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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.
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
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."
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.
Articulation problems resulting from dysarthria are treated by speech language pathologists, using a variety of techniques. Techniques used depend on the effect the dysarthria has on control of the articulators. Traditional treatments target the correction of deficits in rate (of articulation), prosody (appropriate emphasis and inflection, affected e.g. by apraxia of speech, right hemisphere brain damage, etc.), intensity (loudness of the voice, affected e.g. in hypokinetic dysarthrias such as in Parkinson's), resonance (ability to alter the vocal tract and resonating spaces for correct speech sounds) and phonation (control of the vocal folds for appropriate voice quality and valving of the airway). These treatments have usually involved exercises to increase strength and control over articulator muscles (which may be flaccid and weak, or overly tight and difficult to move), and using alternate speaking techniques to increase speaker intelligibility (how well someone's speech is understood by peers). With the speech language pathologist, there are several skills that are important to learn; safe chewing and swallowing techniques, avoiding conversations when feeling tired, repeat words and syllables over and over in order to learn the proper mouth movements, and techniques to deal with the frustration while speaking. Depending on the severity of the dysarthria, another possibility includes learning how to use a computer or flip cards in order to communicate more effectively.
More recent techniques based on the principles of motor learning (PML), such as LSVT (Lee Silverman voice treatment) speech therapy and specifically LSVT may improve voice and speech function in PD. For Parkinson's, aim to retrain speech skills through building new generalised motor programs, and attach great importance to regular practice, through peer/partner support and self-management. Regularity of practice, and when to practice, are the main issues in PML treatments, as they may determine the likelihood of generalization of new motor skills, and therefore how effective a treatment is.
Augmentative and alternative communication (AAC) devices that make coping with a dysarthria easier include speech synthesis and text-based telephones. These allow people who are unintelligible, or may be in the later stages of a progressive illness, to continue to be able to communicate without the need for fully intelligible speech.
Developmental verbal dyspraxia is a developmental inability to motor plan volitional movement for the production of speech in the absence of muscular weakness. Research has suggested links to the FOXP2 gene.
A speech sound disorder is a speech disorder in which some speech sounds (called phonemes) in a child's (or, sometimes, an adult's) language are either not produced, not produced correctly, or are not used correctly. The term protracted phonological development is sometimes preferred when describing children's speech to emphasize the continuing development while acknowledging the delay.
Dysarthria is a motor speech disorder resulting from neurological injury of the motor component of the motor-speech system and is characterized by poor articulation of phonemes. In other words, it is a condition in which problems effectively occur with the muscles that help produce speech, often making it very difficult to pronounce words. It is unrelated to problems with understanding language (that is aphasia), although a person can have both. Any of the speech subsystems (respiration, phonation, resonance, prosody, and articulation) can be affected, leading to impairments in intelligibility, audibility, naturalness, and efficiency of vocal communication. Dysarthria that has progressed to a total loss of speech is referred to as anarthria.
Neurological injury due to damage in the central or peripheral nervous system may result in weakness, paralysis, or a lack of coordination of the motor-speech system, producing dysarthria. These effects in turn hinder control over the tongue, throat, lips or lungs; for example, swallowing problems (dysphagia) are also often present in those with dysarthria.
Dysarthria does not include speech disorders from structural abnormalities, such as cleft palate, and must not be confused with apraxia of speech, which refers to problems in the planning and programming aspect of the motor-speech system. Just as the term "articulation" can mean either "speech" or "joint movement", so is the combining form of the same in the terms "dysarthria", "dysarthrosis", and "arthropathy"; the term "dysarthria" is conventionally reserved for the speech problem and is not used to refer to arthropathy, whereas "dysarthrosis" has both senses but usually refers to arthropathy.
Cranial nerves that control the muscles relevant to dysarthria include the trigeminal nerve's motor branch (V), the facial nerve (VII), the glossopharyngeal nerve (IX), the vagus nerve (X), and the hypoglossal nerve (XII). The term is from New Latin, "dys-" "dysfunctional, impaired" and "arthr-" "joint, vocal articulation")
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.
Dysarthria is the reduced ability to motor plan volitional movements needed for speech production as the result of weakness/paresis and/or paralysis of the musculature of the oral mechanism needed for respiration, phonation, resonance, articulation, and/or prosody.
One technique that is frequently used to treat DVD/CAS is integral stimulation. Integral stimulation is based on cognitive motor learning, focusing on the cognitive motor planning needed for the complex motor task of speech. It is often referred to as the "watch me, listen, do as I do" approach and is founded on a multi-step hierarchy of strategies for treatment. This hierarchy of strategies allows the clinician to alter treatment depending upon the needs of the child. It uses various modalities of presentation, emphasizing the auditory and visual modes. Experts suggest that extensive practice and experience with the new material is key, so hundreds of target stimuli should be elicited in a single session. Furthermore, distributed (shorter, but more frequent) and random treatment, which mix target and non-target utterances, produces greater overall learning.
The 6 steps of the hierarchy upon which integral stimulation therapy for children is loosely organized are:"
- The child watches and listens and simultaneously produces the stimulus with the clinician.
- The clinician models, then the child repeats the stimulus while the clinician simultaneously mouths it.
- The clinician models and provides cues and the child repeats.
- The clinician models and the child repeats with no cues provided.
- The clinician elicits the stimulus without modeling, such as by asking a question, with the child responding spontaneously.
- The child produces stimuli in less-directed situations with clinician encouragement, such as in role-play or games".
Many of these types of disorders can be treated by speech therapy, but others require medical attention by a doctor in phoniatrics. Other treatments include correction of organic conditions and psychotherapy.
In the United States, school-age children with a speech disorder are often placed in special education programs. Children who struggle to learn to talk often experience persistent communication difficulties in addition to academic struggles. More than 700,000 of the students served in the public schools’ special education programs in the 2000-2001 school year were categorized as having a speech or language impediment. This estimate does not include children who have speech and language impairments secondary to other conditions such as deafness". Many school districts provide the students with speech therapy during school hours, although extended day and summer services may be appropriate under certain circumstances.
Patients will be treated in teams, depending on the type of disorder they have. A team can include SLPs, specialists, family doctors, teachers, and family members.
After the initial diagnosis of speech delay, a hearing test will be administered to ensure that hearing loss or deafness is not an underlying cause of the delay. If a child has successfully completed the hearing test, the therapy or therapies used will be determined. There are many therapies available for children that have been diagnosed with a speech delay, and for every child, the treatment and therapies needed vary with the degree, severity, and cause of the delay. While speech therapy is the most common form of intervention, many children may benefit from additional help from occupational and physical therapies as well. Physical and occupational therapies can be used for a child that is suffering from speech delay due to physical malformations and children that have also been diagnosed with a developmental delay such as autism or a language processing delay. Children that have been identified with hearing loss can be taught simple sign language to build and improve their vocabulary in addition to attending speech therapy.
The parents of a delayed child are the first and most important tool in helping overcome the speech delay. The parent or caregiver of the child can provide the following activities at home, in addition to the techniques suggested by a speech therapist, to positively influence the growth of speech and vocabulary:
- Reading to the child regularly
- Use of questions and simple, clear language
- Positive reinforcement in addition to patience
For children that are suffering from physical disorder that is causing difficulty forming and pronouncing words, parents and caregivers suggest using and introducing different food textures to exercise and build jaw muscles while promoting new movements of the jaw while chewing. Another less studied technique used to combat and treat speech delay is a form of therapy using music to promote and facilitate speech and language development. It is important to understand that music therapy is in its infancy and has yet to be thoroughly studied and practiced on children suffering from speech delays and impediments.
In relation to other types of aphasia, TMoA occurs less frequently, so there is less information on its prognosis. In general, for individuals with aphasia, most recovery is seen within 6 months of the stroke or injury although more recovery may continue in the following months or years. The timeline of recovery may look different depending on the type of stroke that caused the aphasia. With an ischemic stroke, recovery is greatest within the first two weeks and then diminishes overtime until the progress stabilizes. With a hemorrhagic stroke, the patient often shows little improvement in the first few weeks and then has relatively rapid recovery until they stabilize.
In a study involving eight patients with border zone lesions, all patients presented with transcortical mixed aphasia initially after the stroke. Three of these patients made a complete recovery within a few days post-stroke. For three other patients with more anterior lesions, their aphasia transitioned to TMoA. All participants in the study regained full language abilities within 18 months following their stroke. This suggests a positive long-term prognosis for patients with TMoA. However, this might not be the case for all patients and more research is needed in order to solidify these findings. Another study found that prognosis of TMoA is affected by lesion size. Smaller lesions typically cause delays in speech initiation; whereas, larger lesions lead to more profound language abnormalities and difficulty with abstract language abilities.
Research has shown that treatment has a direct effect on aphasia outcomes. Intensity, duration and timing of treatment all need to be taken in to consideration when choosing a course of treatment and determining a prognosis. In general, greater intensity leads to greater improvement. For duration, longer-term treatment produces more permanent changes. As for timing, beginning treatment too early may be difficult for the system which has not recovered enough to do intensive therapy, but beginning too late may result missing the window of the opportunity in which the most change can occur. Neuroplasticity, the brain's natural ability to reorganize itself following a traumatic event, occurs best when treatment connects simultaneous events, maintains attention, taps into positive emotion, utilizes repetition tasks, and is specific to the individual's needs.
Other factors affecting prognosis includes location and site of lesion. Since the lesion that results in TMoA usually occurs in the watershed area and does not directly involve the areas of the brain responsible for general language abilities, prognosis for these patients is good overall. Other factors that determine a patient’s prognosis include age, education prior to the stroke, gender, motivation, and support.
Treatment for all types of aphasia, including transcortical motor aphasia, is usually provided by a speech-language pathologist. The SLP chooses specific therapy tasks and goals based on the speech and language abilities and needs of the individual. In general for individuals with TMoA, treatment should capitalize on their strong auditory comprehension and repetition skills and address the individual's reduced speech output and difficulty initiating and maintaining a conversation. New research in aphasia treatment is showing the benefit of the Life Participation Approach to Aphasia (LPAA) in which goals are written based on the skills needed by the individual patient to participate in specific real-life situations (i.e. communicating effectively with nurses or gaining employment). Based on the specific needs of the patient, SLPs can provide a variety of treatment activities.
To improve word retrieval and initiation difficulties, clinicians may use confrontation naming in which the patient is asked to name various objects and pictures. Depending on the severity, they may also use sentence completion tasks in which the clinician says sentences with the final word(s) missing and expects the patient to fill in the blank. Limited research suggests that nonsymbolic limb movement on the left side (i.e. tapping the left hand on the table) during sentence production can increase verbal initiations. The use of the left arm in left space stimulates initiation mechanisms in the right hemisphere of the brain which can also be used for language allowing individuals to produce more grammatical sentences with higher fluency and more verbal initiation.
To increase speech output, the clinician may provide a set of pictures and prompt the patient to describe or elaborate on the events pictured. The clinician can also provide spoken or written words and prompt the patient to use the words in a sentence. Additionally, the clinician can ask questions based on the patient’s experiences, opinions, or general knowledge and prompt the patient to answer with phrases or sentences. To work on more connected speech, the clinician may ask the patient to describe procedures such as making a sandwich or doing laundry. A study found that syntax training in which sentence constructions are elicited on a hierarchy of difficulty produced gains in grammatically complete utterances and utterances that successfully communicated novel and accurate information.
To improve conversational skills, SLPs may engage the patient in structured conversations in which supports are provided to help the patient take appropriate conversational turns, maintain the topic of conversation, and formulate appropriate sentences. Clinicians often need to provide pragmatic guidelines so that the patient’s responses go beyond the clinician’s request and so the clinician does not do the majority of the talking. Research shows that conversation therapy can improve percent of complex utterances, the efficiency of the utterances for expressing ideas, and total time spent talking over more traditional stimulation therapy.
In order to improve the patient’s abilities to functionally communicate in their natural settings, the SLP will provide strategies and techniques to enhance their success in communicative settings (i.e. supplementing speech with nonverbal communication). Research supports the use of reduced syntax therapy to help patients overcome the non-fluent speech and agrammatism that often occurs with TMoA. Because agrammatism inhibits the patient's ability to form grammatically correct sentences, this type of treatment involves reducing these agrammatic deficits and teaching the patient to simplify linguistic structures while still conveying the message in order for language used to be more productive in conversation.
Additionally, they may train the patient’s communication partners to support the conversational abilities of the patient by facilitating the use of preserved cognitive and social functions. Research supports the use of various partner training programs such as Supported Conversation for Adults with Aphasia from the Aphasia Institute. In this program, the focus is put on acknowledging the patient’s competence and helping them to reveal that competence. Strategies include saying “I know you know” when appropriate, using gestures to supplement messages, limiting background noise, and given sufficient time for response.
From a neuroscience perspective, research has found that a dopamine agonist, bromocriptine, taken by mouth, has provided positive outcomes during intervention for non-fluent types of aphasia, such as TMoA or adynamic aphasia. Studies have found that bromocriptine increased neural networks which assist with the initiation of speech in individuals who possess non-fluent characteristics of speech.
In order to capitalize on neuroplasticity for treatment of all types of aphasia, timing, intensity, duration, and repetition of treatment should be taken into consideration. Research has found that aphasia treatment initiated during the earlier acute post-injury phase is more effective compared to treatment initiated in the chronic phase. With regard to intensity and duration of treatment, studies reported maximum recovery occurred with intense weekly therapy (approximately 8 hours per week) was delivered over a 2–3 month period. Other research shows that distributed therapy may be more beneficial than high intensity therapy. More research is needed to determine which is best, but it may be found that the ideal duration and intensity of therapy is variable depending on the patient and their needs.
Speech delay, also known as alalia, refers to a delay in the development or use of the mechanisms that produce speech. Speech, as distinct from language, refers to the actual process of making sounds, using such organs and structures as the lungs, vocal cords, mouth, tongue, teeth, etc. Language delay refers to a delay in the development or use of the knowledge of language.
Because language and speech are two independent stages, they may be individually delayed. For example, a child may be delayed in speech (i.e., unable to produce intelligible speech sounds), but not delayed in language. In this case, the child would be attempting to produce an age appropriate amount of language, but that language would be difficult or impossible to understand. Conversely, since a child with a language delay typically has not yet had the opportunity to produce speech sounds, it is likely to have a delay in speech as well.
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.
Pressured speech may also lead to the development of a stutter. The person's need or pressure to speak causes them to involuntarily stutter. Therefore, the person's need to express themselves is greater than their ability to vocalise their thoughts.
Scanning speech, also known as explosive speech, is a type of ataxic dysarthria in which spoken words are broken up into separate syllables, often separated by a noticeable pause, and spoken with varying force. The sentence "Walking is good exercise", for example, might be pronounced as "Walk (pause) ing is good ex (pause) er (pause) cise". Additionally, stress may be placed on unusual syllables.
The name is derived from literary scansion, because the speech pattern separates the syllables in a phrase much like scanning a poem counts the syllables in a line of poetry.
There is no universal agreement about the exact definition of this term. Some sources require only a noticeable pause between syllables, while others require other speech abnormalities, such as the unusual stress pattern on syllables. Some sources consider it a common, but not necessary, feature of ataxic dysarthria; others consider it exactly synonymous with ataxic dysarthria.
Treating auditory verbal agnosia with intravenous immunoglobulin (IVIG) is controversial because of its inconsistency as a treatment method. Although IVIG is normally used to treat immune diseases, some individuals with auditory verbal agnosia have responded positively to the use of IVIG. Additionally, patients are more likely to relapse when treated with IVIG than other pharmacological treatments. IVIG is, thus, a controversial treatment as its efficacy in treating auditory verbal agnosia is dependent upon each individual and varies from case to case.
Cluttering (also called tachyphemia or tachyphrasia) is a speech and communication disorder characterized by a rapid rate of speech, erratic rhythm, and poor syntax or grammar, making speech difficult to understand.
In 2006, the U.S. Department of Education indicated that more than 1.4 million students were served in the public schools' special education programs under the speech or language impairment category of IDEA 2004. This estimate does not include children who have speech/language problems secondary to other conditions such as deafness; this means that if all cases of speech or language impairments were included in the estimates, this category of impairment would be the largest. Another source has estimated that communication disorders—a larger category, which also includes hearing disorders—affect one of every 10 people in the United States.
ASHA has cited that 24.1% of children in school in the fall of 2003 received services for speech or language disorders—this amounts to a total of 1,460,583 children between 3 –21 years of age. Again, this estimate does not include children who have speech/language problems secondary to other conditions. Additional ASHA prevalence figures have suggested the following:
- Stuttering affects approximately 4% to 5% of children between the ages of 2 and 4.
- ASHA has indicated that in 2006:
- Almost 69% of SLPs served individuals with fluency problems.
- Almost 29% of SLPs served individuals with voice or resonance disorders.
- Approximately 61% of speech-language pathologists in schools indicated that they served individuals with SLI
- Almost 91% of SLPs in schools indicated that they servedindividuals with phonological/articulation disorder
- Estimates for language difficulty in preschool children range from 2% to 19%.
- Specific Language Impairment (SLI) is extremely common in children, and affects about 7% of the childhood population.
Tachylalia or tachylogia is extremely rapid speech. Tachylalia occurs in many clutterers and many people who have speech disorders.
Tachylalia is a generic term for speaking fast, and does not need to coincide with other speech problems. Tachylalia by itself is not considered a speech disorder.
Tachylalia may be exhibited as a single stream of rapid speech without prosody, and can be delivered quietly or mumbled. Tachylalia can be simulated by stimulating the brain electronically.
Tachylalia can occur with the following:
- Normal speech
- Cluttering
- Parkinson's disease
- Cluttered speech
- Pressure of speech
Speech and language impairment are basic categories that might be drawn in issues of communication involve hearing, speech, language, and fluency.
A speech impairment is characterized by difficulty in articulation of words. Examples include stuttering or problems producing particular sounds. Articulation refers to the sounds, syllables, and phonology produced by the individual. Voice, however, may refer to the characteristics of the sounds produced—specifically, the pitch, quality, and intensity of the sound. Often, fluency will also be considered a category under speech, encompassing the characteristics of rhythm, rate, and emphasis of the sound produced
A language impairment is a specific impairment in understanding and sharing thoughts and ideas, i.e. a disorder that involves the processing of linguistic information. Problems that may be experienced can involve the form of language, including grammar, morphology, syntax; and the functional aspects of language, including semantics and pragmatics
An individual can have one or both types of impairment. These impairments/disorders are identified by a speech and language pathologist.