Childhood apraxia of speech (CAS) is a neurological childhood (pediatric) speech sound disorder in which the precision and consistency of movements underlying speech is impaired in the absence of neuromuscular deficits (e.g., abnormal reflexes, abnormal tone). CAS may occur due to known neurological impairment, in association with complex neurobehavioral disorders of known and unknown origin, or as an idiopathic neurogenic speech sound disorder. The core impairment in planning and spatiotemporal programming parameters of movement sequences results in errors in speech sound production and prosody. (ASHA, 2007b, Definitions of CAS section, para. 1).
Augmentative and alternative communication (AAC) is an area of clinical practice that addresses the needs of individuals with significant and complex communication disorders characterized by impairments in speech-language production or comprehension, including spoken and written modes of communication (ASHA, 2020). AAC uses various techniques and tools, including picture communication boards, line drawings, speech-generating devices (SGDs), tangible objects, manual signs, gestures, and fingerspelling, to help the individual express thoughts and wants and needs feelings, and ideas. AAC is augmentative when used to supplement existing speech, and alternative when used in speech production that is absent or not functional (ASHA, 2020). AAC may be temporary, as when used by patients postoperatively in intensive care, or permanent, as when used by an individual who will require the use of some form of AAC throughout his or her lifetime (ASHA, 2020).
Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by deficits in social communication and social interaction and the presence of restricted, repetitive behaviors. Social communication deficits present in various ways and can include impairments in joint attention and social reciprocity and challenges using verbal and nonverbal communication behaviors for social interaction. One might see restricted, repetitive behaviors, interests, or activities manifested by stereotyped, repetitive speech, motor movement, or use of objects; inflexible adherence to routines; limited interests; and hyper- or hypo-sensitivity sensory input.
In cluttering, the breakdowns in clarity that accompany a perceived rapid and irregular speech rate are often characterized by deletion and/or collapsing of syllables (e.g., “I wanwatevision”) or omission of word endings (e.g., “Turn the televisoff”). The child may make many revisions and interject other words and put pauses in places in sentences not expected grammatically, such as “I will go to the/store and buy apples” (St. Louis & Schulte, 2011). Clutter can occur with other disorders.A condition that can be a consequence of cluttering is pragmatic disorder; individuals with cluttering may not attempt to repair breakdowns in communication, resulting in less than significant social interaction (Teigland, 1996) (ASHA, 2020).
Early intervention (EI) is the process of providing services. It supports infants, toddlers, and their families when a child has or is at risk for a developmental delay, disability, or health condition that may affect typical development and learning. The goal of EI is to lessen the effects of a disability or delay by addressing the identified needs of young children across five developmental areas:
- Cognitive development
- Communication development
- Physical development, including vision and hearing
- Social or emotional development
- Adaptive development (Individuals with Disabilities Education Act [IDEA], 2004)
The earlier that services are delivered, the more likely children are to develop effective communication, language, and swallowing skills and achieve successful learning outcomes (Guralnick, 2011). The Program for Infants and Toddlers with Disabilities, also called Part C of IDEA, is a federal grant program that helps individual states operate comprehensive systems of interdisciplinary EI services for children ages birth to 3 with disabilities and their families/primary caregivers. EI services can also be provided outside of Part C programs in settings such as neonatal intensive care units (NICUs), pediatric rehabilitation hospitals or clinics, preschools, and private practices. Services in these settings may not be covered by federal or state dollars but can be billed to public or private insurance or the family.
is the aspect of speech production that refers to continuity, smoothness, rate, and effort. Stuttering, the most common fluency disorder, is an interruption in the flow of speaking characterized by repetitions (sounds, syllables, words, phrases), sound prolongations, blocks, interjections, and revisions, which may affect the rate and rhythm of speech. These disfluencies may sometimes accompany physical tension, adverse reactions, secondary behaviors, and avoidance of sounds, words, or speaking situations (ASHA, 1993; Yaruss, 1998; Yaruss, 2004). Cluttering, another fluency disorder, is characterized by a perceived rapid and irregular speech rate, which results in breakdowns in speech clarity or fluency (St. Louis & Schulte, 2011)(ASHA, 2020).
Functional speech sound disorders include those related to the motor production of speech sounds and those related to speech production’s linguistic aspects. Historically, these disorders are referred to as articulation disorders and phonological disorders, respectively. Articulation disorders focus on errors (e.g., distortions and substitutions) in the production of individual speech sounds. Phonological disorders focus on predictable, rule-based errors (e.g., fronting, stopping, and final consonant deletion) that affect more than one sound. It is often difficult to differentiate between articulation and phonological disorders; therefore, many researchers and clinicians prefer to use the broader term, “speech sound disorder,” when referring to speech errors of unknown cause. See Bernthal, Bankson, and Flipsen (2017) and Peña-Brooks and Hegde (2015) for relevant discussions.
The definitions of intellectual disability (ID) and related terminology have evolved to reflect the legal and social gains made by individuals with such a disability and their families. See Changes in Services for Persons With Developmental Disabilities: Federal Laws and Philosophical and Perspectives and Federal Programs Supporting Research and Training in Intellectual Disability. These changes reflect the movement from institutionalization to inclusive practices, self-advocacy, and self-determination. There has also been the movement toward recognizing the fundamental communication rights of people with severe disabilities. A Communication Bill of Rights—initially developed by the National Joint Committee for the Communication Needs of Persons with Severe Disabilities (NJC) in 1992 and updated in 2016—recognizes the right of all people to effective communication (NJC, 1992; Brady et al., 2016) (ASHA, 2020).
ID is characterized by
significant limitations in intellectual functioning (e.g., reasoning, learning, and problem-solving);
significant limitations in adaptive behavior (i.e., conceptual, social, and practical skills in everyday life); and
onset in childhood (before the age of 18 years; American Association on Intellectual and Developmental Disabilities [AAIDD, 2013]) (ASHA, 2020).
This definition of ID balances limitations with an equal emphasis on skills. Consequently, language and philosophy concerning ID now focus on levels of support necessary to maximize an individual’s ability, rather than strictly on functioning (ASHA, 2020).
There is general agreement that auditory perceptual abilities influence language development—particularly the pre-literacy skills—and that it can be challenging to separate aural and language skills concerning academic demands (Richard, 2012, 2013; Watson & Kidd, 2008). The act of processing speech is very complex and involves the engagement of auditory, cognitive, and language mechanisms, often simultaneously (Medwetsky, 2011).
Richard’s (2013) continuum of processing includes both auditory processing and language processing. This continuum involves the following types of processing:
Central auditory processing begins when the neural representation of acoustic signals is processed after they leave the cochlea and travel through the auditory nerve to the left and right hemispheres (Heschl’s gyri).
Phonemic processing, during which acoustic features of the signal, is discriminated against utilizing phonemic skills such as sound discrimination, blending, and segmenting.
Linguistic processing is where meaning is attached to the signal (begins at the level of Heschl’s gyrus, expands to Wernicke’s area, to the angular gyrus, and finally to the prefrontal and frontal cortex, in planned, organized, and mediated responses) (ASHA, 2020).
Late language emergence (LLE) is a delay in language onset with no other diagnosed disabilities or developmental delays in other cognitive or motor domains. LLE is when language development trajectories are below age expectations. Toddlers who exhibit LLE are considered “late talkers” or “late language learners.”
Late talkers may present with expressive language delays only or mixed expressive and receptive delays. Children with only expressive delays exhibit delayed vocabulary acquisition and often demonstrate slow development of sentence structure and articulation. Those with mixed expressive and receptive language delays indicate delays in language comprehension and oral language production.
Some researchers distinguish a subset of children with LLE as “late bloomers.” Research also indicates that late bloomers are less likely to demonstrate concomitant language comprehension delays when compared with children who remain delayed (Thal et al., 1991) (ASHA, 2020).
Organic speech sound disorders include those resulting from the motor/neurological disorders (e.g., childhood apraxia of speech and dysarthria), structural abnormalities (e.g., cleft lip/palate and other structural deficits or anomalies), and sensory/perceptual disorders (e.g., hearing impairment).
Social communication is the use of language in social contexts. It encompasses social interaction, social cognition, pragmatics, and language processing.
Social communication skills include the ability to vary speech style, take others’ perspectives, understand and appropriately use the rules for verbal and nonverbal communication, and use the structural aspects of language (e.g., vocabulary, syntax, and phonology) to accomplish these goals. For more details, see ASHA’s resources on components of social communication [PDF] and social communication benchmarks [PDF] (ASHA, 2020).
Social communication, spoken language, and written language have an intricate relationship. Social communication plays a role in language expression and comprehension in both spoken and written modalities. Spoken and written language skills allow for effective communication in various social contexts and a variety of purposes (ASHA, 2020). Social communication, such as eye contact, facial expression, and body language, is sometimes influenced by sociocultural and individual factors (Curenton & Justice, 2004; Inglebret, Jones, & Pavel, 2008). There is a wide range of acceptable norms within and across individuals, families, and cultures.
Social Communication Disorder
Children with social communication disorder have difficulties with the use of verbal and nonverbal language for social purposes. Primary challenges are social interaction, social cognition, and pragmatics. Specific deficits are evident in the individual’s ability to communicate for social purposes
- in ways that are appropriate for the particular social context
- change communication to match the context or needs of the listener
- follow the rules for conversation and storytelling
- understand nonliterate or ambiguous language
- understand what is not explicitly stated (ASHA, 2020)
This definition is consistent with the diagnostic criteria for Social (Pragmatic) Communication Disorder detailed in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5; American Psychiatric Association [APA], 2013).A social communication disorder may be a distinct diagnosis or may co-occur with other conditions, such as:
spoken language disorders;
written language disorders;
attention-deficit/hyperactivity disorder (ADHD);
traumatic brain injury (pediatric and adult);
In autism spectrum disorder (ASD), social communication problems are a defining feature, along with restricted, repetitive patterns of behavior. Therefore, social communication disorder is diagnosed separately from ASD (AHSA, 2020).
Speech sound disorders is an umbrella term referring to any difficulty or combination of problems with perception, motor production, or phonological representation of speech sounds and speech segments.Speech sound disorders can be organic or functional. Organic speech sound disorders result from an underlying motor/neurological, structural, or sensory/perceptual cause. Available speech sound disorders are idiopathic—they have no known reason (ASHA, 2020).
A spoken language disorder (SLD), also known as an oral language disorder, represents a significant impairment in the acquisition and use of language across modalities due to deficits in comprehension or production across any of the five language domains (i.e., phonology, morphology, syntax, semantics, pragmatics). Language disorders may persist across the lifespan, and symptoms may change over time.
When SLD is a primary disability—not accompanied by intellectual disability, global developmental delay, hearing or other sensory impairment, motor dysfunction, or other mental disorder or medical condition—is considered a specific language impairment (SLI).
An SLD may also occur in the presence of other conditions, such as
autism spectrum disorder (ASD),
intellectual disabilities (ID),
developmental disabilities (DD),
attention deficit hyperactivity disorder (ADHD),
traumatic brain injury (TBI),
Stuttering typically has its origins in childhood. Most children who stutter begin to do so around 2 ½ years of age (e.g., Mansson, 2007; Yairi & Ambrose, 2005; Yaruss, LaSalle, & Conture, 1998). Approximately 95% of children who stutter start to do so before five years (Yairi & Ambrose, 2005).
All speakers produce disfluencies, which may include hesitations, such as silent pauses and interjections of word fillers (e.g., “The color is like red”) and nonword fillers (e.g., “The color is uh red”). Other examples include whole-word repetitions (e.g., “But-but I don’t want to go”) and phrase repetitions or revisions (e.g., “This is a- this is a problem”). These speech behaviors are generally considered nonstuttered (typical) disfluencies (Ambrose & Yairi, 1999; Tumanova, Conture, Lambert, & Walden, 2014). When a child uses many nonstuttered (typical) disfluencies, differential diagnosis is critical to distinguish between stuttering, avoidance, and a language disorder.Less typical, stuttering-like disfluencies (Yairi, 2007) include part-word or sound/syllable repetitions (e.g., “Look at the b-b-baby”), prolongations (e.g., “Ssssssssometimes we stay home”), and blocks (i.e., inaudible or silent fixations or inability to initiate sounds). Compared with typical disfluencies, stuttering-like disfluencies are usually accompanied by more significant than average duration, effort, tension, or struggle. Aspects that factor into the perception of severity includes frequency and type of stuttering and stutters to communicate effectively.
Some young children go through a period of excessive disfluency, which does not persist for many of these children.
The terms clinical supervisor and clinical supervision are often used about student clinicians’ training and education, recognizing that supervision is part of the training and education process. Clinical supervisors do more than oversee the work of the student clinician. They teach specific skills, clarify concepts, assist with critical thinking, conduct performance evaluations, mentor, advise, and model professional behavior (Council of Academic Programs in Communication Sciences and Disorders [CAPCSD], 2013).
Many professionals involved in the supervisory process suggest that clinical educators and clinical instructors more accurately reflect what the clinical supervisor does (CAPCSD, 2013).
Telepractice is applying telecommunications technology to delivering speech-language pathology and professional audiology services at a distance by linking clinician to client or clinician to clinician for assessment, intervention, and consultation (ASHA, 2020).
ASHA adopted the term telepractice rather than the frequently used terms telemedicine or telehealth to avoid the misperception that these services are used only in health care settings. Practitioners also use other terms such as teleaudiology, telespeech, and speech teletherapy in addition to telepractice. Services delivered by audiologists and speech-language pathologists (SLPs) include the broader generic term telerehabilitation (American Telemedicine Association, 2010).
Use of telepractice must be equivalent to the quality of services provided in-person and consistent with adherence to the Code of Ethics (ASHA, 2016a), Scope of Practice in Audiology (ASHA, 2018), Scope of Practice in Speech-Language Pathology (ASHA, 2016b), state and federal laws (e.g., licensure, Health Insurance Portability and Accountability Act [HIPAA; US Department of Health and Human Services, n.d.-c]), and ASHA policy (ASHA, 2020).
Telepractice venues include schools, medical centers, rehabilitation hospitals, community health centers, outpatient clinics, universities, clients’ homes, residential health care facilities, child care centers, and corporate settings. There are no inherent limits where telepractice sites as long as the services comply with national, state, institutional, and professional regulations and policies. See ASHA State-by-State for state telepractice requirements (ASHA, 2020).
Standard terms describing types of telepractice are as follows:
Synchronous (client interactive)—services are conducted with interactive audio and video connection in real-time to create an in-person experience similar to that achieved in a traditional encounter. Synchronous services may connect a client or group of clients with a clinician or include consultation between a clinician and a specialist.
Asynchronous (store-and-forward)—images or data are captured and transmitted (i.e., stored and forwarded) for viewing or interpretation by a professional. Examples include transmission of voice clips, audiologic testing results, or outcomes of independent client practice.
Hybrid—applications of telepractice that include combinations of synchronous, asynchronous, and in-person services.
Traumatic brain injury (TBI) is a form of nondegenerative acquired brain injury resulting from a bump, blow, or jolt to the head (or body) or a penetrating head injury that disrupts normal brain function (Centers for Disease Control and Prevention [CDC], 2015).
TBI can cause focal brain damage (e.g., gunshot wound), diffuse (e.g., shaken baby syndrome), or both. Symptoms can vary depending on the lesion’s site, extent of damage to the brain, and the child’s age or stage of development (ASHA, 2020).
TBI’s functional impact in children can be different from in adults—deficits may not be immediately apparent because the pediatric brain is still developing. TBI in children is a chronic disease process rather than a one-time event, because symptoms may change and unfold over time (DePompei & Tyler, in press; Masel & DeWitt, 2010).
Concussion, a form of TBI, is an injury to the brain characterized by TBI’s physical and cognitive sequelae. Concussion typically occurs due to a blow, bump, or jolt to the head, face, neck, or body that may or may not involve loss of consciousness (McCrory et al., 2013). Concussion has received more attention in recent years, particularly for sports injuries (ASHA, 2020).
A disorder of written language involves a significant impairment in fluent word recognition (i.e., reading decoding and sight word recognition), reading comprehension, written spelling, or written expression (i.e., written composition; Ehri, 2000; Gough & Tunmer, 1986; Kamhi & Catts, 2012; Tunmer & Chapman, 2007, 2012). A word recognition disorder is also known as dyslexia.
Written language disorders can involve any of the five language domains (i.e., phonology, morphology, syntax, semantics, and pragmatics). Problems can occur in the awareness, comprehension, and production of language at the sound, syllable, word, sentence, and discourse levels, as indicated in the table below (Nelson, 2014b; Nelson, Plante, Helm-Estabrooks, & Hotz, 2015). See ASHA’s resource, disorders of reading, and writing (ASHA, 2020).