Speech and Hearing Therapy ~

Reiko Sakata, MA Robert Sakata, PhD

INTRODUCTION Speech and language are the means by which we

communicate ideas, thoughts, beliefs and feelings to ourselves as well as to others. Anything which significantly interferes with or prevents this process from occurring has the potential of seriously jeopardiz- ing an individual’s emotional, social, educational, and economic adjustment - the underpinnings of positive mental health. Positive mental health must take into account the total individual interacting with his or her environment. The public school is a unique ecosystem in which the speech and hearing therapist attempts to foster child growth and development through the provision of services basic to awareness of self and others, management of personal and social interactions, and development of strategies for coping with the handicap.

REVIEW OF LITERATURE A review of the literature in the areas of speech and

language indicates that few if any studies specifically addressed the relationship between positive mental health attributes and communication disorders among school-age children. Much of the literature contains the under-lying implication that improved communication leads to positive mental health.

Bryngelson’, as early as 1927, indicated an awareness that speech disorders had emotional implications - hurt feelings, social stigma, and social discrimination. Travis and Sutherland indicate that communication is the major process that affects behavior change.

Studies of speech-defective individuals suggest that (1) speech defects may negatively affect the listener’s perceptions and judgments of speech-defective individ- uals along several dimensions, and (2) there may be a relationship between speech defects and self-concept. Perrin utilized a sociogram with elementary school children and found that a large percentage of speech- defective children (21.6%) were rated as social isolates.

534 THE JOURNAL OF SCHOOL HEALTH

In a study conducted by Silverman, listeners rated the lisping speaker more negatively on a 49-item rating scale than the speaker who correctly articulated /s/ sounds. Mowrer and coworkers 5 found that lisping negatively influenced the judgment of listeners when they were asked to rate speakers with regard to speaking ability, intelligence, education, masculinity and social appeal. Querry and Wolf 6 and Barrett and Hoops found that children with speech defects scored significantly lower on self-concept measures than their normally-speaking classmates. While studies of stuttering children have fail- ed to establish that they are severely maladjusted, one study 8 suggested that stutterers display greater anxiety in interpersonal relationships, and that they tend to be hypersensitive and shy.

Language and language disorders have been studied extensively in this decade. The importance of language to reading and to all areas of academic achievement is rapidly being established. A language-delayed or disordered child generally lacks the skills needed to learn to read. A heavy penalty is imposed by parents, teachers and peers upon the child who does not successfully acquire reading skills. Successful academic progress depends upon the acquisition of language and reading skills. A child who fails to develop these skills will undoubtedly experience difficulty throughout the school years and on into adulthood. This contention is supported by Hall and Tomblin, who, in a follow-up study of language-impaired (LI) and articulation- impaired (AI) subjects, found that the LI group showed a lower level of academic achievement in all subjects - especially reading - than the A1 group. Additionally, 50% of the LI group were judged by their parents to continue to demonstrate a communication problem; and fewer language-impaired individuals than AI individuals obtained higher educations. The results of this study suggest that language impairment limits academic achievement, not only in childhood, but also in adulthood.

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IDENTIFICATION Identification of individuals needing remediation is

generally accomplished through annual and/or periodic screening of selected grades, classes, and individuals, and by teacher referral. Included in the screening, along with tests for articulation and language, should be a test of hearing acuity. An audiometric sweep-screen of hearing is an important part of the Hearing Conserva- tion Program that should be a part of every school’s speech and hearing therapy program. Good vision and good hearing are necessary requisites to learning; hearing seems to be most important. According to the 1969 report of the subcommittee on Human Communi- cation and its Disorders to the National Institute of Neurological Diseases and Stroke, approximately 250,000 children of school age have hearing losses that are severe enough to impair their communicative ability and social efficiency. Since hearing is the major modality through which children learn the language of their culture, it is of utmost importance to determine that a child has normal hearing acuity. According to Moores, * I “The ease with which a child acquires language varies inversely with the severity of the hearing loss.” A chronic or intermittent hearing loss of sufficient severity may result in social consequences which cause the afflicted child to withdraw from contact with peers and others. The speech and hearing therapist can assist hearing impaired children accept the disability and to minimize its potentially-impairing influences by serving as a consultant to the classroom teacher, by providing direct therapy to correct an associated speech defect, or to instruct in auditory training and/or lip reading.

In general, speech services have been concentrated at the elementary school level due to a traditional emphasis on early diagnosis and treatment. One advantage of early intervention is a decreased possibility of the development of psychological or emotional problems related to the speech impairment. Some children become frustrated and may react negatively to frequent requests to repeat what they said. Being teased by other children because they “talk funny,’’ and being admonished by adults to “speak more slowly or more carefully” may also have a negative effect on the speech-impaired child. The result may be a child who feels that communication with others is. ‘just not worth the effort,” and such an attitude may possibly translate itself into lack of participation in the classroom.

THERAPY The purpose of therapy is to improve communication

of the child with others and most importantly, to make children more aware of themselves. Children identified through screening as having a communication impair- ment are then considered for therapy. A priority system

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must be established as generally there are more children requiring service than can be accommodated. The most important consideration has been the severity of the problem, but the degree of handicap this presents for the child should be another important consideration. There are some children for whom a slight lisp or other minor speech deviation represents a significant problem. Other children who may have more severe speech problems according to testing results, may in fact be quite satisfied with their speech.

Children are seen for therapy individually or in groups. It is imperative that the speech and hearing therapist get to know each child in the caseload, his or her interests and feelings about the speech problem, what motives that child, likes and dislikes, typical ways of responding and interacting. These are clues to optimize and enhance the therapy experience. Since most children are seen in groups, it is important for the therapist to have knowledge of group dynamics in order to enhance interaction among the participants. Having one’s speech-impaired peers lend support and encour- agement can be very meaningful and motivating.

Because of the severity of most language problems, the traditional method of scheduling children for group therapy two or three times per week for a given period of time (ie, one-half hour) has been found to be inadequate. Since this problem responds more favorably to full-time attention, remediation is best accomplished in a self-contained language classroom with a speech and hearing therapist as the teacher. Aides should be utilized to assist in the classroom; but the curriculum, which is heavily language-oriented, is planned by the language specialist. These classes are usually limited to small groups of children who remain in this self-con- tained classroom until their language skills have developed to the point that they can be mainstreamed into their regular classrooms. These programs have been found to be very successful in remediating language problems of children with normal intelligence.

PREVENTION Prevention of speech and language problems in the

schools has traditionally been thought of in terms of speech improvement programs. These programs are usually conducted in the classroom by the speech and hearing therapist and consist of systematic instruction in oral communication. The major purpose of these programs is to develop abilities in articulation, voice, and language that will enable the children to communicate effectively with their teachers and peers. Studies l29l3 of the effects of speech improvement programs have indicated improvement in articulation and reading skills, although the degree of i-mprovement in articulation was not as great as that which resulted from direct speech therapy.

THE JOURNAL OF SCHOOL HEALTH 535

Another approach to prevention is through preschool screening. Early identification of children at risk for speech, hearing and/or language problems, or who already demonstrate such problems, may be ac- complished in this manner. Many school systems conduct screening programs for pre-kindergarten children. Parent-training programs emphasizing ways to stimulate speech and language development have been found to be invaluable for those children who are too young for direct therapy. The Joint County School System of Cedar Rapids, IA has developed a compre- hensive program of preschool communication services which might serve as a model to other school systems. l4 In the past, problems of implementing these services have been related to administrative and financial support, time allocation and transportation. However, with the passage of Public Law 94-142, the Education for All Handicapped Children Act of 1975, adequate funding should hopefully be available in the future since this bill mandates that services be provided to handi- capped individuals from three to eighteen years of age.

FUTURE DIRECTIONS Considerable progress has been made in the delivery

of speech, hearing and language services in the public schools. In the past, the tendency in terms of training and practice has been to treat only the speech disorder using sensory-motor techniques rather than to treat the child. A recent trend is to treat the whole child in the context of his environment.

Travis 15 and MangeI6 , in their discussions about the therapist as counselor, emphasize the need for therapists to actively participate in the emotional adjustment of the child. There appears to be no reason for the speech and hearing therapist to resist dealing with emotional adjustment problems related to the speech or language dysfunction. A close supportive relationship with the child could reduce the trauma of being singled out and then subjected to therapy. Minimally, the speech and hearing therapist should be prepared and trained to recognize emotional reactions to therapy for a dis- ability.

The constant emphasis upon the sensory-motor aspects of speech and language disorders results in the overlooking of the concomitant psychosocial needs of the child. Silberman l 7 indicates that the impact of most therapy methods has not been adequately established. Additional information is needed to assess many of the therapy methods used when working with persons who have communication disorders.

Silberman17, in a classic study, depicts schools as mindless institutions characterized by passive learning, memorization and conformity. Speech therapists could absorb this attitude and develop therapy in a similar manner. In the critical areas of speech and language

development, the speech therapist can play a vital role in determining subsequent child attitude and adjustment through the types of behaviors the therapist chooses to encourage or reinforce.

Mental health in the schools appears closely linked to teacher and therapist professional preference. Therapy can be viewed as a therapist-directed activity which should not be attempted or initiated by parents or the child, ir it can be viewed as an encouragement to develop initiative and control by the child. It appears that therapists’ attitudes and approach must be responsive to socioeconomic differences dictated by the child’s environment.

BrownI8 indicates that there is a need for clinicians to expand their roles in the public schools. His findings would indicate that the speech therapist can no longer simply rely on sensory-motor techniques with each child, but that the speech therapist must expand the role and become more intimately involved in educational activities as well as assist id the development of school- wide programs. Lastly, he concludes that the speech therapist should become involved as a specialist in communication disorders.

Future emphasis might include sharing with the child and the parents the responsibility of establishing the process as well as the goals of therapy, This involvement could do a great deal to ensure that consideration is given the total child in context of the immediate environment, which carries the implications for implementation of PL 94-142, the mainstreaming of handicapped children.

Mange16 points out much of the speech therapy in schools is provided with underlying implications that “good speech” leads to positive mental health. As a consequence, it appears that most of the studies done on the outcome of therapy do not include measures of impact on mental health. Much of the research is designed to attack the task orientation of overcoming sensory-motor deficits. Conscious effort must go toward assessing the impact of therapy on the total child and the reaction to dysfunction and its remediation or rehabilitation.

REFERENCES 1 . Bryngelson B: Speech and personality, Travis LE (ed):

Handbook of Speech Pathology and Audiology. New York, Appleton-Century-Crofts, 1971.

2. Travis LE, Sutherland LD: Psychotherapy in public school speech correction, Travis LE (ed): Handbook of Speech Pathology and Audiology. New York, Appleton-Century-Crofts, 1971.

3. Perrin EH: The social position of the speech defective child. J Speech Hear Disord 18:250-252, 1954.

4. Silverman E: Listener’s impressions of speakers with lateral lisps. J Speech Hear Disorders 41547-552, 1976.

5. Mowrer DE, Wahl P. Doolan SJ: Effect of lisping on audience evaluation of male speakers. JSpeech Hear Disord 43:140-148, 1978.

6. Querry PH, Wolf 0: A study of the self-concept of children with functional articulation disorders and normal speaking children.

536 THE JOURNAL OF SCHOOL HEALTH NOVEMBER 1978

Presented at the American Speech and Hearing Association, New York, 1970. 7. Barrett CM, Hoops HR: The relationship between self-concept

and the remission of articulatory errors. Lang Speech Hearing Services in Schools 5:67-70, 1974. 8. Robbins SD: lo00 stutterers: a personal report of clinical

experience and research with recommendations for therapy. J Speech Hear Dkord 29:178-186, 1964. 9. Hall PK, Tomblin JB: A follow-up study of children with

articulation and language disorders. J Speech Hear Dkord

10. Subcommittee on Human Communication and Its Disorders: An Overivew. National Institute of Neurological Diseases and Sroke, US Department of Health, Education, and Welfare, 1969.

1 1 .Moore D: Language disabilities of hearing-impaired children. Irwin JV. Marge M (eds): Principles of Childhood Language Disabil- ities. Englewood Cliffs, Prentice-Hall, 1972. 12. Sommers RK. Cockerill C, Bowser D, et al: Effects of speech

therapy and speech improvement upon articulation and reading. J Speech Hear Disord 26:U-37, 1%1. 13. Van Harrum RJ, Page G, Baskervill RD, et al: The speech

improvement system (SIS). Taped program for remediation of articulation problems in the schools. Lung Speech Hearing Services in

14. Daum W, Fisher LI: A comprehensive model for preschool com- munication services in the schools. Lang Speech Hearing Services in

43~227-241. 1978.

Schools 5:91-97, 1974.

Schools 6~44-53, 1975.

15. Travis LE: The psychotherapeutical process, Travis LE (ed): Handbook of Speech Pathology and Audiology. New York, Appleton-Century-Crofts, 1971. 16. Mange CV: The speech clinician - as a counselor, Van Hattum

RH (ed): Clinical Speech in the Schools. Springfield, Charles C Thomas, 1969. 17. Silberman C: C r k t in the Classroom. New York, Random

House, 1970. 18. Brown JC: The expanding responsibilities of the speech and

hearing clinician in the public schools. J Speech Hear Dbord 36538- 542, 1971.

Reiko Sakata, MA, is Clinical Assistant Professor, Department of Surgery, and Speech Pathologist for the Oral Facial and Communicative Disorders Program, School of Dentistry, University of North Carolina, Chapel Hill, NC 27514. Robert Sakata, PhD, k Associate Professor and Acting Chairman, Department of Medical Allied Health Professions, School of Medicine, University of North Carolina, Chapel Hill, NC 27514.

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