Speech Sound Disorder (Phonological Disorder) DSM-5 315.39 (F80.0)

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DSM-5 Category: Communication Disorders

Introduction

Speech is the verbal expression of one's cognitive content and process, and emotions. Clarity of speech is essential to social interaction, and educational and occupational functioning, as well as one's self confidence, self image, and sense of self efficacy. Impairment in speech can have a negative influence on all of these areas. Speech Sound Disorder (SSD), formerly known as Phonological Disorder in the DSM -IV, (Diagnostic and Statistical Manual of Mental Disorders, fourth Edition) is a DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, fifth edition), diagnosis assigned to individuals who have difficulties in productive speech which interferes with communication, and produces impairment in functioning, and distress. In Speech Sound Disorder, phonemes, or the basic units of speech, can be added, omitted, distorted or changed, or substituted in a manner which makes the speaker difficult to understand (American Speech Language Hearing Association, 2014). Addition of sounds is defined as including unneeded sounds in the pronunciation of the word. Omission involves deleting sounds or syllables, e,g, the word Doggie is pronounced as “oggie”. Distortions involve altering the correct sound of the word, which includes lisping. Substitution is using an incorrect sound to pronounce the word, e.g., cry is pronounced as “Cwy”. Acquisition of articulate speech is a developmental process which unfolds over almost a decade from birth. At age two, about 50% of a child's speech should be intelligible, and by age four, speech should be mostly understandable. At age eight, all words used by a child should be intelligible. Difficulties with speech production outside of these normal developmental parameters, in the absence of a sensory -motor deficit, neurological problem, or facial structural abnormality can indicate Speech Sound Disorder (American Psychiatric Association, 2013).

Symptoms of Speech Sound Disorder

According to the DSM-5, there are four criterion for Speech Sound Disorder:

  1. Persistent unintelligible speech consisting of phoneme addition, omission, distortion, or substitution, which interferes with verbal communication.
  2. There is interference with either social participation, academic performance, or occupational performance (or any combination thereof).
  3. The onset of symptoms is during childhood.
  4. The symptoms cannot be accounted for by another medical or neurological condition, including TBI (Traumatic Brain Injury) (American Psychiatric Association, 2013).

Onset

The DSM-5 notes that the onset of Speech Sound Disorder is in childhood. (American Psychiatric Association, 2013). Speech Sound Disorder responds well to speech therapy, with good resolution, however, some speech errors can persist into adulthood.

Prevalence

The DSM-5 does not indicate the prevalence of Speech Sound Disorder (American Psychiatric Association, 2013). Other sources indicate the prevalence of Speech Sound Disorder is 8%-9% in children (National Institute on Deafness and other Communication Disorders, 2010).

Risk Factors

The DSM-5 does not list specific risk factors for Speech Sound Disorder (American Psychiatric Association, 2013). Other sources indicate children who experience frequent ear infections may develop hearing impairment and be at risk for Speech Sound Disorder (American Speech Language Hearing Association, 2014).

Comorbidity

The DSM-5 does not indicate any specific comorbid disorders with Speech Sound Disorder

(American Psychiatric Association, 2013). Other sources indicate Language Impairment (LI) is also seen in children with Speech Sound Disorder (Lewis, Avrich, Freebairn,Hansen, Sucheston, Kuo, Taylor, Iyengar, & Steina, 2011). If Speech Sound Disorder is not corrected, and a lisp or other speech impediment persists into adulthood, it can be a contributing factor in social anxiety disorder. Some individuals will be very self-conscious of their lisp, overestimating how noticeable it is by others, or assigning an overly negative impression to it.

Treatment for Speech Sound Disorder

The DSM-5 does not specify treatment options for Speech Sound Disorder(American Psychiatric Association, 2013). Speech Sound Disorder can be diagnosed, evaluated, and treated by an SLP (Speech Language Pathologist) (American Speech Language Hearing Association, 2014). In some cases, supportive psychotherapy may be beneficial to prevent Speech Disorders from contributing to Social Anxiety, or problems with self confidence, particularly in adults who are self-conscious about residual speech errors.

Impact on Functioning

Speech Sound Disorder can impact educational, interpersonal, and occupational functioning.

(American Psychiatric Association, 2013). Peers may bully or ridicule children who lisp, or have other indicators of Speech Sound Disorder. Children with Speech Sound Disorder, as well as adults with residual speech errors may be perceived as less intelligent, or mature, as speech production is generally considered a marker of one's intellect and maturity. Speech Sound Disorder can impact learning and literacy. Studies have shown that 18% of children with Speech Sound Disorder will have difficulty reading in elementary school by about third or fourth grade (Lewis, et al, 2011). Adults with unresolved Speech disorders may restrict their participation in certain activities to prevent revealing their speech difficulty (Board of Regents of the University Of Oklahoma, 2011)

Differential Diagnosis

There are several diagnostic rule-outs for the clinician to consider in Speech Sound Disorder. In the DSM -5, it is noted that disorders such as hearing impairment can in turn produce speech impairment, which if in excess of what is typically expected for the degree of hearing loss, can be diagnosed separately as Speech Sound Disorder. There may be structural facial abnormalities such as a cleft palette which can produce difficulty with speech articulation. Dysarthria is a discrete speech disorder due to a neurological disorder, such as cerebral palsy. Following a TBI affecting Broca's area (Productive speech center of the cerebral cortex), there may be difficulties with speech production, articulation, and ability to retrieve words appropriate for the context (aphasia). This is not only a different etiology, but different qualitatively than Speech Sound Disorder. Selective Mutism involves limited speech production secondary to anxiety, There are also normal speech variations which are not considered a Speech Sound Disorder, such as accents. (American Psychiatric Association, 2013). Accents are regional differences in pronunciation due to the influence and filtering of one language through another, e.g, in northern Vermont, the “Au” sound in the word Aunt is pronounced with an “ awh” sound, whereas in New York State the same word is pronounced with an “eh” sound. The difference is due to English being filtered through French, which is an ancestral language in northern Vermont. The correct pronunciation is relative, depending on the region.

References

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders. (5th Edition). Washington, DC.

American Speech Language Hearing Association. (2014). Speech Sound Disorders: Articulation and Phonological Processes. American Speech Language Hearing Association. Retrieved March 17, 2014, from http://www.asha.org/public/speech/disorders/speechsounddisorders.htm

Board of Regents of the University Of Oklahoma. (2011). Common Development Speech and Language Disorders. The Department of Communication Sciences and Disorders. Retrieved March 22, 2014, from http://www.ah.ouhsc.edu/csd/leaps_disorders.asp

Lewis, B.A., Avrich, A.A., Freebairn,L.A., Hansen A.J., Sucheston, L.E., Kuo, I., Taylor, H.G., Iyengar, S.K., and Steina, C.M. (2011). Literacy Outcomes of Children With Early Childhood Speech Sound Disorders: Impact of Endophenotypes. Journal of Speech, Language and Hearing Residents. 54(6):1628–1643. doi: 10.1044/1092-4388(2011/10-0124)

National Institute on Deafness and other Communication Disorders (2010). Statistics on Voice, Speech, and Language. National Institute on Deafness and other Communication Disorders. Retrieved March 23, 2014, from https://www.nidcd.nih.gov/health/statistics/pages/vsl.aspx


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