A process-oriented approach to differential diagnosis and treatment planning of pediatric speech sound disorders

De classificatie en differentiaaldiagnose van spraakontwikkelingsstoornissen is nog altijd een controversieel thema. De verschillende diagnostische categorieën zijn gedefinieerd op procesniveau, in termen van het cognitieve proces waar de kern van de onderliggende stoornis zich bevindt, en ook de meeste behandelmethoden zijn gericht op verschillende delen van het spraakproductieproces. In de klinische praktijk wordt de differentiaaldiagnose echter gebaseerd op gedragssymptomen, met methoden die bovendien vaak niet gestandaardiseerd en/of genormeerd zijn.Het diagnostische dilemma is dat het onderzoek naar de gedragskarakteristieken van de verschillende subtypes afhankelijk is van ‘zuivere’ casussen geselecteerd op basis van niet-ambigue, helder afgebakende criteria, die echter alleen gedefinieerd en beschikbaar gemaakt kunnen worden als resultaat van onderzoek naar a priori ongedefineerde casussen. In dit paper bespreken we een procesgerichte aanpak van differentiaaldiagnose en indicatiestelling gebaseerd op drie onderzoekslijnen waarmee die circulariteit doorbroken kan worden. De kern van de aanpak bestaat uit drie belangrijke punten/inzichten:Waar gedragssymptomatologie onduidelijk is, is het wel mogelijk om op procesniveau specifieke problemen in deelprocessen helder te definiëren. (Een focus op onderliggende processen in plaats van classificatie op basis van gedragssymptomen.)Processen beïnvloeden elkaar: een stoornis op één procesniveau beïnvloedt het functioneren en de ontwikkeling van andere processen. (Een focus op procesprofielen met gradaties van betrokkenheid.)Spraakproductiesysteem en -stoornis ontwikkelen zich. (Een focus op het veranderen van procesprofielen.)Op basis van deze inzichten opperen we een model van differentiaaldiagnose en therapieplanning voor spraakstoornissen bij kinderen dat ─naast vloeiendheidsstoornis─ bestaat uit twee algemene diagnostische categorieën: spraakachterstand en spraakontwikkelingsstoornis. Binnen deze categorieën worden vervolgens op procesniveau de behandeldoelen geformuleerd. Deze procesgeoriënteerde aanpak van diagnose en therapieplanning heeft belangrijke voordelen. In tegenstelling tot diagnostische classificatie op basis van gedragssymptomen biedt het directe aanknopingspunten voor een dynamisch behandelplan op maat; een behandelplan afgestemd op de specifieke tekortkoming(en) van het individu dat continue wordt geëvalueerd en bijgesteld gedurende het verloop van de spraakstoornis. Aan de hand van een voorbeeld wordt geïllustreerd hoe een dergelijke aanpak er in de praktijk uit kan zien.The classification and differentiation of paediatric speech sound disorders (SSD) remains a controversial issue. The definitions used in classifying childhood SSD and motor speech disorders (MSD) refer to speech production processes, and accordingly a variety of methods of intervention has been developed aiming at different parts of the speech production process. However, diagnosis in clinical practice is primarily based on behavioural speech symptoms rather than the underlying deficits. The diagnostic dilemma is that the ability to investigate the characteristics of subtypes of SSD requires &amp;#39;pure&amp;#39; cases selected on the basis of unambiguous/clear-cut criteria. These criteria can only be defined and made available as a result of research (into a priori undefined /undetermined cases). In this paper we propose a process-oriented approach to diagnosis and treatment planning of paediatric SSD based on three pillars of research that will allow us to break through this circularity. The core of this approach comprises three important notions: 1. Although the behavioural symptomatology of paediatric SSD&amp;#39;s is not completely clear, it is possible to precisely define a specific core problem in terms of processes. (A focus on underlying processing deficits rather than classification based on symptoms.) 2. Developmental interaction between processes: a specific underlying impairment on one level or domain also affects the development on adjacent levels or domains. (A focus on process profiles with degrees of involvement.) 3. The speech production system and -disorder develop/evolve in time. (A focus on changing profiles.) Based on these three notions,we propose a model of differential diagnosis and treatment planning for childhood speech disorders that - besides &amp;quot;fluency disorder&amp;quot; - comprises two general diagnostic categories labelled &amp;quot;speech delay&amp;quot; and &amp;quot;developmental speech disorder&amp;quot;. Within these categories, treatment goals are formulated on the level of processes. This process-oriented approach to diagnosis and treatment planning holds important advantages. In contrast to diagnostic classification based on a description ofbehavioural symptoms, it offers direct leads for treatment aimed at the specific underlying impairment tailored to the specific needs of the individual that is evaluated and adjusted in the course of the speech disorder. The approach is illustrated with an example.</p

Articulation in children with developmental speech disorders

A central issue in studies on developmental speech disorders, especially with regard to childhood apraxia of speech (CAS) and phonological disorder (PD) is the distinction between phonological and motoric processes. Acoustic studies suggest that children with CAS produce incorrect realizations of correctly selected phonemes, whereas the opposite is postulated for children with PD. Thus conceived, the underlying impairment is located at different levels of speech production in these two groups of children

Stability and composition of functional synergies for speech movements in children and adults

The consistency and composition of functional synergies for speech movements were investigated in 7 year-old children and adults in a reiterated speech task using electromagnetic articulography (EMA). Results showed higher variability in children for tongue tip and jaw, but not for lower lip movement trajectories. Furthermore, the relative contribution to the oral closure of lower lip was smaller in children compared to adults, whereas in this respect no difference was found for tongue tip. These results support and extend findings of non-linearity in speech motor development and illustrate the importance of a multi-measures approach in studying speech motor development

Music and musical elements in the treatment of childhood speech sound disorders:A systematic review of the literature

Purpose: Music-based interventions are used in the treatment of childhood speech sound disorders (SSDs). Hypotheses on working mechanisms are being developed, focussing on shared neural processes. However, evidence of the effect of treatment with musical elements in SSDs in children is lacking. This study reviews the literature regarding the use of music-based interventions in the treatment of childhood SSDs.Method: A systematic search in six databases was conducted, yielding 199 articles, eight of which met the inclusion criteria. Included articles were reviewed on study characteristics, patient characteristics, interventions, outcomes and methodological quality.Result: This review included four case studies, three single-subject design studies and one cohort study. Seven studies reported positive outcomes on speech production, but outcome measures in the four studies with experimental design were not all aimed at the level of speech (motor) processes. Methodological quality was sufficient in one study.Conclusion: Seven out of eight studies in this review report positive outcomes of music-based interventions in the treatment of SSDs. However, these outcomes are not sufficiently supported by evidence due to insufficient methodological quality. Suggestions for improving methodological quality in future research are presented.</p

Rate-related kinematic changes in younger and older adults

This study aimed to investigate the effects of speech rate changes on kinematic characteristics and stability of speech movements in younger and older speakers using electromagnetic midsagittal articulography (EMMA). Eight young adults and eight older adults engaged in a series of syllable repetition tasks of /pa, /sa/ and /ta/ obtained at self-paced slow, habitual and fast speech rates, as well as in a series of metronome guided speech rates, ranging from 2 to 4 syllables per second. The kinematic parameters duration, amplitude and peak velocity were obtained for opening and closing movements. Older speakers were able to increase speech rate to the same degree or higher compared to younger speakers in both pacing conditions. Kinematic data show that older adults increased duration and decreased peak velocity in closing movements of alveolar constrictions at slower rates more prominently than younger adults. The results on movement stability revealed no differences between age groups. The results suggest that an age-related difference in speed-accuracy trade-off can be ruled out. Differences in kinematic characteristics point towards the possibility that older adults aimed to facilitate a closed loop control system to maintain movement stability at slower speech rates

An analysis of speech rate strategies in ageing

Effects of age and speech rate on movement cycle duration were assessed using electromagnetic articulography. In a repetitive task syllables were articulated at eight rates, obtained by metronome and self-pacing. Results indicate that increased speech rate is associated with increasing movement cycle duration stability, while decreased rate leads to a decrease in uniformity of cycle duration, supporting the view that alterations in speech rate are associated with different motor control strategies involving durational manipulations. The relative contribution of closing movement durations increases with decreasing speech rate, and is a more dominant strategy for elderly speakers

Issues in higher education policy : an update on higher education policy issues in 2004 in 11 Western countries

Higher education is a dynamic field. It is, however, also a field where changes don¿t take place overnight. This 2004 update report covers a period of 1.5 years, a period in which some earlier policy initiatives have been implemented and new ones have emerged. It is therefore not surprising to observe that many of the policy issues on the agenda in the previous Update Report (April, 2003) still are a topic of debate today.\ud The main part of the report are the descriptions of the current (2004) higher education debates and policy initiatives for each of the eleven IHEM countries, arranged in four themes educational and research infrastructure, finance, governance and quality. In conclusion, four `overarching¿ policy issues in contemporary European (and Australian) higher education are discussed. These issues are:\ud * The Bologna process and changing degree structures\ud * The changing organisation of research\ud * Financial accountability and responsibility\ud * Interactive governanc