tolerable morals, who can read and write, is esteemed
sufficiently qualified for a schoolmaster; when indeed, the
best and wisest men are but sufficient for so weighty a
charge.[94]

He endeavors to show that the work of a teacher is pleasant and

should interest a better class of masters than it has in the past. The
experiences of Benezet in the school work were of most pleasant
nature. Not only by his own statement, but judged also by the
accounts given in his memoirs by Robert Vaux, it seems that he was
unusually kind and sympathetic as a master, which won him the
greatest respect of his pupils.[95] The tasks of schoolteaching are
only unpleasant when being performed merely for the sake of the
wage obtained. Those who attempt to teach large numbers for the
sake of a large income find it disagreeable; they form the class of
teachers against whom he would discriminate.[96] Add to these three
principles, his great contribution toward the freedom and education
of the Negroes, his long life of service, and we have all for which he
lived. It is stated that he had no private life; at any rate it sinks into
oblivion in comparison with his interest and active work in public
philanthropies.[97]
The educational influence of John Woolman in [Sidenote: John
regard to Negro and Indian education will be Woolman, his
position in regard
mentioned in another chapter,[98] but concerning to education]
education generally he was equally outspoken, and
being a member of some consequence he was [Sidenote: The
able to make his influence felt. Like Benezet, he responsibility
tutors and
of

regarded education as a social duty, both to each parents]

individual and to the community of individuals. This
duty could not be performed by immoral tutors and schoolmasters,
for the pupil could be made to rise no higher than the master; so the
result would be an immoral society.[99] The responsibility, in the last
analysis, for the right conduct of schools falls upon the parents. If
they are indifferent, nothing can be accomplished for the schools, for
the whole community is no better or more insistent in its demands
than the individuals constituting it. For this reason he urges individual
philanthropy to come to the aid of the schools, which are badly
neglected; those who possess wealth can do no better, for, as he
says:

Meditating on the situation of schools in our provinces, my

mind hath, at times, been affected with sorrow, and under
these exercises it hath appeared to me, what if those that
have large estates were faithful stewards, and laid no rent or
interest nor other demand, higher than is consistent with
universal love; and those in lower circumstances would under
 a moderate employ, shun unnecessary expense, even to the
smallest article; and all unite humbly in seeking the Lord, he
would graciously instruct and strengthen us, to relieve the
youth from various snares, in which many of them are
entangled.[100]

If to this list of advocates of education, it is [Sidenote: Tuke,

necessary to add others, mention should be made Whitehead,
of Henry Tuke, George Whitehead, and William Crouch as
advocates of
Crouch. In defending certain differences between education]
the Quaker doctrine and that of other
denominations, the former discusses this one, in not considering
human learning essential to a minister of the gospel.[101] The
reasons adduced are chiefly biblical; the knowledge of human
literature is not recommended by the New Testament as being
necessary for a minister, and this is considered conclusive proof.
Moreover, it is pointed out that Paul, though a well educated man,
disclaimed the value of his education for that service, and wished
always to appear to the people as an unlettered man of God.[102] But
Tuke goes on to explain that though it is not essential for a minister,
learning is not unesteemed nor its usefulness slighted.[103] Members
are desired to direct their attention to education, for a right use of it
may promote religion and benefit civil society.[104] That the use of
Latin and Greek is not decried may be seen in the work of Penn and
Whitehead, who were both scholars, and whose works are full of
classical references and illustrations. In one instance their chief
argument against swearing is produced from certain references to
the works of Socrates and Xenocrates, pointing out that the Greeks
were aware of a higher righteousness excelling that of the legal
Jews.[105] The same point of view with reference to a knowledge of
the classics is taken by William Crouch, as is understood at once by
this statement:

They acknowledge the understanding of languages,

especially of Hebrew, Greek and Latin, formerly was and still
 is very useful, yet they take them not therefore to be
necessary to make a minister nor so profitable as that one
unacquainted with them must be styled an idiot, illiterate and
of no authority.[106]

Moreover, from various sources one is assured [Sidenote: The

that a classical education was not abhorred by the Latin School of
Quakers of Philadelphia. The work offered in the Philadelphia
exemplifies
classical school was for any one who had the contention of
ability to do it and its attainment was encouraged those quoted
by Friends. The higher education was for girls as above]
well as for boys, as we may judge from reading the [Sidenote:
journal kept by Sally Wister (or Wistar), a Quaker Education an
girl of the days of the Revolution.[107] She attended asset; but apt to
be perverted]
the school kept by Anthony Benezet,[108] which
was one of the highest class, moral and literary, and patronized by
the best classes of the citizens. Extracts from her Journal indicate
that her education had not been limited to the mere rudiments, but
that she enjoyed also an elementary knowledge, at least, of Latin
and French.[109] This sort of education was clearly not uncommon
among Friends and it was not the object of opposition on their part. It
must, however, be kept in mind that the Quakers never confused
education necessarily with true Christianity.[110] Religion in this life
and the salvation of one’s soul in the next was a problem which
concerned the poor as well as the rich, the untutored as well as the
learned. How could the demands be greater for one than the other;
the same tests had to be met and passed by all, the educated one
received no favors though more might be expected of him.[111]
Education was looked upon as an asset which might be turned to
great use for Christianity, but the lack of it was never a bar to
Christianity.[112] On the other hand, education might easily become,
according to the Quakers’ views, a definite hindrance to Christianity.
[113]

It would be quite improper in connection with this [Sidenote:

subject to fail to mention the scheme, Utopian in Scheme of
that day, which was conceived in the mind of education
Thomas Budd, for the development of a system of suggested by
Thomas Budd]
education for Pennsylvania and New Jersey. At the
very outset it seems more comprehensive than anything suggested
by any other leader, and in fact it embodied so much that it was quite
beyond the limit of expectation for either of the colonies. Thomas
Budd, though not at first a member of Friends, became convinced of
the justice of their principles and joined the society before the year
1678.[114] He was a man of affairs and became greatly interested in
the colonization of Pennsylvania and New Jersey, whither he soon
came as a colonist himself. At that time it was equally true, as at the
present, that if a scheme or undertaking was to be put through, it
must be made as attractive as possible to the prospector. The
attempt to do this called forth a considerable exercise of individual
initiative, and one result was the educational plan outlined by
Thomas Budd and published in Philadelphia in 1685. The details of
the scheme as outlined are deemed of sufficient interest and
importance to warrant their reproduction here.
[Sidenote:
1. Now it might be well if a law were made by Children to be in
the Governors and General Assemblies of public school
Pennsylvania and New Jersey, that all persons seven
more]
years or

inhabiting the said provinces, do put their

children seven years to the Public School, or longer, if the
parent please.

2. That schools be provided in all towns and [Sidenote: To

cities, and persons of known honesty, skill and receive instruction
understanding be yearly chosen by the in the arts and
sciences and to
Governor and General Assembly, to teach and learn a trade]
instruct boys and girls in all the most useful arts
and sciences that they in their youthful capacities may be
capable to understand, as the learning to read and write true
English and Latin, and other useful speeches and languages,
and fair writing, arithmetic and bookkeeping; the boys to be
taught and instructed in some mystery or trade, as the making
of mathematical instruments, joinery, turnery, the making of
clocks and watches, weaving, shoemaking or any other useful
trade or mystery that the school is capable of teaching; and
the girls to be taught and instructed in spinning of flax and
wool, and knitting of gloves and stockings, sewing, and
making of all sorts of useful needlework, and the making of
straw work, as hats, baskets, etc., or other useful art or
mystery that the school is capable of teaching.

3. That the scholars be kept in the morning [Sidenote: Eight

two hours at reading, writing, bookkeeping, etc., hours per day
and other two hours at work in that art, mystery allotted to studies
and chosen trade]
or trade that he or she most delighteth in, and
then let them have two hours to dine, and for recreation and
in the afternoon two hours at reading, writing, etc., and the
other two hours at work at their several employments.

4. The seventh day of the week the scholars [Sidenote:

may come to school only in the forenoon, and at Regular school
a certain hour in the afternoon let a meeting be work five and
one-half days per
kept by the schoolmasters and their scholars, week; moral
where good instruction and admonition is given instruction on
by the masters to the scholars and thanks Saturday]
returned to the Lord for his mercies and
blessings that are daily received from him, then let a strict
examination be made by the masters, of the conversation of
the scholars in the week past, and let reproof, admonition and
correction be given to the offenders, according to the quantity
and quality of their faults.

5. Let the like meetings be kept by the school [Sidenote: Similar

mistresses, and the girls apart from the boys. arrangement for
By strictly observing this good order our girls educated
separately]
children will be hindered from running into that
excess of riot and wickedness that youth is incident to, and
they will be a comfort to their tender parents.
 6. Let one thousand acres of land be given
and laid out in a good place, to every public [Sidenote: Land
endowment for
school that shall be set up, and the rent or schools]
income of it to go towards the defraying of the
charge of the school.

7. And to the end that the children of the poor [Sidenote: Indians
people, and the children of Indians may have and the poor to be
the like good learning with the children of the educated
cost]
free of

rich people, let them be maintained free of

charge to their parents, out of the profits of the school, arising
by the work of the scholars, by which the poor and the Indians
as well as the rich, will have their children taught, and the
remainder of the profits, if any be to be disposed of in the
building of the schoolhouses and improvements on the
thousand acres of land, which belongs to the school.[115]

The author does not claim to be entirely original [Sidenote: The

in his scheme, having been influenced, he says, by industrial and
a similar thing described by Andrew Yarenton in a commercial
values to be
book, England’s Improvements by Sea and Land. derived are
[116] His chief interest seems to be in the benefit to pointed out]
be derived for the commercial life of the colonies,
and for that reason there is accordingly a great stress on the
industrial education. By this introduction of the industrial schools,
spinning for example, in the larger cities and the preparation of
children at an early age for participation in that great occupation, the
production of linen cloth could be made equal not only to the
domestic demands but also a considerable margin for the foreign
trade.[117] It is pointed out that the colonial consumer pays twice as
much for his purchase as its cost of production in France or
Germany, and that he pays this extra cost into the coffers of the
English merchants. This profit should accrue to the home merchants.
The educational and also the industrial scheme [Sidenote:
is to receive the backing of the colonial Scheme to be
government. It is recommended that laws be
passed for the encouragement of linen encouraged by
manufacturers and that farmers “that keep a plow” the government]
should sow an acre of flax and two of hemp, with [Sidenote:
which to supply the manufacturers.[118] Educational Essential points
urged in the
support by the government was not secured, as is scheme]
amply evidenced by the unsurpassed development
of private and parochial schools of all [Sidenote: The
denominations. The churches were the sponsors lack of
governmental
for education. It is worthy of note, however, that the support; supplied
elements emphasized by Budd, (1) education in the through meetings
arts and sciences for all those capable of it, (2) of Quakers]
industrial education for a trade for every one, (3)
moral and religious training, and (4) equal educational opportunities
for poor and rich or otherwise unfavored classes, are the same as
those urged officially by the Quakers.[119]
Far from receiving governmental support, it was necessary that
the schools be supported by individual or small group enterprise.
The society recognized this, and it is stated in the organization of the
church that the duty of the monthly meeting is to provide for the
subsistence of the poor and for their education.[120] Furthermore it is
recommended that all special bequests of Friends be kept as a
distinct fund for the purpose originally intended by the donor, and
that if expended for any other purpose, it must be again made up by
the quarterly meeting.[121] One of the most frequent uses
designated, judging from the records, seems to have been the
educational.[122]
The reader may have perused the foregoing [Sidenote: Have
pages with more or less interest; a curiosity may Quaker schools
have been aroused concerning the present-day kept pace with the
public?]
attitude of Friends, educationally. Have they
experienced any considerable change? The institutional evidences
of their continued interest are familiar enough to the educationist. But
what is the attitude within the schools: Is instruction stiff and more
formal there than in the public schools, and what can be said of the
progress among the teachers? To answer all of these questions and
similar ones is not the purpose of this present work. And in the
following excerpt, taken from an expression drawn up by a body of
teachers, it is not hoped to find conclusive proof of this or that, but
perhaps it may be taken as a fairly reliable indication of the present
professional attitude.
[Sidenote: The
The teachers’ subjects are not Mathematics, pupil as an
nor Latin, nor Scripture, nor Quakerism—they individual to be
emphasized]
are boys and girls. The information imparted is,
in a sense, a minor matter: the growth of the [Sidenote: Well-
mind that assimilates it is all-important—growth equipped
teachers needed;
in keenness, efficiency and power.... and their
To the Society at large we would put forward academic
freedom
this view that the principles urged above are essential]
deserving of careful consideration in making
any forward move. The quality of the teaching given in our
schools is in a measure in the hands of Friends; they have
raised admirable buildings in many places—these are a small
matter compared with the character of the staff. The freedom
of the teacher, which is an indispensable condition of
excellence is a gift they can grant or withhold. And that we
who are responsible for the term of school life may have the
best chance and the best reward, we would press upon
Friends the need of laying foundations and awakening
interest in the days of childhood, and of turning to best
account the powers of those who go forth from our schools.
[123]

SUMMARY
This chapter treats of the attitude of Friends [Sidenote:
towards education. At the beginning there is Summary of
presented a criticism of S. H. Cox, which is a Cox’s position]
concrete example of the type of criticism referred to
in these pages. Following this there are presented the educational
views of several Friends,—Penn, Barclay, Benezet, Woolman,
Whitehead, Crouch, Tuke, and Thomas Budd, in order that the
reader may judge of the truth or error presented in the criticism. The
chief points made in Cox’s criticism are: (1) hostility of the Quaker
system to classical education, (2) general hostility of the Friends to
colleges and seminaries of learning, and (3) that the “light within”
was sufficient without any education.
From the material next presented it is shown [Sidenote:
that: (1) Penn recommended both practical and Summary of
higher education, (2) useful arts and sciences are points maintained
by certain Quaker
recommended to be taught in public schools, (3) leaders]
the classics were introduced as a part of the
curriculum in the Penn Charter School, and also in other schools
established by the society, (4) Barclay explains that the society holds
a classical education not absolutely necessary for a minister, though
it is useful, (5) the learning of languages is recommended by the
London Yearly Meeting, (6) education is advocated by Benezet as a
religious and social duty; the education of the poor and unfortunate
classes and races is urged; a higher education for schoolmasters is
recommended, (7) Woolman urges the education of Negroes and
Indians as a social duty; the responsibility is placed on the individual,
(8) Crouch states that Hebrew, Greek, and Latin are recognized as
useful and are not opposed when taught for that purpose, (9) Budd,
one of the early Quakers in Pennsylvania, introduced a very
comprehensive and Utopian scheme for (a) industrial education and
(b) higher education, proposing to organize it under the control of the
General Assembly, and (10) indications are that progress, within the
teaching body in Friends’ institutions, is quite comparable with that of
other institutions, though there is no attempt to produce conclusive
evidence either to that effect or the contrary.
 CHAPTER IV
EDUCATION IN PHILADELPHIA[124]

On ye 27th day of October, 1682, arrived before ye Towne

of New Castle from England, William Penn, Esqe., whoo
produced twoo deeds of feofment for this Towne and twelve
myles about itt, and also for ye twoo lower counties, ye
Whoorekills and St. Jones’s—wherefore ye said William Penn
received possession of ye Towne ye 28th of October, 1682.
[125]

It is probable that Penn reached Philadelphia in [Sidenote: The

the latter days of October or the early part of date of Penn’s
coming disputed]
November,[126] though no student of Philadelphia
history has yet been able to settle the question of the day absolutely.
Tradition says he came up the river in an open boat and landed at
the landing on Dock Street near the new tavern, the Blue Anchor,
which had just been erected by George Guest, a Quaker.[127] The
formal ceremony of transferring the territory which had been
arranged between Penn and the Duke of York before leaving
England,[128] was accomplished with the Duke’s commissioners,
Moll and Herman,[129] and the official debut of Pennsylvania in
colonial society was no longer a hope but a reality.
The foundation of the colony’s educational [Sidenote:
institutions had, however, not been delayed till the Education
formalities of “making” a colony were over. provided for in
first Frame of
Education received early consideration in the Government]
Frame of Government which was drawn up from
England by Penn and agreed to on April 25, 1682, before he
prepared to depart for Pennsylvania.[130] In that document it is
clearly set forth that education was the function of the civil authority,
though the intentions of the author were not realized fully for more
than a hundred and fifty years.[131] The same idea is present in each
of the three Frames of Government which were drawn up; the first,
April 25, 1682;[132] the second, April 2, 1683;[133] and the third,
November 7, 1696,[134] under Governor Markham. The instrument
drawn on April 2, 1683, contained in part the following stipulations,
which bear the impression of the Quaker ideal of education.
[Sidenote: The
Tenth. That the Governor and the Provincial provisions]
Council shall erect and order all public schools
and encourage and reward the authors of useful sciences and
laudable inventions in the said provinces and territories
thereof.
Eleventh. That one-third of the Provincial Council residing
with the Governor from time to time shall, with the Governor,
have the care and management of public affairs relating to
peace, justice, treasury and improvement of the province and
territories, and to the good education of the youth, and
sobriety of the manner of the inhabitants therein aforesaid.
[135]

The plan for education as above set forth was [Sidenote: Quaker
not destined to be the one followed consistently for Council provides
more than a century and a half of development, a school]
though throughout the first decades the relations
between the schools of Friends and the governing Council were very
close.[136] It is significant that the first school was actually ordered by
the Council, in keeping with Penn’s provisions. About one year after
Penn’s arrival in Philadelphia the educational problem came to the
attention of the Council and received decided recognition, as the
following witnesses:

The Governor and Provincial Council having taken into their

serious consideration the great necessity there is of a
schoolmaster for the instruction and sober education of the
 youth in the town of Philadelphia, sent for Enock Flower, an
inhabitant of said town, who for twenty years past has been
exercised in that care and employment in England, to whom
having communicated their minds, he embraced it upon the
following terms: to learn to read English 4s by the quarter, to
learn to read and write 6s by the quarter, to learn to read,
write and cast accounts 8s by the quarter; for boarding a
scholar, that is to say, diet, washing, lodging, and schooling,
ten pounds for one whole year.[137]

Thus the first impetus to education in [Sidenote:

Pennsylvania came through properly constituted Additional
governmental authority. The Council records show provisions or
books]
that the interest in educational affairs was
maintained for some time. In the month following a [Sidenote: Charter
law was proposed for making several sorts of of 1701 does not
refer to education
books for the use of persons in the province, and as did the former
also recommended that care be taken about ones]
“Learning and Instruction of youth, to witt: a school
in the arts and sciences.”[138] This interest in, and the close relation
of the Council to, education were not long continued however; for
this there is no satisfactory explanation, though it is very clear that
the attitude on the part of the government did change.[139] This
change is evidenced in the policy as outlined by the Charter of 1701,
in which there is no reference made to education or the responsibility
of the Governor or Council therefor.[140] To the writer it seems that
the withdrawal of the Council from any very active participation in the
affairs of education may have been due to two reasons: first, the
willingness evinced by private interests to establish schools and thus
take over to themselves the duties of educators (evidenced by the
establishment of Keith’s school by Friends in 1689 without the
assistance or advice of the Council);[141] and second, the urgent
details of establishing a new government, which occupied their first
attention.
 If further proof of the withdrawal of the colonial government from
the active establishment of schools, and of the fact that they did
accept and recognize the assistance of private agencies is desired, it
is to be found in various acts of legislation of the first half century.
Specific instances of such permissive legislation were the acts of
May 28, 1715,[142] and also of February 6, 1730-1.[143] This
legislation is chiefly concerned with granting privileges to purchase
and hold land and erect buildings for the use of institutions stated
therein, among which schools are mentioned. In this connection the
statute of 1715, which evidences the facts stated above, is quoted.

Be it enacted by Charles Gookin, Esq., by the royal

approbation Lieutenant-Governor, under William Penn, Esq.,
Proprietary and Governor-in-Chief of the Province of
Pennsylvania, by and with the advice and consent of the
freemen of the said provinces in General Assembly met, and
by the authority of the same, that it shall and may be lawful to
and for all religious societies or assemblies and
congregations of Protestants, within this province, to
purchase any lands or tenements for burying grounds, and for
erecting houses of religious worship, schools and hospitals;
and by trustees, or otherwise, as they shall think fit, to receive
and take grants or conveyances for the same, for any estate
whatsoever, to and for the use or uses aforesaid, to be holden
of the lord of the fee by the accustomed rents and services.
And be it further enacted by the authority aforesaid, that all
sales, gifts or grants made to any of the said societies, or to
any person or persons in trust for them, or any of them, for or
concerning any lands, tenements or hereditaments within this
province, for and in any estate whatsoever, to and for the use
and uses aforesaid, shall be and are by this Act ratified and
confirmed according to the tenor and true meaning thereof,
and of the parties concerned therein. And where any gifts,
legacies or bequests have been or shall be made by any
person or persons to the poor of any of the said respective
religious societies, or to or for the use or service of any
meeting or congregation of the said respective societies, the
 same gifts and bequests shall be employed only to those
charitable uses, or to the use of those respective societies or
meetings, or to the poor people to whom the same are or
shall be given or intended to be given or granted, according to
what may be collected to be the true intent and meaning of
the respective donors or grantors.

On “11th month, 9th, 1682,” the Friends met and [Sidenote: The
enacted business relating chiefly to the sick, a first meeting of
meeting house, purchase of books and such other record]
details of importance, but made no reference to [Sidenote: The
schools or the education of youth.[144] This probable length of
Flower’s tenure
remained true for all meetings till 1689,[145] the as teacher]
chief part of business in the meantime having to do
with either (1) strictly religious affairs or (2) raising money for the
poor and the orphans. The absence of any remarks or any plans for
schools from 1682 to 1689 is more easily understood when it is
recalled that the school under Enock Flower was set up in 1683.[146]
There is no evidence to prove definitely that Flower continued as
schoolmaster during the whole of this time, but (1) the absence of
any record of change, (2) no record of schools kept by the Friends
Meeting, (3) the fact that he was a teacher of long experience
(twenty years) and probably as satisfactory as any to be found, and
(4) the absence of keen competition on the part of neighboring
places to draw him away, would lead one to believe it probable that
he remained there for the greater part of the period at least.
In 1689 Friends determined to establish a school, designed to
meet the demands of rich and of poor,[147] which does not seem at
all strange since they were known to have been supporting their poor
and the orphans by subscriptions since their first establishment.[148]
The transaction of the business relating thereto was performed in the
monthly meeting and referred to the quarterly meeting (higher) for its
approval. The following extract from the records of the meeting gives
the result of their decision: