Dysarthria in children and young people


The Dysarthrias


'Dysarthria' or 'the dysarthrias' are the terms used to denote speech impairment due to neurological damage, or to conditions that affect the muscles involved in speaking.

There are several types of dysarthrias that can occur in children and young people. They are Spastic dysarthria, Flaccid dysarthria, Ataxic dysarthria, Hyperkinetic dysarthria and Mixed dysarthria. An additional type, Hypokinetic dysarthria, is mainly seen in Parkinson’s disease in adults.

The Mayo Clinic provides information about the dysarthrais in adults.

The dysarthrias in children and young people have many different causes, including cerbral palsy, neonatal stroke and traumatic brain injury. In affected individuals the speech mechanism, including the muscles of respiration, may be paralysed, weak or poorly co-ordinated. The dysarthrias can affect all motor speech processes: breathing, producing sounds in the larynx, articulation, resonance, and the 'prosody' or rhythm of speech.

 

 


Characteristics


Commonly observed characteristics of the dysarthrias in children and young people are:

  • Slowed speech
  • Effortful speech due to breathing coordination difficulties
  • Impresise articulation
  • Slurred speech
  • Excessively quiet or loud voice, or a voice that varies erratically between the two
  • Difficulties regulating the pitch of the voice
  • Difficulties using appropriate intonation patterns to convey meaning
  • Some combination of hoarse voice quality, hypernasal voice quality or breathy voice quality

The dysarthrias in children (MSD-DYS) may co-occur with childhood apraxia of speech (CAS) (MSD-AOS).



Examining for dysarthria


The speech-language pathologist / speech and language therapist assesses the child's or young person's speech (in the speech assessment), observes the child eating and drinking (in the feeding assessment), and performs a structural/functional examination.


Structural/functional examination


Note that the following procedures, described by Skinder-Meredith (2009), are for assessment / differential diagnosis purposes and are not suggestions for intervention or "exercises" to improve speech.

Respiratory function

Use a static blowing task to evaluate the adequacy of respiratory support. In this procedure the client blows bubbles in a cup of water with a straw placed 10cm below the surface.

If bubbles are produced, theclient can generate enough subglottal pressure for speech (Hixon, Hawley & Wilson, 1982). For clients with Velo-pharyngeal incufficiency (VPI), occlude the nares.

Sustained phonation

Determine the client's ability to imitate steady phonation for five seconds with normal voice (noting vocal loudness).

Velopharyngeal function and resonance

Use a 45cm ‘listening tube’ (aquarium tubing) or straw. Put one end near the client’s nares and the other to your ear. Have the child repeat utterances with high pressure oral sounds (‘sixty-six’, ‘Buy Bobby a puppy’), and with nasal consonants (‘ninety-nine’; ‘Mummy makes yummy meals’). If nasal emission is present, the examiner will feel the air and if there is hypernasality oral sounds will be amplified similarly to nasal sounds.

Comparison of resonance with nares occluded and open

Pinch and release the nares while the client says /pa/. Resonance should be the same in both conditions. If hypernasality occurs, structurally-based or neurologically-based VPI warrants investigation.

Soft palate movement

When producing /a a a/ quickly and loudly, the velar movements should be observed to be forceful and quick.

Laryngeal function

Have the client cough and listen for indications of adequate vocal fold adduction. Eliciting even, sustained phonation allows observations of voice quality. Breathiness may signal a flaccid dysarthria; strained, strangled quality may signal a spastic dysarthria.

Diadochokinesis (DDK)

Compare production rates of /pa/, /ta/ and /ka/ sequences, and /pataka/ to developmental norms. Norms are provided by Fletcher (1972) for ages 6-13; Yaruss & Logan (2002) for boys 3-7; and Williams & Stackhouse (1998) for ages 3-5. In DDK testing note syllable sequencing, rhythm, voicing errors, and coordination of respiration, phonation, articulation, and above all, any performance change between duplicated syllables (/papa/) and sequencing a variety of syllables of (/pataka/).

Cranial Nerve Examination

The function of cranial nerves V (jaw), VII (face and lips), IX and X (pharynx and larynx) is addressed by default during DDK, phonatory, and resonance tasks. In addition, cranial nerves for speech can be quickly assessed by observing symmetry of movement, strength, range of motion, and coordination while doing the following:

Cranial Nerve V

Observe jaw opening, jaw closing and side-to-side movements of the jaw. Palpate the masseter and have the child bite down, feeling for (appropriate) bulging as the muscle contracts.

Cranial Nerve VII

Observe the client smiling, eating, laughing and puckering-and-smiling. Test resistance  of the four quadrants of the lips, with either your finger or a tongue depressor, while the child or young person keeps his or her lips closed tightly.

Cranial Nerve XII

Check tongue protrusion, retraction, lateral movement, and elevation. Check strength  by pushing against the tongue with a tongue depressor.


Management of dysarthria


SLP/SLT treatment for dysarthria may involve specific activities, to improve speech intelligibility and voice (in terms of pitch, quality or loudness) while helping the child or young person, if necessary, to:

  • Look at the person they are talking with
  • Take a breath before speaking
  • Slow down
  • Speak in short utterances, pausing deliberately between utterances

The SLP/SLT may work closely with family members, school personnel and others to help make communication easier for the child or young person, using strategies like:

  • Giving feedback when parts of utterances are unclear and providing feedback for communicative success;
  • Asking the individual with dysarthra to show their conversational partner what they want (when words are unintelligible);
  • Stopping and allowing time to listen attentively to the person with a dysarthria.

If a individual's speech is very impaired, the SLP/SLT may be able to help by teaching the use of an alternative communication system. Such systems can be high tech or low tech, ranging from gestures and signs to picture symbols, to voice output devices, to writing or typing to communicate.


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