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Speech, language and communication difficulties
A guide for patients and carers
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Language difficulties: Speech and language for people with aphasia
The primary source of help for the person with aphasia and their family is the speech and language therapist, who will usually be based at their local hospital or rehabilitation unit. They may also be accessed via local community clinics or their GP. The speech and language therapist will aim to assess and treat the underlying language problems whilst at the same time attempting to help the person minimise the difficulties these problems give them in everyday life and the affect they have on their lifestyle.
A thorough assessment of a person’s impairments, disabilities and handicaps (see the examples given in the communication section) will enable the therapist to identify the strengths and weaknesses in a person’s language and communication skills. The findings of the assessment enable the therapist to plan appropriate treatment and provide a yardstick with which to measure improvement.
Assessing the extent of impairment in a person with aphasia can be complex and time consuming. However, if the speech and language therapist decides that this is appropriate, language can be evaluated at a number of levels.
Sounds are the building blocks of spoken language and letters are the building blocks of writing. Most people are able to recognise and distinguish between similar letters and sounds and recognise the words of their own language. In people with aphasia, however, these abilities can become impaired so that they find speech difficult to understand and they often don’t realise when they make a mistake while they are speaking. This accounts for some of the features of fluent aphasia.
The speech and language therapist can test a person’s ability to discriminate between similar words and to recognise words. Treatment will usually involve finding a level at which the person can succeed and slowly building up from this, possibly using letters to ‘relearn’ sounds. In everyday life, people with aphasia will find that recognising other words in a sentence, knowing what is being spoken or written about and the use of gestures will all help them to understand better.
The next stage in our processing of language is actually finding the meaning of words from the mental dictionary in our brain. This is probably the most crucial aspect of language processing and one that is often impaired in aphasia. Normally we have a precise understanding of words, so that we would never confuse ‘knife’ with ‘fork’ or ‘today’ with ‘yesterday’. The meaning of words is often referred to as semantics.
In aphasia, the system that stores the meaning of words in our brain can become disorganised, resulting in errors in both understanding and producing words. A person with aphasia might pick up a fork when asked for a knife or say knife when trying to ask for a fork. They also may not notice their own errors. The speech and language therapist will have a number of tests which allow him or her to assess a person’s so-called semantic abilities. These assessments will tell them at what level the meaning of words is reliably understood by the person with aphasia, and this will be the level at which the therapist will begin to work. This may initially involve non-language tasks in which the person is required to call on their understanding of words, such as sorting pictures according to categories. These abilities can then be built upon to re-establish the meaning of spoken and written words.
Knowing the precise meaning of a word is crucial to producing it, and problems with this will often be the cause of word-finding difficulties. In some people with aphasia, the ‘mental dictionary’ that should systematically store all the words in their vocabulary has become disrupted and very difficult to get into - a bit like trying to get into a room through a door that has a very tricky lock. Sometimes you can open the door first time and get what you need, but more often you have to try again and again to turn the key.
People with aphasia can often be helped if they are given the first sound of the word they are trying to find, rather like putting a drop of oil in the lock, but this relies on someone knowing the word they are looking for. Speech and language therapy can take two main approaches here. The person with aphasia may be taught strategies to help them find the word they are looking for. Alternatively, they can be encouraged to describe or ‘talk round’ the word they are stuck on. This is called circumlocution.
It may be the case that even when a person with aphasia has found the word that they want to say or write down there is a problem keeping sounds and letters in the right order. For example, in some forms of fluent aphasia the person finds it difficult to produce more than one syllable without the sounds becoming jumbled up. Similarly in writing, most of the letters of a word may be written, but not in the right order.
The speech and language therapist will attempt to find the length of word that the person can deal with successfully and build up from this, slowly increasing the length of words they can cope with either sound by sound or letter by letter. At the same time, the therapist will work with the person on developing ways to make the best use of shorter words to communicate.
Many people with aphasia have difficulty understanding sentences. This may be due to the length of the sentence. A person may be able to understand ‘Can you pass me a plate’ but have difficulty with ‘Can you pass me a plate and then go upstairs and get the laundry basket’. These problems can be dealt with by encouraging those close to the person with aphasia to adapt the way they talk so that they convey just one idea per sentence. People with non-fluent aphasia may also have a particular difficulty with grammar. As a result it may be difficult for them to understand the difference between ‘John kicked the girl’ and ‘the girl kicked John’. It will also be difficult for them to produce a sentence with the words in the right order, and they may say ‘John..girl..kick’.
If a grammatical difficulty is detected the therapist will work on helping the person ‘re-learn’ the rules of sentence construction. This work will aim to improve understanding and overcome the rather telegram-like sentences that are produced.
Disability refers to the difficulty in communicating that each person with aphasia experiences. Examples of disability may range from difficulty with ordering food in a restaurant to problems with writing letters. However, the most obvious disability experienced by people with aphasia centres around social situations, such as sharing a joke, socialising with friends or talking to a partner.
The speech and language therapist will usually spend time exploring disabilities with the person affected by aphasia and significant people in that person’s life. The therapist may give the person’s partner or family a questionnaire looking at a whole range of communication situations. A person may have the ability to communicate in certain situations but fail to fulfil their potential or feel dissatisfied with the way they manage. This is because the way they communicate is often perceived by themselves and others as ‘not normal’. People can feel that although they understand and make themselves understood, the way they do so is ‘second best.’ The speech and language therapist must therefore spend a lot of time working with the person and their family to make sure that the goals that they set themselves are achievable and that they don’t expect too much of themselves. These goals will vary for each individual and will change in the course of their recovery.
Accepting the need to approach communication in a different way and adapt to limitations can be a very bitter pill to swallow for many people. People with aphasia and their families cannot be expected to make these adjustments overnight. They will need the help and support of a speech and language therapist and others. It is very important to be positive, to try and work around the disability as much as possible and not to expect too much.
Since we use language to initiate, build and maintain relationships and to put across our personalities, the loss of language is often devastating. People with aphasia may experience difficulties fulfilling their roles as father, mother or grandparent, or they may have problems with doing their job. These difficulties will inevitably affect the quality of life of the person and their family. The effect this has on people can be very different. One person who is aphasic may experience very little handicap because their lifestyle and interests are not really affected, whereas someone with a milder aphasia may be devastated by their inability to work, help their children with homework and maintain relationships with friends. Once again, by talking to people with aphasia and their families, the speech and language therapist will gain an insight into an individual’s level of handicap. Of particular importance is the relationship between the person with aphasia and the person they talk to most.
The speech and language therapist will be able to provide emotional support alongside practical help. The therapist may be involved in liaison with employers or with looking at the ability of the person with aphasia to return to college. They may help the person with aphasia to reorganise activities in their daily life so that they take on responsibilities that they can manage and delegate to others those that they cannot. This approach can be applied to anything from looking after children to going to work. In addition, the speech and language therapist may run groups for people with aphasia which aim to help them address issues to do with the disabilities and handicaps that they experience by sharing their problems with others.
People with aphasia often experience a strong emotional reaction to their communication difficulties. Depression is common in people who have had a stroke and particularly in those with aphasia. In addition, changes in personality may occur, including increased irritability, anger, frustration or indifference. Although these characteristics are understandable reactions to the aphasia, they often affect the whole family. It may therefore be necessary for the speech and language therapist or others involved in their care to seek some form of counselling for the person with aphasia or occasionally refer them for psychiatric help.
People with aphasia may also have a problem with how they are perceived by others. Many unfortunately suffer the experience of being treated as if they were intellectually impaired and unable to make their own decisions. It is important to try and counteract these misconceptions and increase people’s understanding of aphasia. The speech and language therapist can help with this by trying to explain the nature of the person’s difficulties to family, friends and employers. In addition, charities and societies that try and support people with aphasia aim to educate the public about the abilities and needs of people with aphasia. Perhaps the best advocates of all are people with aphasia and their families who know what aphasia is really like (see Personal experiences).
Assessing and treating language impairments
Assessing the extent of impairment in a person with aphasia can be complex and time consuming. However, if the speech and language therapist decides that this is appropriate, language can be evaluated at a number of levels.
Sound, letter and word recognition
Sounds are the building blocks of spoken language and letters are the building blocks of writing. Most people are able to recognise and distinguish between similar letters and sounds and recognise the words of their own language. In people with aphasia, however, these abilities can become impaired so that they find speech difficult to understand and they often don’t realise when they make a mistake while they are speaking. This accounts for some of the features of fluent aphasia.
The speech and language therapist can test a person’s ability to discriminate between similar words and to recognise words. Treatment will usually involve finding a level at which the person can succeed and slowly building up from this, possibly using letters to ‘relearn’ sounds. In everyday life, people with aphasia will find that recognising other words in a sentence, knowing what is being spoken or written about and the use of gestures will all help them to understand better.
Finding the meaning of words
The next stage in our processing of language is actually finding the meaning of words from the mental dictionary in our brain. This is probably the most crucial aspect of language processing and one that is often impaired in aphasia. Normally we have a precise understanding of words, so that we would never confuse ‘knife’ with ‘fork’ or ‘today’ with ‘yesterday’. The meaning of words is often referred to as semantics.
In aphasia, the system that stores the meaning of words in our brain can become disorganised, resulting in errors in both understanding and producing words. A person with aphasia might pick up a fork when asked for a knife or say knife when trying to ask for a fork. They also may not notice their own errors. The speech and language therapist will have a number of tests which allow him or her to assess a person’s so-called semantic abilities. These assessments will tell them at what level the meaning of words is reliably understood by the person with aphasia, and this will be the level at which the therapist will begin to work. This may initially involve non-language tasks in which the person is required to call on their understanding of words, such as sorting pictures according to categories. These abilities can then be built upon to re-establish the meaning of spoken and written words.
Finding the right word
Knowing the precise meaning of a word is crucial to producing it, and problems with this will often be the cause of word-finding difficulties. In some people with aphasia, the ‘mental dictionary’ that should systematically store all the words in their vocabulary has become disrupted and very difficult to get into - a bit like trying to get into a room through a door that has a very tricky lock. Sometimes you can open the door first time and get what you need, but more often you have to try again and again to turn the key.
People with aphasia can often be helped if they are given the first sound of the word they are trying to find, rather like putting a drop of oil in the lock, but this relies on someone knowing the word they are looking for. Speech and language therapy can take two main approaches here. The person with aphasia may be taught strategies to help them find the word they are looking for. Alternatively, they can be encouraged to describe or ‘talk round’ the word they are stuck on. This is called circumlocution.
Sequencing sounds and letters
It may be the case that even when a person with aphasia has found the word that they want to say or write down there is a problem keeping sounds and letters in the right order. For example, in some forms of fluent aphasia the person finds it difficult to produce more than one syllable without the sounds becoming jumbled up. Similarly in writing, most of the letters of a word may be written, but not in the right order.
The speech and language therapist will attempt to find the length of word that the person can deal with successfully and build up from this, slowly increasing the length of words they can cope with either sound by sound or letter by letter. At the same time, the therapist will work with the person on developing ways to make the best use of shorter words to communicate.
Understanding and producing sentences
Many people with aphasia have difficulty understanding sentences. This may be due to the length of the sentence. A person may be able to understand ‘Can you pass me a plate’ but have difficulty with ‘Can you pass me a plate and then go upstairs and get the laundry basket’. These problems can be dealt with by encouraging those close to the person with aphasia to adapt the way they talk so that they convey just one idea per sentence. People with non-fluent aphasia may also have a particular difficulty with grammar. As a result it may be difficult for them to understand the difference between ‘John kicked the girl’ and ‘the girl kicked John’. It will also be difficult for them to produce a sentence with the words in the right order, and they may say ‘John..girl..kick’.
If a grammatical difficulty is detected the therapist will work on helping the person ‘re-learn’ the rules of sentence construction. This work will aim to improve understanding and overcome the rather telegram-like sentences that are produced.
Assessing and coping with disability
Disability refers to the difficulty in communicating that each person with aphasia experiences. Examples of disability may range from difficulty with ordering food in a restaurant to problems with writing letters. However, the most obvious disability experienced by people with aphasia centres around social situations, such as sharing a joke, socialising with friends or talking to a partner.
The speech and language therapist will usually spend time exploring disabilities with the person affected by aphasia and significant people in that person’s life. The therapist may give the person’s partner or family a questionnaire looking at a whole range of communication situations. A person may have the ability to communicate in certain situations but fail to fulfil their potential or feel dissatisfied with the way they manage. This is because the way they communicate is often perceived by themselves and others as ‘not normal’. People can feel that although they understand and make themselves understood, the way they do so is ‘second best.’ The speech and language therapist must therefore spend a lot of time working with the person and their family to make sure that the goals that they set themselves are achievable and that they don’t expect too much of themselves. These goals will vary for each individual and will change in the course of their recovery.
Accepting the need to approach communication in a different way and adapt to limitations can be a very bitter pill to swallow for many people. People with aphasia and their families cannot be expected to make these adjustments overnight. They will need the help and support of a speech and language therapist and others. It is very important to be positive, to try and work around the disability as much as possible and not to expect too much.
Assessing and coping with handicap
Since we use language to initiate, build and maintain relationships and to put across our personalities, the loss of language is often devastating. People with aphasia may experience difficulties fulfilling their roles as father, mother or grandparent, or they may have problems with doing their job. These difficulties will inevitably affect the quality of life of the person and their family. The effect this has on people can be very different. One person who is aphasic may experience very little handicap because their lifestyle and interests are not really affected, whereas someone with a milder aphasia may be devastated by their inability to work, help their children with homework and maintain relationships with friends. Once again, by talking to people with aphasia and their families, the speech and language therapist will gain an insight into an individual’s level of handicap. Of particular importance is the relationship between the person with aphasia and the person they talk to most.
The speech and language therapist will be able to provide emotional support alongside practical help. The therapist may be involved in liaison with employers or with looking at the ability of the person with aphasia to return to college. They may help the person with aphasia to reorganise activities in their daily life so that they take on responsibilities that they can manage and delegate to others those that they cannot. This approach can be applied to anything from looking after children to going to work. In addition, the speech and language therapist may run groups for people with aphasia which aim to help them address issues to do with the disabilities and handicaps that they experience by sharing their problems with others.
People with aphasia often experience a strong emotional reaction to their communication difficulties. Depression is common in people who have had a stroke and particularly in those with aphasia. In addition, changes in personality may occur, including increased irritability, anger, frustration or indifference. Although these characteristics are understandable reactions to the aphasia, they often affect the whole family. It may therefore be necessary for the speech and language therapist or others involved in their care to seek some form of counselling for the person with aphasia or occasionally refer them for psychiatric help.
People with aphasia may also have a problem with how they are perceived by others. Many unfortunately suffer the experience of being treated as if they were intellectually impaired and unable to make their own decisions. It is important to try and counteract these misconceptions and increase people’s understanding of aphasia. The speech and language therapist can help with this by trying to explain the nature of the person’s difficulties to family, friends and employers. In addition, charities and societies that try and support people with aphasia aim to educate the public about the abilities and needs of people with aphasia. Perhaps the best advocates of all are people with aphasia and their families who know what aphasia is really like (see Personal experiences).
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Contents
- Introduction
- What is communication?
- Why do neurological disorders affect communication?
- Language difficulties: What is language?
- What is aphasia?
- Language difficulties: Speech and language for people with aphasia
- Language difficulties: Recovery
- Language Difficulties: Progressive aphasia
- Language difficulties: Personal experiences of aphasia
- Language difficulties: What can you do to help a person with aphasia communicate?
- Speech difficulties
- Speech difficulties: How is speech affected in people with neurological disorders?
- Speech difficulties: Speech and language therapy for people with dysarthria
- Speech difficulties: Medical and surgical treatment
- Speech difficulties: Personal experiences
- Speech difficulties: What can you do to help communication?
- Other communication problems
- Further reading
- Other organisations that may be able to help
- Your feedback on Speech, language and communication difficulties
