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Review of  Clinical Linguistics

Reviewer: Leah R. Paltiel-Gedalyovich
Book Title: Clinical Linguistics
Book Author: Louise Cummings
Publisher: Edinburgh University Press
Linguistic Field(s): Applied Linguistics
Issue Number: 19.3411

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AUTHOR: Cummings, Louise
TITLE: Clinical Linguistics
PUBLISHER: Edinburgh University Press
YEAR: 2008

Leah R. Paltiel-Gedalyovich, Ben-Gurion University of the Negev

Following the introductory chapter 1, ''The scope of clinical linguistics'', this
book is divided into six sections, each devoted to a different category of
communication disorder. The introduction gives a very intense overview of the
role of the speech-language pathologist (hereafter, SLP), her areas of interest
and other professionals with whom she corroborates. This chapter also sets up
the structure which will be followed in the remaining sections of the book: (1)
epidemiology and etiology, (2) clinical assessment and (3) clinical
intervention. Within the categories of clinical assessment and intervention,
sections are subdivided into topics such as feeding, speech, hearing and
language. Current research is surveyed both to support the clinical description
and in the discussion of intervention methods, thus supporting evidence based
practice. Throughout the book, the role of parents and caregivers in successful
intervention and as partners in communication is stressed.

Chapter 2. ''Disorders of the pre- and peri-natal period.'' The discussion in this
chapter is restricted to two main groups of disorders, cleft lip and palate and
cerebral palsy, which have a clear pre- or peri-natal neurological or other
organic etiology.

The discussion of cleft lip and palate begins with a summary of the embryonic
etiology. Then feeding difficulties are discussed, which are often a primary
difficulty with this population, thus emphasizing one of the major
non-communicative intervention areas of the SLP. Within the language section,
Cummings includes phonological disorders, lexical delay – often directly related
to the child's phonetic abilities, and expressive syntactic disorders. The need
for constant reevaluation is emphasized. The following section describes
clinical intervention. First surgical options and timing implications are
brought, with an emphasis on speech outcomes and facial growth. Then speech and
language intervention is discussed, including indirect intervention through
parental participation and direct intervention methods, particularly in
phonology and articulation. Alongside procedures used with many populations, the
specific benefits of electropalatography with children with cleft lip and palate
are stressed. Language therapy is incorporated only in the second stage of

The second half of this chapter deals with cerebral palsy (CP). Possible factors
involved in CP are listed. Different types and classifications of CP are
enumerated. The clinical assessment of the individual with CP begins soon after
birth and includes communication, feeding and swallowing skills. The first
question regarding feeding is an assessment of the appropriateness of oral
feeding or the necessity of an alternative method. This is a question primarily
of safety. Video-fluoroscopy is an important part of the feeding and swallowing
assessment. The feeding assessment should provide detailed information on the
nature of the oromotor dysfunction and how it may affect other areas of
communication. The majority of children with CP present with developmental
dysarthria. Speech assessment includes characterizing the individual's dynamic
speech pattern. Articulation, resonation, phonation and respiration must be
considered. Likely symptoms accompanying CP are listed. As many children with CP
are at risk for hearing loss, neonatal screening is critical. Language deficits
may be the result of hearing impairment, motor disability and/or intellectual
disability. Phonological processing deficits may underlie vocabulary and
literacy difficulties. In using formal assessments, mode of response may need to
be modified to suit the individual's motor disability. Feeding intervention is
discussed in detail, including the need for work on drooling control. With
regard to communication intervention, perhaps the most important statement made
here is ''Normal speech is not a realistic goal of treatment for CP children and
adults with dysarthria'' (p. 99). Successful communication is the aim, including
use of augmentative and alternative communication systems, improving
articulation and breathing where possible and adapting the environment
(communicative partners) to facilitate communication.

Chapter 3 ''Disorders of cognitive development.'' This chapter includes two types
of disorders: learning disability (LD) and autistic spectrum disorder (ASD).

The definition of LD as given resembles traditional definitions of 'intellectual
disability' and 'mental retardation'. A wide range of genetic, infectious and
traumatic etiologies can result in LD. Although feeding problems may not be as
central in cognitive disorders as in CP and cleft lip and palate, many of the
etiologies that result in cognitive disorders also result in feeding disorders,
in addition the cognitive impairment may hinder remediation progress. Assessment
methods and monitoring procedures are similar to those suggested for CP and
cleft lip and palate. Speech assessment aims to determine the relative
contributions of structural deficits neurological/cognitive involvement and
hearing loss to impaired speech. Dysarthric and dyspraxic types of speech
disorders are described. In addition to articulatory and phonological disorders,
fluency disorders may also occur. Different types of hearing loss may co-occur
with cognitive impairments with conductive loss most common in cases of
cranio-facial anomalies. General cognitive impairment adversely affects language
development as general cognitive skills used in language learning are not
available. However, language impairment in the presence of (relatively) intact
cognitive skills has also been widely reported. In addition to etiologies where
language skills lag behind non-language cognition, Cummings brings examples of
clinical populations in which language skills have been traditionally held to be
intact relative to general cognitive development, for instance in Williams'
Syndrome and Fetal Alcohol Syndrome. Current research suggests language deficits
in these populations in both linguistic and pragmatic skills. Language and
pragmatic skills of individuals with Down's Syndrome are discussed in detail.
The intervention section begins with a survey of methods for early communication
intervention, or the facilitation of pre-language behaviors. This is followed by
a summary of speech and language intervention. Intervention with specific
populations requires a familiarity with the particular, often atypical,
developmental pattern of this population, thus enabling ordering and sequencing
of treatment goals. A review of articulation and phonological treatment
techniques follows. A detailed discussion of the treatment of DS includes
emphasis on various visual techniques including signing, reading and visual
bio-feedback. The final subsection on intervention in LD deals with alternative
and augmentative communication.

The second main section of this chapter deals with the assessment and treatment
of autistic spectrum disorder (ASD). Before discussing the etiologies,
assessment and intervention with ASD, Cummings presents a survey of the various
types of ASD and the discriminating symptoms. Studies are brought supporting a
genetic correlation and a survey of neurological findings is included. Before
presenting the assessment section for ASD, a summary of clinical presentation is
given, beginning with a rundown of comorbid conditions. A discussion of
formalized tools for both linguistic and pragmatic skill assessment introduces
the section on assessment. For pragmatic skills, formal assessments are
insufficient since it is imperative to view conversational skills in context.
Furthermore, high functioning children may perform typically on formal,
structured tests, a performance not indicative of their unstructured
communicative behavior. Checklists can aid assessment of communication skills.
Intervention techniques range from augmentative or alternative communication
systems to play, and social and communication skills training, while all
intervention strategies require involvement of regular conversational partners.

Chapter 4. ''Disorders of speech and language development''. In this chapter after
a brief introduction, four different populations are discussed: developmental
verbal dyspraxia (DVD), developmental phonological disorder (DPD), specific
language impairment (SLI), and Landau-Kleffner syndrome (LKS).

DVD has been found to be linked to several genetic syndromes. It has been
correlated with neurological abnormalities. However, there is also a correlation
with some types of metabolic disorders. Cummings introduces a description of the
characteristics of DVD with a note on the lack of agreement in the literature on
what these are. She then aims to report those characteristics for which there is
consensus, although she does note throughout the descriptions given that even
those which she includes are not universally agreed upon. In the assessment of
children with DVD in addition to the regular assessment regime, special
attention should be paid to the developmental history, audiological evaluation,
play skills, and morpho-syntactic, semantic and phonological abilities, as well
literacy skills. Specifically with regard to speech behaviors, phonological and
prosodic skills as well as physiological support for speech should be assessed.
Intervention usually involves more than one technique. Issues such as therapy
intensity and group versus individual therapy are discussed together with a
survey of some commonly used techniques and research which reports the success
of these techniques.

The second subsection of this chapter deals with DPD. There are great
discrepancies in the reported incidence of DPD. By definition DPD is a disorder
of unknown origin but there is increasing evidence of a genetic basis.
Generally, children with DPD present with persisting normal phonological
processes, chronological mismatch, variability in the use of processes,
over-substitution with a chosen sound or sounds and idiosyncratic processes.
Children with DPD experience difficulties with other language skills, including
literacy skills, which may persist into adulthood. Assessment begins with a
detailed case history which provides information helpful in diagnosis and in
prognosis. Oral structures, as well as hearing, are assessed. Sound assessment
should include standardized and non-standardized assessments to insure
sufficient sample size. The result of assessment should include: a phonetic
inventory of the child's sounds and phonological (word, syllable and word)
processes, as well as a rating of intelligibility in spontaneous speech. A
speech sample also constitutes a language sample and can be used to evaluate
expressive and receptive language skills (lexicon, syntax, morphology, prosody,
fluency, etc.). Assessment should also include stimulability of disordered
sounds. Approaches to phonological intervention are surveyed. Choice of which
sounds/processes should be targeted first is based on developmental order, as
well as factors related directly to the child's specific speech pattern.
Different treatment regimes and orientations are brought. Note that like DVD,
DPD requires many treatment sessions to effect change.

The third population addressed in this chapter is SLI. Increased reports of
familial incidence suggest that this disorder, too, has a genetic basis; in
addition there is some support for a neurological basis for SLI. A high
percentage of children with SLI present with phonetic and/or phonological
disorders. Other areas of impairment include morpho-syntax, particularly tense
markers, lexical semantics, literacy skills and perhaps also pragmatic skills.
There are also reports of increased frequency of dysfluency in children with
SLI. Techniques which show research support are those that work on increasing
lexical skills and syntactic skills. In addition, it appears that children with
SLI have difficulty with cognitive processing and memory, particularly
auditory-verbal processing.

The final section of this chapter deals with LKS. This is a relatively late
onset disorder related to convulsive epilepsy. The primary symptom is a sudden
failure to recognize spoken words. Relatively little is said about the
assessment and remediation of this population, reflecting the paucity of
reported research.

Chapter 5. ''Acquired communication and swallowing disorders'' covers five types
of disorders, acquired dysarthria, apraxia of speech, acquired aphasia, acquired
dysphagia and schizophrenia. With the exception of schizophrenia, all of these
disorders have clear neurological origins. Adult disorders differ from
developmental disorders in that they involve a disruption of mature speech and
language skills and that the adult brain lacks the plasticity of the developing
brain which may aid in the development of compensatory mechanisms.

The first subsection deals with acquired dysarthria. Dysarthria is most commonly
the result of CVA but may also result from degenerative neuro-muscular diseases,
head injury and tumors. Because of the nature of the etiologies, all aspects of
speech production are affected. Cummings surveys the different types of
dysarthria, their symptoms and the etiologies with which they are associated.
Assessment and description involves neurological, perceptual, acoustic and
physiological characteristics. Assessment must also consider that often the
patients' status is not static. Perceptual assessments are the most common;
these are supplemented by the objective acoustic analysis. Acoustic analysis
technology is however expensive. Physiological assessments give information
about the physiological basis of the speech disorder. Like acoustic analyses
their use is limited because of the nature of the assessments and the equipment
and staff needed to use them. Intervention techniques may be similar to those
used for children. In some cases augmentative communication systems may be
recommended. As for children, there is great importance in training the
communicative environment.

The second subsection deals with apraxia of speech (AOS). It is not yet clear if
AOS is a language or a speech disorder. Characteristics distinguishing
dysarthria from apraxia are briefly related. Accompanying movement disorders of
the limbs may impair the ability to support speech using augmentative
communication. Assessment is primarily perceptual. As for dysarthria acoustic
and physiological assessments supplement perceptual testing where available. The
clinician must differentiate the symptoms of dysarthria, AOS and aphasia.

The third subsection of this chapter deals with acquired aphasia. As opposed to
dysarthria, and possibly AOS, aphasia is a disorder of language, rather than
speech. Aphasia types have been classified based on the sight of the lesion in
the brain and/or linguistic characteristics. In addition to language skills,
language use/pragmatics may also be affected. In the assessment section,
Cummings emphasizes the relatively neglected pragmatic assessments, while noting
''the abundance'' of linguistic assessments. Communicative effectiveness should
also guide intervention. Intervention may be in group sessions which afford
opportunity for more naturalistic communication demands. Here too,
conversational partner training is an important part of the treatment program.

The fourth subsection is devoted to acquired dysphagia. Speech-language
therapists aid the assessment and remediation of acquired dysphagia as part of a
multi-disciplinary team. Assessment begins at bedside and involves an assessment
of the swallowing mechanism and aspiration risks. This initial assessment
screens patients who will need instrumental assessments such as videofluroscopy
or endoscsopy. Intervention is primarily behavioral, sometimes supported by
biofeedback procedures. Where oral feeding is unsafe alternative techniques may
be necessary. The importance of recruiting caregivers to support the swallowing
program is stressed.

This chapter concludes with a section on schizophrenia. In addition to the
general cognitive and behavioral symptoms, specific language symptoms have been
found. All areas of language behavior may be disordered. Some of these may be
related to problems in thought organization and executive planning. There is a
summary of research into the lexical, syntactic and pragmatic abilities of this
population but no specific discussion of assessment or intervention. From this
it is not clear whether or not Cummings considers the SLP to have a role in the
management of these patients.

Chapter 6 ''Disorders of fluency'' includes a discussion of stuttering and
cluttering. Stuttering is defined and its defining characteristics listed.
Incidence figures are given for a variety of languages with numbers ranging
between almost 1% and over 5%. There appears to be a genetic basis for
stuttering. Although there is no apparent neurological basis for developmental
stuttering, neurological stuttering in adults following trauma or stroke has
been reported. In addition some approaches consider stuttering to be a
psychological disorder. In addition to dysfluent behaviors, stutterers often
present with language and phonological disorders or auditory disorders.
Secondary behaviors may also occur. Intervention is based on assessment both of
fluency itself and the individual's attitude. Some programs focus on changing
the parents/caregivers as communicators as well as the child. Different
intervention issues at different ages need to be considered. Alongside
behavioral and psychological techniques, medications and auditory feedback
devices may be employed

The second section of this chapter deals with cluttering. Cluttering is not only
a speech disorder but also a disorder of language organization. Both genetic and
neurological factors have been implicated. Characteristics distinguishing
cluttering from stuttering are listed. Often clutterers are also stutterers.
Some assessment and intervention strategies specific to cluttering are brought.

The final chapter of this book is devoted to voice disorders. In voice
disorders, the SLP works primarily together with otolaryngologists in assessment
and remediation. Voice disorders may be more prevalent in certain occupations,
age groups and clinical populations. Voice disorders may have organic or
non-organic etiology. Patients with voice disorders present with a variety of
physiological and acoustic symptoms. The ENT is responsible for examination of
the physical properties of the vocal cords and larynx by a variety of means.
Acoustic devices may be used by the SLP. The perceptual assessment is still the
main criterion for diagnosis. Intervention should be the job of a broad
interdisciplinary team. First, surgical, radiotherapy, and drug techniques are
surveyed. The description of voice therapy is minimal with the reader referred
to other sources. This section ends the chapter and the book.

The target audience of this massive work is the community of speech-language
clinicians, although, the author aims to make her work accessible to a much
wider population including parents, health workers, and linguists. The book is
well organized with each chapter following a set structure. The justification
for this structure is set out in the introduction. The role of the SLP is
presented not only in direct client/patient contact, but also in contributing to
the planning of health services and advocating the needs of the population which
she serves. For the most part, the definition of the SLP's role is made clear,
either as a direct service provider or as a corroborator. Yet, in some cases,
this role is not well-defined, e.g. it is not clear from the text which
professional is responsible for the diagnosis of Autistic Spectrum Disorders.

The book is written very intensely, packed with information. There is a detailed
overview of each topic and references are provided for more details for
practical application of the ideas. Many topics are expanded in the chapter
endnotes, which I would have found easier to read as footnotes.

To me this book reads like a refresher course for the SLP. It is too detailed to
be a general resource for the uninitiated but not detailed enough to be a
practical guide. As Cummings states explicitly in the first chapter, ''The reader
should not regard the following discussion as a practical guide to therapy with
cleft palate children'' (p.64), and this may be true for all the topics covered
in the text. Thus, although some techniques described in great detail, e.g.
sensory work with CP through brushing, for the most part the book can not be
used as a guide for a clinician looking for ''advice'' for a specific client or
client group.

The question of target readership is brought up again because of the unevenness
in the degree of explanation and the level of the terminology, e.g. much of the
discussion of embryological development uses terminology that will be unfamiliar
to non-professional readers. Much of the linguistic and medical terminology is
not defined. One example, the acronym GIRBAS is presented without any
explanation in the chapter on voice (p.410), while three pages later an
explanation is provided of a further acronym GRBAS. While on the other hand, on
p.167 the author finds a need to define 'generalization'.

Although there is a wealth of information provided and, particularly in later
chapters, clinically applicable research is brought from a variety of languages,
I found the discussion to be Anglocentric in the earlier chapters, particularly
in discussion of cleft lip and palate. In general there are little data brought
from other countries, and at times studies are reported without reference to the
language in which they were carried out. Furthermore, some statements, e.g.
''Formal language assessments are now available in abundance.'' (p.59) are just
not applicable in many non-English speaking countries.

Perhaps given the scope of this book it would be impossible to include all the
relevant information, still, I was surprised at the absence of mention of
'social stories' (e.g Gray, 2008) in the discussion of High Functioning Autism
and of 'cued articulation' (Passy, 1990) in the discussion of developmental
dyspraxia. In the pragmatic assessment of adults, I was missing a reference to
the test of Communication Disorders in Daily Living (Holland, Frattali and
Fromm, 1998). In the discussion of acoustic assessment and applications of
feedback in work with a variety of populations it would be worth mentioning the
availability of cheap (in fact free) software such as PRAAT (Boersema and
Weeninck, 2005) which make acoustic information available to clinicians working
in low budget clinics. The information obtained by the use of this program on a
home computer with home standard equipment will be far from the level of
accuracy provided by equipment such as the Kay Computerized Speech Lab, but it
may be an affordable alternative for many of us who do not have ready access to
this expensive equipment and who otherwise will do without any acoustic
information at all.

Perhaps Cummngs cannot be criticized for the omissions brought in the previous
paragraph – this work is so comprehensive and mentions and refers the reader to
so many procedures that covering all current procedures would probably be
impossible. A more serious omission in my opinion is that in the discussion of
SLI there is no mention of the mass of literature emphasizing the heterogeneous
nature of the disorder in terms of sub-groups such as Grammatical/Syntactic-SLI,
Lexical/Word-SLI, Phonological-SLI and Pragmatic-SLI (Friedman and colleagues,
e.g. Friedmann and Novogrodsky, in press, and van der Lely and colleagues, e.g
Fonteneau and van der Lely, 2008). This differentiation has implications for
both assessment and intervention. This omission is in line with a more general
comment. The books title is ''Clinical Linguistics''. I expected to find more
explicit references to the relationship between clinical work and theoretical
linguistics. Following from this, I beg to differ on a point brought in the
introduction of the book (''...issues (e.g. truth-conditional semantics) are not
directly relevant to the work of clinical linguistics'' p.11) There is relatively
little work at present on the typical acquisition of compositional semantics,
however, with the growth of the body of psycholinguistic research investigating
this knowledge (the work of Noveck and colleagues, e.g. Noveck, Chevalier,
Chevaux, Musilino and Bott, in press, and my own work, e.g.
Paltiel-Gedalyovich, 2008), the relevance of formal truth-conditional semantics
to the assessment of (a) typical language and its remediation should become clear.

I would also like to make some comments on the book's presentation. It was not
clear to me why some topics are discussed at great length, while others very
little. This does not appear to reflect incidence. I also missed charts and
diagrammatic summaries. The few that are presented show only the pathological
presentation (e.g. on p.415 diagrams of laryngectomy and consequent intervention
options are shown, but there is no parallel diagram of the healthy larynx).

Louise Cummings' book makes a significant contribution to the literature on the
SLP's role and the critical areas of her occupation. Practicing SLPs will find
it a comprehensive reference, providing evidence on which to base clinical
practice and many useful references for practical guidance.

Paul Boersma & David Weenink (2005): Praat: doing phonetics by computer (Version
4.3.14) [Computer program]. Retrieved May 26, 2005, from

Fonteneau, E., & van der Lely, H. (2008) Electrical brain responses in
language-impaired children reveal grammar-specific deficits. _PLoS ONE_, 3(3).

Friedmann, Naama & R. Novogrodsky (in press) Subtypes of SLI. In A. Gavarrò & M.
João Freitas, (eds.) _Language acquisition and development_. Cambridge:
Cambridge Scholars Press

Gray, Carol (2008) New Social Stories Book: Illustrated Edition. The Gray

Holland Audrey L., C. M. Frattali & D. Fromm (1998) _Communicative Activities
for Daily Living_ (2nd Edition). SuperDuper Publications.

Noveck, Ira, C. Chevalier, F. Chevaux, J. Musilino and L. Bott, (in press)
Children's enrichments of conjunctive sentences in context. In M. Khissine,
(Ed.) _Semantics and pragmatics_. Emerald Group, Elsevier.

Paltiel-Gedalyovich, Leah R. and Jeannette Schaeffer (2008) Scales and
non-scales in (Hebrew) child language. Paper presented at the Workshop on
Contrastiveness and/or Scalar Implicatures, CIL 18, Seoul, July, 2008.

Passy, Jane (1990) _Cued Articulation_. ACER: Camberwell

Leah R. Paltiel-Gedalyovich is a practicing speech-language clinician currently
completing post-doctoral research at Ben-Gurion University of the Negev.

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