I walk in a commercial area I have not been in before and see lots of new businesses. The door of one of them has a sign “Apraxia Dallas.” I have no idea what this means, but upon looking at the website discover it was founded over 20 years ago by Kay Giesecke and is a small private practice composed of five speech-language pathologists. According to the Mayo Clinic, child apraxia of speech is an uncommon speech disorder in which a child has difficulty making accurate movements when speaking.
In CAS, the brain struggles to develop plans for speech movement. With this disorder, the speech muscles aren't weak, but they don't perform normally because the brain has difficulty directing or coordinating the movements.
To speak correctly, the child's brain has to learn how to make plans that tell his or her speech muscles how to move the lips, jaw and tongue in ways that result in accurate sounds and words spoken with normal speed and rhythm. CAS is often treated with speech therapy, in which children practice the correct way to say words, syllables and phrases with the help of a speech-language pathologist.
Besides child apraxia of speech, there are many more communication disorders that speech-language pathologists treat. Let’s learn more about them.
Broca’s area
According to Wikipedia, Broca's area, or the Broca area is a region in the frontal lobe of the dominant hemisphere, usually the left, of the brain with functions linked to speech production.
Language processing has been linked to Broca's area since Pierre Paul Broca reported impairments in two patients. They had lost the ability to speak after injury to the posterior inferior frontal gyrus of the brain. Since then, the approximate region he identified has become known as Broca's area, and the deficit in language production as Broca's aphasia, also called expressive aphasia.
Functional magnetic resonance imaging has shown language processing to also involve the third part of the inferior frontal gyrus the pars orbitalis, as well as the ventral part of BA6 and these are now often included in a larger area called Broca's region.
Studies of chronic aphasia have implicated an essential role of Broca's area in various speech and language functions. Further, fMRI studies have also identified activation patterns in Broca's area associated with various language tasks. However, slow destruction of the Broca's area by brain tumors can leave speech relatively intact, suggesting its functions can shift to nearby areas in the brain.
Wernicke’s area
Wernicke's area — also called Wernicke's speech area — is one of the two parts of the cerebral cortex that are linked to speech, the other being Broca’s area. It is involved in the comprehension of written and spoken language, in contrast to Broca's area, which is involved in the production of language. It is traditionally thought to reside in Brodmann area 22, which is located in the superior temporal gyrus in the dominant cerebral hemisphere, which is the left hemisphere in about 95% of right-handed individuals and 60% of left-handed individuals.
Damage caused to Wernicke's area results in receptive, fluent aphasia. This means that the person with aphasia will be able to fluently connect words, but the phrases will lack meaning. This is unlike non-fluent aphasia, in which the person will use meaningful words, but in a non-fluent, telegraphic manner.
Wernicke's area is named after Carl Wernicke, a German neuropathologist and psychiatrist who, in 1874, hypothesized a link between the left posterior section of the superior temporal gyrus and the reflexive mimicking of words and their syllables that associated the sensory and motor images of spoken words. He did this on the basis of the location of brain injuries that caused aphasia. Receptive aphasia in which such abilities are preserved is also known as Wernicke's aphasia. In this condition there is a major impairment of language comprehension, while speech retains a natural-sounding rhythm and a relatively normal syntax. Language as a result is largely meaningless, a condition sometimes called fluent or jargon aphasia.
Speech-language pathology overview
Speech-language pathology is a field of expertise practiced by a clinician known as a speech-language pathologist or SLP or a speech and language therapist, both of whom may be known by the shortened description, speech therapist. SLP is considered a "related health profession" or "allied health profession" along with audiology, optometry, occupational therapy, rehabilitation psychology, physical therapy, behavior analysis and others.
SLPs specialize in the evaluation, diagnosis and treatment of communication disorders or speech disorders and language disorders, cognitive-communication disorders, voice disorders and swallowing disorders. SLPs also play an important role in the diagnosis and treatment of autism spectrum disorder, often in a team with pediatricians and psychologists.
The profession
Speech-language pathologists provide a wide range of services, mainly on an individual basis, but also as support for individuals, families, support groups and providing information for the general public. SLPs work to prevent, assess, diagnose and treat speech, language, social communication, cognitive-communication, voice, fluency and swallowing disorders in children and adults. Speech services begin with initial screening for communication and swallowing disorders and continue with assessment and diagnosis, consultation for the provision of advice regarding management, intervention, treatment and providing counseling and other follow-up services for these disorders.
Services are provided in the following areas:
- Cognitive aspects of communication e.g., attention, memory, problem-solving, executive functions.
- Speech — phonation, articulation, fluency, resonance and voice including aeromechanical components of respiration.
- Language — phonology, morphology, syntax, semantics and pragmatic/social aspects of communication — including comprehension and expression in oral, written, graphic and manual modalities; language processing; preliteracy and language-based literacy skills; and phonological awareness.
- Augmentative and alternative communication, for individuals with severe language and communication impairments.
- Swallowing or other upper aerodigestive functions such as infant feeding and aeromechanical events; evaluation of esophageal function is for the purpose of referral to medical professionals.
- Voice (hoarseness, dysphonia), poor vocal volume (hypophonia), abnormal (e.g., rough, breathy, strained) vocal quality. Research demonstrates voice therapy to be especially helpful with certain patient populations; individuals with Parkinson's disease often develop v voice issues as a result of their disease.
- Sensory awareness related to communication, swallowing or other upper aerodigestive functions.
- Speech, language and swallowing disorders result from a variety of causes, such as a stroke, brain injury, hearing loss, developmental delay, a cleft palate, cerebral palsy or emotional issues.
A common misconception is that speech-language pathology is restricted to the treatment of articulation disorders — e.g., helping English-speaking individuals enunciate the traditionally difficult "r" — and/or the treatment of individuals who stutter but, in fact, speech-language pathology is concerned with a broad scope of speech, language, literacy, swallowing and voice issues involved in communication, some of which include:
- Word-finding and other semantic issues, either as a result of a specific language impairment such as a language delay or as a secondary characteristic of a more general issue such as dementia.
- Social communication difficulties involving how people communicate or interact with others — pragmatics.
- Language impairments, including difficulties creating sentences that are grammatical (syntax) and modifying word meaning (morphology).
- Literacy impairments (reading and writing) related to the letter-to-sound relationship (phonics), the word-to-meaning relationship (semantics) and understanding the ideas presented in a text (reading comprehension).
- Voice difficulties, such as a raspy voice, a voice that is too soft or other voice difficulties that negatively impact a person's social or professional performance.
- Cognitive impairments — e.g., attention, memory, executive function — to the extent that they interfere with communication.
The components of speech production include: (1) phonation or producing sound, (2) resonance, (3) fluency, (4) intonation, (5) pitch variance; and (6) voice, including aeromechanical components of respiration.
The components of language include: (1) phonology or manipulating sound according to the rules of a language, (2) morphology or understanding components of words and how they can modify meaning, (3) syntax or constructing sentences according to the grammatical rules of a target language, (4) semantics or interpreting signs or symbols of communication such as words or signs to construct meaning, (5) pragmatics or social aspects of communication.
Primary pediatric speech and language disorders include: (1) receptive language disorders, (2) expressive language disorders, (3) speech sound disorders, (4) childhood apraxia of speech or CAS, (5) stuttering and (6) language-based learning disabilities. Speech pathologists work with people of all ages.
Swallowing disorders include difficulties in any system of the swallowing process — i.e., oral, pharyngeal and esophageal — as well as functional dysphagia and feeding disorders. Swallowing disorders can occur at any age and can stem from multiple causes.
Multidiscipline collaboration
SLPs collaborate with other health care professionals, often working as part of a multidisciplinary team. They can provide information and referrals to audiologists, physicians, dentists, nurses, nurse practitioners, occupational therapists, rehabilitation psychologists, dietitians, educators, behavior consultants for applied behavior analysis and parents as dictated by the individual client's needs. For example, the treatment for patients with cleft lip and palate often requires multidisciplinary collaboration. Speech-language pathologists can be very beneficial to help resolve speech problems associated with cleft lip and palate. Research has indicated that children who receive early language intervention are less likely to develop compensatory error patterns later in life, although speech therapy outcomes are usually better when surgical treatment is performed earlier. Another area of collaboration relates to auditory processing disorders, where SLPs can collaborate in assessments and provide intervention where there is evidence of speech, language and/or other cognitive-communication disorders.
Working environments
SLPs work in a variety of clinical and educational settings. SLPs work in public and private hospitals, private practices, skilled nursing facilities, long-term acute care facilities, hospice and home health care. SLPs may also work as part of the support structure in the education system, working in both public and private schools, colleges and universities. Some SLPs also work in community health, providing services at prisons and young offenders’ institutions or providing expert testimony in applicable court cases.
Following the American Speech-Language-Hearing Association's 2005 approval of the delivery of speech/language services via video conference or telepractice, SLPs in the United States have begun to use this service model.
U.S. education and training
In the United States, speech-language pathology is a master's entry-level professional degree field. Clinicians must hold a master's degree in communicative disorders/speech-language pathology — e.g., M.A., M.S. or M.Ed. — that is from a university that holds regional accreditation and from a communication sciences and disorders program that is accredited by the American Speech-Language-Hearing Association, the profession's national governing body as well as individual state's governing board. Programs that offer the M.Ed. degree are often housed within a university's college of education but offer the same education and training as programs with an M.A. or M.S. degree. Beyond the master's degree, some SLPs may choose to earn a clinical doctorate in speech-language pathology (e.g., CScD or SLPD) or a doctoral degree that has a research and/or professional focus (e.g., Ph.D., or Ed.D.). All degrees must be from a university that holds regional accreditation, but only the master's degree is accredited by the American Speech-Language-Hearing Association.
All clinicians are required to complete 400 clinical hours — 25 observation hours often completed during the undergraduate degree and 375 hours of graduate clinical practicum. They must pass multiple comprehensive exams, also called Knowledge and Skills Acquisition or KASA exams.
After all the above requirements have been met during the SLP's path to earning the graduate degree, SLPs must earn state licensure and national certification by:
- Passing the National Speech-Language Pathology board exam — Praxis.
- Successfully completing a clinical fellowship year or CFY as a clinical fellow or CF under the mentorship of a fully licensed mentor clinician. The CFY is no less than 36 weeks of full- time experience, totaling a minimum of 1,260 hours. During the CFY, the CF cannot earn CFY hours unless they work more than five hours in a week and cannot earn any CFY hours beyond 35 hours in a week.
- Receiving the American Speech-Language-Hearing Association certificate of clinical competence or CCC and full state licensure to practice, following successful completion of t the clinical fellowship year.
- States are responsible for licensure of clinicians and other professionals and — as far as the new SLP — these requirements are often similar to that of the CFY. Following the state licensure procedures and national certification requirements are usually done simultaneously.
Maintaining licensure through continuing education:
To maintain licensure, SLPs are required to participate in periodic earning of continuing educational units or CEUs.
Continuing education and training obligations:
- Educate, supervise and mentor future SLPs.
- Participate in continuing education.
- Educate and provide in-service training to families, caregivers and other professionals.
- Train, supervise and manage speech-language pathology assistants or SLPAs and other support personnel.
- Educate and counsel individuals, families, co-workers, educators and other persons in the community regarding acceptance, adaptation and decisions about communication and swallowing.
Professional suffix:
- Credentials of a clinical fellow typically read as: MA, MS or M.Ed, CF-SLP — e.g., Jane Doe, MA, CF-SLP.
- Credentials of a fully licensed SLP commonly read as: MA, MS or M.Ed, CCC-SLP — e.g., Jane Doe, MA, CCC-SLP — indicating a practitioner's graduate degree and successful completion of the fellowship year/board exams to obtain the "three Cs," the certification of clinical competence, in speech-language pathology.
Salary information
Salaries of SLPs in the United States depend on a variety of factors including educational background, work experience and location. The ASHA 2016 Schools Survey revealed that SLPs received a median academic year salary of $62,000, which is a 2% increase from the latest Schools Survey done in 2014. The 2015 SLP Health Care Survey placed the median salary for SLPs working within the health care industry at $75,000. According to the Bureau of Labor Statistics in 2019, the median salary for SLPs in the U.S. is $79,120. In Australia, the basic salary that a graduate SLP would earn is estimated at AU$59,500 and around AU$55,000 for a private SLP.
Clients and patients
Speech-language pathologists work with clients and patients who may present a wide range of issues.
Infants and children
Infants with injuries due to complications at birth, feeding and swallowing difficulties, including dysphagia.
Children with mild, moderate or severe:
- Genetic disorders that adversely affect speech, language and/or cognitive development including cleft palate, Down syndrome and DiGeorge syndrome.
- Attention deficit hyperactivity disorder.
- Autism spectrum disorders, including Asperger syndrome.
- Developmental delay.
- Feeding disorders, including oral motor deficits.
- Cranial nerve damage.
- Hearing loss.
- Craniofacial anomalies that adversely affect speech, language and/or cognitive development.
- Language delay.
- Specific language impairment.
- Specific difficulties in producing sounds, called articulation disorders, including vocalic /r/ and lisps.
- Pediatric traumatic brain injury.
- Developmental verbal dyspraxia.
United States
In the U.S., some children are eligible to receive speech therapy services, including assessment and lessons through the public school system. If not, private therapy is readily available through personal lessons with a qualified speech-language pathologist or the growing field of telepractice. Teleconferencing tools such as Skype are being used more commonly as a means to access remote locations in private therapy practice, such as in the geographically diverse south island of New Zealand. More at-home or combination treatments have become readily available to address specific types of articulation disorders. The use of mobile applications in speech therapy is also growing as an avenue to bring treatment into the home.
United Kingdom
In the UK, children are entitled to an assessment by local National Health Service speech and language therapy teams — usually after referral by health visitors or education settings — but parents are also entitled to request an assessment directly. If treatment is appropriate, an educational plan will be drawn up. Speech therapists often play a role in multidisciplinary teams where a child has speech delay or disorder as part of a wider health condition. The Children’s Commissioner for England reported in June 2019 that there was a postcode lottery. £291.65 a year per head was spent on services in some areas, while the budget in some areas was £30.94 or less. In 2018, 193,971 children in English primary schools were on the special educational needs register needing speech therapy services.
Children and adults
- Puberphonia, characterized by the habitual use of a high-pitched voice after puberty.
- Cerebral palsy.
- Head injury — traumatic brain injury.
- Hearing loss and impairments.
- Learning difficulties including dyslexia, specific language impairment and auditory processing disorder.
- Physical disabilities.
- Speech disorders such as oral dyspraxia.
- Stammering, stuttering — disfluency.
- Stroke.
- Voice disorders — dysphonia.
- Language delay.
- Motor speech disorders — dysarthria or developmental verbal dyspraxia.
- Naming difficulties — anomia.
- Disgraphia, agraphia.
- Cognitive communication disorders.
- Pragmatics.
- Laryngectomies.
- Tracheostomies.
- Oncology — ear, nose or throat cancer.
Adults
Adults with mild, moderate or severe eating, feeding and swallowing difficulties, including dysphagia.
Adults with mild, moderate, or severe language difficulties as a result of:
- Motor neuron diseases.
- Alzheimer’s disease.
- Dementia.
- Huntington’s disease.
- Multiple sclerosis.
- Parkinson’s disease.
- Mental health issues.
- Stroke.
- Progressive neurological conditions such as cancer of the head, neck and throat — including laryngectomy.
- Aphasic, an inability to comprehend or formulate language because of damage to specific
brain regions.
Adults seeking transgender-specific voice training, including voice feminization and voice masculinization.
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