Dysarthria in Childhood
Outline
- Definition
- Dysarthria subtypes - Speech characteristics
- Management approaches
- System approach of management - (LSVT ) article
Dysarthria Defention
A group of motor speech disorders that affects the neuromuscular execution of speech as a result of central or peripheral nervous system damage.
It is not :
a language disorder , or cognitive disorder and not a result of an abnormal anatomical structure (cleft palate), a sensory loss (deafness) or psychological disturbance.
It is strictly a speech production disorder caused by neuromotor damage.
Severity: mild severe
Salient Features of
Neuromuscular Function
Muscles can be impaired in terms of:
• Range of motion
• Direction
• Strength
• Endurance
• Speed or timing
If any of these are defective, the motor speech system will be affected adversely
Motor Speech Systems
The lack of neurological
control with dysarthria can affect the motor-speech subsystems of respiration, phonation, resonance,
articulation, and prosody.
Causes of dysarthria
Congenital
Cerebral palsy
Mobeius syndrome
Neuromuscular diseases
Muscular Dystrophy
Acquired
TBI
CVA
Brain tumors
Children VS Adults
• The impact of central nervous system lesion on a child who is still
developing adult speech is different compared to lesion that occurred in adults.
• Potential recovery for children with dysarthria differ than potential recovery for the adults.
• Clinical diagnosis is challenging , since symptoms of childhood dysarthria overlaps with developmental speech characteristics
Dysarthria Subtypes
Mayo clinic or DAB Classification (Darely, Aronson, and Brown)
• The most frequently cited classification system for the dysarthria is based on the Mayo clinic research studies based on site of lesion ,etiology and pathophysiology
Dysarthria Type Site of lesion Clinical and speech characteristics
• Spastic Dysarthria Upper motor neurons (Bilateral) Voluntary movements affected Spasticity
• Hyperkinetic Dysarthria Basal Ganglia control circuit Both voluntary and involuntary
• Ataxic Dysarthria Cerebellar system damaged Slowness, movement incoordination
• Flaccid Dysarthria Lower motor neurons (spinal and cranial nerves)
Weakness
• Mixed Dysarthria Combination of signs of more than one subtypes
• Hypokinetic dysarthria (mostly seen in adults with Parkinson disease)
A reduction of dopamine in part of the basal
ganglia.
Rigidity, reduced range of movement
Unilateral upper motor
neuron Unilateral damage to
upper motor neurons. irregular
articulatory breakdowns
Speech Characteristic
38 speech characteristics related to pitch, loudness, voice, resonance, respiration, prosody, and articulation according to DAB.
Speech Characteristic
Speech Characteristic that children with Dysarthria May exhibit
• Short breath groups .
• Abnormal voice quality and volume.
• Difficulty using contrastive stress (equal stress on all words)
• Slow rate of speech movements .
• Nasal resonance and nasal air emission
• Imprecise vowels/consonant overall
• effortful speech
Management
The goal is to improve intelligibility.
• For severely impaired individuals use of augmentative or alternative systems.
• Mild dysarthria reestablish speech patterns that closely approximate normal production
Management
Four basic approaches to dysarthria therapy:
Behavioral:
Verbal reinforcement, metronome, pacing, biofeedback, delayed auditory feedback, and pacing boards.
• Prosthetic devices: palatal lift.
Palatal lift: elevates the soft palate toward the posterior pharyngeal wall to decrease hypernasal resonance in clients with velopharyngeal incompetence (VPI).
Medical and surgical procedures
A pharyngeal flap and phono surgery are examples of surgical intervention approaches.
Pharyngeal flap surgery joins soft tissue from the posterior pharyngeal wall to the soft palate to improve velopharyngeal closure during speech.
Augmentative/alternative devices
Nonvocal modes of communication to supplement or replace speech.
Communication boards, alphabet boards, gestural systems, computers, softwares.
Behavioral Management
• Treatment approaches related to Dysarthria type.
• Speech subsystem involvement (respiratory, articulatory,…)
• Treatment goal
Behavioral Management System Approach
• Dysarthria is an impairment that may affect all motor speech subsystems.
• Treatment of dysarthria is generally based on the hierarchical
organization of these subsystems: respiration, phonation, resonance, articulation, and prosody.
Behavioral Management
• Respiratory Subsystem.
• Inefficient use of the breath stream for speech, rather than a reduction of vital capacity (total volume of air in the lungs).
• Establish consistent, controlled exhalation of air to support speech production.
• Establish a stable base for respiratory function through adjustments of body posture.
Improve exhalation by producing speech of increasing length and
duration (beginning with isolated phonemes and progressing gradually to longer segments).
Phonatory Subsystem
• Phonation problems can be classified into three main patterns of vocal fold movement: hyperadduction, hypoadduction, and
incoordination.
• One specific technique that addresses both phonatory and respiratory dimensions is the Lee Silverman Voice Technique (LSVT).
Articulation Subsystem
• Oral-motor exercises
• Phonetic placement
• Phonetic shaping
• Over articulation
Oral motor exercises
Resonance Subsystem
• hypernasality and accompanying nasal air emission due to impairment of the velopharyngeal musculature.
• Behavioral, prosthetic, and surgical approaches can be used to accomplish this goal.
• A behavioral regimen is with clients who demonstrate mild resonance problems.
• For clients with moderate to severe impairments a prosthetic or surgical approach.
Prosody
• Improve stress and intonation patterns through contrastive drills
• Modify speaking rate through manipulation of the number and duration of pauses.
• Metronomes, pacing boards, DAF, or tapping.
JSLHR Article
Intensive Voice Treatment (LSVT LOUD) for Children With Spastic Cerebral
Palsy and Dysarthria
Cynthia Marie Fox and Carol Ann Boliekb
Intensive Voice Treatment (LSVT LOUD) for Children With Spastic Cerebral Palsy and
Dysarthria
The purpose of this study was to examine the effects of an intensive voice treatment (Lee Silverman Voice Treatment, commonly known as LSVT
LOUD) for children with spastic cerebral palsy (CP) and dysarthria.
LSVT Loud
Used with Parkinson's disease (PD) and has documented efficacy for that population.
• The training mode of LVST LOUD is consistent with principles that drive activity -dependent neuroplasticity and motor learning.
• LSVT uses intensive, high effort treatment coupled with proprioceptive feedback and auditory-vocal self monitoring to improve self-perception of speech motor output.
• Rationale:
Which is increasing vocal loudness will trigger improved vocal quality, articulation and intonation as well as reduce rate of speech
Why it is suitable to be applied with CP?
• The single focus on vocal loudness limits cognitive demands associated with treatment.
• The target vocal loudness trained in LSVT LOUD is elicited through modeling behavior .
The LSVT LOUD technique aims to:
• Increase vocal loudness.
• Improve articulation
• Improve intonation
• Modify sensory processing related to voice and speech.
Improvements due to LSVT LOUD training require work. Continued practice, self-monitoring, and attention to specific actions to sustain lasting change.
Method \Participants
Five children between the ages of 5 and 7 years with a medical diagnosis of spastic CP participated in this study (3 male and 2 female)
• Additional selection criteria:
• Dysarthria
• Hearing that was within normal limits or aided to normal limits
• No vocal pathology as determined by an otolaryngologist
• Ability to follow directions for the study tasks
• Stable medications.
Exclusion for:
• Children with severe velopharyngeal incompetence
• Structural disorders of the speech mechanism
• Concomitant speech disorder (stuttering)
• The severity of dysarthria for the participants range from mild to moderate.
Method/participants
Perceptual characteristics of speech disorder in children with spastic cerebral palsy:
• Consistent hypernasality
• Breathy voice quality
• Monotonous speech
• Reduced loudness
• Uncontrolled rate and rhythm of voice
• Short vowel duration
• Shallow inspirations
• Forced expirations.
• In addition , disordered articulation has been described in these chidren.
• Intensive Voice Treatment
• 16 individual 1-hour treatment sessions /4 consecutive days each week / 4 consecutive weeks.
• Homework and carryover exercises were assigned every day during the month of treatment.
• The first half of each treatment session consisted of three daily tasks:
• Maximum duration sustained vowels
• Maximum frequency range
• Repetition of 10 functional phrases five times each.
• The second half of the treatment sessions was spent on a speech hierarchy progressing in difficulty from single words to conversational speech.
Auditory-perceptual Analysis
Auditory–perceptual analysis of speech, acoustic measures of vocal functioning, and perceptual ratings by parents of participants were
obtained at baseline, post-treatment, and 6-weeks follow-up recording sessions.
• Results:
Listeners consistently preferred the speech samples taken immediately post-treatment over those taken during the baseline phase for most perceptual characteristics rated in this study.
• Conclusions:
The findings of study provide some preliminary observations that the children with spastic CP in this study not only tolerated intensive voice treatment but also showed improvement on select aspects of vocal functioning.
Thank You!
Mais Shkukani
Speech Therapy Specialist Hamad Medical Corporation
