Intellectual Disability

and Communication
Disorders
Intellectual Disability
 Intellectual disability
• Mental Retardation Diagnosis has been Replaced with
Intellectual Disability
• Both Cognitive capacity (IQ) and adaptive functioning are
assessed with severity based on adaptive functioning rather
than IQ
Intellectual Disability- is a group of disorders that have in common deficits of adaptive
and intellectual function and an age of onset maturity is reached.
DSM-IV-TR
Significantly subaverage intellectual functioning – An intelligence quotient (IQ) of
approximately 70 or below.
Concurrent deficits of impairments in adaptive functioning in at least 2 of the following
areas: communication, self-care, home living, social/ interpersonal skills, use of
community resources , self-direction, functional academic skills, work, leisure, health and
safety.
DSM – 5
A disorder with onset during the developmental periods that includes both intellectual and
adaptive functioning deficits in conceptual, social and practical domains.
Global Developmental Delay
 Diagnosed reserved for individuals under 5 when clinical severity
level cannot be reliably assessed.
 Diagnosed when an individual fails to meet expected
developmental milestone in several areas of intellectual
functioning and applies to individuals who are unable to undergo
systematic assessments of intellectual functioning.
 Requires reassessment after a period of time.
Unspecified Intellectual Disability
- Diagnosed in individuals over 5 when assessment of degree of
intellectual disability by means of locally available procedures is
difficult or impossible because of:
- associated sensory or physical impairments
- presence of severe problem behaviors or co-occurring mental
disorder
- Should only be used in exceptional circumstances and requires
reassessment after a period of time.
ICD-11
Uses the term Intellectual developmental disorders to
indicate that these are disorders that involve impaired
functioning early in life. These orders are described in ICD-
11 as meta syndrome occurring in the developmental period
analogous to dementia or neurocognitive disorder in later
life.
CLASSIFICATION
DSM IV –TR Levels of Mental Retardation
• Mild MR
-55-70 IQ
-Adaptive Limitations in 2 or more domains
• Moderate MR
-35-54 IQ
-Adaptive Limitations in 2 or more domains
• Severe MR
-20-34 IQ
-Adaptive Limitations in all domains
• Profound MR
-Below 20 IQ
-Adaptive Limitations in all domains
CLASSIFICATION of DSM-5
Mild
 Conceptual Domain
-In preschool children, there may be no obvious conceptual differences.
-For school-age children and adults, there are difficulties in learning academic skills needed to meet
age-related expectations.
-In adults, abstract thinking, executive function and short-term memory as well as functional use of
academic skills are impaired.
 Social Domain
Compared with typically developing age-mates, the individual is immature in social interactions.
 Practical Domain
Individuals need some support with complex daily living task in comparison to peers.
CLASSIFICATION of DSM-5
Moderate
 Conceptual Domain
-All through development, the individual's conceptual skills lag markedly behind
those of peers.
 Social Domain
-Friendship with typically developing peers are often affected by communication or
social limitation.
 Practical Domain
-The individual can care for personal needs involving eating, dressing, elimination
and hygiene.
CLASSIFICATION of DSM-5
Severe
 Conceptual Domain
-Attainment of concepts is limited. Caretakers provide extensive supports for
problem solving throughout life.
 Social Domain
-Spoken language is quite limited in terms of vocabulary and grammar.
 Practical Domain
-The individual requires support for all activities of daily living, including meal's,
dressing, bathing and elimination.
CLASSIFICATION of DSM-5
Profound
 Conceptual Domain
-Conceptual skills generally involved the physical world rather than
symbolic processes. The individual may use objects in goal-directed fashion for
self-care, work and recreation. Motor and sensory impairments may prevent
functional use of objects even if certain visuospinal skills are intact.
 Social Domain
-The individual has very limited understanding of speech or gestures
COMMORBIDITY

-Co-occurring mental, neurodevelopmental, medical and physical conditions are frequent in intellectual
disability with rates of some conditions three to four times higher than in the general population.

The most common co-occurring mental and neurodevelopmental disorders are:

 Attention-deficit/hyperactivity disorder

 Depressive and bipolar disorder

 Anxiety disorder

 Autism spectrum disorder

 Stereotypic movement disorder (with or without self-injurious behavior)

 Impulse-control disorder

 Major neurocognitive disorder

Different studies in the review showed that among children with Mental
Retardation
 Autism is present in about 25%
 ADHD in about 10%
 Cerebral Palsy in 7-30%
Among Adults with Down Syndrome
 Dementia is the common cause of mortality and morbidity, an earlier age of
onset ()8.9% in 45–49-year-old age-group
DIAGNOSIS
EVALUATION
PREVENTION
PREVENTION
PREVENTION
MANAGEMENT
Communication Disorders
Communication disorders is a category in Neurodevelopmental Disorders that
include:
▫ Language Disorder
▫ Speech Sound Disorder
▫ Childhood-Onset Fluency Disorder
▫ Social (Pragmatic) Communication Disorder (SCD)
LANGUAGE DISORDER
 Language disorder (Combines Expressive and Mixed
Receptive-Expressive Disorder)

▫ Language Disorder or Language impairments are disorder that

involve the processing of linguistic information. Problems that may
experience can involve grammar, semantics or other aspects of
language. These problems may be Expressive or Receptive or a
combination of both.
▫ Language disorder can affect both spoken and written language and
can also affect sign language.
Receptive Language
the understanding of language “Input”.

Receptive Language Disorder

Is an impairment in the comprehension of a spoken, written,
gestural or other symbol system
 Symptoms of Receptive Language Disorder
There is no standard set of symptoms that indicates receptive language disorder, since it varies
from one child to the next. However, symptoms may include:
• Not seeming to listen when they are spoke to
• Appearing to lack interest when storybooks are read to them
• Inability to understand complicated sentences
• Inability to follow verbal instructions
• Parroting words or phrases of things that are said to them (echolalia)
• Language skills below the expected level of their age
Expressive Language
Is most simply the “Output”

Expressive Language Disorder

Is a Communication disorder in which there are difficulties with
spoken or written expression.
This includes not only words, but also the grammar rules that
indicate how words are combined into phrases, sentences and
paragraphs as wells as the use of gestures and facial expressions.
 Symptoms of Expressive Language Disorder
•Children with an expressive language disorder have problem using language to
express what they are thinking or need. These children may;
•Have a hard time putting words together into sentences
•Have a difficulty finding the right words when talking.
•Have a vocabulary that is below the level of other children the same age.
•Use certain phrases over and over again
•Frustration
 Speech Disorder
•Speech Disorder or speech impediments are a type of
communication disorder where ”normal ”speech is
disrupted.
•This can mean stuttering, lips, etc.
•Someone who is unable to speak due to speech disorder is
considered mute.
 Communication Disorder

•Any disorder that can affects somebody’s ability to

communicate.
•The delays and disorders can range from simple sound
substitution to the inability to understand or use one’s native
language.
 Types of Language Disorders:
•Sensory Impairments
•Apraxia
•Dyslexia
•Dysgraphia
•Stuttering
•Down Syndrome
•Autism
•ADHD
 Sensory Impairments
Blindness
– a link between communication skills and visual impairment with children
who are bind is currently being investigated.
– It impairs ones speech ability. One cannot recognize gestures and facial
expressions
Deafness
Trouble with hearing during language acquisition ,ay lead to spoken language
problems.
 Apraxia

•It can cause problems in parts of the body, such as legs and arms
•Apraxia of speech is a motor disorder
•Have trouble sequencing the sounds in syllables and words.
 Symptoms of Apraxia
•Difficulty imitating speech sounds
•Difficulty imitating non-speech movements
•Groping when trying to produce sounds
•Inability to produce sound at all
•Inconsistent errors, slow rate of speech
•Somewhat preserved ability to produce “automatic speech”
 Dyslexia
•Or developmental reading disorder is characterized by difficulty with learning
to read fluently and with accurate comprehension despite normal or above
average intelligence.
•This include difficulty with phonological awareness, phonological decoding,
pressing aped, orthographic coding, auditory short term memory language
skills/verbal comprehension and rapid naming.
 Effects of Dyslexia
•Dyslexia can affect people differently
•Some with dyslexia can have trouble with reading and spelling, while others struggle to
write, or to tell left from right.
•Some children show few signs of difficulty with early reading and writing. But later on,
they may have trouble with complex language skills, such as grammar reading
comprehension and more in depth writing.
•Dyslexia can also make it difficult for people to express them clearly.
•It can be hard for them to use vocabulary and structure of their thoughts during
conversation.
 Dysgraphia
•The word "dysgraphia" comes from Greek words "dys" means impaired and "graphic" means
writing by hard
•Dysgraphia is a deficiency in the ability to write, primarily in term of handwriting, but also in terms
of coherence. Dysgraphia is a transcription disability, meaning that it is a writing disorder association
with impaired writing, orthographic coding and finger sequencing. They may lack basic grammar
spellings and often will write the wrong spelling while writing their own thought on the paper.
•Just having bad handwriting means a person has dysgraphia. Since dysgraphia is processing
disorder difficulties can change throughout lifetime. However since writing is a developmental
process. Children learn the motor skills needed to write, while learning the thinking skills needed to
communicate on paper-difficulties can overlap.
•There are many ways to help a person with dysgraphia achieve success. General strategies fall in
three main categories.
1: Accommodation: providing alternatives to written material
2: Modification: changing expectations or tasks to minimize or avoid the area of weakness
3: Remadiation: providing instruction for improving handwriting and writing skills.
 Stuttering
•Stuttering is a speech disorder in which sounds, syllables, or words are repeated or prolonged,
disrupting the normal flow of speech. These speech disruptions may be accompanied by struggling
behaviours, such as rapid eye blinks or tremors of the lips.
Causes of Stuttering
•Possible causes of persistence stuttering include:
•Abnormalities in speech motor control.
•Genetics- It appears that stuttering can result from inherited (generic) abnormalities in the language
centres of the brain
•Medical conditions. Stuttering can sometimes result from a stroke, trauma or other brain injury.
•Mental health problems. In rare, isolated cases, emotional trauma can lead to stuttering.
 Down Syndrome
▫ Down syndrome is a genetic abnormality. This syndrome occurs because of an
extra copy of chromosome 21.
▫ It is typically associated with physical growth delays, characteristic facial
features, and mild to moderate intellectual disability. The average IQ of a young
adult with Down Syndrome is 50, equivalent to mental age of am 8- or 9-year-old
child, but this varies widely.
▫ Down Syndrome causes lifelong developmental delays that can range from
moderate to severe. It cannot be cured, but there are options.
 Types of Down Syndrome
▫ Trisomy 21: Trisomy 21 means there is an extra copy of chromosome 21 in
every cell. This is the most common form of Down Syndrome.
▫ Mosaicism: Mosaicism means there is an extra chromosome in some but not all
of a child's cells. Individuals with mosaic Down Syndrome tend to have fewer
symptoms.
▫ Translocation: In this condition, children have only an extra part of chromosome
21. There are 46 total chromosomes. However, one of them has an extra piece of
chromosome 21 attached.
 Autism
▫ Autism is a neurodevelopment disorder characterized by impaired
social interaction, verbal and non-verbal communication, and by
restricted and repetitive behaviour.
▫ The diagnostic criteria require that symptoms become apparent
before a child is three years old. Autism affects information
processing in the brain by altering how nerve cells and their
synapses connect and organize; how this occurs is not well
understood.
▫ Subtypes of Autism Include:
⬝ Autistic disorder
⬝ Asperger's syndrome
⬝ Rett syndrome
⬝ Childhood disintegrative disorder
⬝ Pervasive development disorder
 ADHD

▫ Attention deficit hyperactivity disorder (ADHD) is one of the most

common childhood disorders and can continue through adolescence
and adulthood. Symptoms include difficulty staying focused and
paying attention, difficulty controlling behaviour, and hyperactivity
(over-activity).
▫ ADHD is a condition of the brain that affects a person's ability to
pay attention. It is most common in school age children.
▫ Children who have symptoms of inattention may:
⬝ Be easily distracted, miss details, forget things, and frequently switch from one activity to
another.
⬝ Have difficulty focusing on one thing.
⬝ Become bored with a task after only a few minutes.
⬝ Have difficulty focusing attention on organization and completing a task or learning something
new.
⬝ Not seem to listen when spoken to
⬝ Daydream, become easily confused, and move slowly
⬝ Have difficulty processing information as quickly and accurately as others
⬝ Struggle to follow instructions
▫ Children who have symptoms of hyperactivity may:
⬝ Fidget and squirm in their seats
⬝ Talk nonstop
⬝ Dash around, touching or playing with anything and everything in sight
⬝ Have trouble sitting still during dinner, school, and story time
⬝ Be constantly in motion
⬝ Have difficulty doing quiet tasks or activities
▫ Children who have symptoms of impulsivity may:
⬝ Be very impatient
⬝ Blurt out inappropriate comments, show their emotions without
restraint, and act without regard for consequences
⬝ Have difficulty waiting for things they want to waiting their turn
in games
⬝ Often interrupt conversations or other's activities
▫ What cause ADHD
⬝ In most, the cause of ADHD is unknown. The most likely cause
of ADHD appears to be genetics. Many children with ADHD
have a family history of the disorder or behaviour associated
with ADHD
SPEECH SOUND DISORDER
• Speech Sound Disorder (SSD), (formerly known as
Phonological Disorder in the DSM-IV), is a DSM-5,
diagnosis assigned to individuals who have difficulties
in productive speech which interferes with
communication, and produces impairment in
functioning, and distress.
• Speech sound disorders are speech disorder in which some
speech sounds in a child's language are either
• not produced
• not produced correctly
• are not used correctly
Symptoms of Speech Sound Disorder
▫ According to the DSM-5, there are four criterion for Speech Sound
Disorder:
1. Persistent unintelligible speech consisting of phoneme addition,
omission, distortion, or substitution, which interferes with verbal
communication.
2. There is interference with either social participation, academic
performance, or occupational performance (or any combination
thereof).
3. The onset of symptoms is during childhood.
4. The symptoms cannot be accounted for by another medical or
neurological condition, including TBI (Traumatic Brain Injury) (American
 SPEECH SOUND DISORDERS
1. Motor/Neurological Disorders
⬝ Childhood Apraxia of Speech (CAS)
⬝ Dysarthria
2. Functional Disorders – no known cause
⬝ Articulation
⬝ Phonological
 1. MOTOR/NEUROLOGICAL DISORDERS

Childhood apraxia of speech

▫ Childhood apraxia of speech (CAS) is a motor speech disorder. Children with
CAS have problems saying sounds, syllables, and words. This is not because of
muscle weakness or paralysis. The brain has problems planning to move the body
parts (e.g., lips, jaw, tongue) needed for speech. The child knows what he or she
wants to say, but his/her brain has difficulty coordinating the muscle movements
necessary to say those words.
 Types of Apraxia
▫ Ideomotor Apraxia
⬝ These patients have deficits in their ability to plan or complete motor actions that rely
on semantic memory. They are able to explain how to perform an action, but unable
to "imagine" or act out a movement such as "pretend to brush your teeth" or "pucker
as though you bit into a sour lemon." The ability to perform an action automatically
when cued, however, remains intact. This is known as automatic-voluntary
dissociation.
▫ Ideational/conceptual apraxia
⬝ Patients have an inability to conceptualize a task and impaired ability to complete
multistep actions. Consists of an inability to select and carry out an appropriate motor
program.
 SIGNS/SYMPTOMS OF CHILDHOOD APRAXIA OF SPEECH

▫ Variability in production (says it differently each time he tries)

▫ Vowel errors (kids typically master vowels between 18-24 months)
▫ Trouble sequencing sounds (can say “oh” but has trouble putting it with a
consonant to say “toe” or “go”).
▫ Unusual prosody (the pith, tone and pausing of speech)
▫ Severe sound errors
 1. MOTOR/NEUROLOGICAL DISORDERS

DYSARTHRIA
▫ Dysarthria is a motor speech disorder. It results from impaired
movement of the muscles used for speech production,
including the lips, tongue, vocal folds, and/or diaphragm. The
type and severity of dysarthria depend on which area of the
nervous system is affected.
Types of Dysarthria
The type of dysarthria depends on the part of
nervous system affected:
▫ Central dysarthria: caused by damage the brain.
▫ Peripheral dysarthria: caused by damage to what the organs
needed for speech.
WHAT CAUSES DYSARTHRIA?
▫ Dysarthria is caused by damage to the brain. This may occur at birth, as in cerebral palsy or muscular
dystrophy, or may occur later in life due to one of many different conditions that involve the nervous
system, including:
⬝ Stroke
⬝ Brain injury
⬝ Tumors
⬝ Parkinson's disease
⬝ Lou Gehrig's disease/amyotrophic lateral sclerosis (ALS)
⬝ Huntington's disease
⬝ Multiple sclerosis.
SYMPTOMS OF DYSARTHRIA
▫ The main symptom of dysarthria is a change in the way you talk.
People may have trouble understanding you because you:
⬝ Speak more quickly, slowly or softly than intended.
⬝ Have speech that becomes slurred, mumbled, robotic or choppy.
⬝ Have difficulty moving your lips, jaw or tongue.
⬝ Sound hoarse, breathy or nasal.
 2. FUNCTIONAL DISORDERS
ARTICULATION DISORDERS
▫ A speech disorder involving difficulties in articulating specific type of sounds.
Articulation disorders often involve substitution of one sound for another, slurring of
speech, or indistinct speech.
▫ Articulation disorders focus on errors (e.g., distortions and substitutions) in
production of individual speech sounds.
 TYPES OF ARTICULATION ERRORS
⬝ Substitution is using an incorrect sound to pronounce the word,
(e.g., cry is pronounced as “Cwy”).
⬝ Omission involves deleting sounds or syllables, (e.g., the word
Doggie is pronounced as “oggie”).
⬝ Distortions involve altering the correct sound of the word, which
includes lisping.
⬝ Addition of sounds is defined as including unneeded sounds in
the pronunciation of the word.
 SYMPTOMS OF ARTICULATION DISORDERS

▫ Have problems making sounds and forming particular

speech sounds properly (e.g., they may lisp, so that s sounds
like th)
▫ May not be able to produce a particular sound (e.g., they
can’t make the r sound, and say ‘wabbit’ instead of ‘rabbit’).
 CAUSES OF ARTICULATION DISORDERS
Main causes in children Main causes in adult
• Faulty learning is the number one reason • Poor learning. This is usually corrected
in children by adulthood but not always.
• Hearing loss causes trouble with • Hearing loss makes it harder for adults to
consonants and vowels in severe cases. monitor their own speech.
• Structural differences such as cleft palate • Changes in anatomy and oral structures
or poor dentations (misalignment of teeth such as a glosectomy (removal of pieces
or poor shape of dental arc). of the tongue) or car accidents that can
• Neurological-cerebral palsy results in cause facial fractures, or tumors in the
tight muscles that may cause a delay in mouth that may or may not have been
articulation and poor coordination. removed.
• Neurological-stroke may cause paralysis
of the tongue and face or cranial nerves.
Also multiple sclerosis or an aneurism
can cause damage.
 2. FUNCTIONAL DISORDERS

PHONOLOGICAL DISORDERS

▫ Phonological Disorders is a type of speech sound disorder that is

used to describe children who do not follow the typical pattern of
speech development.
▫ Phonological Disorders focus on predictable, rule-based errors (e.g.,
fronting, stopping, and final consonant deletion) that affect more
than one sound.
 SYMPTOMS OF PHONOLOGICAL DISORDER
▫ Are able to make the sound correctly, but they may use it in the
wrong position in a word, (e.g., a child may use the d sound instead
of the g sound, and so they say ‘doe’ instead of ‘go’).
▫ Make mistakes with the particular sounds in words, e.g., they can
say k in ‘kite’ but with certain words, will leave it out, e.g ‘lie’
instead of ‘like’.
 CAUSES OF PHONOLOGICAL DISORDER
▫ Hearing loss
▫ Cleft palate
▫ Dental problems
▫ Developmental disorders, such as autism spectrum disorder
▫ Genetic syndromes, such as Down Syndrome
▫ Neurological disorders, such as cerebral palsy
 TREATMENT FOR SPEECH SOUND DISORDER

▫ Speech therapy – is usually helpful when a child is

diagnosed with speech sound disorder. Children will learn
how to create and differentiate between certain sounds.
Certain milder forms of the disorder have been known to
disappear spontaneously.
CHILDHO OD
ONSE T
F RE QUEN CY
DISOR DER
TYPES OF CHILDHOOD ONSET FREQUENCY DISORDER

 STUTTERING
• Developmental Stuttering
• Neurogenic Stuttering
• Psychogenic Stuttering
 CLUTTERING

73
 D E V E L O P M E N TA L S T U T T E R I N G
• This is the most common type of stuttering in children. It may happen when a child’s
speech and language development lags behind what he or she needs or wants to say.

FEATURES:
• Typically occurs at the beginning of utterances
• May fluctuate a great deal across situations
• Stuttering influenced by environmental, linguistic and other communicative pressures
• May delay (postpone) or avoid saying certain words/sounds
• Can have associated symptoms including overt body movements such as facial
twitches, grimaces, head jerking, extraneous limb movement
• Can have associated symptoms of anxiety, shame, fear and guilt

75
76
 D E V E L O P M E N TA L S T U T T E R I N G
Natural History of disorder
• Begins in early childhood (preschool)
• Early stuttering may be difficult to distinguish from normal disfluency
• Features of stuttering tend to change over time
• In developed form, expectancy, fear and avoidance play significant roles

Who tends to stutter?

• Those with a family history of disorder
• Slower developing/ disordered speech and language
• Boys more likely to stutter than girls
• Children who are vulnerable to stress

77
 NEUROGENIC STUTTERING
Neurogenic stuttering may happen after a stroke or brain injury. It happens when there are signal
problems between the brain and nerves and muscles involved in speech.

THESE INJURIES INCLUDE:

• Cerebrovascular accident (stroke), with or without aphasia
• Head trauma
• Ischemic attacks (temporary obstruction of blood flow in the Brain)
• Tumors, cysts, and other neoplasms
• Degenerative diseases, such as Parkinson’s disease or multiple sclerosis
• Other diseases, such as meningitis, Guillain-Barré Syndrome
• Drug-related causes such as side-effects of some medications

79
 NEUROGENIC STUTTERING
Neuropathology
• Distinct from:
Aphasia. Loss of ability to understand or express speech, caused by brain damage. It can
affect your ability to speak, write and understand language, both verbal and written. Aphasia
typically occurs suddenly after a stroke or a head injury. But it can also come on gradually from a
slow-growing brain tumor or a disease that causes progressive, permanent damage
(degenerative).
Dysarthria. Occurs when the muscles you use for speech are weak or you have difficulty
controlling them. Dysarthria often causes slurred or slow speech that can be difficult to
understand. Common causes of dysarthria include nervous system disorders and conditions that
cause facial paralysis or tongue or throat muscle weakness. 
Apraxia.  Is an effect of neurological disease. It makes people unable to carry out everyday
movements and gestures. For example, a person with apraxia may be unable to tie their
shoelaces or button up a shirt. People with apraxia of speech find it challenging to talk and
express themselves through speech.

80
 NEUROGENIC STUTTERING
⬝ There are a few characters that help in distinguishing neurogenic stuttering
from other forms of stuttering –
⬝ Repetitions, blocks and repetitions can occur at any position of the word as
opposed to developmental stuttering where dysfluencies only occur at the
beginning of the word.
⬝ The speaker may experience annoyance, but they do not appear overly anxious
about their fluency problem.
⬝ There is an absence of an adaptation effect
⬝ Secondary symptoms common in developmental stuttering are almost absent.

81
 PYSCHOGENIC STUTTERING
⬝ Stuttering secondary to emotional trauma or stress
⬝ Some Features
1. Sudden onset, typically related to some event
2. Repetition of initial or stressed word
3. Fluency enhancing effects not observed
4. No periods of stutter free speech
5. Initially no interest in problem

82
 PYSCHOGENIC STUTTERING
• The causes of psychogenic speech disorders including psychogenic stuttering can include –
1.Depression
2.Conversion disorders
3.Emotional response(s) to traumatic events
4.Anxiety
TREATMENT
• The therapist may recommend the use of abdominal breathing exercises.
• Speech modification strategies like changing the timing of pauses between the words and syllables can
also work.
• The SLP may try different postural changes of the jaw to relieve the tension that may be contributing to
the stuttering.

83
 PYSCHOGENIC STUTTERING
Diagnosing psychogenic stuttering can be challenging even for the most experienced
SLPs and psychologists. According to Roth, Aronson and Davis (1989), psychogenic
stuttering has a few common characteristics –

• Psychogenic stuttering mainly affects phonation and articulation

• A history of psychological stress or trauma before the onset of stuttering
• No secondary behaviours like avoidance or escape like in case of developmental
stuttering
• The presence of la belle indifference (the person is unphased or unaware of their
stuttering)

84
 OTHER SYMPTOMS OF STUTTERING

A child may have symptoms of stuttering that are part of his or her normal speech and
language development. If the symptoms last for 3 to 6 months, he or she may have
developmental stuttering. Symptoms of stuttering may vary throughout the day and in different
situations.

• Talking slowly or with a lot of pauses

• Stopped or blocked speech. The mouth is open to speak, but nothing is said.
• Being out of breath or nervous while talking
• Fast eye blinking or trembling or shaking lips when speaking
• Increased stuttering when tired, excited, or under stress
• Being afraid to talk

85
 WHEN TO SEEK HELP TO A HEALTH CARE PROVIDER?
• Has stuttering that lasts for more than 6 months
• Has a fear of talking
• If child is not talking at all
• Develops problems in school

WHAT ARE THE POSSIBLE COMPLICATIONS OF STUTTERING IN A CHILD?

• Limited participation in some activities
• Lower self-esteem
• Poor school performance
• Social problems

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 T R E AT M E N T
Speech therapy. Speech therapy can teach you to slow down your speech and learn to notice
when you stutter. You may speak very slowly and deliberately when beginning speech therapy,
but over time, you can work up to a more natural speech pattern.

Cognitive behavioral therapy. This type of psychotherapy can help you learn to identify and
change ways of thinking that might make stuttering worse. It can also help you resolve stress,
anxiety or self-esteem problems related to stuttering.

Parent-child interaction. Parental involvement in practicing techniques at home is a key part

of helping a child cope with stuttering, especially with some methods. Follow the guidance of
the speech-language pathologist to determine the best approach for your child.

87
 CLUTTERING
• Fluency disorder characterized by a rate that is perceived to be abnormally rapid,
irregular, or both for the speaker (although measured syllable rates may not exceed
normal limits)” (St. Louis, et al., 2007)
• “Cluttering is a disorder of speech and language processing resulting in rapid,
dysrhythmic, sporadic, unorganized an frequently unintelligible speech. Accelerated
speech is not always present, but an impairment in formulating language almost
always is” (Daly, 1992)

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 CLUTTERING
Ten Significant Features of Cluttering: Expert Opinion (Daly & Cantrell, 2006)
• Telescopes or condenses words
• Lack of effective self-monitoring skills
• Lack of pauses between words; run-on sentences
• Lack of awareness
• Imprecise articulation
• Irregular speech rate
• Interjections; revisions; filler words
• Compulsive talker; ‘talks in circles’
• Language disorganized; confused wording
• Seems to verbalize before adequate thought formulation

89
 CLUTTERING SYMPTOMS

• Rapid and/or irregular rate of speech

• Racing thoughts.
• Leaving off the ends of words.
• Omitting or distorting sounds or syllables.
• Words sound as if they are running into each other.
• Lots of starts and stops in speaking.
• Excessive use of disfluencies such as “um”, “uh”, repeating or revising phrases, or repeating
words, unlike stuttering.
• Difficulty organizing thoughts and/or getting to the point.
• Limited awareness of how one’s speech sounds to others.
• Difficulties slowing down even when asked to do so.
• The tendency to interrupt the conversational partner.

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 CLUTTERING SYMPTOMS

• Words or ideas come out differently than intended.

• Difficulties with handwriting- legibility decreases with time.
• Difficulties sustaining attention for such activities like reading and/or small talk.
• Always “on the go.”
• Difficulties with typing words accurately, such as having to do excessive editing of email
messages.
• Speech is often at its best in a structured situation in which the person is actively monitoring it,
such as when being videotaped. Speech is usually at its worst when the person is more relaxed.

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 NURSING INTERVENTIONS
1. Relaxation
Not only mentally, but physically also need to be relaxed. If people can not relax, stuttering and cluttering will
occur. But if the stuttering and cluttering can be more relaxed, to speak would be more easily and smoothly, with a
habit of relaxing, of course fluency in speech will be obtained.

2. Do breathing exercises
Respiratory need to be trained, so as not to slip in speaking. Doing this breathing exercise will help breathing
becomes normal and can breathe long. A relaxed breathing will help to speak more fluently. Due to the condition of
calm and do not rush. Even by doing breathing exercises, when spoken in a long time, will not be gasping at the
time of speaking. Of course it is very necessary for those who stutter. Because stuttering takes a long time in
speaking and tranquillity in speaking.

3. Slowly in speaking
At the time of the conversation, do it slowly, talking too fast can make a quick mind in thinking. Unlike the case with
the slow of speech, by talking slowly means allowing the brain to form words on the brain. Thus it would be fluent in
speaking. By way of even this can eliminate the stress of speaking.

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 NURSING INTERVENTIONS
4. Do it in a good frame of mind
Before speaking should try to remain optimistic, do not feel pessimistic because pessimism may create difficulties
in learning. Even pessimists will actually make depression in people who stutter. Doing framework in thinking will
help the stuttering more confident in speaking, so that, after a long time will be easier to talk. Doing things
regularly will produce a good anyway. Therefore, not only do once but should be done several times. It could even
be done speak for themselves or make a speech in front of a mirror to train in speaking fluently.

5. Positive Thinking
By always positive thinking will make more mentally strong and courageous. Positive thinking often helps us when
in difficulty, including the difficulty in speaking. Positive thinking is a thing that is quite important, with positive
thinking everyone will get used to be kind to others.

6. Compose words
Before talking familiarize trained to weave words in advance, so that in the pronunciation is not wrong, so it will
allay fears and stuttering.

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 SOCIA L
PRA GMAT IC
DIS ORDE R
 S O C I A L P R A G M AT I C D I S O R D E R
Impairment of pragmatics. Primary difficulties are in social interaction, social cognition,
and pragmatics. Specific deficits are evident in the individual's ability to:
▫ communicate for social purposes in ways that are appropriate for the particular social context;
▫ change communication to match the context or needs of the listener;
▫ follow rules for conversation and storytelling;
▫ understand nonliterate or ambiguous language; and
▫ understand what is not explicitly stated.

o Diagnosed based on difficulty in the social uses of verbal and nonverbal communication in
naturalistic contexts
o which affects the functional development of social relationships and discourse comprehension
and cannot be explained by low abilities in the domains of word structure and grammar or
general cognitive ability
o Rule out Autism Spectrum Disorder

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 S O C I A L P R A G M AT I C D I S O R D E R
Social communication disorder may be a distinct diagnosis or may co-occur with other
conditions, such as
• intellectual disability;
• developmental disabilities;
• learning disabilities;
• spoken language disorders;
• written language disorders;
• attention-deficit/hyperactivity disorder (ADHD);
• traumatic brain injury (pediatric and adult);
• aphasia;
• dementia; and
• right-hemisphere damage.

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 SIGNS AND SYMPTOMS
Individuals with this disorder may present with difficulties across a number of areas of social
communication including:
▫ Social greetings, such as saying hello or introducing oneself
▫ Sharing personal information and general knowledge
▫ Modifying communication based on characteristics of the listener; for example, understanding
that one interacts differently with a young child versus an adult, and differently with a close
friend versus an acquaintance
▫ Taking turns in conversation, which includes difficulty responding to others in conversation,
staying on topic, or allowing the other person an opportunity to speak
▫ Changing communication to match the behavior of the listener or the context of the situation
▫ Using gestures in conversation, such as pointing or waving
▫ Understanding various forms of nonverbal communication
▫ Understanding aspects of verbal communication that are not explicitly stated; for example,
difficulty understanding implied and indirect uses of language, such as metaphors and humor

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 T R E AT M E N T
▫ Treatment should be specific to the individual with a focus on functional improvements in
communication skills, especially within social situations. Other goals of treatment may include:
▫ Address weaknesses related to social communication
▫ Work to build strengths
▫ Facilitate activities involving social interactions to build new skills and strategies
▫ Look for and address barriers that may be making social communication more difficult
▫ Build independence in natural communication environments
▫ Treatment for SCD often includes parents and other family members. The therapist working with your child
may also reach out school personnel, including teachers, special educators, psychologists, and vocational
counsellors to ensure that your child receives consistent practice and feedback in a variety of social
situations

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 T R E AT M E N T
▫ Tools used during treatment might include:
▫ Augmentative and alternative communication (AAC), which includes supplementing speech with pictures,
line drawings or objects, gestures, and finger spelling.
▫ Computer-based instruction for teaching language skills including vocabulary, social skills, social
understanding, and social problem solving.
▫ Video-based instruction that uses video recording to provide a model of target behavior.
▫ Comic book conversations, which depict conversations between two or more people illustrated in comic-book
style.
▫ Social skills groups that incorporate instruction, role playing, and feedback with two to eight peers and a
facilitator, who may be a teacher or counsellor.

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