Speech pathology and audiology: assessing and treating communication disorders

CHAPTER 23 Speech pathology and audiology: assessing and treating communication disorders



Christopher Lind, Catherine Olsson


When you finish this chapter you should be able to:


• identify common speech, hearing, language and communication disorders and their impact on everyday life

• distinguish the range of clinical activities undertaken by speech pathologists and audiologists

• identify the common speech, language and hearing disorders that occur over the lifespan and the consequences of communication difficulties

• contrast the patterns of public and private service provision in speech pathology and audiology

• identify the financial consequences of the Federal government’s current hearing provision scheme for hearing aid provision in Australia.


Introduction — communication and communication disorders


Human communication commences at birth and is critical to the quality of social life one experiences across the lifespan. Babies’ earliest communicative experiences include eye contact with a parent and taking turns in play, such as making noises or clapping hands. Babbling and early attempts at words, to which parents respond are gradually shaped into intelligible speech. At the same time that speech develops, so does receptive language (i.e. understanding others’ speech); for example, understanding that ‘hot’ means ‘don’t touch’. Young children engage in and negotiate relationships with others which impact on their early personal and social identities, and how they learn spoken language, reading and writing at school. As children grow so does their understanding of more complex language, and gradually of metaphor and humour, until they reach adult language competence, often at around 16 years of age (Nippold 1998).


As adults, communication allows us to establish and maintain relationships, to plan, work and create communities. It allows us to discuss, to tell stories, to argue and to change. We use communication to create images of ourselves and of others. In our later years, it allows us to remember and to share our memories, to look forward and to reflect. There is no human behaviour more subtle, more critical to our existence as individuals and as members of a community, than our shared ability to speak and to understand each other. Communication most commonly occurs through the use of spoken language and through reading and writing but extends to sign language and other symbol systems, all of which are enhanced by the use of extra-verbal actions such as facial expression and body language.


There are many points at which the process of communication may be compromised or interrupted and result in a communication disorder. Expressive communication disorders may arise from: cognitive and motor planning of communication which may be immature or impaired; the muscles of speech which may be unable to move smoothly to utter intelligible sounds; or from the support required from the lungs and/or larynx to make speech audible, which may be inadequate. Difficulties at any of these levels are likely to limit the intelligibility of a spoken message. Conversely, receptive communication problems include impairments of hearing or the ability to process and make sense of another’s speech or to decode another’s spoken or written language. Each may prevent clear understanding of another’s communication and thus compromise an individual’s ability to participate in everyday interaction.


Impairments of speech, hearing, language and communication are more prevalent than is generally realised, as they are often ‘invisible’ to the community until the person who is affected by them tries to engage with others. Activities that allow us to live healthy and independent lives may be difficult — everyday events like shopping or taking a new bus, returning an unsatisfactory item, having morning tea with work colleagues, talking with loved ones. People with communication difficulty may experience limitations in their participation in everyday community and social life. This may be because of their own response to their experiences, because the people around them do not understand their difficulties or know how to help make the communication process more successful, or both.


The prevalence of speech and language difficulties varies considerably within different populations. Differences in definitions of speech and language impairment and in research methodologies used in demographic studies also lead to variability in prevalence estimates. Speech Pathology Australia reports that one in seven, or around 14%, of Australians have communication impairments (Speech Pathology Australia 2007). Between 6% and 32% of children have been found to have difficulties understanding and making speech sounds, and/or using and understanding language (the words we use, and how we put these together to create different meanings) (Law et al 1998, 2000). A recent study found that 13% of children in primary and secondary schools had an identified communication disorder (McLeod & McKinnon 2007). As well as impacting on children’s ability to develop and negotiate social relationships with other children and adults in their world, these are also linked with difficulties learning to read and write, and with overall educational outcomes and social, educational and economic outcomes as adults (Conti-Ramsden & Botting 2004; Felsenfeld, Broen & McGue 1994; Law et al 1998).


Many people with developmental disabilities such as autism (Autism Spectrum Australia 2007; Better Health Channel 2007), cerebral palsy (Watson, Stanley & Blaier 1999) or intellectual disability, and acquired communication difficulties from traumatic brain injury (TBI) or cerebral vascular accidents (CVA) have difficulty understanding and/or producing speech to meet their communicative needs. As many as 1 in 500 people are estimated to have Complex Communication Needs (CCN) (Perry et al 2004). Language and speech difficulties such as aphasia occur in as many as 30% of people who have stroke, and in some cases continue to affect their lives for years to follow. Speech pathologists provide expert support to people such as teachers and singers who use their voice professionally, to help them learn how to use their voice in the best way to keep it healthy and working well, and to help heal any damage that may have already occurred.


Swallowing problems, commonly following stroke, have been found to impact on respiratory problems, health risks and length of hospital stay. As the only health professional whose degree course includes comprehensive information about the process of swallowing and its assessment and management, speech pathologists have increasingly found themselves providing dysphagia services. The incidence of swallowing difficulties (difficulties being able to swallow safely and comfortably, or to eat or drink enough to meet nutritional needs) in people over 50 years of age has been estimated as being between 7% and 44%. Changes in the texture, temperature, or taste of food or liquid, the rate or frequency of intake, placement of food or positioning of the person are among the strategies that may be suggested after assessment.


The prevalence of hearing loss varies and is commonly reported to be between 5% and 10% of the population in Australia and has been reported to be as high as 16% to 20% (Wilson et al 1999). Further, the prevalence of hearing loss is substantially skewed, particularly by age and gender. Among the conditions audiologists diagnose and provide rehabilitation for, the most common cause of hearing loss in children is otitis media (OM), a condition affecting the middle ear (and thus causing a conductive hearing loss) which has its highest prevalence among children up to the age of 6 or 7 years (Wilson et al 1999). Otitis media is a fluctuating condition that may, at worst, result in a moderate degree of hearing loss.


The prevalence of OM is influenced not only by the child’s exposure to the various possible infectious agents but also by his/her access to primary health care. Hearing health has been established as critical to quality of life, yet many children in the community do not have access to the primary health care either through a general practitioner or directly to a local audiologist. Chronic middle ear infection including ruptured eardrums and chronic discharge of pus into the ear canal, known as otitis media with effusions or OME, is widely recognised to be more prevalent in some Australian communities than in others. Alongside the medical problems that underlie OME, any child with OME has an increased likelihood of educational disadvantage as a result of the combination of poor hearing and the poor acoustic conditions in most classroom settings. Indigenous children, especially those living in rural and remote communities, have much higher prevalence rates of OM than do urban non-Indigenous children (Coates, Morris, Leach et al 2004; Gunasekera et al 2007).


Among adults, the most commonly occurring causes of hearing loss include: (a) noise-induced hearing loss (NIHL) which has its effect largely on adults working in industry, and results in permanent and usually bilateral damage to the inner ear and (b) age-related hearing loss (or presbycusis) having its greatest effect on those over 55 to 60 years of age, also a permanent condition affecting the high frequencies. Hearing losses such as these, which affect the perception of the high frequencies of speech and often make others’ speech sound muffled and unclear, are often ameliorated by the use of hearing aids and other assistive listening devices.



image Pause for reflection


The work of audiologists and speech pathologists moves beyond health to consider issues of disability. In what way might their clinical work be part of a social model of health?



Education, practice and registration


Audiologists assess and offer intervention for hearing and hearing related disorders, while speech pathologists diagnose and treat communication disorders primarily affecting speech, language, and voice. Both professions assess the everyday needs arising from these communication disorders and ultimately support the increased participation of the individual in everyday activities.



Speech pathology


Speech pathology in Australia had its beginnings in 1931 with a clinic at the Royal Alexandra Hospital for Children in Sydney, and a 2-year diploma course established in 1939. The initial focus on expressive communication difficulties such as cleft palate and stuttering has broadened to include areas such as language understanding and use, pragmatics, swallowing, and provision of alternative methods of communication, including voice output technology as well as diverse therapies such as accent modification. Education of speech pathologists has been largely via undergraduate tertiary courses since the mid-1960s, although there are increasing numbers of masters degree courses being offered in Australian universities. There are currently eight universities in Australia offering accredited speech pathology bachelors or masters degrees.


The majority of speech pathologists are employed by government, non-government and charitable organisations across the hospital, community health, rehabilitation, education, aged care and disability services, as well as working within the private sector. Some level of service is available through the public sector for most populations of people with communication impairment or dysphagia. There is a continuing focus on early identification and intervention for communication difficulties in children, with early intervention services often provided through community health services or disability-specific services. In some states and territories of Australia speech pathologists are also employed in pre-school and early-school settings. Unfortunately, there is little information available about the speech pathology workforce in Australia, including about private practitioners.


The main demand for services from private practitioners tends to be for services that are not a priority for provision through the public sector, and/or to provide more intensive services than it is possible to access from the public sector. Voice therapy services linked with Occupational Health Safety and Welfare (OHS&W) issues has developed as an area for private service delivery. There is variation among the different states and territories, but services for pre-school and school-aged children, particularly where the issues are mild (and therefore may not be a priority for service provision through the public sector) or severe (and therefore requiring a greater quantity, more intensive or longer term intervention) are a major component of the workload of private speech pathologists.


Payments for speech pathology services from private health funds are limited and may be inadequate to cover the quantum or type of intervention that may be most effective. The recent Medicare allied health and dental care initiative allows chronically ill people who are being managed by their GP under an Enhanced Primary Care (EPC) plan to access Medicare rebates for allied health services, which may include speech pathology, but this is currently limited to five allied health sessions in total for a year and the focus ends to be on older adults, rather than children.


Although able to work autonomously, speech pathologists often work as members of a multidisciplinary team which may encompass a range of other professions including general practitioners (GPs), medical specialists, nurses, dietitions, pychologists, rehabilitation engineers and educationalists. Some private practitioners choose to establish practices which enable them to work with a team of service providers to enable a comprehensive and holistic service, particularly when working with clients with complex issues whose needs may overlap with areas of practice of other professions.

Related posts:

  1. Primary health care system
  2. The Pharmaceutical Benefits Scheme
  3. The profession of medicine
  4. Podiatry in Australia: past, present and future

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Mar 24, 2017 | Posted by in MEDICAL ASSISSTANT | Comments Off on Speech pathology and audiology: assessing and treating communication disorders

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