SPEECH AND LANGUAGE IMPAIRMENT

Looking at the disability category from the perspective of three lenses

Disability has often been portrayed one dimensionally by the prevalent discourse throughout the ages. Today, I attempt look at a specific branch of disability through three different lenses and in the process demystify how fluent speech has always been held as the golden standard of intelligence in our society and what repercussions it may have on people who have speech and language impairments.

Close up of a silver corded microphone in a blurry backgound

MEDICAL LENS

Generally, speech is how we say sounds and words while language is the words we use to share ideas and get what we want.

According to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition: DSM-5, Communication Disorders are classified as follows:

  1. Language Disorders

This includes persistent difficulties in the acquisition and use of language across modalities (i.e., spoken, written etc.) including

  • Reduced vocabulary
  • Limited sentence structure
  • Impairments in discourse

2. Speech Sound Disorders

These disorders encompass persistent difficulty with speech sound production that interferes with speech intelligibility or prevents verbal communication of messages which includes

  • Omissions — fi’ instead of fish
  • Substitutions — wabbit instead of rabbit

3. Childhood Onset Fluency Disorder (Stuttering)

Stuttering is characterized by disturbances in the normal fluency and time patterning of speech. It may include one or more of the following:

  • Sound and syllable repetitions.
  • Sound prolongations of consonants as well as vowels.
  • Broken words
  • Audible or silent blocking
  • Circumlocutions
  • Words produced with an excess of physical tension.
  • Monosyllabic whole-word repetitions

4. Social (Pragmatic) Communication Disorder

This includes persistent difficulties in the social use of verbal and nonverbal communication as manifested by:

  • Deficits in using communication for social purposes.
  • Impairment of the ability to change communication to match context or the needs of the listener.
  • Difficulties following rules for conversation and storytelling.
  • Difficulties understanding what is not explicitly stated.

Characteristics which are similar to all of the above stated disorders are few but distinct. The deficits result in functional limitations in effective communication, social participation, social relationships, academic achievement, or occupational performance, individually or in combination. Secondly, the onset of the symptoms is in the early developmental period. Lastly, the symptoms are not attributable to another medical or neurological condition or any other disability.

Two facial profiles facing away from each other with empty speech bubbles issuing from their mouths

The diagnosis for these disorders follow a very systemic procedure. If a child fails to meet the speech and language milestones set by American Speech-Language-Hearing Association (ASHA), he or she might have a speech and language impairment. Parents are usually the first to suspect that a child might possess such an impairment. It is imperative to avoid misdiagnosis because speech and language impairments can often be mistaken for other conditions and vice versa.

Assessment is done by a professional who is knowledgeable about normal milestones e.g., a child psychologist, counselor, speech therapist or speech pathologist requires that special testing occur. With younger children, communication assessments may be conducted within the context of a play situation so as to help keep these children at ease. Older children may simply be presented with tests or be interviewed by an examiner knowledgeable about speech pathology.

Management of speech and language pathologies are centered on “treating the individual”. Intervention is usually in the form of speech and language therapy. The setting depends upon the age, type, and severity of the individual’s impairment. Services to an infant/toddler are delivered in a naturalistic environment — probably his/her home while services to a school-aged child might be delivered at an outpatient clinic, or even at his/her home school as part of a weekly program.

A Caucasian woman providing an African American girl with speech therapy by asking her to feel her vocal chords

Therapy sessions usually focus on a particular therapeutic activity, such as coordination and strengthening exercises of speech muscles or improving fluency through breathing techniques. Aids, such as mirrors, tape recorders, and tongue depressors may be utilized to help the children to become aware of their speech sounds and to work toward more natural speech production. Assistive technology may also be used which include electronic devices that may or may not provide some form of voice output. Gestures, body language, sign language, and communication boards may also be used to aid the child to communicate.


SOCIAL LENS

As compared to the medical model which places the problem within the person with disability and focuses all rehabilitative procedures on the individual, the social model takes a completely different stance. According to it, difficulties that a dysfluent person experiences in life are due to a process of disability separate to the impairment: the disability is due to the particular barriers the person faces rather than due to their dysfluent speech per se.

Drawing of an African American girl holding a slice of pizza and talking to Alexa

There can be physical barriers to different sounding speech e.g. not being able to be understood by computers in automated calls. Alexa and Siri are the future of personal assistance but this future has no place for people with speech impairments. This article eloquently dissects the topic.

Barriers can also be attitudinal — both the external barriers fueled by negative social attitudes to dysfluency and the self limitation of internalized oppression due to the person absorbing negative attitudes dominant in our society. Indeed, internal barriers are more difficult to break down and navigate that external ones.

As Katy Bailey in Stammering and the Social Model of Disability: Challenge and Opportunity says —

“However, the effects of our own internalised attitudes about dysfluency are often more significant; people who stammer themselves can be among those with the most negative attitudes towards dysfluency. Part of the internalised oppression is an increased sensitivity to our own impairment, to our dysfluency, that interrupts the ‘perfect’ version of speech we hold in our imagination. We can be the first to judge our speech harshly, often before a word or sound is formed.”

In the field of speech and language pathology, a number of alternative approaches are emerging and offering a welcome break from the traditional therapeutic model. People with communication impairments are increasingly being given a voice and a role in the definition of their lived experience and the evaluation of therapy services. Indeed, there are several disabled people with communication impairments who are becoming speech pathologists and therapists so that they can bring their unique experience to table. This has led to therapy to broaden and address the role that self-identity, society and social stigma play in making the processes of living with a communication impairment more challenging.

Along with a change the conventional approach, several alternatives to speech and language therapy are also emerging which include but not restricted to the following:

  • Self-disclosure and assertiveness
  • Peer support of self-help groups
  • Web chats and conferences through which experiences and stories can be shared
  • Cognitive reframing of mindfulness techniques
  • Cognitive behavior therapy to foster more positive and realistic thinking patterns and behaviors
  • Voluntary stammering

There are several advocacy groups which center around speech and language pathologies and stuttering in particular. Some of them are National Stuttering Association (NSA), SAY: The Stuttering Association for the Young and American Institute for Stuttering which recently spoke out against the problematic remarks made by Steve Harvey on his show relating to stuttering and its treatment and hence play a role in dispelling the assumptions people have about speech impairments.

Other advocacy movements across the globe include Stutter UAE, which aims at raising awareness and reducing stigma regarding stuttering and Did I Stutter?, a project which aims to create a space for community, art, and discussion where stutters and other speech dysfluencies can be rethought in affirming ways.

A cartoon skunk walking with a swagger with the words “Stuttering is Cool” written on top

Another amazing project coming out of Galway, Ireland is the Hear Me! Communication Awareness Training which is a training program for catering staff to learn tools and strategies to engage effectively with people who have communication difficulties.


AUTOBIOGRAPHICAL LENS

My disability surfaced when I was 5 and just started to go to school. Whether it was some traumatic psychological experience which caused the speech impediment was never found out or investigated. For the initial few years, my parents thought of it as just a “phase” which would eventually go away but when my stammer persisted, that is when my parents’ worry settled in. I consulted with numerous speech therapists, psychiatrists and psychologists — several times against my wishes I admit, just to find a “cure”. I have tried hypnosis and have taken anti anxiety prescription like Xanax and Prozac all to no avail.

My childhood was spent suspended in a constant pendulum motion, my feelings regarding my stammer swinging from embarrassment to anger to self pity and then to shame all over again. I would shy away from talking in public and pathetically cling to my circle of friends. Talking on the telephone, asking for directions, asking for help in a store or ordering something at a restaurant would be a “nightmare”. It is ironic how social awkwardness is supposed to be ‘cute and endearing’ in the time we are currently living in but unfortunately it isn’t how I or anyone else around me felt when I would be trying to navigate through a conversation and failing miserably.

The Frankfurt skyline through a lens which has inverted it

Even though my family and friends would try to enthuse confidence in me, I just couldn’t handle my disability. I felt “trapped” in my body. I felt I could be so many things and could do so many things but my stammer somehow held me back. I never felt comfortable in my own skin. I would always be daunted by the fear of what others would think about me due to my stammer. I would project my insecurities onto others and then a vicious cycle would begin. It didn’t help when people would actually not make an effort to make me comfortable, stare, laugh or just ask me to shut up and ask the person next to me what I was saying.

This is the reason, the concept of Disabled and Proud was very new to me until a short while ago. Because I felt utterly ashamed at not being able to even string a simple sentence together. I loathed my stutter and myself for having it. This feeling was further cemented when I faced discrimination in securing employment even though I am a qualified dentist.

It was pure luck, the support of a few good friends and my own need to change my life that I began to look into disability advocacy and disability rights about two years ago. This journey to self realization which helped me get rid of the internalized oppression I had been subjecting myself to for all these years. I confess I still have days where I struggle with acceptance of my own self but for the better part of my time I am glad to say that I am a stutterer and I am proud of it.

Point to be noted, this is no success story. There are so many barriers to be broken, opinions informed and people liberated from the shackles of ignorance that a constant perseverance is required.

At the end, I would like to share an article I wrote for one of the leading newpapers in Pakistan and my blog which compared to my stammer I’m not proud of because in retrospect I’m sure because of my ignorance it might be problematic in several ways — the name being the first and foremost — for which I apologize. But one is constantly in the process of making mistakes and learning from them and I am happy to be such a student who is learning something new each and every moment of my life.