Sensomotor alalia

Alalia are speech deficits that result from damage to the speech areas of the brain during fetal development or during childbirth. Sensomotor alalia develops directly when organic auditory and motor disorders are combined. The degree of severity of the violation varies: there may be a predominance of motor defects over sensory defects, or vice versa. The pathology belongs to the category of severe deficit conditions and is difficult to correct. [1]

Epidemiology

When examining children in the early age category, it was found that speech disorders were the most common - more than 50%. In comparison, emotional-volitional disorders were found in about 30% of cases. Cases of early childhood autism (more than 13%), behavioral and attention disorders (more than 7% of cases) are becoming more frequent.

As for sensorimotor alalia itself, the statistics here are unclear. According to various data, alalia affects about 1% of all preschool children. More often the problem is faced by boys, although the disorder is also found in girls. [2]

Causes of the sensorimotor alalia

Most cases of sensorimotor alalia are caused by intrauterine lesions, birth injuries, all sorts of complications that occurred during pregnancy. Certain areas of the brain responsible for speech function may be damaged due to fetal oxygen deficiency, acute cardiac and pulmonary insufficiency of the expectant mother. Another common cause is intrauterine infection of the fetus.

Sensomotor alalia can be provoked by difficult labor, late or premature births, asphyxia, birth trauma, obstetric errors, etc. It should be noted that sensorimotor alalia in most cases is not caused by a single cause, but by a combination of several factors. The subsequent development of pathology depends on individual characteristics of the organism, and on timely and competent correction.

A newborn baby is faced with a mass of unfavorable phenomena, to which it is most often defenseless. These can be traumas, infectious and inflammatory diseases (including meningitis or encephalitis), viral diseases that can run in severe forms and complications. Some experts also point to the possibility of genetic predisposition to the development of sensorimotor alalia. [3]

Risk factors

Damaging factors can have a negative impact at different stages of a baby's development:

1. In the period of intrauterine development unfavorable factors are infectious diseases in the expectant mother and the threat of spontaneous abortion, a lot and low water, premature amniotic fluid drainage and umbilical cord coiling, intoxication (including those caused by harmful habits of the mother) or the use of medications contraindicated during pregnancy, as well as chronic diseases and hypovitaminosis.
2. During labor, birth trauma, oxygen deprivation, rapid labor, and the use of obstetric forceps are risks.
3. After birth, head injuries, meningitis or encephalitis, complicated by co-morbidities, can be a potential risk to the baby.

A certain role is played by unfavorable social and living conditions, lack of maternal care, stress.

Pathogenesis

Exposure to individual risk factors, or a combination of them, causes damage to nerve cells belonging to motor and sensitive speech centers (postcentral, premotor, superior temporal cortex and arcuate bundle), as well as wire channels responsible for interhemispheric connections (in particular, the corpus callosum). At the same time, neurons do not mature functionally: the degree of their excitation decreases and the transportation of nerve signals is impaired. Auditory perception is impaired and oral-articulation activity is impaired.

Patients with sensorimotor alalia have pronounced deviations of speech formation, the whole mechanism of speech is insufficiently and incorrectly formed:

• there are pronunciation defects;
• there is a pronounced lack of understanding of spoken language;
• lacking in vocabulary;
• lacking in phrase-building skills.

Toddlers with sensorimotor alalia are not invested in the age terms of mastering language communication. It is important to realize that the anomaly is observed against the background of initially adequate intellectual development and peripheral hearing. [4]

The mechanism of sensorimotor alalia predominantly affects these areas:

• organic lesions of the cortical cerebral cortex;
• lesion of the cortical section of the speech-aural analyzer (Wernicke's center, posterior third of the superior temporal gyrus) with impairment of higher cortical analysis and synthesis of sounds.

Symptoms of the sensorimotor alalia

The summarized features of all varieties of alalia are eloquence, poor vocabulary and lack of connection between the action-meaning and vocabulary sides. Speech skills are formed late, there is a prolonged presence of one-syllable utterances, babbling, etc.

The details of the clinical picture, depending on the type of pathology, are already different. Thus, motor alalia is described as follows:

• Speech is completely absent, mimicry and gestures are used instead of statements and words, less often - incoherent sounds or babbling;
• the pronunciation of the sounds is wrong;
• the vocabulary used is sparse;
• There are difficulties in producing or understanding phrases (agrammatism);
• sounds, syllables blend, complex sounds are replaced by simple ones;
• Statements are based on simple phrases and a small number of words;
• all motor skills are underdeveloped;
• has difficulty with motor coordination;
• memory and ability to concentrate are impaired;
• difficulties in living and self-care.

In mixed sensorimotor alalia, signs such as:

• the patient does not understand the speech addressed to him or understands it only within one context;
• demonstrates active but meaningless speech (pronounces individual sounds or syllables);
• Widespread use of facial expressions, gestures and sounds instead of adequate language;
• uses repetition of sounds and syllables;
• substituting sounds, skipping syllables;
• gets distracted a lot, gets tired quickly.

The first signs of sensorimotor alalia are detected in children from the age of 3 years. The absence of speech draws attention initially, then the lack of understanding of addressed speech is added. When collecting anamnesis, the delayed appearance of such stages as humming, babbling, humming is characteristic. Parents note the lack of reaction to the mother's voice, voicing the baby's name, foreign sounds.

The preschool child does not understand the names of common things, can not show them on the illustration, is not able to fulfill a simple verbal request. Auditory attention is unstable, the capacity of auditory memory is reduced, there is excessive distractibility. In sensorimotor alalia, the baby is not interested in listening to stories and tales, and contact with him is possible only through gestures, facial and emotional actions. Speech is often absent altogether, or is manifested as babbling. Perseverations, echolalia are characteristic, but they are unstable, meaningless and have no speech fixation. Verbal repetitions are accompanied by numerous substitutions of sounds, errors, distortions.

In general, children with sensorimotor alalia are characterized by hyperactivity and may show some autistic features (isolation, stereotypy, aggressive reactions). Motor and coordination distraction is observed, and there are difficulties in performing such actions as dressing, buttoning, drawing. [5]

Speech in sensorimotor alalia

The first "bells" draw attention to themselves already a few months after the baby's birth. He does not hum, and attempts to babble are limited to a monotonous sound. Folding of the first syllables occurs after the age of one year, and the appearance of the first words is noted not earlier than 3 years old, when other children usually already speak well. Features of the voice: bright, ringing, loud, with clearly marked individual sounds, which can not be combined into words. Upon reaching the age of 5, some words are already successful, but against the background of an extremely small vocabulary speech remains meager and poor.

Additional problems for a child with sensorimotor alalia are caused by words that are similar in sound but have different meanings. In such a situation, the child falls into a stupor, as panic and misunderstanding arise against the background of the already formed visual image and the semantic meaning of the word.

At school age, children can only use words in the nominative case, with incorrect endings.

If sensorimotor alalia and autism are combined, the speech development of children with early infantile autism has the following features:

• communicative speech activity is impaired;
• there is a clear speech stereotypicality;
• neologisms, word creation predominate;
• there are frequent echolalia;
• sound pronunciation, pace and fluency of speech are impaired.

Sensomotor alalia and mental retardation have characteristic features:

With sensory alalia.	With mental retardation
Children show interest, want to learn new things.	Kids aren't interested in learning.
Accepting outside help.	Reluctant to accept outside help.
If a toy falls out of the visual field, children continue to search for it.	If the toy falls out of the visual field, the child loses interest in it.
Possess self-criticism, understand their own inferiority.	Weakly critical of their own shortcomings.
From an early age, they are selective about their loved ones.	Selectivity in relation to loved ones is formed rather late.
Memorize ways of performing a task and use them when performing similar tasks.	Require an explanation of the instruction each time they approach a task.
Emotions are varied.	Emotions are poor.
Not mentally inert.	Generally mentally inactive.

Sensomotor alalia in children

The psychological development of children suffering from sensorimotor alalia has some peculiarities. Preschool patients with general speech underdevelopment differ in terms of mental functionality: defects impose their imprint on the state of memory, attention, thinking. There is a marked decrease in the volume of attention, its unsteadiness. Alalics do not memorize the proposed sequence of actions, do not perform even two or three-syllable instructions.

Preschoolers are difficult to analyze, synthesize, lags and verbal and logical thinking.

General speech defect in sensorimotor alalia is often combined with dysarthria, there is poor motor coordination and awkwardness, underdeveloped fine motor skills. There is no or reduced interest in games.

The task of specialists should be to identify the individual psychological characteristics of the patient, which fundamentally determines the direction of correctional and developmental work.

Stages

In sensorimotor alalia, there are varying degrees of severity:

• in relatively mild forms, speech function develops, but gradually, slowly and distorted, starting from 3-4 years of age;
• In severe forms, the child may not be able to use speech function even by the age of 10-12 years.

Children with a severe form of sensorimotor alalia, if regularly and competently corrected, eventually do master speech. However, it is characterized by paucity and incompleteness.

Forms

There are two basic types of alalia: motor (expressive) and sensory (impressive). Most often these variants are combined: mixed (sensorimotor) alalia is noted, with a predominance of impulsive or expressive speech disorders.

• In sensory alalia, the baby does not understand what is said to him and, accordingly, does not speak. The causes are usually traumatic and pathological brain damage, accompanied by a violation of auditory-verbal differentiation in the acoustic mechanism (in the temporal zone). Characteristic symptoms include impaired phonemic hearing, poor memory and attention to oral utterances.
• In motor alalia, there is a systemic underdevelopment of expressive sound production of a central organic nature. Pathology is caused by underdevelopment, insufficient formation of language components and speech processes against the background of preserved semantic and sensorimotor reactions. The child in time begins to understand the statements addressed to him, but does not speak, ignoring complex words, turns and phrases. There are violations in motor imitation (children do not repeat words that they already know). Actively developed facial expressions and gestures, through which the child and transmits information. Causes of pathology: congenital or acquired anomalies of the speech-motor mechanism, their defeat by disease, trauma, toxic effects, or delayed development of differentiation in the motor centers of the cerebral cortex.

Complications and consequences

Speech defects complicate the patient's communication with relatives and peers, preventing the necessary socialization. As a result, personality deviations are actively formed:

• Behavioral disorders appear;
• emotional and volitional sphere suffers (irritability, aggression, anxiety are noted);
• mental retardation occurs with a significant lag from the generally accepted age-appropriate psychological norms.

Children with sensorimotor alalia experience difficulties in learning to write and read. Even when classes are conducted taking into account a special correction program, learning the material causes considerable problems. Additionally, dyslexia, dysgraphia, dysorphography may develop. Timely and intensive classes to correct the disorder allow to "smooth" the symptoms and improve the prognosis.

Other possible co-occurring disorders include:

• poor motor coordination, motor disorders;
• hyperexcitability;
• self-care problems;
• mental retardation;
• cognitive impairment.

Diagnostics of the sensorimotor alalia

If sensorimotor alalia is suspected, the child should be shown to a pediatrician and pediatric neurologist, then consult with a speech therapist, otolaryngologist and psychiatrist. Diagnosis is directed to eliminate the cause of the violation and assess the degree of pathology. In this aspect, mainly instrumental diagnostics is used:

• encephalography - an examination that assesses the functional capacity of the brain by recording its electrical activity;
• echoencephalography is a sonographic method that allows assessing the size and location of midbrain structures, as well as determining the state of the cellular space;
• magnetic resonance imaging - a diagnostic procedure based on layer-by-layer visualization of the brain in different planes, which allows you to detect even small deviations and anomalies in all brain structures;
• audiometry and otoscopy - auditory diagnostics prescribed to clarify the absence or presence of hearing loss;
• assessment of auditory-speech memory - a test speech therapy method that determines the degree of development of figurative memory and speech perception;
• Oral Speech Assessment - a comprehensive diagnostic procedure aimed at detecting impairments in oral speech.

Tests may be ordered as part of general diagnostic measures and are nonspecific. [6]

Differential diagnosis

Distinctive diagnostic measures should be performed with these pathologies:

• hearing loss;
• delayed speech development;
• dysarthria (a disorder caused by damage to the central nervous system);
• autism;
• Oligophrenia (insufficient mental development provoked by organic brain damage).

The relationship between speech and intellectual development is often difficult to diagnose, because oligophrenia, for example, always occurs with underdevelopment of speech. At the same time, in sensorimotor alalia there is a delay or irregularity in the development of intelligence. In oligophrenia there is a complete lack of development of higher forms of cognitive activity. Violated processes of thinking, perception, memory, attention, there are personality disorders, failure of abstract-logical thinking. In sensorimotor alalia there is no inertness of mental processes, there is the ability to transfer the learned methods of intellectual actions to other, similar tasks. Children with alalia show sufficient interest in the tasks, there is self-criticism of their own speech deficiency (if possible, the child tries to avoid the need to speak out), there are differentiated emotional responses. Diagnostic difficulties inevitably arise:

• If oligophrenia is combined with symptoms of cerebral palsy or hydrocephalus;
• if oligophrenia is complicated by alalia and dysarthria.

Other differential signs:

The difference between sensorimotor alalia and aphasia is that in alalics speech is not formed initially, while in aphasia previously formed speech is disturbed.

The difference between sensorimotor alalia and dyslalia is that in the latter there are disorders only of the sound sphere, while in alalics mainly the semantic sphere is affected.

The difference between sensorimotor alalia and dysarthria is a sharp limitation in dysarthria motor capabilities of the articulatory apparatus during the speech process.

How can sensorimotor alalia be distinguished from autism? Children with autism spectrum disorders do not respond to words spoken to them, avoid eye contact, avoid touch or respond with harsh reactions (screaming, crying). At the same time, echolalia is typical for patients with both alalia and autism. Autism spectrum disorder is also manifested by stereotypes, stimulation (tactile, olfactory), and attempts to change the usual routine or lifestyle provokes a violent negative reaction in the child. A coolness towards the mother is also noticed.

How does motor alalia differ from sensorimotor alalia? In motor alalia, the baby understands the words addressed to him, but cannot respond. With sensory alalia, the child has speech activity, but does not understand the words addressed to him. In sensorimotor alalia there are signs of both variants of pathology. That is, the baby does not understand other people's speech and can not reproduce the necessary words. Speech is either completely absent or is present in the form of babbling, incoherent and unintelligible.

Another disease that requires careful differentiation is residual encephalopathy, a brain pathology caused by tissue damage and neuronal death. The problem is associated with impaired blood supply in the brain region and increasing hypoxia. Risk factors are head injuries, vegeto-vascular dystonia, atherosclerosis, ischemic and infectious processes, diabetes mellitus, intoxication, etc. The main symptom is pain in the head. The main symptoms are pain in the head, dizziness, sleep disorders, hearing and vision impairment, slurred speech, decreased intelligence, coordination disorders, lethargy or excessive excitability.

Treatment of the sensorimotor alalia

Treatment involves the use of a comprehensive biopsychosocial approach, and the following methods of correction are used:

• medications (nootropic, neuroprotective drugs, neuropeptides, vascular agents, B vitamins, other drugs that can stimulate the maturation of brain structures);
• neuro and speech therapy;
• physiotherapy (laser therapy, magnetotherapy, electrophoresis, DMV, hydrotherapy, IRT, electropuncture, transcranial electrical stimulation, etc.) and manual therapy.

It is important to actively develop general and manual motor skills, mental functions (memory, thinking, representation, attentiveness).

Since the systemic nature of sensorimotor alalia should be taken into account, speech therapy sessions should be aimed at working on all components of speech:

• stimulate active conversation;
• form active and passive vocabulary;
• Achieve vocabulary and then phrase statements;
• grammaticalize statements;
• develop coherent communication and pronunciation.

At the first stage, specialists solve the problem of improving speech comprehension, teaching words and one-syllable sentences. At the second stage, the child learns to build easy phrases and word combinations, and to react logically to the statements of others. Then they move on to the reproduction of complex words consisting of several syllables, as well as to the construction of sentences of several words. After that, training in the primary skills of composing short phrases, emphasizing the correctness of sound pronunciation. And the next stage is the expansion of the vocabulary, mastering retellings in their own words.

Speech therapy programs necessarily include exercises in speech therapy and speech therapy massage.

It is recommended that the child be taught literacy as early as possible: both reading and writing help to consolidate what has been learned and control oral expressions.

A neurologist determines the degree of damage to brain structures, differentiates sensorimotor alalia from other similar pathologies (e.g., autism, dysarthria). Otolaryngologist must exclude the presence of hearing loss and other disorders of the auditory apparatus. The task of a speech therapist - first of all, to assess the level of speech comprehension, to find out the vocabulary, to determine the possibility of imitating speech, to analyze the state of all anatomical structures involved in articulation and sound production. A child psychologist should correct behavior, which often suffers in children with combined sensorimotor alalia.

Additionally, the child will be recommended family activities that promote the development of gross and fine motor skills, allowing the child to form the correct diaphragmatic breathing required for adequate speech production. [7]

Is sensorimotor alalia treatable?

For each child with sensorimotor alalia an individual program is drawn up, involving a set of therapeutic and corrective measures. The program includes:

• drug therapy prescribed by a neurologist;
• corrective classes with a speech pathologist or speech therapist;
• neuropsychological recovery classes to develop interhemispheric interconnections;
• activation of cerebellar function (recommended when the motor side of the pathology is predominant);
• speech-correction complex of Biofeedback (indicated for stimulation of frontal brain lobes responsible for self-control and regulation);
• use of speech therapy simulator Delpha-M (helps to establish correct pronunciation of sounds);
• application of the Timocco neurocorrective complex (it is a game variation of neurorecovery for patients with concentration problems).

With timely and adequate assistance from speech therapists and neuropsychologists, it is often possible to achieve a sustainable positive result. However, it is important not to stop at what has been achieved, but to continue practicing with the child and in the usual mode, at home, independently, periodically consulting and switching to the right specialists.

When to see a speech therapist?

As early as preschool age, active learning should be practiced with children with sensorimotor alalia. As a rule, the diagnosis is made from the age of 3. Immediately after that, intensive work is started, with the involvement of speech therapists and neuropsychologists. The earlier the classes start, the better the prognosis will be. It is important to realize that speech defects and developmental delays have a negative impact on mental development and personality formation.

Recovery should be carried out comprehensively and include both medication and pedagogical influence: classes with a speech therapist are conducted in combination with physical therapy, speech massage, development of mental components (memory, attention, thought processes).

Early and competent correction with a systemic impact on all speech components - these are the main links of success in the treatment of sensorimotor alalia. [8]

Sensomotor Alalia Correction Programs

In sensorimotor alalia already from the age of 2.5-3 years the following correction programs are actively used:

• Logopedic massage (massage of articulation muscles involved in the formation and pronunciation of sounds).
• Classes to "kick-start" and further speech development with special Forbrain headphones that train the brain's processing of the auditory stream.
• Neuroacoustic correction according to the Tomatis method, with a built-in program of defectology involving listening to specially processed musical pieces.
• Neuroacoustic stimulation with integrated neurodynamic correction and rhythm therapy In Time.
• Neuropsychological correction for preschoolers with biofeedback, VR simulators.
• Expanded cerebellar stimulation program.
• Sensory integration and antigravity programs.
• Rhythm therapy and cognitive multitasking development programs.
• Timocco's video biocontrol program for the development of motor and cognitive skills, including bilateral coordination, attention coordination, communication, etc.
• Interactive Metronome for speech and behavioral disorders.
• OMI Beam programs (aka smart beam system).
• OMI FLOOR programs that develop spatial representations, interhemispheric connections, etc.
• Play Attention biofeedback programs to develop active attention.
• Kinesiotherapy and Brainfitness for the development of brain reserves.
• Pecs and Macaton's alternative communication defectology programs.
• Psycho-communication classes to correct emotional and communication disorders.

Programs include exercises to develop motor skills, activate the vestibular apparatus and frontal brain lobes, as well as warm-ups, stretches, functional and respiratory exercises, relaxation, yoga, etc.

Exercises for sensorimotor alalia

The main principle of sensorimotor alalia is to consistently and systematically influence the entire spectrum of the child's speech activity. At the same time, specific treatment that activates the maturation of cortical cells should be carried out.

Corrective classes are conducted in the following areas:

1. Properly organize sound and speech regime, exclude chaotic auditory load, create periods of auditory and visual deficit (to improve sound receptivity), avoid sounds accompanied by vibration (clapping, stomping, knocking).
2. Form communication skills and pre-verbal communication (eye-to-eye contact, joint attention to the object, observing the order, establishing a connection between action and sound). They use joint and parallel games, practice "familiar situations" (the baby knows and guesses in advance what actions or phrases will follow). They teach the use of meaningful gestures, facial expressions, intonations.
3. Form interest in sounds (non-speech and speech), develop conditioned-motor reaction, skills of assessment of location and sound direction. Teach to distinguish between noises, memorize their sequence. They practice separating words from sentences.
4. Develop understanding of simple words, contributing to the filling of passive vocabulary. Gradually complicate phrases, tasks, instructions, analyzing both their own statements and those of others.

It is important that classes start as early as possible and are conducted systematically. Parents should be actively involved in the correctional process and properly organize the developmental atmosphere.

Prevention

Since sensorimotor alalia can be acquired and congenital, you should start preventive measures at the stage of planning a child:

• parents should give up bad habits;
• take the necessary tests to detect hereditary pathologies;
• expectant mother should carefully monitor her health, prevent viral infections, avoid exacerbation of chronic diseases;
• Do not take medications that are potentially harmful to the fetus;
• to register for pregnancy in a timely manner, to carry out all necessary examinations;
• take care of the choice of a maternity hospital in advance, talk to the doctors about the nuances of labor and preparation for labor.

After the baby's appearance in the world, you need to pay active attention to communication with him, and if there are signs of mental or neurological abnormalities, immediately contact a pediatric neurologist, psychologist, speech therapist.

There is no specific prevention of sensorimotor alalia.

Forecast

The degree of effectiveness of remedial sessions to eliminate sensorimotor alalia can be considered favorable if correction therapy is started early (no later than 3-3½ years of age). Correction should have a comprehensive approach, involving neurologists, speech therapists, neuropsychologists, and speech therapists. It is important to ensure systemic influence on all speech components, to form and connect the process of speech formation with mental functions.

It should be understood that sensorimotor alalia is not just a transient functional delay in speech development, but a systemic underdevelopment affecting all components of the speech mechanism. If the problem is ignored and not engaged in its solution until the period of maximum development of communicative activity (4-5 years), the defect can be fixed: the child will realize his condition, worry, it will be difficult for him to communicate with relatives and peers. As a result, persistent negative psycho-emotional disorders will be formed. And with gross underdevelopment of speech significantly increases the risk of secondary intellectual disability.

Disability in sensorimotor alalia

Issues related to the assignment or non-assignment of a disability group to a child with sensorimotor alalia are usually resolved when the child reaches the age of five. Until then, active therapeutic and restorative measures are carried out. And only if they are ineffective, against the background of intense mental deviations (which must be established by a psychiatrist or psychoneurologist) can be established disability. Specialists take into account mental, speech skills, speech comprehension, motor activity. In the presence of not only pronounced, but also persistent pathology (not amenable to correction), we can talk about the likelihood of disability.

Sensomotor alalia itself, without persistent and significant abnormalities, is not an indication for a finding of disability.