Skip to main content

Speech Disorders: Voice, Articulation, and Fluency Disorders

Speech disorders are characterised by a difficulty in producing normal speech patterns. Unlike language disorders, which involve problems with language itself, speech disorders specifically involve difficulty with the act of speech production.

Children go through many stages of speech production while they are learning to communicate. What is normal in the speech of a child of one age may be a sign of a problem in an older child.

Overview of Speech Disorders​

Speech is the vocal utterance of language and it is considered disordered in three underlying ways:

  1. Voice: Abnormalities in phonation and resonance
  2. Articulation: Problems producing speech sounds
  3. Fluency: Impairments in the rate or rhythm of speech

Let's examine each category in detail.

Voice Disorders​

Understanding Voice Production​

Voice involves the coordinated effects of:

  • Lungs: Provide air pressure for speech
  • Larynx: Houses the vocal folds
  • Vocal cords: Vibrate to produce sound
  • Nasal passage: Adds resonance quality

Voice can be considered disordered if it is incorrectly phonated or if it is incorrectly resonated.

Types of Voice Disorders​

Incorrect Phonation​

An individual could have:

  1. Breathy voice

    • Excessive air escaping during speech
    • Weak, whisper-like quality
    • May indicate vocal fold problems

  2. Strained voice

    • Tight, tense voice quality
    • Sounds effortful
    • Associated with muscle tension

  3. Husky voice

    • Rough, raspy quality
    • Low-pitched and gruff
    • May indicate vocal fold damage

  4. Hoarse voice

    • Combination of breathiness and roughness
    • Variable pitch
    • Common after vocal abuse

Incorrect Resonation​

An individual could have:

  1. Hyper-nasality

    • Too much nasal resonance
    • Sound escapes through nose during speech
    • Causes: Cleft palate, velopharyngeal insufficiency
    • Example: "Bad" sounds like "mad"

  2. Hypo-nasality

    • Too little nasal resonance
    • Sounds congested or "stuffy"
    • Causes: Nasal obstruction, enlarged adenoids
    • Example: "Mom" sounds like "Bob"

Paralanguage and Voice Disorders​

The voice disorders could also be due to improper voicing habits.

Paralanguage issues, such as use of pitch, volume, and intonation, are diverse for they are culturally determined. Every sound of voice has a possible range of meanings that could be conveyed simply through the voice rather than the words we use.

Features to Consider in Determining a Voice Disorder​

1. Volume​

Definition: How loudly or softly we speak

Disorders:

  • Too loud: May indicate hearing loss, social inappropriateness
  • Too soft: May indicate shyness, vocal fold weakness, respiratory problems
  • Variable: Inconsistent volume control

Cultural Considerations:

  • Some cultures value soft speech as polite
  • Others expect louder, more animated speech

2. Pitch​

Definition: How pleasant or unpleasant; the highness or lowness of one's voice

Disorders:

  • Abnormally high pitch: May not match age/gender expectations
  • Abnormally low pitch: Unusual for age or gender
  • Monotone: Lack of pitch variation
  • Pitch breaks: Sudden, uncontrolled pitch changes

Normal Variation:

  • Men: Typically 85-180 Hz
  • Women: Typically 165-255 Hz
  • Children: Higher fundamental frequency

3. Quality​

Definition: The overall character of the voice

Quality Disorders:

  • Harsh: Rough, grating sound
  • Breathy: Air escape audible
  • Hoarse: Raspy, strained
  • Tremulous: Shaky, quavering

4. Rate​

Definition: The speed at which one speaks

Disorders:

  • Too fast: May indicate anxiety, cluttering
  • Too slow: May indicate motor problems, depression
  • Variable: Inconsistent speech rate

Cultural Interpretations of Voice Disorders​

Voice disorders are interpreted variously in different cultures.

Example from African Cultures: In many African cultures, masculinity and femininity are determined by paralinguistic features:

  • A man who speaks in:
    • Low volume → Frowned upon
    • High pitch → Considered unmasculine
    • Smooth and slow voice → Would be called upon to "speak like a man"

Clinical Implication: What may be considered a disorder in one culture might be:

  • Normal in another culture
  • Valued in some contexts
  • Inappropriate in others

Causes of Voice Disorders​

  1. Vocal abuse/misuse

    • Excessive shouting or screaming
    • Chronic throat clearing
    • Speaking over noise

  2. Medical conditions

    • Vocal fold nodules or polyps
    • Laryngitis
    • Neurological disorders
    • Hormonal changes

  3. Structural abnormalities

    • Cleft palate
    • Velopharyngeal insufficiency
    • Enlarged adenoids

  4. Psychological factors

    • Psychogenic voice disorders
    • Stress-related voice problems

Speech Sound Disorders​

Speech Sound Disorders involve difficulty in producing specific speech sounds (most often certain consonants, such as /s/ or /r/), and are subdivided into:

  1. Articulation disorders (also called phonetic disorders)
  2. Phonemic disorders

However, it is not uncommon for a single person to have a mixed speech sound disorder with both phonemic and phonetic components.

Articulation Disorders (Phonetic Disorders)​

Definition: Articulation disorders are characterised by difficulty learning to physically produce sounds.

What Is Articulation?​

Articulation involves the use of:

  • Tongue: Most versatile articulator
  • Lips: Shape sounds
  • Teeth: Help form certain sounds
  • Mouth: Resonating cavity

These work together to produce recognizable speech sounds.

When Is Articulation Disordered?​

Articulation is disordered if sounds are:

  1. Added

    • Extra sounds inserted
    • Example: "buhlack" for "black"

  2. Omitted

    • Sounds left out
    • Example: "ca" for "cat"

  3. Substituted

    • One sound replaces another
    • Example: "wabbit" for "rabbit"

  4. Distorted

    • Sounds produced incorrectly
    • Example: Lateral lisp on /s/

Causes of Articulation Disorders​

1. Structural Abnormalities:

  • Cleft lip and/or palate

    • Opening in lip or roof of mouth
    • Affects sound production
    • Often requires surgery

  • Tongue-tie (ankyloglossia)

    • Restricted tongue movement
    • Affects certain sounds (/l/, /r/, /s/)

  • Missing teeth

    • Especially front teeth
    • Affects sounds like /s/, /z/, /th/

  • Heavy tongue (macroglossia)

    • Enlarged tongue
    • Difficulty with precise movements

  • Deformed mouth

    • Various structural anomalies
    • Impact depends on specific deformity

2. Faulty or Incomplete Learning:

  • Inadequate models
  • Limited practice
  • Reinforcement of errors
  • Insufficient correction

3. Damage to the Nervous System:

  • Stroke
  • Traumatic brain injury
  • Cerebral palsy
  • Neurodegenerative diseases

Impact on Self-Concept​

Apart from affecting articulation, such conditions also affect the self-concept of the persons.

Case Example: Pinky Sonkar

An eight-year-old girl from Mirzapur in Uttar Pradesh:

  • Had a cleft lip
  • Stopped smiling
  • Stopped going to school because she was ashamed of her cleft lip
  • A deformity 35,000 children are born with in India every year

Intervention:

  • In 2008, The Smile Train arrived in Pinky's village
  • Routine plastic surgery was offered free by doctors abroad
  • Her world was changed forever
  • Documentary "Smile Pinky" made by American filmmaker Megan Mylan
  • Won Oscars for Best Documentary

Key Point: Physical speech problems have profound psychological and social impacts.

Phonemic Disorders​

Definition: Phonemic disorders are speech disorders in which individuals have trouble physically producing certain sounds.

Common Terminology​

In the general population, phonemic disorders are sometimes called speech impediments.

Characteristics​

Usually, individuals with phonemic disorders:

  • Have trouble distinguishing the sounds made by certain letters
  • Some letters, for example all "t"s or all "c"s, are always pronounced with an incorrect sound as a substitution
  • May substitute one sound consistently across all contexts

Examples:

  • All /k/ sounds replaced with /t/: "tat" for "cat", "tey" for "key"
  • All /s/ sounds replaced with /th/: "thun" for "sun", "mith" for "miss"

Prognosis​

Phonemic disorders usually improve with speech therapy, though:

  • How much improvement may be made will depend upon each individual case
  • Earlier intervention typically yields better results
  • Severity affects outcomes
  • Consistency of therapy is important

Fluency Disorders​

Fluency involves appropriate pauses and hesitations to keep speech sounds recognisable. Fluency is disordered if the normal flow of speech is interrupted.

Types of Fluency Disruptions​

Fluency is disordered if sounds are:

  1. Very rapid with extra sounds (cluttered)
  2. Repeated or blocked, especially at the beginnings of words (stuttered)
  3. Words are repeated excessively

Prevalence and Causes​

Demographics:

  • Fluency disorders are more prevalent in children
  • Often improve or resolve with age
  • More common in boys than girls (ratio of about 3:1)

Causes: Fluency disorders are due to a combination of factors:

  1. Familial factors

    • Genetic predisposition
    • Family history of stuttering

  2. Psychological factors

    • Anxiety
    • Stress
    • Perfectionism

  3. Neurological factors

    • Brain structure differences
    • Neural timing issues
    • Processing speed variations

  4. Motoric factors

    • Speech motor control
    • Coordination problems

Types of Fluency Disorders​

1. Stuttering​

Characteristics:

  • Repetitions: "b-b-b-ball"
  • Prolongations: "sssssnake"
  • Blocks: Silent pauses where no sound comes out
  • Secondary behaviors: Eye blinking, head movements

Pattern:

  • Often worse at the beginning of words
  • May be situation-specific
  • Varies in severity

Types of Stuttering:

  • Developmental stuttering: Begins in childhood (2-5 years)
  • Acquired stuttering: Due to brain injury or trauma
  • Psychogenic stuttering: Related to psychological factors

2. Cluttering​

Characteristics:

  • Very rapid speech rate
  • Irregular rate
  • Excessive disfluencies
  • Reduced intelligibility

Additional Features:

  • Poor organization of thoughts
  • Lack of awareness of problem
  • Improves when asked to slow down
  • May co-occur with learning disabilities

Example: Normal: "I went to the store yesterday and bought some milk and bread." Cluttering: "Iwentthestoreyesterdayboughtsomemilkbread" (rushed, running together)

Social Impact of Fluency Disorders​

The social nature of communication is affected when one has disfluent speech.

Impact on Social Development:

  • Human beings are social and spend much of their time together
  • They first learn how to communicate in a social setup (with parents, siblings, relations, or friends)
  • Socialisation is adversely affected if one has a fluency speech disorder

Consequences:

  • A person with disfluency is often mishandled at home, in school, or in public places
  • Often the individual becomes withdrawn
  • May develop anticipatory anxiety about speaking situations
  • Avoidance behaviors develop

Specific Situations That May Be Difficult:

  • Speaking on the phone
  • Introducing oneself
  • Ordering in restaurants
  • Asking questions in class
  • Job interviews
  • Public presentations

Treatment Approaches for Fluency Disorders​

For Stuttering​

1. Fluency Shaping:

  • Slow speech techniques
  • Easy onset of sounds
  • Light articulatory contacts
  • Smooth transitions

2. Stuttering Modification:

  • Identifying stuttering moments
  • Cancellation techniques
  • Pull-outs
  • Preparatory sets

3. Delayed Auditory Feedback (DAF):

  • Stutterers hear an echo of their own speech sounds
  • Has been effective in treating stuttering
  • Helps slow speech rate
  • Increases awareness

4. Fluency Training:

  • Develops coordination between speech and breathing
  • Slows down the rate of speech
  • Develops the ability to prolong syllables
  • Practice in various situations

For Cluttering​

1. Rate Control:

  • Slowing speech rate
  • Chunking information
  • Pausing appropriately

2. Awareness Training:

  • Self-monitoring
  • Recording and listening to own speech

3. Organization Skills:

  • Planning what to say
  • Organizing thoughts before speaking

Treatment Considerations Across Speech Disorders​

For Children with Isolated Speech Disorders​

Children with isolated speech disorders are often helped by:

Articulation Therapy:

  • Practice repeating specific sounds
  • Then practice in words
  • Then practice in phrases
  • Finally practice in sentences
  • Generalization to conversation

For Multiple or Severe Disabilities​

When a speech problem is caused by serious or multiple disabilities, a neurodevelopmental approach is often preferred:

Neurodevelopmental Approach:

  • Inhibits certain reflexes to promote normal movement
  • Focuses on foundational motor patterns
  • Addresses postural control
  • Integrates sensory and motor systems

Other Therapeutic Techniques​

Motor-Kinesthetic Approach​

  • Clinician manually guides articulators
  • Provides tactile feedback
  • Develops kinesthetic awareness
  • Builds motor memory

Biofeedback​

  • Helps children know whether the sounds they are producing are faulty or correct
  • Visual feedback (palatometry, spectrograms)
  • Auditory feedback
  • Tactile feedback

For Severe Communication Disorders​

For children with severe communication disorders, speech pathologists can assist with alternate means of communication, such as:

  1. Manual signing

    • Sign language
    • Key word signing
    • Makaton

  2. Computer-synthesized speech

    • Speech-generating devices
    • Apps and tablets
    • Eye-gaze technology

  3. Picture systems

    • Picture Exchange Communication System (PECS)
    • Communication boards
    • Visual schedules

Summary​

Speech disorders represent a diverse group of conditions affecting the physical production of speech. Unlike language disorders, these problems primarily involve the motor act of speaking rather than the linguistic content. The three main categories—voice disorders, articulation/phonemic disorders, and fluency disorders—each have distinct characteristics, causes, and treatment approaches.

Early identification and appropriate intervention are crucial for optimal outcomes. Modern speech therapy offers a range of effective techniques, from traditional articulation therapy to technological solutions for severe disorders. Understanding cultural context and the social-emotional impact of speech disorders is essential for comprehensive, person-centered care.

Source PDFs:

Self-Assessment Questions​

  1. Explain the difference between hyper-nasality and hypo-nasality, providing causes and examples of each.

  2. What are the four types of errors seen in articulation disorders? Give an example of each.

  3. Describe the case of Pinky Sonkar and explain why it illustrates the importance of treating speech disorders beyond just the physical aspects.

  4. Compare and contrast stuttering and cluttering. How are they similar and how do they differ?

  5. Explain how Delayed Auditory Feedback (DAF) works to treat stuttering and why it might be effective.

  6. Why is it important to consider cultural factors when assessing voice disorders? Provide at least two examples.

Memory Aids​

🎵 "VPQR" for Voice Disorder Features​

  • Volume (loudness)
  • Pitch (highness/lowness)
  • Quality (character)
  • Rate (speed)

🗣️ "SODA" for Articulation Error Types​

  • Substitutions
  • Omissions
  • Distortions
  • Additions

💨 "FPN" for Sound Production Causes​

  • Faulty learning
  • Physical abnormalities
  • Nervous system damage

⚡ "RPB" for Stuttering Characteristics​

  • Repetitions
  • Prolongations
  • Blocks