How does speech therapy help with aphasia?
Aphasia is a disorder caused by damage to parts of the brain responsible for language. It typically occurs suddenly, often following a stroke or head injury, but it can also develop gradually as a result of a brain tumor or a progressive neurological disease. The disorder affects language expression and comprehension as well as reading and writing. Aphasia may coexist with speech disorders, such as dysarthria or apraxia of speech, which are also consequences of brain damage.
Prevalence and Common Causes of Aphasia
Aphasia is most commonly caused by a stroke. However, any alteration in the brain can lead to aphasia, including traumatic brain injury. Other causes may include brain infections, tumors, and other brain disorders that can worsen over time.
Most people who develop aphasia are middle-aged or older, but it can affect anyone, including young children. Approximately one million people in the United States live with aphasia, and nearly 180,000 Americans acquire it each year, according to the National Aphasia Association.
In Spain, over 350,000 people have aphasia and around 70% of those who suffer a stroke experience language impairments. Among these, 40% to 60% recover during the first year, while the remainder develop chronic aphasia.
Types of Aphasia
Global Aphasia
This is the most severe form of aphasia, where patients can produce few recognizable words and understand little or none of spoken language. Individuals with global aphasia cannot read or write. It is often observed immediately after a stroke and may improve quickly if the damage is not too extensive. However, if the brain damage is more significant, severe and lasting disability may occur.
Broca's Aphasia ("Non-Fluent Aphasia")
In this type of aphasia, speech production is minimal, often restricted to short utterances of fewer than four words. Vocabulary access is limited, and sound formation by individuals with Broca’s aphasia is usually laborious. The person may understand speech relatively well and be able to read, but writing abilities are limited. Broca’s aphasia is often called «non-fluent aphasia» due to the effortful quality of speech.
Conduction Aphasia
This form of aphasia is characterized by difficulty producing isolated words. It resembles Broca’s aphasia but is restricted to single-word production.
Wernicke's Aphasia ("Fluent Aphasia")
In this type of aphasia, the ability to grasp the meaning of spoken words is significantly impaired, while the ease of producing connected speech is less affected. For this reason, Wernicke’s aphasia is called «fluent aphasia.» However, the speech is far from normal. Sentences are often incoherent and interspersed with irrelevant words, sometimes to the point of jargon in severe cases. Reading and writing are usually severely impaired.
Anomic Aphasia
This term applies to individuals with a persistent inability to provide the words for things they wish to talk about, particularly meaningful nouns and verbs. As a result, their speech, while grammatically fluent and well-formed, is full of vague circumlocutions and expressions of frustration. They understand spoken language well and, in most cases, read adequately. Word-finding difficulty is as evident in writing as in speech.
Primary Progressive Aphasia (PPA)
Primary progressive aphasia is a neurological syndrome in which language capabilities gradually and progressively deteriorate. Unlike other forms of aphasia caused by strokes or brain injuries, PPA is caused by neurodegenerative diseases, such as Alzheimer’s disease or frontotemporal lobar degeneration. PPA results from the degeneration of brain tissue critical for speech and language. Although the initial symptoms involve speech and language difficulties, other problems associated with the underlying disease, such as memory loss, often appear later.
Transcortical Motor Aphasia
This type of aphasia is characterized by difficulties with speech initiation, spontaneity, and organization. Although language production and comprehension are preserved, the individual struggles to initiate speech and to structure ideas coherently when communicating.
Assessment and Diagnosis
Aphasia is typically first identified by the physician treating the individual for their brain injury. Most individuals undergo an MRI or CT scan to confirm the presence of brain damage and determine its precise location. The physician usually evaluates the person’s ability to understand and produce language by assessing their ability to follow commands, answer questions, name objects, and engage in conversation.
If aphasia is suspected, the patient is often referred to a speech and language therapist, who conducts a comprehensive evaluation of the person’s communication abilities. This evaluation includes assessing the individual’s capacity to speak, express ideas, engage in social conversation, comprehend language, read, and write.
Speech and language therapists may use static assessments (designed to describe current functioning levels across relevant domains) and/or dynamic assessments (a continuous process involving hypothesis testing to identify potentially effective intervention and support strategies).
Evaluation protocols may include standardized and non-standardized tools and data sources. When assessing individuals with aphasia, speech and language therapists consider various factors that may impact intervention and outcomes, including:
- Languages and Dialects Used: Ensuring the assessment is culturally and linguistically appropriate.
- Coexisting Speech Motor Disorders: Such as dysarthria or apraxia of speech.
- Oral and Limb Apraxia: Which may interfere with gestural communication and other skills.
- Hearing Ability: To rule out hearing-related difficulties.
- Cognitive Impairment: That may affect memory, attention, or reasoning.
- Visual Deficits: Including visual agnosia, visual field cuts, or reduced visual acuity.
- Upper Limb Hemiparesis: Which may affect writing, pointing, and gesturing.
- Chronic Pain: Related to pre-existing or recent conditions, which could impact participation.
- Mental Health Disorders: Such as anxiety or depression, which may influence motivation and performance.
- Endurance and Fatigue: Potential reasons to divide testing into shorter sessions.
The Role of the Speech and Language Therapist in Aphasia Intervention
Speech and language therapy is essential in helping individuals with aphasia regain their language abilities. This specialized therapy aims to enhance communication skills by focusing on various linguistic processes, such as speech production, comprehension, and expression. Recovering speech and language abilities allows patients to express themselves, participate in conversations, and convey their thoughts and emotions. Speech and language therapists work closely with patients to achieve these goals.
Aphasia can impact a person’s confidence and self-esteem. During speech therapy sessions, patients practice and develop their communication skills in a safe environment. As they progress, their self-confidence often improves, enhancing their overall quality of life. Communication skills are vital for everyday life, and speech therapy helps individuals with aphasia perform daily tasks such as ordering food at a restaurant, making phone calls, or participating in family gatherings, thereby restoring their independence.
Aphasia can strain relationships by increasing frustration and misunderstandings. Speech therapy benefits both patients and their loved ones by teaching friends and family how to better understand and interact with them. This fosters stronger, more fulfilling relationships. Feelings of loneliness, sadness, and worry are common side effects of aphasia. Beyond language development, speech therapy also provides indirect emotional support.
Individualization is a key component of speech therapy. Each person with aphasia has unique needs and goals, so therapists tailor strategies to meet these specific requirements. This personalized approach ensures that therapy is more effective and beneficial for the individual. Patients with aphasia who receive speech therapy acquire practical skills, improving their ability to communicate their needs and preferences more effectively.
Therapeutic Approaches and Treatments for Aphasia
Treatment approaches for aphasia target various aspects of language and communication. Some of the most common strategies employed by speech and language therapists are outlined below:
- Constraint-Induced Language Therapy (CILT): This approach encourages verbal communication by limiting non-verbal strategies, thereby promoting the use of spoken language.
- Semantic Feature Analysis (SFA): Focuses on improving word retrieval by emphasizing semantic properties such as category, usage, or characteristics of words.
- Phonological Component Analysis (PCA): Targets the phonological aspects of words, helping individuals retrieve them through sounds, syllables, and rhymes.
- Verb Network Strengthening Treatment (VNeST): Concentrates on verbs and their associated nouns to enhance sentence formulation and broader linguistic structures.
- Melodic Intonation Therapy (MIT): Uses musical elements like rhythm and melody to improve verbal expression, particularly for individuals with non-fluent aphasia.
- Response Elaboration Training (RET): Encourages more elaborate speech by expanding the patient's spontaneous responses, fostering more detailed and flexible communication.
These approaches are tailored by the speech and language therapist to suit each patient’s specific strengths and needs, ensuring a personalized and effective therapy plan.
Importance of Family and Social Participation
A crucial component of aphasia treatment is family involvement, as it helps loved ones learn the best ways to communicate with the person affected by aphasia. Family members are encouraged to:
- Participate in therapy sessions whenever possible.
- Simplify language by using short, simple phrases when comprehension is impaired.
- Repeat words or write down key phrases to clarify meaning when necessary.
- Maintain natural, age-appropriate conversations.
- Include the person with aphasia in discussions.
- Ask for and value the person’s opinion, especially on family-related matters.
- Encourage any form of communication, whether verbal, gestural, pointing, or drawing.
- Avoid correcting the person’s speech.
- Allow sufficient time for the person to speak.
In conclusion, the goal of speech and language therapy for individuals with aphasia is to help them regain their speech and language abilities as much as possible (reducing impairment), support them in communicating as effectively as they can (enhancing activity and participation), identify alternative communication methods (using compensatory strategies or aids), and provide information about aphasia to patients and their families.
The approach to therapy will vary based on individual circumstances. Some individuals may benefit from intensive speech therapy, while others might be better suited to shorter, less intensive sessions. The appropriate path of treatment is determined based on a thorough evaluation. Progress largely depends on the severity of each person’s condition and the intervention provided.
Division of Speech Therapy
Speech Therapist
Children, adolescents and adults
Languages: English, Romanian and Spanish
Autism disorder and speech difficulties
Autism spectrum disorder (ASD) is a complex developmental condition involving persistent challenges with social communication, restricted interests, and repetitive behavior. While autism is considered a lifelong disorder, the degree of impairment in functioning because of these challenges varies between individuals with autism. Communication is sending and receiving messages through verbal or nonverbal means, including speech or oral communication; writing and graphical representations (such as infographics, maps, and charts); and signs, signals, and behavior. More simply, communication is said to be «the creation and exchange of meaning.»
The act of communicating has different functions:
– Instrumental. Used to ask for something.
– Regulatory. Used to give directions and direct others.
– Interactional. Accustomed to interacting and socially conversing with others.
– Personal. Used to express a state of mind or feelings about something.
– Heuristic. Used to find out information.
– Imaginative. Used to tell stories and role play.
– Informative. Used to provide an organized description of an event or object.
These communicative functions appear early in babies, present long before the first words appear. For example, a 9-month-old baby who points with his finger has the purpose of sharing an interest by looking at the accompanying adult. However, the development of this capacity for interaction and communication is affected from the early stages of people’s lives with ASD. It, therefore, becomes one of the main elements of the intervention. To understand it in-depth, it is essential to be clear about a series of concepts. For example, not speaking does not imply not being able to communicate.
Formal language development is of little use if it is not used functionally and appropriately. It is essential to remember that each person will have different needs and require individualized support that each professional will have to assess and establish. To define communication and language characteristics in people with ASD, it is necessary to remember that the concept of «Autism Spectrum» implies that similar features will not be found in all people who present these conditions.
Therefore the difficulties in this area will manifest in a variety of ways. Regarding the communicative functions, we can find different affections:
– Lack of communication and instrumental behavior with people.
– Instrumental behaviors with people to achieve changes in the physical world, without other communication guidelines.
– Communicative behaviors to ask (change the physical world) but not share an experience or change the mental world.
– Communicative behaviors of declaring, commenting, etc., with few «subjective qualifications of experience» and statements about the inner world.
– There is no qualitative disorder of communicative functions.
About expressive language, affectations can also vary:
- Total or functional mutism. There may be verbalizations that are not adequately linguistic.
- Speech is composed of single words or echolalias. There is no creation of phrases and sentences.
- Sentence language. Some sentences are not echolalic, but they do not configure discourse or conversation.
- Speech and conversation, with limitations of flexible adaptation in conversations and selection of relevant topics. There are often prosodic anomalies.
- There is no qualitative expressive language disorder.
Finally, regarding receptive language, the characteristics vary:
- ”Central deafness.” Tendency to ignore language. There is no response to orders, calls, or directions.
- Association of verbal statements with their behaviors, without indications that the words are assimilated to a code.
- Comprehension (literal and not very flexible) of sentences, with some structural analysis. The speech is not understood.
- Speech and conversation are understood, but the literal meaning is distinguished from the intended purpose with incredible difficulty.
- There is no qualitative disorder of comprehension abilities. The most crucial alteration will be related to pragmatic aspects: the use made of the communication.
Therefore, within the spectrum, we can sometimes find people who do not even make basic requests. On other occasions, we can find people who cannot use appropriate courtesy formulas with fluent oral language development. Another essential aspect is the communicative modality. A percentage of people with ASD do not develop oral language or do so partially, making it necessary to provide tools that the person can use to communicate regardless of the work being done at the level of vocal production. Alternative Communication Systems are particularly relevant in this area. They are forms of expression other than spoken language (sign language, pictograms, digital systems, etc.), aiming to complement or replace oral language.
The person with ASD, regardless of the characteristics they show and how differentiated they may be in other areas, will always present needs within the field of communication and language. The prognosis and evolution of people with ASD are directly related to the type of care received, especially when it starts. A person who receives individualized and specialized treatment based on scientific evidence from a very early age will present more possibilities for development and a better quality of life. The first step to start intervening is to assess the characteristics and needs of the person.
As a general rule, in the intervention in autism, the achievement and generalization of the objectives related to the function are prioritized over those related to the form; that is, learning to make a functional request that provides the person with the necessary tool to get what he wants is more important than insisting on making the request verbally and with the correct pronunciation.
When the person’s communicative needs are basic (learning basic behaviors of request or rejection), the most appropriate approach is to offer a response through Alternative Communication Systems. It is essential to choose the most suitable for each person, and this selection will be extraordinary influence by the development of the capacity for abstraction. Cognitive development, in this case, is essential and significant because the different require Alternative Communication Systems have different levels of representation.
On the other hand, the need changes when the person can communicate fundamentally. The focus is no longer on implementing a tool that allows them to share, but on developing an increase in their communicative repertoire, both in function and in form (through the gradual complexity of, for example, morphosyntactic structures or the increase in vocabulary).
The more complex the communication skills that the person presents, the needs arising in this area will have an associated component of a more social nature, especially in cases where an elaborate verbal language is shown, and support is required for its use in complex pragmatic functions, such as conversational or in more social contexts. All existing intervention models provide resources and strategies to intervene in communication and language. It is common to use elements from different programs to achieve a more complete or personalized intervention.
Multiple professional teams support and allow progress in achieving maximum development. Any intervention must be shared and coordinated between the parents, the school, and the therapist responsible for the child. Parents and professionals must know the specific needs of their children and apply the appropriate strategies to each particular child. Both in the diagnosis and the design of the intervention, the team must be multidisciplinary, made up of speech therapists, occupational therapists, psychologists, social educators, caregivers, and teachers, and have the opportunity to collaborate with other specialties if considered appropriate.
Regarding the general principles of intervention, the following stand out:
- Start the intervention the sooner, the better. It is essential to consult with a speech therapist.
- Spontaneity, the search for information and generalization to the most significant number of contexts, is prioritized by overtraining to respond to initiatives or questions from the adult.
- It is essential to be guided by the child’s interest, always considering their emotional wellbeing.
- Reinforce communicative attempts, even if they are very slight, to reinforce their motivation or communication.
- Reinforce efforts with “rewards” directly related to the task.
- Promote natural, genuine, and functional work environments.
- Establish routines and structured situations, and then make them more flexible.
- Select functional objectives necessary for the person, choosing the vocabulary they need.
- Teach self-initiated communicative behaviors that do not require support or cues from an adult. – Start intervention without considering teaching prerequisites (attention skills, gaze control, etc.).
- Carry out teaching in natural contexts: routines of daily life, significant planned activities, or unexpected situations.
- Involve the family in the intervention process.
- Promote the teaching of production objectives versus comprehension, especially in the initial phase, to encourage motivation towards communication.
- Take advantage of strengths, such as particular interests. Try to turn weakness into a strength. At a general level, it is essential to rely on their strengths and, therefore:
– Present information visually since it remains in time and space, making the invisible tangible.
– Eliminate distracting stimuli to focus attention on relevant aspects.
– Establish routines to learn and develop different skills that will allow greater independence of the person, constantly introducing a component of flexibility.
– Employ structured learning. The structure is an excellent ally in the intervention with ASD.
– Promote autonomy by establishing a good support base that can be gradually withdrawn.
– Use positive reinforcement, taking advantage of the person’s interests by implementing reinforcement programs.
In addition to these methodological strategies, it is necessary to always take into account two aspects that will make the interventions successful: proposing practical learning, which has a real utility for the person in the vital moment in which he finds himself, and promoting generalization so that learned skills can be developed in different contexts.
Finally, it is essential to emphasize that the responsibility for success should not be placed on the interlocutor with the most significant difficulties. As mentioned above, there is an essential section within the intervention programs that concern parents, educators, therapists, speech therapists, etc., and it is related to facilitating communication by attributing communicative intention, where it is not seen so clearly or when it cannot be expressed in the «conventional» way. It is mainly in the hands of therapists and parents to facilitate fluency in exchanging these communicative messages.
My kid has ASD and doesn't speak. What can I do to help him improve?
Question:
«Hello, my name is Inmaculada, my 4-year-old son has Autism Spectrum Disorder and still does not speak, he communicates very little with us. What can we do to help him improve? Thank you.»
Answer:
Hi Inmaculada, thanks for asking. As we all know, communication and language are one of the main affected areas by Autism Spectrum Disorder. In the first place, it would be necessary to carry out an evaluation to obtain an objective and realistic assessment of the communicative characteristics of the child. The most basic need that can be found is to have a communication tool.
A small child, a person who has not been previously intervened and does not handle any tools, or someone who has confused the tools they have and is not capable of making functional use of them, will present this first need that will be the basis on which to build more complex skills.
Children will always try to develop oral language as a vehicle of communication. As a general rule, functional communication will always be prioritized over formal communication. It is essential that the child understands the importance of the communicative act and therefore it will be reinforced and attended to at all times. Bearing in mind that you, the family, are the most stable element of the child and with whom he spends most of his time, it is essential that you have strategies that promote communication and social relationships.
We can highlight the following strategies:
- Always face to face.
- Adjust to the level of the child, that is, if their understanding is reduced to one word or to simple commands, the language with which we should address them should also be simple, with sentences of 1 or 2 words at most.
- Use high-impact words, that is, those that have the most meaning, coinciding with their interests. For example, if the child is playing with the ball, we can say the word «ball» instead of longer phrases like «that’s great, how the ball jumps».
- Be consistent with the language used. That is, always use the same word for objects or actions. For example, every time the child plays with the bubbles, we say the word «bubbles», avoiding using other words such as «bubbles» so as not to create confusion.
- Use short and informative sentences that reflect what is happening at a given moment.
- Model language whenever the child communicates nonverbally. That is, if the child gives us a bag of chips to open it, we can say «help» or «open», giving voice to their communication.
- Avoid speaking quickly, quickly, or asking many questions.
- Avoid anticipating the child’s communication or emissions. Be patient and wait as long as it takes.
- Create communications opportunities throughout everyday life situations. Create game routines that allow the child to initiate communication and make it as spontaneous and natural as possible.
- Avoid commands and the use of conditional sentences, replacing them with declarative sentences. For example: “we are going to open the door”, “we are going to eat”.
- Avoid forcing repetition. Communication should be as natural and spontaneous as possible. Giving commands such as “say I want a car” inhibits functional communication, and even if the child repeats it, it would not have a communicative function.
To promote the most basic function of communication, the first in which we put the focus of attention, that of request and rejection, it is recommended:
- Put in sight, but out of reach, containers with food or objects of interest. Transparent shelves and cans are two very useful elements in this case.
- Play interactive games and use children’s songs. These little routines usually contain simple, repetitive language that includes an element of anticipation before the climax. Careful use of time pauses, and rhythm in this type of game help create opportunities to develop communication in playful situations.
- Finally, it should be noted that the key to stimulation is to always follow the interest and motivation of the child and create situations and opportunities for communication in all of the child’s vital contexts and especially in situations of their daily life, bearing in mind that any time can be conducive to learning.
We hope this has been helpful, and remember that these are general parameters. Ideally, a speech therapist should attend to your child’s case and help you.