Spraakstoornissen in alalia

In alalia, speech is impaired when hearing and intelligence are initially normal. The pathology is caused by organic brain damage in the intrauterine period or before the third year of life. Speech disorders in alalia are characterized by a disorder of phonetic-phonemic, lexical and grammatical structure. In addition, non-speech pathologies may be present: coordination and motor disorders, perception and sensory disorders, psychopathologies. Speech disorders manifest themselves in different ways, which depends on the type and degree of alalia. [1]

Speech and non-speech symptomatology of alalia

A distinction is made between motor, sensory and combined (sensorimotor) alalia.

Motor alalia is characterized by impaired formation of expressive speech activity, speech praxis, articulation, fluency, but the child understands the speech addressed to him. On the neurological side, motor alalia is often combined with focal symptomatology, and many alalic children are left-handed. Encephalography can detect regional inhibition or epileptiform activity.

Speech comprehension is impaired in sensory alalia, while elementary hearing is preserved, there is a secondary insufficient development of own speech. To a greater extent, the area of speech gnosis is affected: sound analysis is impaired, which applies to perceived speech. There is no relationship between the image of the sound and the object. Thus, the baby hears but does not understand the utterances addressed to him, which is denoted by the term auditory agnosia.

Identification and diagnosis of alalia is difficult. It is important to exclude hearing loss and psychopathology. Often specialists have to observe the child for several months, to record all the existing speech disorders and other features.

Other signs of alalia include:

• Motor alalia: underdeveloped movement of the upper limbs, poor coordination, reduced efficiency, the emergence of speech only after 3-4 years, lack of ability to express their own thoughts in words, verbal substitutions, incorrect construction of phrases, lack of desire to express themselves, capriciousness, resentfulness, tendency to seclusion, irritability.
• Sensory alalia: impaired speech perception, verbal repetition (echolalia), general reticence; substitution of letters within words, combining two words into one, excessive excitability, impulsivity, frequent depression; lack of understanding of the relationship between a word and its object.

Sensomotor alalia combines motor and speech disorders, so the symptomatology of this pathology is wider, and treatment is more complicated.

Speech symptomatology in alalia

In motor alalia, there is a pronounced underdevelopment of all speech aspects: phonetic, phonemic, lexical, syllabic word structure, syntactic, morphological, as well as all types of speech function, oral and written speech. It is difficult for children to actualize even familiar words.

Phonetic design is characterized by:

• maximum preservation of tempo, rhythm, intonation, volume and other prosodic components;
• the presence of multiple periodic sound substitutions (mainly consonant sounds);
• a sharp discrepancy between the relatively normal repetition of certain sounds and their use in speech.

The syllabic structure is deliberately simplified, individual (difficult for the child) sounds and syllables are omitted, substitutions of sounds, syllables, letters or words are noted, permutations are observed. Distortions are unstable and varied.

In terms of syntactic and morphological speech disorders, difficulties with the formation of utterances are detected. Phrases are shortened, structurally simplified, with numerous omissions (prepositions are mostly omitted). The case endings are incorrectly selected, the voiced sentences belong to simple non-spoken sentences.

Preschool children are able to sound only syntactically banal sentences. Schoolchildren identify only the subject and rarely the predicate from all the proposed members of a common sentence, cannot independently determine the elements of grammatical structure.

Against the background of speech disorders in alalia there is no automation of the process, the dynamic stereotype of speech function is not sufficiently developed, a special incorrect type of language behavior is formed.

The primary structural link in speech disorder is an unformed arbitrary speech function. The secondary link is impaired communicative activity with regular signs of speech and behavioral negativism. [2]

Structure and mobility of the speech apparatus in alalia

The human speech apparatus consists of a central and peripheral department. The central department is represented directly by the brain and cortex, subcortical nodes, conductive channels and nerve nuclei. The components of the peripheral department are the executive speech organs, including bone and cartilage elements, musculature and ligamentous apparatus, as well as sensory and motor nerves that control the function of the above mentioned organs.

A normal child has an innate readiness for speech development, sufficient intelligence and stimuli to encourage the brain apparatus to mature. It is important that the individual analyzers and superimposed modalities be united by adequately "working" wire pathways that transmit information between the various brain areas. Without such a connection, speech ability cannot develop, which is what happens in patients with alalia.

Left-hemispheric lateralization of the speech function is of great importance in the processes of early speech development. First of all, non-speech noises (ambient, natural) are assimilated. On the basis of this, the features necessary for further reproduction of own sounds are selected, and auditory-verbal gnosis is formed.

In severe variants of alalia, identification of non-speech noises is impaired, although children have a sense of rhythm, draw well, and actively use gestures. However, the sounds produced by the human voice often remain inaccessible to them unless appropriate measures are taken.

Speech auditory gnosis in the brain is localized mainly in the left temporal lobe. Its timely activation occurs as a certain auditory basis is accumulated against the background of preserved wired interhemispheric pathways. If such conditions are not provided, the baby does not form the ability to perceive acoustic noises in the form of speech sounds.

In sensory alalia, there are simply no such connections between the brain hemispheres. In motor alalia, the problem is most often localized in the left hemisphere.

For example, a baby can distinguish sounds to a certain extent and grasp their meaning. But in order for it to begin to reproduce its own speech, it needs the ability to transform these sounds into speech movements. That is, the product perceived by hearing must be "rewritten" into articulation. Such a development is possible only when there are complete wiring pathways connecting the motor and sensory brain areas. [3]

For oral adequate speech to emerge, such connections must be made:

• between the left parietal lobe and the right temporal lobe (sound-imitative function);
• between the postcentral zone and the temporal left hemispheric lobe (function of reproducing individual motor patterns);
• between the premotor area and the temporal lobe (function of reproducing a series of motor patterns).

Delay of speech development by motor alalia type

Motor alalia is not only a speech disorder. We are talking about a polysyndromic pathology, delayed speech development, which includes such disorders:

• Dynamic articulation type of dyspraxia. The child lacks the ability to quickly switch between speech actions, which leads to a violation of the syllabic word structure. For a long time, the baby only repeats the same syllables (mo-mo, pee-pee, bo-bo), or speaks only the first syllable. Even with the emergence of the possibility of voicing phrases babbling is still long delayed in conversation. Sound substitutions, syllable repetitions, omissions and permutations are noted. The appearance of errors is characterized by irregularity: the baby can each time pronounce the same word in a different way. With the complexity of speech activity, the number of errors increases.
• Verbal type of dyspraxia. The meaning-sound scheme of a word is not automated for a long time. There are violations of phonological organization, each time the child tries to "build" the word anew, not applying the pattern already known to him.
• Articulation kinesthetic type of dyspraxia. The child has impaired pronunciation of sounds, but not isolated, but as part of the speech stream.
• Oral type of dyspraxia. There is a disorder of dynamic oral praxis: the child has difficulty in trying to reproduce a number of movements with the tongue.
• Syntax disorders. The start of speech in the baby begins around 3 years old, and for a long time there are only simple phrases, with the omission of prepositions, although there is a fairly good understanding of cause-and-effect relationships. A similar sign is present in the school years.
• Morphological dysgrammatism. Toddlers often make mistakes in case endings, which is especially noticeable during dialog rather than monologue.

This type of speech disorder even against the background of intensive corrective measures has a high probability of forming agrammatical dysgraphia. [4]

Speech in sensory alalia

Patients with sensory alalia are dominated by speech gnosis disorder. There is incorrect sound analysis, heard speech is not perceived, there is no connection between the sound image and the corresponding object. Thus, the child hears, but does not understand, does not perceive what is said to him (the so-called auditory agnosia is present).

Multisyllabic speech (otherwise known as logorrhea) is characteristic of sensory alalia. This is intense speech activity, enriched with combinations of sounds, but incomprehensible to others. Many children make uncontrolled repetitions - echolalia. If you ask a child to purposefully repeat a certain word, he will not be able to do it.

The process of relating a phenomenon or thing to a denoting word is disturbed in toddlers. As a result, there is a substitution of letters or their omission, incorrect choice of the stressed vowel, etc. Over time, incorrect pronunciation leads to the lack of formed expressive speech, and general speech underdevelopment occurs.

Speech negativism in alalia

Speech negativism is said when a child simply refuses to speak, which makes it much more difficult to carry out corrective measures.

Two types of speech negativism are distinguished in alalia:

• With active negativism toddlers react violently to requests to say something: they openly demonstrate their discontent, stomp, make noise, run away, throw a tantrum, fight, bite.
• In passive negativism, children persistently remain silent, hide, sometimes "respond" with silence and gestures, or try to do everything on their own as much as possible so as not to ask adults for help.

Any of the forms of negativism in speech disorders appear mainly at the initial stage of alalia, although there are exceptions to the rules. Much depends on the environment of the baby: the more pressure is exerted on the child, the greater the risk of negativism. The problem is more often detected in patients with motor alalia.

The risk of negativisms on the background of speech disorders is significantly increased:

• with overly demanding approaches to children's speech, without taking into account the child's limited abilities;
• with overprotection and pity from loved ones.

Negativisms are easier to eliminate in the early stages of their appearance. Over the years, the situation worsens, the pathology takes hold, and it becomes increasingly difficult to get rid of it.

Correction

To speech therapy correction of speech disorders in alalia should begin as early as possible, at the first manifestations of lag in speech of the baby. Correction should not be limited to teaching the correct pronunciation. It is necessary to pay attention to the formation of vocabulary, the development of grammatical skills, the establishment of coherent speech and intonation and so on. The essence of classes should be aimed at the inclusion of preserved speech channels, replacing damaged ones. In particular, methods that involve restructuring the mechanism of realization of the speaking function become effective.

It is recommended to teach reading and writing to patients with alalia even before they begin to speak "by ear", changing the natural logic of speech development - that is, as if stepping over the stage of speech ontogenesis. Often, this approach helps to achieve full speech recovery, as well as to adapt the child to further activities.

The necessary articulatory features are extracted not from acoustic, but from graphic images of speech and word sounds (reading), i.e. By "switching on" the normally developed cortex of the large hemispheres located behind the parietal and temporal lobes (the so-called visual cortex). In a similar way, the connection between the temporal lobes of the left and right hemispheres, which is basic in normal speech development, is "bypassed". [5], [6]

Early speech development in motor alalia

The "first signs" of motor alalia can be detected in the first year of life, but few parents pay attention to it. The child in general develops no worse than other children. The only difference is that he practically does not use babbling, and if he does, he uses it monotonously.

Most often, suspicions arise only from the age of 2 years. But even in this case, most parents just keep waiting for the baby to speak. Nevertheless, in the presence of speech disorders in the form of alalia, the child does not master speech in 3, 4 and even 5 years old.

What is characteristic of children with motor alalia?

• The voice is usually ringing, clear.
• Words are not formed, or are pronounced as babble, have no ending or middle; sometimes only the syllable on which the accent falls is pronounced.
• If light phrases are spoken, they consist exclusively of accent words that have the main semantic load.
• Without special need, the child does not speak at all, but shows gestures or facial expressions.

It cannot be said that such a speech disorder in alalia is exclusively unfavorable. If certain educational conditions are created, regular classes are held, and the correction itself begins in time, at the earliest possible stage, it is more likely to achieve a positive result. Moreover, early classes often lead to the fact that after 1-2 months the baby begins to speak coherently, although his statements still have some shortcomings that require correction. The main role in this dynamic improvement is played by parents and close people who must be understanding and patient with a "special" child. Additional help is necessarily provided by speech therapists, speech pathologists, neurologists. [7]

Speech chart for non-speaking children with alalia

After confirming the presence of alalia in the child, the speech therapist puts him/her on the register and makes a special individual speech card. The document is a list of questions, diagnostic results and indicators. The doctor regularly enters all data into the card, which helps to trace the dynamics of correction of speech disorders, to find out the best ways of treatment.

Speech charts can be general (summarized) or detailed. In the first case, as a rule, only anamnesis and other general information is described. The detailed version contains all the information about the results of examinations, the current state of the problem, the vocabulary of the baby, the tasks performed by him. Most often, the document is kept until the child enters school.

What is necessarily included in a speech chart?

• General information (summary of the child and parents, short patient profile).
• Anamnesis (data on birth, newborn stage, diseases, early speech development, general health of the baby).
• Non-verbal activity study indicators (picture of visual observation of the patient, data on fine and gross motor skills, auditory attentiveness, visual perception, rhythm sensations).
• Indicators obtained during the diagnosis of speech disorders (demonstrating the state of the mechanism of pronunciation of sounds and articulation apparatus, the quality of sound production and speech motor skills).
• Quality of respiratory and vocal activity (frequency, type identity and duration of respiratory movements, voice evaluation).
• Indicators of phonemic speech sphere and perception, speech comprehension, vocabulary and grammatical structure, state of connected speech (if any).

In the final part of the speech chart, the specialist writes a speech therapy report, in which he or she indicates the diagnosis and draws up a recommended correction scheme. The document is supplemented by the conclusions of doctors of other specialties: neurologist, otolaryngologist, psychotherapist and others. [8]

Stages and levels of speech development in alalia

The period from newborn to the first year of life is very important for a baby's speech development, because during this time the brain areas responsible for speech are actively forming. The first 12 months of life is called the pre-speech, preparatory period, which becomes the basis for subsequent speech recovery. This term is conditionally subdivided into such stages:

1. From newborn to 3 months of age - emotional-expressive responses develop.
2. From 3 months to six months - vocal reactions (humming, babbling) appear.
3. From six months to 10 months of age - understanding of addressed statements begins to develop, active babbling is noted.
4. From 10 months to a year - the first words appear.

The appearance of alalia is noted already at the first stages, when some speech skills - humming, babbling - are formed with a delay or are absent at all. In addition to the lengthening of the terms of function formation, it is typical that the already passed speech stage is retained for a long time. [9]

The degree of speech impairment may vary. Based on this, three levels of such pathologies are distinguished:

• Level 1 of speech development in alalia is characterized by the absence of commonly used speech.
• Level 2 of speech development in alalia is the presence of the rudiments of commonly used speech. The baby has a certain stock of words, but it is very small, has a distorted sound-syllable structure and is characterized by agrammatism. Sounds are pronounced with defects.
• Level 3 is characterized by extended speech with elements of underdevelopment. The child pronounces easy words, and even builds phrases from them. But structurally complex words are pronounced with distortion, speech is full of agrammatisms and defects in the pronunciation of individual sounds.

The indicated levels of speech development in alalia do not correlate with age limits. Thus, a child even at the age of six can be at level 1.

Afferent and efferent alalia

Afferent motor alalia is associated with a disorder localized in the postcentral zone of the cerebral cortex (the lower parietal zone of the left hemisphere), which is responsible for kinesthetic evaluation and production of stimuli and sensations that come to the brain in the speech process, as well as for kinesthetic patterns of speech. If this department is affected, kinesthetic articulatory apraxia develops. It is difficult for the baby to find separate articulations, in speech there are substitutions of articulation-spore sounds. Difficulties appear and when reproducing, repeating a word or phrase. Fixing the correct articulation is difficult.

The appearance of efferent motor alalia is associated with damage to the premotor cerebral cortex (the posterior third of the inferior frontal gyrus - the so-called Broca's center). This area is usually responsible for sequencing and forming complex combinations of motor patterns. Patients with efferent motor alalia may have kinetic articulatory apraxia: the transition between coarticulations is disturbed, the child has difficulty incorporating into the movement, it is difficult for him to make a series of sequential movements. There is a distortion of the syllabic word structure, perseverations are observed.

Comparative analysis of afferent and efferent motor alalia in table

A variation of motor alalia	Cerebral cortex lesion area	Manifestation of the defect
Afferent (kinesthetic) alalia	Dark area near the postcentral gyrus (lower areas near the postcentral gyrus).	The main defect is a disorder of proprioceptive kinesthetic afferentation of the motor act.
Efferent (kinetic) alalia	Lower zones of the premotor department (automation of various mental functions is disturbed).	Disorder of the sequential temporal organization of motor acts as a result of a failure of dynamic praxis in the process of remembering and executing a motor pattern (motor jamming or falling out may be observed).

Such speech disorders in alalia are represented by apraxia - lesions of the cerebral cortex, causing failure of the ability to perform precise directed actions and movements.