Made by DATEXIS (Data Science and Text-based Information Systems) at Beuth University of Applied Sciences Berlin
Deep Learning Technology: Sebastian Arnold, Betty van Aken, Paul Grundmann, Felix A. Gers and Alexander Löser. Learning Contextualized Document Representations for Healthcare Answer Retrieval. The Web Conference 2020 (WWW'20)
Funded by The Federal Ministry for Economic Affairs and Energy; Grant: 01MD19013D, Smart-MD Project, Digital Technologies
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".
Among preschoolers, the prognosis for recovery is good. Based on research, about 65% of preschoolers who stutter recover spontaneously in the first two years of stuttering, and about 74% recover by their early teens. In particular, girls seem to recover well. For others, early intervention is effective in helping the child overcome disfluency.
Once stuttering has become established, and the child has developed secondary behaviors, the prognosis is more guarded, and only 18% of children who stutter after five years recover spontaneously. However, with treatment young children may be left with little evidence of stuttering.
With adult people who stutter, there is no known cure, though they may make partial recovery or even complete recovery with intervention. People who stutter often learn to stutter less severely, though others may make no progress with therapy.
Emotional sequelae associated with stuttering primarily relates to state-dependent anxiety related to the speech disorder itself. However, this is typically isolated to social contexts that require speaking, is not a trait anxiety, and this anxiety does not persist if stuttering remits spontaneously. Research attempting to correlate stuttering with generalized or state anxiety, personality profiles, trauma history, or decreased IQ have failed to find adequate empirical support for any of these claims.
Contrary to popular belief, people with selective mutism do not necessarily improve with age. Effective treatment is necessary for a child to develop properly. Without treatment, selective mutism can contribute to chronic depression, further anxiety, and other social and emotional problems.
Consequently, treatment at an early age is important. If not addressed, selective mutism tends to be self-reinforcing. Others may eventually expect an afflicted child to not speak and therefore stop attempting to initiate verbal contact. Alternatively, they may pressure the child to talk, increasing their anxiety levels in situations where speech is expected. Due to these problems, a change of environment may be a viable consideration. However, changing school is worth considering only if the alternative environment is highly supportive, otherwise a whole new environment could also be a social shock for the individual and/or deprive them of any friends or support they have currently. Regardless of the cause, increasing awareness and ensuring an accommodating, supportive environment are the first steps towards effective treatment. Most often afflicted children do not have to change schools or classes and have no difficulty keeping up except on the communication and social front. Treatment in teenage or adult years can be more difficult because the afflicted individual has become accustomed to being mute.
The exact treatment depends on the person's age, any comorbid mental illnesses, and a number of other factors. For instance, stimulus fading is typically used with younger children because older children and teenagers recognize the situation as an attempt to make them speak, and older people with this condition and people with depression are more likely to need medication.
Like other disabilities, adequate accommodations are needed for the afflicted to succeed at school, work, and in the home. Under the U.S. federal law and the Individuals with Disabilities Education Act (IDEA), those with the disorder qualify for services based upon the fact that they have an impairment that hinders their ability to speak, thus disrupting their lives. This assistance is typically documented in the form of an Individual Educational Plan (IEP). Post-secondary accommodations are also available for people with disabilities.
Under another law, Section 504 of the Rehabilitation Act of 1973, public school districts are required to provide a free, appropriate public education to every "qualified handicapped person" residing within their jurisdiction. If the child is found to have impairments that substantially limit a major life activity (in this case, learning), the education agency has to decide what related aids or services are required to provide equal access to the learning environment.
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.
Spacing is important to integrate, especially with self-modeling. Repeated and spaced out use of interventions is shown to be the most helpful long-term for learning. Viewing videotapes of self-modeling should be shown over a spaced out period of time of approximately 6 weeks.
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.
Because clutterers have poor awareness of their disorder, they may be indifferent or even hostile to speech-language pathologists. Delayed auditory feedback (DAF) is usually used to produce a more deliberate, exaggerated oral-motor response pattern. Other treatment components include improving narrative structure with story-telling picture books, turn-taking practice, pausing practice, and language therapy.
What follows are a list of frequently used measures of speech and language skills, and the age-ranges for which they are appropriate.
- Clinical Evaluation of Language Fundamentals – Preschool (3–6 years)
- Clinical Evaluation of Language Fundamentals (6–21 years)
- MacArthur Communicative Development Inventories (0–12 months)
- The Rossetti Infant-Toddler Language Scale (0–36 months)
- Preschool Language Scale (0–6 years)
- Expressive One-word Picture Vocabulary Test (2–15 years)
- Bankson-Bernthal Phonological Process Survey Test (2–16 years)
- Goldman-Fristoe Test of Articulation 2 (2–21 years)
- Peabody Picture Vocabulary Test (2.5–40 years)
According to the DSM-IV-TR, communication disorders are usually first diagnosed in childhood or adolescence though they are not limited as childhood disorders and may persist into adulthood. They may also occur with other disorders.
Diagnosis involves testing and evaluation during which it is determined if the scores/performance are "substantially below" developmental expectations and if they "significantly" interfere with academic achievement, social interactions and daily living. This assessment may also determine if the characteristic is deviant or delayed. Therefore, it may be possible for an individual to have communication challenges but not meet the criteria of being "substantially below" criteria of the DSM IV-TR.
It should also be noted that the DSM diagnoses do not comprise a complete list of all communication disorders, for example, auditory processing disorder is not classified under the DSM or ICD-10.
The following diagnoses are included in the communication disorders:
- Expressive language disorder – Characterized by difficulty expressing oneself beyond simple sentences and a limited vocabulary. An individual understands language better than their ability to use it; they may have a lot to say but have difficulties organizing and retrieving the words to get an idea across beyond what is expected for their developmental stage.
- Mixed receptive-expressive language disorder – problems comprehending the commands of others.
- Stuttering – a speech disorder characterized by a break in fluency, where sounds, syllables or words may be repeated or prolonged.
- Phonological disorder – a speech sound disorder characterized by problems in making patterns of sound errors, i.e. "dat" for "that".
- Communication disorder NOS (not otherwise specified) – the DSM-IV diagnosis in which disorders that do not meet the specific criteria for the disorder listed above may be classified.
Dysprosody, which may manifest as pseudo-foreign accent syndrome, refers to a disorder in which one or more of the prosodic functions are either compromised or eliminated completely.
Prosody refers to the variations in melody, intonation, pauses, stresses, intensity, vocal quality, and accents of speech. As a result, prosody has a wide array of functions, including expression on linguistic, attitudinal, pragmatic, affective and personal levels of speech. People diagnosed with dysprosody most commonly experience difficulties in pitch or timing control. Essentially, people diagnosed with the disease can comprehend language and vocalize what they intend to say, however, they are not able to control the way in which the words come out of their mouths. Since dysprosody is the rarest neurological speech disorder discovered, not much is conclusively known or understood about the disorder. The most obvious expression of dysprosody is when a person starts speaking in an accent which is not their own. Speaking in a foreign accent is only one type of dysprosody, as the disease can also manifest itself in other ways, such as changes in pitch, volume, and rhythm of speech. It is still very unclear as to how damage to the brain causes the disruption of prosodic function. The only form of effective treatment developed for dysprosody is speech therapy.
Symptoms of developmental dysfluency include the repetition of sounds or pauses between words. These symptoms have generally been noted within youngsters from 18 months to 5 years of age. This may persist for weeks or months but eventually disappears due to the maturation of the child's nervous system.
ex.: "Daddy, I was, I was, um, um, I was..."
Instances like the aforementioned example indicate that the child is learning to use language. On the other hand, children with stuttering disorder, will likely repeat sounds or one-syllable words three or more times. They may also prolong sounds for two or more seconds. In comparison, stuttering can be seen as a process where a word appears to become "stuck," and the person may grimace, jerk the head or neck as he struggles to overcome the stutter.
Children with normal dysfluency tend to have stuttering difficulties that come and go. Generally this is during preschool years and the problem normally ceases altogether by the time a child starts school.
When studies of dysprosody first began, diagnosis involved an untrained ear determining impairments in the prosodic elements. However, over time and as dysprosody has been studied more closely, a more concrete method of diagnosis has been developed. One diagnosis technique is a rating scale, such as the Boston Diagnostic Aphasia Examination. The exam is a subjective rating system of volume (from loud to normal to soft), voice (from normal to whisper to hoarse), speech rate (from fast to normal to slow) and intonation which is rated on a scale from 1-7. One indicates no sentence intonation, four is given when sentence intonation is limited to abrupt pauses, and seven indicates normal intonation.
There are also more involved diagnostic evaluations for which contain both productive and comprehensive parts. In the productive part, the patient is asked to say sentences with certain instructions. In the comprehension section, the patient is asked to listen to sentences being said and then answer questions about how they were stated.
In order to determine linguistic dysprosody, a patient is asked to read sentences that can either be a statement or a question using both declarative and interrogative intonations. How the patient uses prosodic contours to distinguish between asking a question and saying a statement is recorded. During the comprehension section of the evaluation, a clinician reads simple sentences with either a declarative or interrogative intonation and the patient is asked to identify whether the sentence is a question or a statement. Evaluation of these two parts can determine if the patient has linguistic dysprosody.
Emotional dysprosody can be diagnosed by having a patient state a neutral sentence with different emotions, such as happy, sad, and angry. Patients with dysprosody will not be able to convey the emotions very well or differentiate their speech between the different emotions significantly. During the comprehension part, a clinician will say a sentence with specific emotional intonations and the patient must indicate the correct emotion. These techniques ultimately allow for the diagnosis of dysprosody and the degree of its severity in the patient.
Remediation includes both appropriate remedial instruction and classroom accommodations.
Expressive language disorder is a communication disorder in which there are difficulties with verbal and written expression. It is a specific language impairment characterized by an ability to use expressive spoken language that is markedly below the appropriate level for the mental age, but with a language comprehension that is within normal limits. There can be problems with vocabulary, producing complex sentences, and remembering words, and there may or may not be abnormalities in articulation.
As well as present speech production, very often, someone will have difficulty remembering things. This memory problem is only disturbing for speech; non-verbal or non-linguistically based memory will be unimpaired. An example of a child with expressive language disorder can be seen here.
Expressive language disorder affects work and schooling in many ways. It is usually treated by specific speech therapy, and usually cannot be expected to go away on its own.
Expressive language disorder can be further classified into two groups: developmental expressive language disorder and acquired expressive language disorder. Developmental expressive language disorder currently has no known cause, is first observed when a child is learning to talk, is more common in boys than girls, and is much more common than the acquired form of the disorder. Acquired expressive language disorder is caused by specific damage to the brain by a stroke, traumatic brain injury, or seizures.
Care must be taken to distinguish expressive language disorder from other communication disorders, sensory-motor disturbances, intellectual disability and/or environmental deprivation (see DSM-IV-TR criterion D). These factors affect a person's speech and writing to certain predictable extents, and with certain differences.
Careful diagnosis is also important because "atypical language development can be a secondary characteristic of other physical and developmental problems that may first manifest as language problems".
An expressive language disability or delay in kindergarten age children is classified as a Communication Disability/Delay under a Code 30. If there is no marked improvement in the child's ability to express themselves verbally once the student enters Grade 1, a child can be given a Code 57 for a Communication Disability. This diagnosis must be given from a Speech-Language Pathologist in order for the child to receive continued special education funding.
Disorders and tendencies included and excluded under the category of communication disorders may vary by source. For example, the definitions offered by the American Speech–Language–Hearing Association differ from that of the Diagnostic Statistical Manual 4th edition (DSM-IV).
Gleanson (2001) defines a communication disorder as a speech and language disorder which refers to problems in communication and in related areas such as oral motor function. The delays and disorders can range from simple sound substitution to the inability to understand or use their native language.
In general, communications disorders commonly refer to problems in speech (comprehension and/or expression) that significantly interfere with an individual’s achievement and/or quality of life. Knowing the operational definition of the agency performing an assessment or giving a diagnosis may help.
Persons who speak more than one language or are considered to have an accent in their location of residence do not have speech disorders if they are speaking in a manner consistent with their home environment or a blending of their home and foreign environment.
Developmental dysfluency is considered a normal part of childhood development. About twenty-five percent of children experience some loss in fluency.
A reading disability is a condition in which a sufferer displays difficulty reading resulting primarily from neurological factors. Developmental Dyslexia, Alexia (acquired dyslexia), and Hyperlexia (word-reading ability well above normal for age and IQ).
There are several measures that can be employed to assess the executive functioning capabilities of an individual. Although a trained non-professional working outside of an institutionalized setting can legally and competently perform many of these measures, a trained professional administering the test in a standardized setting will yield the most accurate results.
The table below demonstrates the extensive and differential diagnosis of acquired epileptic aphasia along with Cognitive and Behavioral Regression:
Note: EEG = electroencephalographic; ESES = electrical status epilepticus of sleep; RL = receptive language; S = sociability
- Continuous spike and wave of slow-wave sleep (>85% of slow-wave sleep).
The Clock drawing test (CDT) is a brief cognitive task that can be used by physicians who suspect neurological dysfunction based on history and physical examination. It is relatively easy to train non-professional staff to administer a CDT. Therefore, this is a test that can easily be administered in educational and geriatric settings and can be utilized as a precursory measure to indicate the likelihood of further/future deficits. Also, generational, educational and cultural differences are not perceived as impacting the utility of the CDT.
The procedure of the CDT begins with the instruction to the participant to draw a clock reading a specific time (generally 11:10). After the task is complete, the test administrator draws a clock with the hands set at the same specific time. Then the patient is asked to copy the image. Errors in clock drawing are classified according to the following categories: omissions, perseverations, rotations, misplacements, distortions, substitutions and additions. Memory, concentration, initiation, energy, mental clarity and indecision are all measures that are scored during this activity. Those with deficits in executive functioning will often make errors on the first clock but not the second. In other words, they will be unable to generate their own example, but will show proficiency in the copying task.
ASD can be detected as early as 18 months or even younger in some cases. A reliable diagnosis can usually be made by the age of two years. The diverse expressions of ASD symptoms pose diagnostic challenges to clinicians. Individuals with an ASD may present at various times of development (e.g., toddler, child, or adolescent), and symptom expression may vary over the course of development. Furthermore, clinicians must differentiate among pervasive developmental disorders, and may also consider similar conditions, including intellectual disability not associated with a pervasive developmental disorder, specific language disorders, ADHD, anxiety, and psychotic disorders.
Considering the unique challenges in diagnosing ASD, specific practice parameters for its assessment have been published by the American Academy of Neurology, the American Academy of Child and Adolescent Psychiatry, and a consensus panel with representation from various professional societies. The practice parameters outlined by these societies include an initial screening of children by general practitioners (i.e., "Level 1 screening") and for children who fail the initial screening, a comprehensive diagnostic assessment by experienced clinicians (i.e. "Level 2 evaluation"). Furthermore, it has been suggested that assessments of children with suspected ASD be evaluated within a developmental framework, include multiple informants (e.g., parents and teachers) from diverse contexts (e.g., home and school), and employ a multidisciplinary team of professionals (e.g., clinical psychologists, neuropsychologists, and psychiatrists).
After a child shows initial evidence of ASD tendencies, psychologists administer various psychological assessment tools to assess for ASD. Among these measurements, the Autism Diagnostic Interview-Revised (ADI-R) and the Autism Diagnostic Observation Schedule (ADOS) are considered the "gold standards" for assessing autistic children. The ADI-R is a semi-structured parent interview that probes for symptoms of autism by evaluating a child's current behavior and developmental history. The ADOS is a semistructured interactive evaluation of ASD symptoms that is used to measure social and communication abilities by eliciting several opportunities (or "presses") for spontaneous behaviors (e.g., eye contact) in standardized context. Various other questionnaires (e.g., The Childhood Autism Rating Scale, Autism Treatment Evaluation Checklist) and tests of cognitive functioning (e.g., The Peabody Picture Vocabulary Test) are typically included in an ASD assessment battery.
In the UK, there is some diagnostic use of the Diagnostic Interview for Social and Communication Disorders (DISCO) was which was developed for use at The Centre for Social and Communication Disorders, by Lorna Wing and Judith Gould, as both a clinical and a research instrument for use with children and adults of any age. The DISCO is designed to elicit a picture of the whole person through the story of their development and behaviour. In clinical work, the primary purpose is to facilitate understanding of the pattern over time of the specific skills and impairments that underlie the overt behaviour. If no information is available, the clinician has to obtain as much information as possible concerning the details of current skills and pattern of behaviour of the person. This type of dimensional approach to clinical description is useful for prescribing treatment.
The syndrome can be difficult to diagnose and may be misdiagnosed as autism, pervasive developmental disorder, hearing impairment, learning disability, auditory/verbal processing disorder, attention deficit hyperactivity disorder, intellectual disability, childhood schizophrenia, or emotional/behavioral problems. An EEG (electroencephalogram) test is imperative to a diagnosis. Many cases of patients exhibiting LKS will show abnormal electrical brain activity in both the right and left hemispheres of the brain; this is exhibited frequently during sleep. Even though an abnormal EEG reading is common in LKS patients, a relationship has not been identified between EEG abnormalities and the presence and intensity of language problems. In many cases however, abnormalities in the EEG test has preceded language deterioration and improvement in the EEG tracing has preceded language improvement (this occurs in about half of all affected children). Many factors inhibit the reliability of the EEG data: neurologic deficits do not closely follow the maximal EEG changes in time.
The most effective way of confirming LKS is by obtaining overnight sleep EEGs, including EEGs in all stages of sleep. Many conditions like demyelination and brain tumors can be ruled out by using magnetic resonance imaging (MRI). In LKS, fluorodeoxyglucose (FDG) and positron emission tomography (PET) scanning can show decreased metabolism in one or both temporal lobes - hypermetabolism has been seen in patients with acquired epileptic aphasia.
Most cases of LKS do not have a known cause. Occasionally, the condition may be induced secondary to other diagnoses such as low-grade brain tumors, closed-head injury, neurocysticercosis, and demyelinating disease. Central Nervous System vasculitis may be associated with this condition as well.
Loss of language and skills related to social interaction and self-care are serious. The affected children face ongoing disabilities in certain areas and require long term care. Treatment of CDD involves both behavior therapy, environmental therapy and medications.
- Behavior therapy: The main aim of Applied Behavior Analysis (ABA) is to systematically teach the child to relearn language, self-care and social skills. The treatment programs designed in this respect "use a system of rewards to reinforce desirable behaviors and discourage problem behavior." ABA programs may be designed by a board-certified specialist in behavior analysis called a "BCBA" (Board Certified Behavior Analyst), but ABA is also widely used by a number of other health care personnel from different fields like psychologists, speech therapists, physical therapists and occupational therapists with differing levels of expertise. Parents, teachers and caregivers are instructed to use these behavior therapy methods at all times.
- Environmental Therapy: Sensory Enrichment Therapy uses enrichment of the sensory experience to improve symptoms in autism, many of which are common to CDD.
- Medications: There are no medications available to directly treat CDD. Antipsychotic medications are used to treat severe behavior problems like aggressive stance and repetitive behavior patterns. Anticonvulsant medications are used to control seizures.
Although not necessary for the diagnosis, individuals with intellectual disability are at higher risk for SMD. It is more common in boys, and can occur at any age.