Speech Sound and Motor Speech Disorders

• Assessment of Speech Sound Disorders and Motor Speech Disorders

Speech Sound Production Overview

• Speech sounds facilitate the development of a more complex verbal repertoire.
• Typical neuroanatomic structures and speech production mechanisms significantly affect speech sound learning and language skills.

Factors Influencing Speech Sound Production

• Speech sound production is influenced by neuroanatomy and speech mechanisms.

Neuroanatomic Deviations

• Neuroanatomic deviations, such as brain injuries, can affect cranial nerves and the speech muscles they innervate.
• Brain injuries can cause dysarthria and apraxia of speech.

Structural Deficiencies in Speech

• Structural deficiencies in the speech production mechanism affect articulation.
• Cleft palate and velopharyngeal insufficiency can make it difficult to produce certain speech sounds, resulting in hypernasal speech.
• A short or malformed velum, ankyloglossia, poor nasal patency, and severe dental abnormalities impact speech sound production.
• Structural deficiencies can cause mild sound distortions to extremely unintelligible speech, depending on their severity.

Structural Deficiencies

• Structural deficiencies, like cleft palate or ankyloglossia, can affect articulation and lead to hypernasality or unintelligible speech.

SLPs' Role

• SLPs should have a comprehensive understanding of the anatomy and physiology of speech and language.
• SLPs need a strong understanding of speech anatomy and physiology to assess and treat speech disorders.

Contributing Factors to Speech Sound Disorders

• Medical or neurological factors, hearing, and dental problems can contribute to speech sound disorders.
• Motor development, intelligence and cognition, and age and gender can contribute to speech sound disorders.
• Family history of speech disorder or delay, primary language/dialect/culture, and motivation/level of concern are contributing factors.
  • Medical/neurological issues
  • Hearing problems
  • Dental issues
  • Motor development
  • Intelligence
  • Age/gender
  • Family history
  • Language/dialect/culture
  • Motivation

Linguistic, Cultural, and Familial Factors

• Speech and language skills are a product of a verbal and socio-cultural environment, therefore should be understood in context.
• Speech and language skills should be understood also in the context of the home environment and the larger socio-cultural context in which the skills are acquired.
• Speech skills are influenced by the socio-cultural environment, home life, bilingual status, and family dynamics in which a child is raised.

Assessment Process

• Includes case history, client interviews, speech sound assessment procedures, data analysis, impression/recommendation, documentation, and reimbursement.
  • Case history
  • Client interview
  • Speech sound assessment procedures
  • Data analysis
  • Recommendations

Case History and Client Interview

• This stage involves information gathering and interview conduction.
• Gathering information from various sources (parents, teachers) helps identify factors affecting speech development and potential disorders.

Assessment Procedures of Speech Sound Disorders

• Assessment of speech sound disorders consist of screening, formal testing, informal testing, speech sampling, and the stimulability of errors.
  • Screening
  • Formal testing
  • Informal testing
  • Speech sampling
  • Stimulability testing

Screening

• The purpose of a screening session is to quickly identify those individuals who communicate within normal limits and those who may have a communicative disorder.
• Screenings most commonly occur in schools.
• A speech screening test does not have to be formal; it should elicit all age-appropriate phonemes.
• The purpose of a screening is to quickly identify individuals with normal speech and those with potential communication disorders.

Formal/Informal Testing

• Standardized tests are used to identify articulation errors or assess phonological processes.
• Articulation tests identify a client's articulation errors quickly and systematically.
• This makes them popular and useful assessment tools.
• Formal testing involves standardized tests to assess articulation errors, while informal testing observes speech in natural contexts.

Barriers to use of Articulation Tests

• Barriers to use of articulation tests involves eliciting phonemes in only one phonetic context within a preselected word.
• Most articulation tests elicit phonemes at the word level for the assessment of initial, medial, and final position productions, but conversational speech involves complex, coarticulated movements where these sounds may not occur discretely.
• Some articulation tests examine only consonants, but vowels are important for well-developed speech.
• Reliability may be questionable with disorders that result in variable sound productions, like childhood apraxia of speech (CAS), which involves inconsistent sounds.
  • Limited phonetic context of tests
  • The focus on specific words rather than natural speech
  • Neglecting vowel assessment

Speech Sound Sample

• Speech sound sampling is especially important for diagnosing disorders accurately.
• After obtaining one or more representative samples, focus analysis on error types, error patterns, and the number of errors.
• Analysis should also focus on the consistency of errors within and between speech samples and the articulation test.
• Correctly produced sounds, intelligibility, speech rate, and prosody should also be focused on within speech samples.
• A representative speech sample helps analyze error types, intelligibility, prosody, and other critical aspects for diagnosis.

Stimulability

• Stimulability refers to the client's ability to produce a correct or improved production of an erred phoneme.
• This process involves the client attempting to imitate the clinician's correct production, often after specific instructions regarding articulatory placement or sound production manner.
• The assessment of stimulability provides important prognostic information.
• If a clinician can stimulate a target sound during the diagnostic session, the desired sound is typically more trainable at complex levels.
• If the oromotor mechanism is intact for speech, nonstimulable sounds can often be trained.
• Easily stimulated sounds provide excellent starting points in therapy because they often lead to quicker treatment success than less stimulable sounds.
• Stimulability tests if a client can imitate a correct sound after receiving specific instructions. It predicts the likelihood of successful treatment.

Data Analysis

• Analysis and integration of assessment results from various sources are essential for accurate diagnosis and differential diagnosis.
• Although a full analysis and integration happen after the post-assessment interview, experienced clinicians will likely have enough information to suggest a tentative diagnosis, prognosis, and treatment recommendations.
• Data analysis involves reviewing speech samples and test results to make a tentative diagnosis, prognosis, and treatment plan.

Determining A Diagnosis: Articulation Disorder

• Includes the child's difficulty is limited to a few omissions, substitutions, and distortions.
• The difficulty seems to be purely phonetic, there are no discernible patterns in the few errors noted in the child's speech.
• There are no neuromotor control problems; there are no orofacial structural problems (e.g., cleft palate).
• Speech intelligibility is reduced, and the child's speech pattern is not due to ethnocultural factors.
• An articulation disorder is diagnosed when there are omissions, substitutions, or distortions of speech sounds with no underlying patterns or neuromotor issues.

Determining A Diagnosis: Phonological Disorder

• Includes multiple speech sound errors falling into phonological error patterns.
• The child's phonological error patterns should have disappeared, speech intelligibility is greatly reduced (or nearly unintelligible), and the speech pattern is not due to ethnocultural factors.
• A phonological disorder is characterized by multiple speech sound errors following predictable error patterns, often leading to reduced intelligibility.

Determining A Diagnosis: Articulation Disorder & Hearing Impairment

• Should include an audiological diagnosis of hearing loss has been made.
• The child has a history of chronic otitis media contributing to a pattern of speech sound disorder.
• The vocal resonance and speech prosody are affected and deviant, respectively.
• Voice quality is deviant (hoarse or breathy), the child's speech pattern is not due to ethnocultural factors.
• Hearing loss, especially due to chronic ear infections, can lead to articulation problems and resonance issues.

Determining A Diagnosis: Cleft Palate

• Diagnose articulation disorders associated with structural anomalies including cleft palate if there is evidence of clefts, the palatal clefts (surgically closed or not).
• There is a pattern of compensatory articulation, resonance disorders associated with velopharyngeal incompetence, and the child's speech pattern is not due to ethnocultural factors.

Post Assessment Counseling

• Includes making a tentative diagnosis, recommendations, and prognosis.
• Answering questions like "What causes speech sound disorders?", "How long does it take to treat speech sound disorders effectively?", and "Can ear infections have any effect on speech development?"
• As well as, "What are some of the treatment options?" and "When do we start treatment?"
• Post-assessment counseling involves discussing tentative diagnosis, prognosis, and treatment recommendations with the family.

Motor Speech Disorders

• Includes dysarthria, apraxia, childhood apraxia of speech (CAS).
  • Dysarthria: caused by muscle weakness
  • Apraxia: difficulty coordinating muscle movements
  • Childhood apraxia of speech: motor disorder affecting children's speech

Dysarthria Summary

• Dysarthria is a motor speech disorder caused by muscle weakness due to brain damage.
• Dysarthria can coexist with speech and language problems, apraxia, and aphasia.
• Causes of dysarthria: stroke, multiple sclerosis, Huntington's disease, brain damage (at birth or after an illness or injury), brain injury, amyotrophic lateral sclerosis (ALS), Parkinson's disease, and tumors.
• Dysarthria is caused by brain damage due to factors such as stroke, brain injury, or diseases like ALS or Parkinson's.

Apraxia Summary

• Apraxia involves a motor speech disorder that makes it hard to speak, caused by damage to the parts of the brain that control how your muscles move.
• Causes of apraxia: stroke, brain diseases that progress over time, traumatic brain injury, brain tumors, and dementia.
• Apraxia is caused by brain damage or neurological conditions affecting the brains ability to plan and coordinate speech movements.

Childhood Apraxia of Speech Summary

• Childhood Apraxia of Speech (CAS) is a motor speech disorder that makes it hard for children to speak.
• The cause is usually unknown, however, some cases are from brain damage.
• Some are also from a genetic disorder/syndrome that causes brain damage, and a stroke or brain injury.
• Often has no known cause, but it can result from brain damage or genetic disorders that affect speech development.

The Assessment Process

• Includes preassessment and the interview.
• Preassessment involves what information would you be looking for?
• The interview involves what questions you want to ask, and who you want to ask them to.

The Assessment Process: Dysarthria

• For adults and children should asses Case history and voice (respiration, phonation, and resonation), and use articulation and oral exam.
• Voice should also include rhythm for children.
  • Case history
  • Spontaneous speech sample
  • Oral motor assessment
  • Cognition when necessary

The Assessment Process: Apraxia

• For Adults, case history, articulation, spontaneous speech sample, oral motor, Aphasia, cognition is assessed for differential Diagnosis.
• Assessed for Children too, case history, articulation, spontaneous speech sample, oral motor.
• But should also assess non-speech tasks for differential Diagnosis.

Documentation

• Includes a diagnostic report, progress report, and discharge report.
  • Diagnostic reports
  • Progress reports
  • CPT codes for evaluations and treatment

Evaluation CPT Codes

• 92522: Evaluation of speech sound production (articulation, phonological process, apraxia, dysarthria).
• 92523: Evaluation of speech sound production (articulation, phonological process, apraxia, dysarthria) with evaluation of language comprehension and expression (receptive and expressive language).
• 92522: speech sound evaluation: evaluates articulation, phonological processes, apraxia, or dysarthria.
• 92523: speech sound & language evaluation: evaluates articulation, phonology, apraxia, dysarthria, plus language comprehension and expression

Treatment CPT Code

• 92507: Treatment of speech, language, voice, communication, and/or auditory processing disorder, individual.
• 92507: speech treatment: treatment for speech, language, voice, communication, and/or auditory processing disorders (individual)

Guidelines for Assigning Diagnostic Codes

• Use the F80 series of codes when there is no underlying medical condition contributing to the speech or language deficit.
• Use the R00-R99 series when the communication or swallowing disorder is due to a documented medical condition; include the appropriate ICD-10 code for the medical diagnosis.
• Category I69 indicates conditions in I60-I67 as the cause of sequelae (conditions specified as such or as residuals, occurring after the onset of the causal condition).
• F80 = no underlying medical condition
• R00-R99 = speech disorders due to a medical condition (like brain injury or a stroke
• I69 speech disorders due to cerebrovascular issues (e.g., stroke)

Diagnostic Codes

• F80 series: code when there is no underlying medical condition contributing to the speech or language deficit.
• F80.0: Phonological (speech articulation developmental disorder and speech-sound disorder).
• F80.4: Speech and language development delay due to hearing loss; code also specifies the type of hearing loss (H90.-, H91.-).
• Codes for dysarthria and anarthria, slurred speech, and other speech disturbances can be: R47.1, R47.81, and R47.89, respectively.
• R48.2 is a diagnostic code for apraxia.
• F80 series: codes that have no medical condition thats contributing
• F80.0 speech articulation disorder: problems with sound production (e.g., substitutions, omissions, disortions)
• F80.4 speech/language delay due to hearing loss: speech/language delay that is caused by hearing loss
• R47 Series: codes for speech/language disturbances
• R47.1 dysarthria & anarthria: weak speech due to muscle issues (e.g., slurred or unclear speech)
• R47.81 slurred speech: specifically slurred or unclear speech
• R47.89 other speech disturbances: other types of speech disturbances not listed elsewhere
• R48.2 apraxia: difficulty planning speech movements (motor speech disorder)

Impressions and Recommendations

• Important to consider what you do after completing the assessments and what you do with the data you obtained.
• Key Areas would be of concern and strength.
• Key recommendations would be making referrals to other professionals, completion of assessment(s), treatment recommendations, and prognostic implications/statement.