89 Phonological Disorder (315.39)

DSM-IV-TR criteria

• A. Failure to use developmentally expected speech sounds that are appropriate for age and dialect (e.g., errors in sound production, use, representation, or organization such as, but not limited to, substitutions of one sound for another [use of /t/ for target /k/ sound] or omissions of sounds such as final consonants).
• B. The difficulties in speech sound production interfere with academic or occupational achievement or with social communication.
• C. If Mental Retardation, a speech-motor or sensory deficit, or environmental deprivation is present, the speech difficulties are in excess of those usually associated with these problems.

Coding Note: If a speech-motor or sensory deficit or a neurological condition is present, code the condition on Axis III.

Associated features

• Knowing and learning the various aspects of speech rather than being unable to physically pronounce words are the signs of a phonological disorder. For example, a child with a phonological disorder may not know a word whereas a child with an articulation disorder knows the word but is unable to get their articulators to shape the word so that they can say it.
• According to the American Speech-Language-Hearing Association, signs of a phonological disorder “involve patterns of sound errors. For example, substituting all sounds made in the back of the mouth like “k” and “g” for those in the front of the mouth like “t” and “d” (e.g., saying “tup” for “cup” or “das” for “gas”).” (http://www.asha.org)
• Young children expectantly leave out sounds when they are learning to speak, especially when pronouncing words that begin with two consonants, such as the word spoon, but as the child gets older, these problems should dissipate. If they do not, the child could be showing signs of a phonological process disorder. Person’s with phonological disorders are presumed to experience difficulty acquiring the rules that underlie speech. (Bleile, 2003)

Child vs. adult presentation

• Phonological disorder is most commonly a childhood disorder. If a child’s speech is not easily understood by non-family members by the age of 4, a phonological disorder may be present. Most will grow out of the disorder by third grade, but spontaneous recovery becomes less likely after the fourth grade (around age 8).
• In severe cases, the disorder may be unremitting through adulthood. Children who misarticulate only a few phonemes are more prone to a spontaneous recovery. If articulation problems are still present after the age of 5, children are at higher risk for auditory problems.

Gender and cultural differences in presentation

• Taking dialect features into consideration is important so that the patient is not misdiagnosed. Bilingual phonology is a field that there is not enough knowledge in.
• Currently bilingual children are assessed using monolingual standards. According to the MIT encyclopedia of communication disorders,
• Nearly two-thirds of Children under the age of 18 who are diagnosed with speech-language disorders are male. Communication disorders are twice as likely to be diagnosed in males age 45 and younger than in females. African Americans younger than 45 and of the same age are one-third as likely to be diagnosed as Caucasians. (Bleile, 2003)

Epidemiology

Phonological and Articulation disorders compose nearly 32% of the communication disorders. Six million children under the age of 18 are estimated to have a language disorder. According to Arsano, et al. (2008), approximately 20% of pre-school aged children and 6% of school aged children are affected by phonological disorder. The prevalence rates decrease as age increases.

Etiology

• According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), “Phonological Disorder includes phonological production (i.e., articulation) errors that involve the failure to form speech sounds correctly and cognitively based forms of phonological problems that involve a deficit in linguistic categorization of speech sounds (e.g., a difficulty in sorting out which sounds in the language make a difference in meaning).” (American Psychiatric Association, 2000).
• Some professionals prefer to distinguish between language knowledge (phonological) and speech-motor control (articulation). Phonological disorder can develop due an environment where the child is abused or neglected, placed in an environment with a bad teacher, or long term hospitalization. Direct physical damage to the brain or body can also be responsible for the development of the disorder.
• A child who presents with another disorder, such as attention deficit disorder (ADD), can suffer indirect physical damage due to the fact that they may not be able to concentrate long enough to acquire complex communication skills. While phonological disorder is usually an isolated problem, occasionally it occurs simultaneously with another medical condition such as cognitive limitations, neurological conditions, hearing impairments, orofacial anomalies, structural deficits of the oral peripheral speech mechanism, psychosocial problems, or respiratory problems.

Empirically supported treatments

• Children who present with moderate to severe disorders are usually recommended for treatment. The two most popular forms of treatment are the phonological approach and the traditional approach. According to Kaplan & Saddock, the phonological approach is for children with extensive patterns of multiple speech sound errors where treatment involves practice of specific sounds and is then extended into using the words in meaningful words and sentences.
• The traditional approach involves speech therapy by a speech-language pathologist (SLP). The American Speech-Language-Hearing Association defines speech-language pathologists as professionals who identify, assess, and provide treatment for individuals with speech, language, and swallowing problems. (http://www.asha.org ) They are trained individuals who not only work with the individual experiencing phonological problems, but they also work with the family, teachers, and other professionals involved in the process of correction.
• According to the US Department of Education Institute of Education Sciences, “phonological awareness training is a general practice aimed at enhancing young children’s phonological awareness abilities. It can involve various training activities that focus on teaching children to identify, detect, delete, segment, or blend segments of spoken words (i.e., words, syllables, onsets and rimes, phonemes) or that focus on teaching children to detect, identify, or produce rhyme or alliteration.” (http://www.ed.gov)

Children with phonological disorder believe they are articulating the words they attempt to say although they are not. They often become frustrated when they are told they are not speaking correctly.