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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.
There are two types of Apraxia. Developmental (or Childhood Apraxia of speech) or acquired Apraxia. Childhood apraxia of speech (CAS) is a neurological childhood speech sound disorder that involves impaired precision and consistency of movements required for speech production without any neuromuscular deficits (ASHA, 2007a, Definitions of CAS section, para. 1). Both are the inability to plan volitional motor movements for speech production in the absence of muscular weakness. Apraxia is not a result of sensory problems, or physical issues with the articulatory structures themselves, simply the way the brain plans to move them.
AOS and expressive aphasia (also known as Broca's aphasia) are commonly mistaken as the same disorder mainly because they often occur together in patients. Although both disorders present with symptoms such as a difficulty producing sounds due to damage in the language parts of the brain, they are not the same. The main difference between these disorders lies in the ability to comprehend spoken language; patients with apraxia are able to fully comprehend speech, while patients with aphasia are not always fully able to comprehend others' speech.
Conduction aphasia is another speech disorder that is similar to, but not the same as, apraxia of speech. Although patients who suffer from conduction aphasia have full comprehension of speech, as do AOS sufferers, there are differences between the two disorders. Patients with conduction aphasia are typically able to speak fluently, but they do not have the ability to repeat what they hear.
Similarly, dysarthria, another motor speech disorder, is characterized by difficulty articulating sounds. The difficulty in articulation does not occur due in planning the motor movement, as happens with AOS. Instead, dysarthria is caused by inability in or weakness of the muscles in the mouth, face, and respiratory system.
Apraxia of speech (AOS) is an acquired oral motor speech disorder affecting an individual's ability to translate conscious speech plans into motor plans, which results in limited and difficult speech ability. By the definition of apraxia, AOS affects volitional (willful or purposeful) movement patterns, however AOS usually also affects automatic speech.
Individuals with AOS have difficulty connecting speech messages from the brain to the mouth. AOS is a loss of prior speech ability resulting from a brain injury such as a stroke or progressive illness.
Developmental verbal dyspraxia (DVD), also known as childhood apraxia of speech (CAS) and developmental apraxia of speech (DAS); is an inability to utilize motor planning to perform movements necessary for speech during a child's language learning process. Although the causes differ between AOS and DVD, the main characteristics and treatments are similar.
Dysarthrias are classified in multiple ways based on the presentation of symptoms. Specific dysarthrias include spastic (resulting from bilateral damage to the upper motor neuron), flaccid (resulting from bilateral or unilateral damage to the lower motor neuron), ataxic (resulting from damage to cerebellum), unilateral upper motor neuron (presenting milder symptoms than bilateral UMN damage), hyperkinetic and hypokinetic (resulting from damage to parts of the basal ganglia, such as in Huntington's disease or Parkinsonism), and the mixed dysarthrias (where symptoms of more than one type of dysarthria are present). The majority of dysarthric patients are diagnosed as having 'mixed' dysarthria, as neural damage resulting in dysarthria is rarely contained to one part of the nervous system — for example, multiple strokes, traumatic brain injury, and some kinds of degenerative illnesses (such as amyotrophic lateral sclerosis) usually damage many different sectors of the nervous system.
Ataxic dysarthria is an acquired neurological and sensorimotor speech deficit. It is a common diagnosis among the clinical spectrum of ataxic disorders. Since regulation of skilled movements is a primary function of the cerebellum, damage to the superior cerebellum and the superior cerebellar peduncle is believed to produce this form of dysarthria in ataxic patients. Growing evidence supports the likelihood of cerebellar involvement specifically affecting speech motor programming and execution pathways, producing the characteristic features associated with ataxic dysarthria. This link to speech motor control can explain the abnormalities in articulation and prosody, which are hallmarks of this disorder. Some of the most consistent abnormalities observed in patients with ataxia dysarthria are alterations of the normal timing pattern, with prolongation of certain segments and a tendency to equalize the duration of syllables when speaking. As the severity of the dysarthria increases, the patient may also lengthen more segments as well as increase the degree of lengthening of each individual segment.
Common clinical features of ataxic dysarthria include abnormalities in speech modulation, rate of speech, explosive or scanning speech, slurred speech, irregular stress patterns, and vocalic and consonantal misarticulations.
Ataxic dysarthria is associated with damage to the left cerebellar hemisphere in right-handed patients.
Dysarthria may affect a single system; however, it is more commonly reflected in multiple motor-speech systems. The etiology, degree of neuropathy, existence of co-morbidities, and the individual's response all play a role in the effect the disorder has on the individual's quality of life. Severity ranges from occasional articulation difficulties to verbal speech that is completely unintelligible.
Individuals with dysarthria may experience challenges in the following:
- Timing
- Vocal quality
- Pitch
- Volume
- Breath control
- Speed
- Strength
- Steadiness
- Range
- Tone
Examples of specific observations include a continuous breathy voice, irregular breakdown of articulation, monopitch, distorted vowels, word flow without pauses, and hypernasality.
There are three significant features that differentiate DVD/CAS from other childhood speech sound disorders. These features are:
- "Inconsistent errors on consonants and vowels in repeated productions of syllables and words
- Lengthened coarticulatory transitions between sounds and syllables
- Inappropriate prosody, especially in the realization of lexical or phrasal stress"
Even though DVD/CAS is a "developmental" disorder, it will not simply disappear when children grow older. Children with this disorder do not follow typical patterns of language acquisition and will need treatment in order to make progress.
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")
There are several types of apraxia including:
- Ideomotor apraxia: These patients have deficits in their ability to plan or complete motor actions that rely on semantic memory. They are able to explain how to perform an action, but unable to "imagine" or act out a movement such as "pretend to brush your teeth" or "pucker as though you bit into a sour lemon." However, when the ability to perform an action automatically when cued remains intact, this is known as automatic-voluntary dissociation. For example, they may not be able to pick up a phone when asked to do so, but can perform the action without thinking when the phone rings.
- Ideational/conceptual apraxia: Patients have an inability to conceptualize a task and impaired ability to complete multistep actions. Consists of an inability to select and carry out an appropriate motor program. For example, the patient may complete actions in incorrect orders, such as buttering bread before putting it in the toaster, or putting on shoes before putting on socks. There is also a loss of ability to voluntarily perform a learned task when given the necessary objects or tools. For instance, if given a screwdriver, the patient may try to write with it as if it were a pen, or try to comb his hair with a toothbrush.
- Buccofacial or orofacial apraxia: Non-verbal oral or buccofacial ideomotor apraxia describes difficulty carrying out movements of the face on demand. For example, an inability to lick one's lips or whistle when requested suggests an inability to carry out volitional movements of the tongue, cheeks, lips, pharynx, or larynx on command.
- Constructional apraxia: The inability to draw or construct simple configurations, such as intersecting shapes.
- Gait apraxia: The loss of ability to have normal function of the lower limbs such as walking. This is not due to loss of motor or sensory functions.
- Limb-kinetic apraxia: voluntary movements of extremities are impaired. For example, a person affected by limb apraxia may have difficulty waving hello.
- Oculomotor apraxia: Difficulty moving the eye, especially with saccade movements that direct the gaze to targets. This is one of the 3 major components of Balint's syndrome.
- Apraxia of speech (AOS): Difficulty planning and coordinating the movements necessary for speech (e.g. Potato=Totapo, Topato.) AOS can independently occur without issues in areas such as verbal comprehension, reading comprehension, writing, articulation or prosody.
Developmental verbal dyspraxia (DVD), also known as childhood apraxia of speech (CAS) and developmental apraxia of speech (DAS), is when children have problems saying sounds, syllables, and words. This is not because of muscle weakness or paralysis. The brain has problems planning to move the body parts (e.g., lips, jaw, tongue) needed for speech. The child knows what they want to say, but their brain has difficulty coordinating the muscle movements necessary to say those words. The exact cause of this disorder is unknown. Some observations suggest a genetic cause of DVD, as many with the disorder have a family history of communication disorders. There is no cure for DVD, but with appropriate, intensive intervention, people with this motor speech disorder can improve significantly.
Primary stuttering behaviors are the overt, observable signs of speech disfluencies, including repeating sounds, syllables, words or phrases, silent blocks and prolongation of sounds. These differ from the normal dysfluencies found in all speakers in that stuttering dysfluencies may last longer, occur more frequently, and are produced with more effort and strain. Stuttering dysfluencies also vary in quality: common dysfluencies tend to be repeated movements, fixed postures, or superfluous behaviors. Each of these three categories is composed of subgroups of stutters and dysfluencies.
- Repeated movements
- Part-word repetition—a single segment of a word is repeated (for example: "s-s-stuttering!") or a part of a word which is still a full syllable such as "un—un—under the..." and "o—o—open".
- Incomplete syllable repetition—an incomplete syllable is repeated, such as a consonant without a vowel, for example, "c—c—c—cold".
- Whole-word repetition—a whole word, or more than one word is repeated, such as "I know—I know—I know a lot of information.".
- Fixed postures
- Prolongation—prolongation of a sound occurs such as "mmmmmmmmmom".
- Block—such as a block of speech or a tense pause where nothing is said despite efforts.
- Superfluous behaviors
- Interjections—this includes an interjection such as an unnecessary "uh" or "um" as well as revisions, such as going back and correcting one's initial statements such as "I—My girlfriend...", where the "I" has been corrected to the word "my".
- Secondary characteristics—these are visible or audible speech behaviors, such as lip smacking, throat clearing, head thrusting, etc., usually representing an effort to break through or circumvent a block or stuttering loop.
Apraxia is a motor disorder caused by damage to the brain (specifically the posterior parietal cortex), in which the individual has difficulty with the motor planning to perform tasks or movements when asked, provided that the request or command is understood and he/she is willing to perform the task. The nature of the brain damage determines the severity, and the absence of sensory loss or paralysis helps to explain the level of difficulty.
The term comes from the Greek ἀ- "a-" ("without") and πρᾶξις "praxis" ("action").
Echolalia can be categorized as immediate (occurring immediately after the stimulus) vs. delayed (some time after the occurrence of a stimulus). Immediate echolalia results from quick recall of information from the short-term memory and "superficial linguistic processing". A typical pediatric presentation of immediate echolalia might be as follows: a child is asked "Do you want dinner?"; the child echoes back "Do you want dinner?", followed by a pause, and then a response, "Yes. What's for dinner?"
In delayed echolalia the patient repeats words, phrases, or multiple sentences after a delay that can be anywhere from hours to years later. Immediate echolalia can be indicative that a developmental disorder exists, but this is not necessarily the case. Sometimes echolalia can be observed when an individual echoes back a statement to indicate they are contemplating a response and fully heard the original statement.
Researchers observed the daily repetitions of an autistic six-year-old in order to examine the differences between triggers for delayed versus immediate echolalia. Researchers further distinguished immediate echos by the sequential context in which they occur: after corrections, after directives, or in indiscernible sequential positions. Delayed echos are distinguished on the basis of ownership: self-echos, other-echos, and impersonal echos. The results showed that nearly all immediate echos produced by the six-year-old were found in sequential contexts, while the delayed echoes also occurred in the basis of ownership.
Although echolalia can be an impairment, the symptoms can involve a large selection of underlying meanings and behaviors across and within subjects. "Mitigated echolalia" refers to a repetition in which the original stimulus is somewhat altered, and "ambient echolalia" refers to the repetition (typically occurring in individuals with dementia) of environmental stimuli such as a television program running in the background.
Examples of mitigated echolalia are pronoun changes or syntax corrections. The first can be seen in the example of asking the patient “Where are you going?” and with patient responding “Where am I going?” The latter would be seen in the clinician asking “Where are I going?” and the patient repeating “Where am I going?” In mitigated echolalia some language processing is occurring. Mitigated echolalia can be seen in dyspraxia and aphasia of speech.
A Japanese case report describes a 20-year-old college student who was admitted to the hospital complaining about headaches and meningitis; however, he also exhibited signs of ambient echolalia. The researchers stated that the young patient's repetition was occurring at approximately the same tempo as his normal speech rate. The patient did not simply repeat words he had heard one after another. The patient reported that his ambient echolalia appeared to be random but appeared when he was distracted. He was also aware of his echolalia, but said he is unable to stop the repetitions.
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.
Echolalia (also known as echologia or echophrasia) is defined as the unsolicited repetition of vocalizations made by another person (by the same person is called palilalia). In its profound form it is automatic and effortless. It is one of the echophenomena, closely related to echopraxia, the automatic repetition of movements made by another person; both are "subsets of imitative behavior" whereby sounds or actions are imitated "without explicit awareness". Echolalia may be an immediate reaction to a stimulus or may be delayed.
The word "echolalia" is derived from the Greek , meaning "echo" or "to repeat", and ("laliá") meaning "speech" or "talk" (of onomatopoeic origin, from the verb ("laléo"), meaning "to talk").
Stuttering, also known as stammering, is a speech disorder in which the flow of speech is disrupted by involuntary repetitions and prolongations of sounds, syllables, words or phrases as well as involuntary silent pauses or blocks in which the person who stutters is unable to produce sounds. The term "stuttering" is most commonly associated with involuntary sound repetition, but it also encompasses the abnormal hesitation or pausing before speech, referred to by people who stutter as "blocks", and the prolongation of certain sounds, usually vowels or semivowels. According to Watkins et al., stuttering is a disorder of "selection, initiation, and execution of motor sequences necessary for fluent speech production." For many people who stutter, repetition is the primary problem. The term "stuttering" covers a wide range of severity, encompassing barely perceptible impediments that are largely cosmetic to severe symptoms that effectively prevent oral communication. In the world, approximately four times as many men as women stutter, encompassing 70 million people worldwide, or about 1% of the world's population.
The impact of stuttering on a person's functioning and emotional state can be severe. This may include fears of having to enunciate specific vowels or consonants, fears of being caught stuttering in social situations, self-imposed isolation, anxiety, stress, shame, being a possible target of bullying (especially in children), having to use word substitution and rearrange words in a sentence to hide stuttering, or a feeling of "loss of control" during speech. Stuttering is sometimes popularly seen as a symptom of anxiety, but there is actually no direct correlation in that direction (though as mentioned the inverse can be true, as social anxiety may actually develop in individuals as a result of their stuttering).
Stuttering is generally not a problem with the physical production of speech sounds or putting thoughts into words. Acute nervousness and stress do not cause stuttering, but they can trigger stuttering in people who have the speech disorder, and living with a stigmatized disability can result in anxiety and high allostatic stress load (chronic nervousness and stress) that reduce the amount of acute stress necessary to trigger stuttering in any given person who stutters, exacerbating the problem in the manner of a positive feedback system; the name 'stuttered speech syndrome' has been proposed for this condition. Neither acute nor chronic stress, however, itself creates any predisposition to stuttering.
The disorder is also "variable", which means that in certain situations, such as talking on the telephone or in a large group, the stuttering might be more severe or less, depending on whether or not the stutterer is self-conscious about their stuttering. Stutterers often find that their stuttering fluctuates and that they have "good" days, "bad" days and "stutter-free" days. The times in which their stuttering fluctuates can be random. Although the exact etiology, or cause, of stuttering is unknown, both genetics and neurophysiology are thought to contribute. There are many treatments and speech therapy techniques available that may help decrease speech disfluency in some people who stutter to the point where an untrained ear cannot identify a problem; however, there is essentially no cure for the disorder at present. The severity of the person's stuttering would correspond to the amount of speech therapy needed to decrease disfluency. For severe stuttering, long-term therapy and hard work is required to decrease disfluency.
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.
The warning signs of early speech delay are categorized into age related milestones, beginning at the age of 12 months and continuing through early adolescence.
At the age of 12 months, there is cause for concern if the child is not able to do the following:
- Using gestures such as waving good-bye and pointing at objects
- Practicing the use of several different consonant sounds
- Vocalizing or communicating needs
Between the ages of 15 and 18 months children are at a higher risk for speech delay if they are displaying the following:
- Not saying "momma" and "dada"
- Not reciprocating when told "no", "hello", and "bye"
- Does not have a one to three word vocabulary at 12 months and up to 15 words by 18 months
- Is unable to identify body parts
- Displaying difficulties imitating sounds and actions
- Shows preference to gestures over verbalization
Additional signs of speech delay after the age of 2 years and up to the age of 4 include the following:
- Inability to spontaneously produce words and phrases
- Inability to follow simple directions and commands
- Cannot make two word connections
- Lacks consonant sounds at the beginning or end of words
- Is difficult to understand by close family members
- Is not able to display the tasks of common household objects
- Is unable to form simple 2 to 3 word sentences
Various areas of development can be affected by developmental coordination disorder and these will persist into adulthood, as DCD has no cure. Often various coping strategies are developed, and these can be enhanced through occupational therapy, psychomotor therapy, physiotherapy, speech therapy, or psychological training.
In addition to the physical impairments, developmental coordination disorder is associated with problems with memory, especially working memory. This typically results in difficulty remembering instructions, difficulty organizing one's time and remembering deadlines, increased propensity to lose things or problems carrying out tasks which require remembering several steps in sequence (such as cooking). Whilst most of the general population experience these problems to some extent, they have a much more significant impact on the lives of dyspraxic people. However, many dyspraxics have excellent long-term memories, despite poor short-term memory. Many dyspraxics benefit from working in a structured environment, as repeating the same routine minimises difficulty with time-management and allows them to commit procedures to long-term memory.
People with developmental coordination disorder sometimes have difficulty moderating the amount of sensory information that their body is constantly sending them, so as a result dyspraxics are prone to sensory overload and panic attacks.
Many dyspraxics struggle to distinguish left from right, even as adults, and have extremely poor sense of direction generally.
Moderate to extreme difficulty doing physical tasks is experienced by some dyspraxics, and fatigue is common because so much extra energy is expended while trying to execute physical movements correctly. Some (but not all) dyspraxics suffer from hypotonia, low muscle tone, which like DCD can detrimentally affect balance.
Even though most speech sound disorders can be successfully treated in childhood, and a few may even outgrow them on their own, errors may sometimes persist into adulthood rather than only being not age appropriate. Such persisting errors are referred to as "residual errors" and may remain for life.
Developmental verbal dyspraxia (DVD) is a type of ideational dyspraxia, causing speech and language impairments. This is the favoured term in the UK; however, it is also sometimes referred to as articulatory dyspraxia, and in the United States the usual term is childhood apraxia of speech (CAS).
Key problems include:
- Difficulties controlling the speech organs.
- Difficulties making speech sounds
- Difficulty sequencing sounds
- Within a word
- Forming words into sentences
- Difficulty controlling breathing, suppressing salivation and phonation when talking or singing with lyrics.
- Slow language development
The following are brief definitions of several of the more prominent speech disorders:
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.
Aphasia is loss of the ability to produce or comprehend language. There are acute aphasias which result from stroke or brain injury, and primary progressive aphasias caused by progressive illnesses such as dementia.
- Acute aphasias
- Expressive aphasia also known as Broca's aphasia, expressive aphasia is a non-fluent aphasia that is characterized by damage to the frontal lobe region of the brain. A person with expressive aphasia usually speaks in short sentences that make sense but take great effort to produce. Also, a person with expressive aphasia understands another person's speech but has trouble responding quickly.
- Receptive aphasia also known as Wernicke's aphasia, receptive aphasia is a fluent aphasia that is categorized by damage to the temporal lobe region of the brain. A person with receptive aphasia usually speaks in long sentences that have no meaning or content. People with this type of aphasia often have trouble understanding other's speech and generally do not realize that they are not making any sense.
- Conduction aphasia
- Anomic aphasia
- Global aphasia
- Primary progressive aphasias
- Progressive nonfluent aphasia
- Semantic dementia
- Logopenic progressive aphasia
Examples of disorders that may include or create challenges in language and communication and/or may co-occur with the above disorders:
- autism spectrum disorder - autistic disorder (also called "classic" autism), pervasive developmental disorder, and Asperger syndrome – developmental disorders that affect the brain's normal development of social and communication skills.
- expressive language disorder – affects speaking and understanding where there is no delay in non-verbal intelligence.
- mixed receptive-expressive language disorder – affects speaking, understanding, reading and writing where there is no delay in non-verbal intelligence.
- specific language impairment – a language disorder that delays the mastery of language skills in children who have no hearing loss or other developmental delays. SLI is also called developmental language disorder, language delay, or developmental dysphasia.
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.