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If a child finds it difficult to blow, pinching the nose can help regulate airflow. The child should then practice speech sounds without pinching the nose.
These exercises only work as treatments if hypernasality is small. Severe deviations should be treated surgically.
In cases of muscle weakness or cleft palate, special exercises can help to strengthen the soft palate muscles with the ultimate aim of decreasing airflow through the nose and thereby increasing intelligibility. Intelligibility requires the ability to close the nasal cavity, as all English sounds, except "m", "n", and "ng", have airflow only through the mouth. Normally, by age three, a child can raise the muscles of the soft palate to close to nasal cavity.
Without the use of a technological aid, nasal emission is sometimes judged by listening for any turbulence that may be produced by the nasal airflow, as when there is a small velopharyngeal opening and there is some degree of mucous in the opening. More directly, methods recommended include looking for the fogging of a mirror held near the nares or listening through a tube, the other end of which is held in or near a nares opening.
There have been many attempts to use technological augmentation more than a mirror or tube to aid the speech pathologist or provide meaningful feedback to the person attempting to correct their hypernasality. Among the more successful of these attempts, the incompleteness of velopharyngeal closure during vowels and sonorants that causes nasal resonance can be estimated and displayed for evaluation or biofeedback in speech training through the nasalance of the voice, with nasalance defined as a ratio of acoustic energy at the nostrils to that at the mouth, with some form of acoustic separation present between the mouth and nose. In the nasalance measurement system sold by WEVOSYS, the acoustic separation is provided by a mask-tube system, nasalance measurement system sold by Kay-Pentax, the acoustic separation is provided by a solid flat partition held against the upper lip, while in the system sold by Glottal Enterprises the acoustic separation can be by either a solid flat partition or a two-chamber mask.
However, devices for measuring nasalance do not measure nasal emission during pressure consonants. Because of this, a means for measuring the degree of velopharyngeal closure in consonants is also needed. A commercially available device for making such measurements is the Perci-Sar system from Microtronics. The Nasality Visualization System from Glottal Enterprises allows both the measurement of Nasal Emission and Nasalance. In the presence of a cleft palate, either of these systems can be helpful in evaluating the need for an appliance or surgical intervention to close the cleft or the success of an appliance or a surgical attempt to close the cleft.
The main objective of physical treatment is to achieve adequate velopharyngeal (VP) function and normal oral-nasal resonance.
The patient can learn to pronounce the words better with the help of a speech therapist. Also a speech therapist can help a patient to learn how to use the VP-port after surgery. Only if the VP mechanism is not working properly after surgery, speech therapy will be of little improvement.
This condition is most often treated using voice therapy (vocal exercises) by speech-language pathologists (SLPs) or speech therapists who have experience in treating voice disorders. The duration of treatment is commonly one to two weeks.
Techniques used include:
- Cough: The patient is asked to apply pressure on the Adam's apple and cough. This results in the shortening of the vocal folds which is the physiological mechanism that reduces pitch. The patient can thus practice voicing at a lower pitch.
- Speech range masking: This procedure is based on the theory that when speaking in noisy backgrounds, people speak louder and more clearly in order to be heard. The patient practices speaking while a masking noise is playing. Then, the patient listens to a recording of his/her voice during the masking session and tries to match it without the masking. By doing this, the patient practices their 'loud and clear' voice.
- Glottal attack before a vowel: A glottal attack is when the vocal folds are fully closed and then pushed open by the air pressure from breathing out or making a sound. In this technique, the patient breathes in and then makes a vowel as he/she breathes out.
- Laryngeal musculature relaxation techniques: Laryngeal muscles surround the vocal folds and by relaxing them, there is reduced pressure on the vocal folds. This can be done by yawning and subsequently sighing, exaggerated chewing while speaking, and speaking or singing the 'm' sound.
- Lowering of larynx to appropriate position: The larynx is lowered by the patient by putting pressure on the Adam's apple. By lowering the larynx, the vocal folds relax, and thus pitch is lowered. The patient does this while speaking to practice speaking with a lower pitch.
- Humming while sliding down the scale: The patient starts humming at the highest pitch that they can reach and then keeps lowering the pitch while humming. This allows the patient to practice using a lower pitch and also to relax the laryngeal muscles.
- Half swallow Boom technique: The patient says 'boom" just after swallowing. This is repeated with the patient turning his/her head to either side and also while lowering the chin. After practice, the patient adds more words. This technique helps to close the vocal folds completely.
Indirect Voice Therapy
Indirect treatment options for puberphonia focus on creating an environment where direct treatment options will be more effective. Counselling, performed by the S-LP, a psychologist, or counsellor, can help patients identify the psychological factors that contribute to their disorder and give them tools to address those factors directly. Patients may also be educated about good vocal hygiene and how their behaviour could have long term effects on their voice.
Audiovisual feedback:
In puberphonia, the use of audiovisual feedback allows the patient to observe graphic and numerical representations of their voice and pitch. This allows the patient to determine an ideal pitch range based on normative data on age and gender, and incrementally work through speech tasks while working in that desired pitch range. As the patient improves, speech tasks progress to become more natural, involving tasks such as reciting automatic information, to reading, to spontaneous speech and conversation. Incorporating audiovisual feedback in speech and voice therapies has been successful in intervention by improving motivation and guidance.
Surgery:
In some cases when traditional voice therapy is ineffective, surgical interventions are considered. This can occur in situations where intervention is delayed or the patient is in denial, causing the condition to become resistant to voice therapy.
There are different types of surgical interventions which have been successful in lowering the vocal pitch in men with puberphonia who had previously received ineffective voice and psychotherapy. The first surgical intervention developed, called "Relaxation Thyroplasty" or "Retrusion Thyroplasty", involves a bilateral excision of 2 to 3 mm vertical strips of thyroid cartilage which lowers the vocal pitch through anteroposterior relaxation and shortening of the vocal folds. It can be performed under local or general anesthesia.
"Relaxation Thyroplasty by a medial approach" is a modified approach of traditional "Relaxation Thyroplasty". This version involves lowering the vocal pitch by creating an incision bilaterally in the thyroid lamina and then depressing the anterior segment of the thyroid cartilage.
A more recent, less invasive intervention is the "Window Relaxation Thyroplasty". This approach involves creating a window at the anterior commissure which is then displaced posteriorly.
With an interdental lisp, the therapist teaches the child how to keep the tongue behind the two front incisors.
One popular method of correcting articulation or lisp disorders is to isolate sounds and work on correcting the sound in isolation. The basic sound, or phoneme, is selected as a target for treatment. Typically the position of the sound within a word is considered and targeted. The sound appears in the beginning of the word, middle, or end of the word (initial, medial, or final).
Take for example, correction of an "S" sound (lisp). Most likely, a speech language pathologist (SLP) would employ exercises to work on "Sssssss." Starting practice words would most likely consist of "S-initial" words such as "say, sun, soap, sip, sick, said, sail." According to this protocol, the SLP slowly increases the complexity of tasks (context of pronunciations) as the production of the sound improves. Examples of increased complexity could include saying words in phrases and sentences, saying longer multi syllabic words, or increasing the tempo of pronunciation.
Using this method, the SLP achieves success with his/her student by targeting a sound in a phonetically consistent manner. Phonetic consistency means that a target sound is isolated at the smallest possible level (phoneme, phone, or allophone) and that the context of production must be consistent. Consistency is critical, because factors such as the position within the word, grouping with other sounds (vowels or consonants), and the complexity all may affect production.
Another popular method for treating a lisp is using specially designed devices that go in the mouth to provide a tactile cue of exactly where the tongue should be positioned when saying the "S" sound. This tactile feedback has been shown to correct lisp errors twice as fast as traditional therapy.
Using either or both methods, the repetition of consistent contexts allows the student to align all the necessary processes required to properly produce language; language skills (ability to formulate correct sounds in the brain: What sounds do I need to make?), motor planning (voicing and jaw and tongue movements: How do I produce the sound?), and auditory processing (receptive feedback: Was the sound produced correctly? Do I need to correct?).
A student with an articulation or lisp disorder has a deficiency in one or more of these areas. To correct the deficiency, adjustments have to be made in one or more of these processes. The process to correct it is more often than not, trial and error. With so many factors, however, isolating the variables (the sound) is imperative to getting to the end result faster.
A phonetically consistent treatment strategy means practicing the same thing over and over. What is practiced is consistent and does not change. The words might change, but the phoneme and its positioning is the same (say, sip, sill, soap, …). Thus, successful correction of the disorder is found in manipulating or changing the other factors involved with speech production (tongue positioning, cerebral processing, etc.). Once a successful result (speech) is achieved, then consistent practice becomes essential to reinforcing correct productions.
When the difficult sound is mastered, the child will then learn to say the sound in syllables, then words, then phrases and then sentences. When a child can speak a whole sentence without lisping, attention is then focused on making correct sounds throughout natural conversation. Towards the end of the course of therapy, the child will be taught how to monitor his or her own speech, and how to correct as necessary. Speech therapy can sometimes fix the problem, but however in some cases speech therapy fails to work.
Permanent lisps can often be corrected through extensive oral operations. Often, when a patient has extreme overbite, causing a lisp, having orthodontic braces and rubber bands for an extended period of time will correct the issue, and resolve the lisp.
There are varying types of intervention for ankyloglossia. Horton "et al.," have a classical belief that people with ankyloglossia can compensate in their speech for limited tongue range of motion. For example, if the tip of the tongue is restricted for making sounds such as /n, t, d, l/, the tongue can compensate through dentalization; this is when the tongue tip moves forward and up. When producing /r/, elevation of the mandible can compensate for restriction of tongue movement. Also, compensations can be made for /s/ and /z/ by using the dorsum of the tongue for contact against the palatal rugae. Thus, Horton "et al." proposed compensatory strategies as a way to counteract the adverse effects of ankyloglossia and did not promote surgery. Non-surgical treatments for ankyglossia are typically performed by Orofacial Myology specialists, and involve using exercises to strengthen and improve the function of the facial muscles and thus promote proper function of the face, mouth and tongue
Intervention for ankyloglossia does sometimes include surgery in the form of frenotomy (also called a frenectomy or frenulectomy) or frenuloplasty. This relatively common dental procedure may be done with soft-tissue lasers, such as the CO laser. However, authors such as Horton "et al." are in opposition to it. According to Lalakea and Messner, surgery can be considered for patients of any age with a tight frenulum, as well as a history of speech, feeding, or mechanical/social difficulties. Adults with ankyloglossia may elect the procedure. Some of those who have done so report post-operative pain.
A viable alternative to surgery for children with ankyloglossia is to take a wait-and-see approach. Ruffoli "et al." report that the frenulum naturally recedes during the process of a child's growth between six months and six years of age;
Successful treatments have shown that causes are functional rather than physical: that is, most lisps are caused by errors in tongue placement within the mouth rather than caused by any injury or congenital deformity to the mouth. The most frequently discussed of these problems is tongue thrust in which the tongue protrudes beyond the front teeth. This protrusion affects speech as well as swallowing and can lead to lisping. Ankyloglossia or tongue tie can also be responsible for lisps in children.
However, it is unclear whether these deficiencies are caused by the tongue tie itself or the muscle weakness following the correction of the tongue tie. Overbites and underbites may also contribute to non lingual lisping. Temporary lisps can be caused by dental work, dental appliances such as dentures or retainers or by swollen or bruised tongues.
Clinicians can also request a self-assessment, in which the client describes their symptoms and their effects on activities of daily living. The clinician may direct this self-assessment to include the identification of personality traits that may maintain the disorder, the social and emotional consequences of the symptoms experienced, and whether the client has any access to their modal voice register.
A complete assessment for puberphonia or any other voice disorder may require a referral to another healthcare professional, such as a psychologist or a surgeon, to determine candidacy for different treatment options.
There are a number of potential treatments for spasmodic dysphonia, including botox, surgery and voice therapy. A number of medications have also been tried including anticholinergics (such as benztropine) which have been found to be effective in 40-50% of people, but which are associated with a number of side effects.
In most cases the cause is unknown. However, there are various known causes of speech impediments, such as "hearing loss, neurological disorders, brain injury, intellectual disability, drug abuse, physical impairments such as cleft lip and palate, and vocal abuse or misuse."
Opinion varies regarding how frequently ankyloglossia truly causes problems. Some professionals believe it is rarely symptomatic, whereas others believe it is associated with a variety of problems. The disagreement among professionals was documented in a study by Messner and Lalakea (2000). The authors sent a survey to a total of 1598 otolaryngologists, pediatricians, speech-language pathologists and lactation consultants with questions to ascertain their beliefs on ankyloglossia. 797 of the surveys were fully completed and used in the study. It was found that 69% of lactation consultants, but only a minority of pediatricians answered that ankyloglossia is frequently associated with feeding difficulties; 60% of otolaryngologists and 50% of speech pathologists answered that ankyloglossia is sometimes associated with speech difficulties compared to only 23% of pediatricians; 67% of otolaryngologists compared with 21% of pediatricians answered that ankyloglossia is sometimes associated with social and mechanical difficulties. Limitations of this study include a reduced sample size due to unreturned or incomplete surveys.
The U.S. Food and Drug Administration (FDA) has not approved any drug for the direct treatment of stuttering. However, the effectiveness of pharmacological agents, such as benzodiazepines, anticonvulsants, antidepressants, antipsychotic and antihypertensive medications, and dopamine antagonists in the treatment of stuttering has been evaluated in studies involving both adults and children.
A comprehensive review of pharmacological treatments of stuttering in 2006 concluded that few of the drug trials were methodologically sound. Of those that were, only one, not unflawed study, showed a reduction in the frequency of stuttering to less than 5% of words spoken. In addition, potentially serious side effects of pharmacological treatments were noted, such as weight gain, sexual dysfunctions and the potential for blood pressure increases. There is one new drug studied especially for stuttering named pagoclone, which was found to be well-tolerated "with only minor side-effects of headache and fatigue reported in a minority of those treated".
Voice therapy appears to be ineffective in cases of true spasmodic dysphonia, however as it is difficult to distinguish between spasmodic dysphonia and functional dysphonias and misdiagnosis is relatively common, a trial of voice therapy is often recommended before more invasive procedures are tried. Some also state that it is useful for mild symptoms and as an add-on to botox therapy and others report success in more severe cases. Laryngeal manual therapy, which is massaging of the neck and cervical structures, also shows positive results for intervention of functional dysphonia.
Many researchers are investigating the characteristics of apraxia of speech and the most effective treatment methods. Below are a couple of the recent findings:
Sound Production Treatment:
Articulatory-kinematic treatments have the strongest evidence of their use in treating Acquired Apraxia of Speech. These treatments use the facilitation of movement, positioning, timing, and articulators to improve speech production. Sound Production Treatment (SPT) is an articulatory-kinematic treatment that has received more research than many other methods. It combines modeling, repetition, minimal pair contrast, integral stimulation, articulatory placement cueing, and verbal feedback. It was developed to improve the articulation of targeted sounds in the mid-1990s. SPT shows consistent improvement of trained sounds in trained and untrained words. The best results occur with eight to ten exemplars of the targeted sound to promote generalization to untrained exemplars of trained sounds. In addition, maintenance effects are the strongest with 1–2 months post-treatment with sounds that reached high accuracy during treatment. Therefore, the termination of treatment should not be determined by performance criteria, and not by the number of sessions the client completes, in order to have the greatest long-term effects. While there are many parts of SPT that should receive further investigation, it can be expected that it will improve the production of targeted sounds for speakers with apraxia of Speech.
Repeated Practice & Rate/Rhythm Control Treatments:
Julie Wambaugh’s research focuses on clinically applicable treatments for acquired apraxia of speech. She recently published an article examining the effects of repeated practice and rate/rhythm control on sound production accuracy. Wambaugh and colleagues studied the effects of such treatment for 10 individuals with acquired apraxia of speech. The results indicate that repeated practice treatment results in significant improvements in articulation for most clients. In addition, rate/rhythm control helped some clients, but not others. Thus, incorporating repeated practice treatment into therapy would likely help individuals with AOS.
Altered auditory feedback, so that people who stutter hear their voice differently, has been used for over 50 years in the treatment of stuttering. Altered auditory feedback effect can be produced by speaking in chorus with another person, by blocking out the person who stutters' voice while talking (masking), by delaying slightly the voice of the person who stutters (delayed auditory feedback) or by altering the frequency of the feedback (frequency altered feedback). Studies of these techniques have had mixed results, with some people who stutter showing substantial reductions in stuttering, while others improved only slightly or not at all. In a 2006 review of the efficacy of stuttering treatments, none of the studies on altered auditory feedback met the criteria for experimental quality, such as the presence of control groups.
Treatment for uncontrolled tongue thrust requires habit retraining in conjunction with a dental appliance.
In cases where the causes are environmental, the treatment is to eliminate or reduce these causes first of all, and then to fit patients with a hearing aid, especially if they are elderly. When the loss is due to heredity, total deafness is often the end result. On the one hand, persons who experience gradual deterioration of their hearing are fortunate in that they have learned to speak. Ultimately the affected person may bridge communication problems by becoming skilled in sign language, speech-reading, using a hearing aid, or accepting elective surgery to use a prosthetic devices such as a cochlear implant.
Most speech sound disorders occur without a known cause. A child may not learn how to produce sounds correctly or may not learn the rules of speech sounds on his or her own. These children may have a problem with speech development, which does not always mean that they will simply outgrow it by themselves. Many children do develop speech sounds over time but those who do not often need the services of a Speech-Language Pathologist to learn correct speech sounds.
Some speech sound errors can result from other syndromes or disorders such as:
- developmental disorders (e.g. autism)
- genetic disorders (e.g. Down syndrome)
- hearing loss, including temporary hearing loss, such as from ear infections
- cleft palate or other physical anomalies of the mouth
- illness
- neurological disorders (e.g. cerebral palsy)
Muteness or mutism () is an inability to speak, often caused by a speech disorder, hearing loss, or surgery. Someone who is mute may be so due to the unwillingness to speak in certain social situations.
Those who are physically mute may have problems with the parts of the human body required for human speech (the esophagus, vocal cords, lungs, mouth, or tongue, etc.).
Trauma or injury to Broca's area, located in the left inferior frontal cortex of the brain, can cause muteness.
There is no cure for DVD/CAS, but with appropriate, intensive intervention, people with the disorder can improve significantly.
DVD/CAS requires various forms of therapy which varies with the individual needs of the patient. Typically, treatment involves one-on-one therapy with a speech language pathologist (SLP). In children with DVD/CAS, consistency is a key element in treatment. Consistency in the form of communication, as well as the development and use of oral communication are extremely important in aiding a child's speech learning process.
Many therapy approaches are not supported by thorough evidence; however, the aspects of treatment that do seem to be agreed upon are the following:
- Treatment needs to be intense and highly individualized, with about 3-5 therapy sessions each week
- A maximum of 30 minutes per session is best for young children
- Principles of motor learning theory and intense speech-motor practice seem to be the most effective
- Non-speech oral motor therapy is not necessary or sufficient
- A multi-sensory approach to therapy may be beneficial: using sign language, pictures, tactile cues, visual prompts, and Augmentative and Alternative Communication (AAC) can be helpful.
Although these aspects of treatment are supported by much clinical documentation, they lack evidence from systematic research studies. In ASHA's position statement on DVD/CAS, ASHA states there is a critical need for collaborative, interdisciplinary, and programmatic research on the neural substrates, behavioral correlates, and treatment options for DVD/CAS.
Transient paraphasias (as well as other language defects such as speech arrest) can be generated by artificially activating the brain's language network with Transcranial magnetic stimulation (TMS). With navigated TMS (nTMS), nodes of the language network can be located presurgically so that critical areas can be saved when performing tumor or epilepsy surgery. Marketed by Nexstim, this method has received Food and Drug Administration (FDA) clearance in the United States.
Speech therapy is usually the most common treatment for asemia. Speech therapy allows the patient to be able to improve their speaking, comprehension, and writing skills. These patients have to learn all of these skills again since they are unable to understand or express anything. It usually depends on how long it takes for the speech therapy to work. If the condition is less severe, it will take less time, such as perhaps a couple of months to years. If the condition is more severe, it may take many years. The way speech therapy works is through speech practice as well as using special computer programs which let the patient practice their communication skills. By using simple and short sentences or writing down these phrases can aid the patients while going through therapy. Giving them enough time to communicate with their friends, family, or therapist will help them increase their skills and be able to manage them.
Complete success is usually achieved with treatment. However, sometimes only partial success is achieved and the patient cannot fully comprehend everything. With the partial restoration of some skills, the speech therapist may only focus on the skills which can be restored. In other cases, the therapist may work on the skills which may not retrieved and teach the patient how to handle those.
In cases of acute AOS (stroke), spontaneous recovery may occur, in which previous speech abilities reappear on their own. All other cases of acquired AOS require a form of therapy; however the therapy varies with the individual needs of the patient. Typically, treatment involves one-on-one therapy with a speech language pathologist (SLP). For severe forms of AOS, therapy may involve multiple sessions per week, which is reduced with speech improvement. Another main theme in AOS treatment is the use of repetition in order to achieve a large amount of target utterances, or desired speech usages.
There are various treatment techniques for AOS. One technique, called the Linguistic Approach, utilizes the rules for sounds and sequences. This approach focuses on the placement of the mouth in forming speech sounds. Another type of treatment is the Motor-Programming Approach, in which the motor movements necessary for speech are practiced. This technique utilizes a great amount of repetition in order to practice the sequences and transitions that are necessary in between production of sounds.
Research about the treatment of apraxia has revealed four main categories: articulatory-kinematic, rate/rhythm control, intersystemic facilitation/reorganization treatments, and alternative/augmentative communication.
- Articulatory-kinematic treatments almost always require verbal production in order to bring about improvement of speech. One common technique for this is modeling or repetition in order to establish the desired speech behavior. Articulatory-kinematic treatments are based on the importance of patients to improve spatial and temporal aspects of speech production.
- Rate and rhythm control treatments exist to improve errors in patients’ timing of speech, a common characteristic of Apraxia. These techniques often include an external source of control like metronomic pacing, for example, in repeated speech productions.
- Intersystemic reorganization/facilitation techniques often involve physical body or limb gestural approaches to improve speech. Gestures are usually combined with verbalization. It is thought that limb gestures may improve the organization of speech production.
- Finally, alternative and augmentative communication approaches to treatment of apraxia are highly individualized for each patient. However, they often involve a "comprehensive communication system" that may include "speech, a communication book aid, a spelling system, a drawing system, a gestural system, technologies, and informed speech partners".
One specific treatment method is referred to as PROMPT. This acronym stands for Prompts for Restructuring Oral Muscular Phonetic Targets, and takes a hands on multidimensional approach at treating speech production disorders. PROMPT therapists integrate physical-sensory, cognitive-linguistic, and social-emotional aspects of motor performance. The main focus is developing language interaction through this tactile-kinetic approach by using touch cues to facilitate the articulatory movements associated with individual phonemes, and eventually words.
One study describes the use of electropalatography (EPG) to treat a patient with severe acquired apraxia of speech. EPG is a computer-based tool for assessment and treatment of speech motor issues. The program allows patients to see the placement of articulators during speech production thus aiding them in attempting to correct errors. Originally after two years of speech therapy, the patient exhibited speech motor and production problems including problems with phonation, articulation, and resonance. This study showed that EPG therapy gave the patient valuable visual feedback to clarify speech movements that had been difficult for the patient to complete when given only auditory feedback.
While many studies are still exploring the various treatment methods, a few suggestions from ASHA for treating apraxia patients include the integration of objective treatment evidence, theoretical rationale, clinical knowledge and experience, and the needs and goals of the patient