By an allied health world contributing writer
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What is the job of a speech-language pathologist?
Speech-language pathologists (SLP), often referred to as speech therapists, evaluate, diagnose, and treat speech and language disorders from birth to the geriatric population. Most people probably do not realize all the areas that fall under the scope of practice of an SLP.
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Speech language pathologists may be employed in many different settings including schools, private clinics, hospitals, nursing homes, and early childhood development facilities. According to the American Speech-Language-Hearing Association Fact Sheet, over 59% of speech pathologists are employed by schools and educational settings and 35% work in health care facilities. The remaining 13% work in nonresidential health care facilities like home health, private practice offices and speech and hearing centers.
There are such a wide variety of disorders these professionals treat in both children and adults. Also, many people are unaware that there is a difference between speech and language. Speech is the actual production and articulation of sounds, which involves coordinating muscles and movements of the jaw, mouth, and tongue. Language is how a person uses and understands words they see and hear. Examples of the impairments SLPs treat for are described below.
Adult clients who need the services of a speech-language pathologist consist mainly of those with voice issues, swallowing issues, trach and vent patients, and stroke victims suffering from aphasia (loss of words).
These are a variety of reasons someone would need to see an SLP for voice issues. Sometimes people who shout frequently or use their voices loudly, such as cheerleaders or singers, develop vocal cord damage from abuse over time. Due to the vocal cords rubbing together constantly, these individuals can develop nodules or polyps. A speech-language pathologist can work with these individuals to identify any vocal abuses (such as smoking and shouting) and teach them techniques on how to use the voice appropriately.
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Some people see an SLP because they have undergone neck surgery which damaged a nerve and lead to paralysis of the vocal cords. Therapy may focus on improving breath support, utilizing their optimal pitch, or using vocal function exercises to help maximize movement and coordination of the cords.
Other individuals develop a common cold or even a perpetual cough, which is very abusive to the vocal cords. If laryngitis doesn’t clear up, these people may need to see an SLP. During the course of their illness, many people develop poor voice production habits and may need complete voice rest for up to a week. The speech pathologist can then teach these individuals how to produce the voice with less strain on the vocal cords by eliminating hard glottal attacks. Neck relaxation exercises and laryngeal massage techniques may also be effective in reducing vocal strain.
Most dysphagia patients tend to be in the geriatric population and have weaker muscles and could even have paralysis on one side of the body. Sometimes patients with swallowing problems choke on thin liquids like water or even their own saliva. Speech-language pathologists can provide these individuals with some compensatory techniques such as turning their head to one side, sitting upright, or doing a “chin tuck” while swallowing to help protect the airway.
If during a “clinical” or “bedside” swallow evaluation an SLP notices signs and symptoms of aspiration such as choking and coughing, they will likely refer them to Radiology for a Video fluoroscopy also known as a Modified Barium or Cookie Swallow. This involves giving them a Barium drink and watching the oral structures, pharynx and other structures while they are swallowing. With this procedure the SLP can determine if the food or liquid is entering the lungs instead of going into the esophagus as it should. The SLP can provide these individuals with some techniques so they are able to swallow with more ease. Sometimes SLPs even have to put swallowing patients on a puree diet if they’re unable to chew food or there is danger of them choking.
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- Tracheotomy and ventilator patients When patients undergo a tracheotomy, a direct airway is put in the neck through an incision in the trachea, and sometimes their larynx is removed during this procedure due to larynx cancer. Those individuals who have had a tracheotomy breathe through their throat and may need a device called an electrolarynx to produce the necessary vibration to speak. Others need a ventilator in their throat to breath due to some type of blockage.
Aphasia is a language disorder that oftentimes occurs in stroke victims or those who have recently come out of a coma. Those with aphasia typically have difficulty with word retrieval and/or the understanding of spoken language. When a stroke occurs on the left side of the brain where the speech and language center is, oftentimes the right side, which is responsible for areas like creativity and music, are not affected. Therefore, speech language pathologists oftentimes use Melodic Intonation Therapy (MIT), which involves singing, as a technique in treating these individuals. The SLP will sing a phrase to the client and have them sing it back. Singing words and phrases creates new pathways in the brain by making both the left (language) and the right (music) work together.
Speech Pathologists spend a lot of their time working with children, especially those employed in the elementary school setting. The vast majority of SLPs are employed by schools and see only children. Typically the children who see an SLP are between the ages of 3-12, and mainly elementary school aged, although in some cases infants and older children also need speech therapy. Below are the main disorders an SLP treats in children.
- Articulation Disorder
An articulation disorder occurs when someone mispronounces words due to substituting one sound for another, or adding, omitting, or distorting sounds. Children with an articulation disorder may just have a few sounds they struggle with, but will repeat these errors on the same sounds in words. Articulation disorders make up the bulk of the speech pathologist’s caseload. Typically the sounds children misarticulate are the /r/, /s/, /th/, and /l/. So for example, rather than saying “frog” a child may pronounce it “fwog”. Or instead of “think” they may say “fink”. A lisp is an articulation disorder where a child substitutes the /th/ sound for the /s/ sound. For example for “sun” they would pronounce it “thun”.
- Phonological Disorder
Children with phonological disorders are unable to form the necessary sounds to create speech at the expected level for their age. These children have unintelligible speech, which is a more serious issue than an articulation disorder because it involves difficulty in the use of their sound speech system. These children have difficulty understanding the rules of the phonological system. One common example of this disorder is with children who substitute the /t/ for the /k/ sound such as “tat” for “cat”.
Apraxia involves a neurological problem that causes a child to have difficulty planning and coordinating the movements necessary to make speech sounds. Typically, these children’s’ receptive language skills are highly developed, but they have deficits in expressive language due to unintelligible speech. A child with apraxia typically knows what he/she wants to say but their brain has does not allow the lips, tongue and jaw move together to produce a sound. This leads to great frustration in these children since they have a desire to communicate but are unable. Oftentimes children with apraxia do not have any type of recognizable speech through the age of three or four. A neurologist typically diagnoses this disorder but the SLP works with the child thereafter. In working with apraxic children, SLPs use constant repetition to retrain the child’s brain to make motor movements.
Fluency impairments involve a disruption in the forward flow of speech with the repetition or prolongation of sounds or words, during speech. One example of a fluency impairment is stuttering, which involves repeating the first sound of a word multiple times before saying the rest of the word. To treat young children who stutter, SLPs typically encourage fluency enhancing tasks rather than directly addressing the stuttering. For example, by singing nursery rhymes, it promotes a nice rhythm and flow. The rate of speech must be slowed down so these children don’t feel rushed. For older children who stutter, an SLP can help them modify the way they produce sounds.
- Language Disorders
Language impairments involve the improper use of words. There are three main types of language disorders; receptive, expressive, and pragmatic. Receptive language disorders are those where a child has difficulty understanding language. Expressive language disorders involve children having difficulty using language. Pragmatic language disorders pertain to social communication and the way a child speaks to others.
Language disorders are not as “black and white” of a problem as speech issues are, which can make them more difficult to resolve. A four-year-old with a receptive language disorder may point to a cow and call it a “giraffe”. He over generalizes that any animal with four legs and spots is called “giraffe”.
- Pragmatic Disorders
Pragmatic disorders occur in children who are non-verbal or verbal children who do not know how to relate socially to others. Speech-language pathologists work with these children on social skills such as to make eye contact when speaking, greetings (hello and goodbye), and how to share and take turns. This language disorder is common in children with Asperger’s Syndrome.
- Central Auditory Processing
A child with Central Auditory Processing Disorder is unable to take verbal input and derive meaning from it. Children with this disorder have difficulty remembering information given to them verbally, including instructions. They may also have difficulty focusing and following directions. Oftentimes this disorder, which originates in the brain and must be diagnosed by an Audiologist, is commonly mistaken for hearing loss initially or poor listening skills. A speech pathologist also plays a role in the diagnosis of Central Auditory Processing Disorder to rule out language delays. An SLP determines if the child understands basic language concepts such as opposites (hot/cold, up, down, etc). The Audiologist then uses special hearing tests to determine how much of the signal is getting into the child’s brain the correct way.
Why do children develop speech and language disorders?
Children can develop speech and language issues due to a variety of reasons. Some children are born tongue-tied which means the tissue at the bottom of the tongue may be too tight, too short or extend too far. Tongue-tied children have limited tongue movement and may not be able to produce the alveolar sounds, which are produced by the tongue tapping on the roof of the mouth (such as the sounds of a /t/, /d/, /l/ and /m/).
Chronic ear infections can be another cause of speech problems in children. Children learn to articulate appropriately based on imitation and if they are unable to hear sounds clearly, their pronunciation may be incorrect.
Developmental reasons also can affect a child’s ability to articulate words and sounds. The /r/, /s/, and /l/ are difficult sounds for many children to produce and therefore are considered developmentally appropriate misarticulations until age 5 or 6. Oftentimes in these situations a child simply outgrows their articulation impairment.
How long do most patients receive treatment from a speech pathologist?
While each patient and each situation vary greatly, typically children with a speech production type of disorder may see a speech pathologist for around six months. The more severe disorders, like apraxia, usually involve years of treatment. For adult patients, it can greatly vary from voice patients who need to see an SLP for maybe three months, to a stroke survivor who may require a longer course of treatment. Typically to justify the need for speech therapy to insurance companies, a speech therapist must prove that progress is being made through the treatment. When a patient has reached a plateau and is not making further progress, the therapy can no longer be justified.
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