Objectives:
1. Be familair with the anatomy of hearing.
2. Be able to describe the two types of hearing loss.
3. Be familiar with the various types of hearing disorders.
4. Know the impact of hearing loss on children's communication.
5. Know the characteristics of CAPD.
6. Describe PPD.
7. Describe the attributes of stuttering.
8. Describe the attributes of autism.

Chapter 5: Speech and Communication Problems

Introduction
    A thorough discussion of the myriad problems that can occur as children develop communication knowledge and abilities is beyond the scope of this text. What’s more, it is beyond the scope of the field of communication. While Speech Pathology and Audiology was once a part of the Speech discipline, these specialties have since branched off to claim membership in the allied medical field. Nonetheless, this chapter attempts to briefly examine several of the most common and salient maladies that can occur as children wind their way toward competent communication. Given the complexities associated with communication in terms of the physical, cognitive, and emotional demands that are made, it is impressing how infrequently problems occur. That is not to suggest that they should be taken lightly. On the contrary, communication is at the core of who and what we are. As a result any complication can have profound effects on humans psychologically and socially.

Deafness
    The Anatomy of Hearing. The hearing apparatus can be divided roughly into three parts: the outer ear, middle ear, and inner ear. As was mentioned in Chapter 1, the outer ear consists of the external structure that is designed to capture sound and funnel it into the alumentary canal and thence to the middle ear. The middle ear is composed of the ear-drum and three small bones, the hammer, anvil, and stirrup. These are attached to the ear drum and conduct vibrations from the ear-drum to the cochlea. The cochlea performs the dual role of governing balance and converting the physical energy created by vibrating air into chemical electric impulses for nervous transmission. The cochlea is ultimately connected to the eighth cranial nerve that leads to the portion of the brain that processes auditory stimuli. When we refer to hearing, we are talking about only the physical act of receiving and transmitting vibrations in the air to the brain. What the brain then does with the information is another matter that will be dealt with shortly.

    Types of Hearing Loss. There are two dimensions to hearing. The first refers to the overall sensitivity of the ear to variations in air pressure. Sound is strictly a matter of vibrating air and the ear is designed to detect those vibrations. When the ability of the ear to conduct air vibration is compromised, it results in tympanic hearing loss. Put another way, everything seems as if it is being heard at a lower volume.
    The second dimension of hearing is related to the range of pitches that the ear is sensitive to. Sounds have frequency. That is, sound vibrates the air at a specific rate and in a specific manner. Since sounds occilate in what is known as a sinus pattern, these vibrations are measured in terms of how frequently they cycle (See Figure X) in a period of time, typically 1 second. Each time the waveform makes one complete movement from high to low it completes one cycle. A cycle is measured in Hertz (Hz) and one Hertz is the same as the completion of one cycle in a period of one second. High-pitched sounds oscillate with greater frequency during the same amount of time while low-pitched sounds oscillate less often (Figure X). As a result, we see higher frequency values (in Hertz) for high frequency sounds than for low. Sounds can be produced from 1 Hertz to infinity. However, the human ear can only detect a limited range of these tones. If we are lucky, we can hear from 20Hz to 20,000Hz. Most people can detect sounds between 100Hz and 17,000Hz. This is referred to as the Human Audio Spectrum. Dog whistles are undetectable to humans but detectable to dogs because dogs have a wider audio spectrum that includes pitches in the area of 30,000Hz. Keepin mind that we are talking about pure tones. When hearing tests are given, they most often use pure tone generators. However, the vast majority of the sounds we hear daily are combinations of many tones. The human voice is a combination of tones but most fall within a range of about 500Hz to 9000Hz.
    It is possible to lose the ability to hear within specific frequency ranges. As a result, no matter how loudly a sound is generated, it cannot be heard. All other sounds that fall outside of the damaged range can be heard well. This is most often labeled as a sensorineural hearing loss. This is important because different hearing disorders produce different type of hearing loss. Those that effect the conductance of vibrations from the air to the inner ear most often product tympanic loss. Sensorineural loss is most often produced by damage to the inner ear from a variety of causes. In any event, the treatment options also vary as a function of the type of hearing loss. Tympanic loss can often be offset by the use of hearing aids that amplify sound. Sensorineural hearing loss cannot be treated with hearing aids since no matter how loudly a sound is produced, if it falls outside of the individual’s audio spectrum, it cannot be detected. Keep in mind however, that this is a gross over-simplification of the matter. Often hearing problems are the product of a combination of these two types of loss and tympanic difficulties can also produce frequency losses as well.

    Common Hearing Disorders. An estimated 28 million Americans suffer from some degree of hearing loss. There is a generous number of hearing disorders that effect various parts of the hearing mechanisms. The outer ear can be damaged by physical trauma that produces swelling and damage to the cartilage. Boxers and wrestlers can fall victim to cauliflower ear. Repeated blows or abrasion can lead to temporary or permanent deformity of the outer ear that impairs the ability of the structure to funnel sound vibrations into the middle ear. The most common problems that arise are the result of blockages. Young children, are prone to put objects into their various orifices. Certainly they place objects into their mouths, occasionally their noses, and sometimes their ears. An all too often difficulty arises when insects seek refuge in the ear of a sleeping child or adult for that matter. The alumentary canal naturally produces a wax-like substance. At times, the ear can become overzealous in its wax production or wax can accumulate. This reduces the size of the canal and can impede the travel of vibrating air to the middle ear.
    The middle ear is somewhat less susceptible to blunt trauma but more at risk to pathological causes. In terms of trauma, the eardrum itself can be damaged by the insertion of objects, including those aimed at cleaning the ear. The drum itself is a very thin membrane and as such, it is very fragile. While it may seem like common sense, great care must be taken to avoid rupturing the eardrum. Not only is it painful, repeated damage can produce scaring that will make the drum less elastic and lead to hearing loss. It addition, air pressures or the sounds themselves can be of sufficient force (volume) to rupture an eardrum. Sound volume or more correctly air pressure is, measured in decibels (dB). According to the American Speech-Language Hearing Association (ASHA), sounds greater then 80 dB’s are potentially hazardous. However, they note that not only the volume of sound but the length of exposure is a factor. A brief exposure to a painfully loud sound may damage the ear. At the same time prolonged exposure to a fairly loud sound may produce hearing loss as well. The table below provides approximate dB levels for a variety of sound sources.
 
Description
dB Level
Source
Painful
140
firearms, air aid siren
Painful
130
jackhammer
Painful
120
jet aircraft at take-off
Extremely Loud
110
Rock Concert
Extremely Loud
100
snow mobile, chainsaw
Extremely Loud
90
lawnmower
Very Loud 
80
alarm clock
Very Loud 
70
busy traffic, vacuum cleaner
Very Loud 
60
conversation, dishwasher
Moderate
50
moderate rainfall
Moderate
40
quiet room
Faint
30
whisper

    The drum itself can also be damaged or destroyed by infections. In children, otitis media or middle ear infections are common and often result from fluid accumulation in the middle ear. Half of all children will have at least one instance of it by one year of age. A further 35% will have had recurrences. The fluid is often brought on by upper respiratory infections that reach the ear through the eustachian tube. The purpose of the eustachian tube is to equalize the pressure on either side of the eardrum. However, it is also a pathway from an infected sinus or throat to the middle ear. With children the tube is smaller in diameter and nearly horizontal to the ground.  These two factors mean that the tube is more easily obstructed and that it is less able to drain. Most often, the fluid temporarily impedes the free motion of the eardrum and bones of the ear so that they do not conduct sound as well as they should. However, repeated infections can damage the eardrum, bones in the ear, the cochlea, or even the auditory nerves. There are also a variety of other diseases and conditions that can produce hearing problems. They range from tumors to cytomegolovirus (CMV) to genetic factors and medications. Large doses of aspirin will produce tinnitus (ear ringing), while streptomycin and cancer treatments drugs can be ototoxic. Postnatally, high fevers due to measles or other pathogens can damage auditory nerves as well.
    The inner ear, in addition to penetrating trauma, is also effected by the presence of noxious sounds in the environment. In this case, the damage has little to do with the conductance of vibration but rather the conversion of the vibration from mechanical energy into electrochemical energy. The inside of the cochlea is filled with fluid and a vast number of small hairs or cilia that are connected to nerves. The cilia are of different sizes so that the cilia that are used to detect high frequencies are smaller and finer than those that are used to detect low frequencies. As a result the cilia that detect high frequencies are more easily damaged if the sound pressure level is excessive. Vibrations in the air strike the eardrum. This causes the bones in the ear to move and conduct the vibration to the cochlea. The physical energy is transmitted to the fluid in the ear and the movement of the fluid is picked up by the cilia. This stimulates the attached nerves and sends the signal down the auditory nerve to the brain for processing. If the cilia are damaged, they are then unable to detect those frequencies and the aforementioned sensorineural hearing loss results.

    Impact of Hearing Loss on Children’s Communication. As the first part of the decoding process, hearing loss has a decidedly negative impact on children’s communication development. However, it also has a profound impact on the acquisition of speech and language as well. Since we rely on our hearing to collect linguistic data as children, a deaf child is at a distinct disadvantage, at least in terms of spoken language acquisition. They have little difficulty acquiring ASL and, as noted earlier, acquire it in the same amount of time, with the same types of errors. We rely on the examples of adult language users to provide syntactical information. We also rely on our hearing to provide articulation data as well. Not only must we hear what others are saying, our hearing provides a source of feedback for our own speech. We listen to ourselves to determine whether we are pronouncing things correctly. If the Saphir-Whorf Hypothesis is correct, then deafness may effect cognitive development as well. Certainly hearing problems have an impact at the emotional, and social level as well. Even slightly diminished hearing can make social situations difficult if not impossible to manage. Across the lifespan, it can produce isolation and disconnectedness from communication situations.

Central Auditory Processing Disorder
    Even if an individual’s hearing is completely healthy and in tact, once the data is delivered to the brain, it must be processed. Here too, problems can arise. Central Auditory Processing Disorder (CAPD) is a condition that alters the way the brain deals with auditory information. Similar to visual dyslexia, it affects how auditory information is perceived. The term is used to cover a wide range of problems that bear some similarity to the types of visual dyslexia. The condition can often manifest itself with symptoms that resemble hearing loss and may accompany hearing difficulties. The following is a list of what are considered “at risk” behaviors: (1.) Frequently misunderstands oral instructions or questions, (2.) Delays in responding to oral instructions or questions, (3.) Says "Huh" or "What" frequently, (4.) Frequently needs repetition of directions or information, (5.) Frequently needs/requests repetition, (6.) Has problems understanding in background noise, (7.) Is easily distracted by background noise, (8.) May have problems with phonics or discriminating speech sounds, (8.) May have poor expressive or receptive language, (9.) May have spelling, reading, and other academic problems, (10.) May have behavioral problems. If these symptoms occur with a great deal of consistency, there may be cause for concern. The specific causes are under investigation but are not known at present. There is some evidence to suggest that otitis media may be a factor. It may also be developmental. It almost certainly has an organic cause.
    There are a variety of ways in which CAPD presents itself. Children may have difficulty with auditory field and ground. That is, they have trouble distinguishing a single sound from background noise. They may be unable to assemble a stream of discourse into a coherent whole. In other words, they understand each utterance as a separate piece of information and cannot put a group of utterances together. As such, a series of statements are not viewed as being related to each other. They may also be unable to distinguish one sound from another. For example, they may be unable to distinguish between the sh and ch sounds.
The causes of CAPD are unknown but are likely the product of some neurological aberration. If it is similar to visual dyslexia, then there may be a hereditary component. Visual dyslexia tends to run in families. What’s more the heredity might be sex-linked in that a preponderance of dyslexics are male. CAPD as a class of disorders are too new to be specific about. However, they are the cause of a great deal of frustration for the sufferers and their families. Yet there are ways to adapt to CAPD. Since auditory figure and ground are problems, a quiet environment, one lacking in background noise is helpful. Repetition is essential and written instructions may also help. If instructions can be given in a step by step sequence rather than in a continuous stream, this can be helpful as well.

Articulation Disorders
    In Chapter 2 we discussed how children normatively develop the ability to make the sounds of their language. We also discussed the anatomy of speech in terms of the moveable and fixed articulators. Articulation disorders refer to the inability to correctly produce sounds. This happens with surprising rarity. In almost all cases, articulation disorders can be remediated by a speech pathologist. Speech involves development at many levels and the relative perfection of articulation can take a number of years. For speakers of English, if all the sounds are not acquired by the age of eight, Speech Pathologists get concerned. However, as was detailed in Chapter 2, children should acquire different sounds at different points in their development. Speech Pathologists who work in the education system screen children’s speech at a variety of points along the way. For example, children should be able to make the m sound early on. If they arrive in kindergarten without that sound, they may intervene.
    The treatment of articulation problems are far from intuitive and depend on the sorts of compensatory behaviors the child is using to overcome their inability to form the sound correctly. For example, in one case a child had difficulty producing the initial r sound (r’s that occur at the beginnings of words) at the age of ten. The child was unable to get their tongue into the right position and shape and the sound came out sounding like a w as in “weally” rather than “really.” As a remedy, the Speech Pathologist had the child over-pronounce the initial r so that the child would get the tongue into position and shape and then hold the sound for a time prior to completing the word, “rrrrrrrreally.” It may sound odd, but the therapy is designed to train the articulators. Eventually, the overemphasis becomes unnecessary. In another case, a child with the same articulation problem required a very different intervention technique. Because this child had difficulty with the initial r, she had compensated by drawing her tongue much too far back in her mouth and over-tensioning the tongue so that it was held so rigid as to inhibit further movement. The sound she produced using this method bore little resemblance to an r sound. In order to overcome this dysfunctional adaptation, the speech pathologist had her begin words that started with r by beginning them with an l sound. Speech pathologists refer to what the child was doing as “backing.” That is, she was trying to pronounce the sound too far back in her throat and mouth. The goal of the therapy was to move the production of the r sound to its proper place further forward in the mouth and with the proper tongue tension. The l sound is produced farther forward and the tongue tension is approximately correct. The child was asked to practice saying words such as “lllllereally.” Once again, once this was mastered, the goal would be to remove the initial l sound.
    Another, more complicated class of articulation disorders is referred to as Phonological Processing Disorders (PPD). In many cases, children have problems with specific sounds. They may have trouble with their f’s or r’s. With PPD, they may have problems with an entire class of sounds that are produced in the same way. That is, they may have trouble producing all siblants, or fricatives. They may also have trouble with compound consonants such as the tr sound or bl or any other combinations of sound. These types of problems are often difficult to figure out and may not present individually. A child may have several processing issues such as an inability to produce fricatives and plosives. Since the correct sounds can be deleted or substituted, children with PPD can seem hopelessly unintelligible. Diagnosis typically involves the recitation of each and every phoneme in initial, medial, and final positions along with all the potential consonant combinations. Speech pathologists then look for patterns of incorrect pronunciations.
    Poor articulation can arise as a result of several factors. Since sounds are mostly modeled from the sounds of language that exist in the environment, poor models can lead to poor pronunciation in children. They may also be products of physical development and maturation. Most important is that most if not all articulation problems are correctable with therapy. It is also important to remember these problems are not often self-repairing and that the remedy is not a matter of common sense. Screening programs in schools are an important part of correction. In addition, speech problems can be indicative of hearing problems. We utilize our hearing to correct our pronunciation errors. If we are unable to hear our own voice, we are unaware of our errors and articulation problems are certain to occur.

Stuttering
    One of the most fascinating and mysterious speech problems is stuttering. Almost all children undergo a period of disfluency in their speech. Given how complex the speech mechanisms are, it shouldn’t be surprising that at some point, usually between the ages of 2 and 5, there is a period of time when children have difficulty properly saying the many things they want to say. In some respects, its as though their busy brains are writing checks that their mouth can’t cash. Yet these disfluencies are usually whole word repetitions (Mom, mom, mom, I, I want a cookie) or vocalized pauses (Um, um, um I want, um, um a um, cookie). Also keep in mind that even adult speech is littered with occasional disfluencies. We correct most of them but they seem to be a normal part of competent speech. In fact, communicators who are too smooth or too polished tend to be less credible. When speech is absolutely free from disfluencies, it seems planned, rehearsed, and insincere. But this is not stuttering. This section will examine the characteristics of stuttering, its possible causes, and methods of treatment. It is a very complex problem that includes physical, emotional, and social dimensions. While it has been the source of humor from Porky the Pig to A Fish Called Wanda, it is anything but funny to the people who stutter.
    Stutterers, like dyslexics are mostly male. The behavioral manifestations of stuttering are divided into two sets. There are primary vocal characteristics and a collection of secondary visual characteristics. The vocal characteristics consist of a collection of disfluencies that are considered problematic if their frequency exceeds 50 for every 1000 words spoken. The vocal markers consist of blocks, prolongations, and repetitions. Blocks are described by stutterers as a sort of vocal wall that they simply cannot push through. Stutterers often have specific phonemes that they have difficulty with. When they attempt to pronounce a word that contains the sound their articulators simply lock up. Prolongations occur when phonemes are drawn out. They are usually accompanied by the schwa sound, as in baby. Repetitions are most often consonant repetitions. It is again important to remember that repetitions are common in non-stutterers speech. In fact we use them as a turn requesting cue. However, in this case they most often whole word repetitions or single repetitions. So a turn taking cue might be something like I, I, I, think we need to… or Mmaybe we need to…. With stutterers, they are more pronounced and involve multiple repetitions as in, CCCCCCCould we llllllook intttttto this…?
    The secondary visual cues accompany the primary cues. They may consist of wide range of ticks, facial contortions, jerks, eye blinks, finger snapping, seeming spasticity, and so forth. They are most often the result of attempts to compensate for the vocal characteristics. What’s more, they tend to multiply over time. The individual may find that an eye blink helps them to push through a block or prolongation but after a time it no longer works. They then add another so now there are two blinks but again after a period of time it no longer works. They add a facial tick, so that now they execute two blinks and a tick, and so forth. They may end up with an elaborate string of secondary events to compensate for the primary vocal stutter. In addition, there are visible signs of anxiety, stress, and fear.
    Explanations as to the cause of stuttering have been varied over time. It was initially thought to be due to relational problems between fathers and sons. Since most stutterers are male and most experts were Freudians, most problems were linked to parental issues. Other explanations linked stuttering to a traumatic fright or communication anxiety. While these are currently thought to be mediating variables, the likely cause is neurological. The exact nature of the problem remains a mystery. Stuttering has been seemingly initiated by children being startled. However, this is thought to be a trigger rather than a cause. If not for that event, another would most certainly have triggered the problem. Stuttering is also exacerbated by communication apprehension. As anxiety increases, so does disfluency among stutterers. However, it is unlikely that apprehension is the causal agent. No doubt it compounds matters. At present there is no cure for stuttering. For some, it becomes a rare occurance that only arises under stress. For others it is a lifelong difficulty. The goal of current treatments is to make better at stuttering.

Autism
    Perhaps the most profound communication problem is autism. Autism is not a disease state in and of itself. It is actually a collection of symptoms or characteristics that present as a result of a variety of conditions. We’ll talk about some of the known and suspected causes of autistic syndrome later. In Chapter 2 we noted that at about the age of two, children begin to acquire language at a vastly accelerated rate. However, at this point autistic children lose any speaking ability that they may have had and do not acquire language. They seemingly retreat into their own world. We said before that when children acquire language, its as though a switch is turned on and they begin absorbing speech. With autistics, the switch simply doesn’t turn on.
There are numerous symptoms that are typical of autistics. What’s more, they may be present to a varying degree. They may exhibit poor eye contact with little or no indication of listening. For this reason and their lack of acquisition, they are often initially screened for hearing problems. However, their hearing is typically fine. They may engage in bizarre play. While other children might use blocks to build a building, the autistic might place them around the room at various locations that seem to make little sense. They are attracted to spinning objects and may spend hours spinning the wheel on a toy car and watching it. The often engage in highly repetitive gestures or body movements, performing them for hours on end. They might gesture wildly, rock back and forth, or grind their teeth. They may be self injurious. Some are violent. They may be touch avoidant. They are most comfortable with routine and find surprise and change disconcerting. Interestingly, they may also have savant tendencies as well. Although 80% of autistics are also mentally retarded, some demonstrate alarming proficiency in mathematics, art, and music.
    While autistics may appear to be cut off from the world, researchers suspect that it is quite the opposite. They suggest that while most of us are able to filter out the many things that are going on around us and attend to the things that we find most important, autistics are unable to do this. We are bombarded on a daily basis by smells, sights, sounds, and sensations of all sorts. Can you feel your underwear? You can now since your attention was called to it but before that, your brain simply ignored the input since it is presently irrelevant. One the other hand, when it gets knotted up, your brain notices it again. Your brain also ignores smells that are present in the environment for a period of time. Rather than devoting valuable processing to an omnipresent smell, your brain ignores it. In this way, we are forced to deal with only the data that is important to what we’re doing at any given point in time. Autistics appear to be unable to filter the myriad things that are going on around them and it produces a profound degree of anxiety. Some researchers suggest that this explains their self-injurious tendencies. Bodily injury apparently produces endorphin-like substances that tend to have a calming effect. For an autistic person then, injury becomes a way to relieve anxiety.
    The causes of autistic syndrome are varied. As was mentioned before, autistic behaviors may be present as a result of many different disorders. In about 10% of cases, autism appears to be related to a genetic abnormality called Fragile X Syndrome. It this case, the X chromosome appears to be weakly constructed. As such, Fragile X is a male disorder. In the case of Cornelia Dulane syndrome, autism appears along with other symptoms such as diminished stature. This gives the sufferers a decidedly youthful appearance when in fact they may be much older. In other cases, the cause is a mystery. For no apparent reason, the child about the age of 2 to 4, just as they should become socially voracious, simply turns off the social world. It is perhaps a compensatory mechanism for the inability to control the sensory data they receive but cannot filter.
    At present, there is little that can be done for them. Autism is not curable. Fortunately it is rare. Only 1 in 10,000 children are autistic. But for the children and their families, it is a life altering complication. In years past they were relegated to life in an asylum. Today while many require periods of hospitalization, they can be reached through a number of techniques. They appear to be responsive to behavior modification techniques such that positive behaviors are rewarded and praised and negative behaviors are ignored or in some cases punished. Token economies have been used with some success as well so that appropriate actions earn them tokens that can be cashed in for food or privileges. They also find success in group homes and some are able to take simple jobs. Chemotherapies have had mixed success but perhaps it is only a matter of time. Autism is almost certainly neurologically based. For the near future, it is highly unlikely that most autistics will be able to live independently and self-sufficiently. Just the same, there is always hope and at least one autistic person has overcome the problems of autism and gone on to earn a doctorate and live on her own. What autism demonstrates very clearly is how central communication is to human beings. It is at the core of our being and is essential for our survival. When it goes awry, we cease to be able to survive on our own.