Auditory dyslalia and Articulation Disorders of a Different Aetiology in Children with Hearing Impairment

: This article presents the results of research carried out to assess the potential non-auditory causes of articulation defects in deaf children. Who was tested were twenty people with hearing impairment between the ages of eleven and seventeen, whose functional hearing is 40 dB on average, as assessed on the basis of tonal audiometry in a free sound field. The study involved a questionnaire assessing the structure of the articulation apparatus, a questionnaire assessing the fitness and muscle tone of the articulation apparatus, and a questionnaire assessing functions (physiological functions) within the articulation apparatus (Lipiec, Więcek-Poborczyk). The obtained results point to the need for an in-depth diagnosis of articulation and its condition among deaf patients, the determination of pathomechanisms of sound disturbances in the assessed speech, and the inclusion of broadly understood preventive mechanisms derived from logopaedics in the therapeutic process.


Introduction
The number of children with congenital hearing impairment has remained at a similar level for many years (Szyfter, Wróbel, Szyfter-Harris, & Greczka, 2013, p. 4).It should be assumed that all of these children require speech therapy support.This is a diverse group because many factors, including the depth and cause of hearing impairment, the age at which the child received a hearing aid device, and the quality of hearing and speech therapy, affect the level of acquisition of language competence.The effectiveness of improvement achieved depends on the proper diagnosis of the state of speech at the beginning of the therapy, as well as exo-and endogenous factors that may affect speech development (Krakowiak 2012;Muzyka-Furtak 2015;Bieńkowska 2017).It is also necessary to systematically verify the progress made in order to adjust the therapeutic action to the state of speech and language development that changes with age.
Kazimiera Krakowiak (2012) proposed a typology of the speech condition of children with hearing impairment, in which the benefits of a hearing prosthesis enabling the acquisition of speech by auditory means are important.The author distinguished four groups of people with hearing impairment: ■ functionally hearing, who show an insignificant and slight decrease in hearing efficiency, communication is difficult only in adverse acoustic conditions; ■ hard of hearing, with a moderate decrease in hearing efficiency and limited ability to notice distinctive features of sounds while maintaining segmentation of the speech stream; the understanding of speech is difficult, which may cause speech distortions; ■ hearing impaired who, despite the use of hearing aids, have significantly reduced hearing performance; ■ deaf, i.e. people without the benefit of hearing aids or not using hearing aids for various reasons, which means that these people do not use hearing in the language communication process (they are functionally deaf) (Krakowiak 2012, pp. 115-127).
In turn, in the classification by Danuta Emiluta-Rozya (2017, p. 115) the criterion is the level of mastery of the language system.The author proposed a description of the speech condition of a child with a hearing impairment, distinguishing: ■ speech underdevelopment due to hearing loss; ■ delayed speech development due to hearing loss; ■ auditory dyslalia; ■ development norm.
The authors of both typologies point out that one should not analyse the child's state of speech through the prism of audiological diagnosis, the result of tonal audiometry, and the depth of hearing damage found.The auditory benefits of individually selected hearing aids are important.The availability of early audiological intervention, quick and effective prosthesis, early hearing and speech therapy, and greater social awareness mean that children with hearing impairment often reach a normative state of speech during the developmental period, and the observed abnormalities occur only on the phonological and phonetic level.

Dyslalia -terminological clarifications
Interferences observed in persons with speech disorders in the implementation of phoneme allophones are referred to as dyslalia and defined differently depending on the adopted criteria and the detailed description.The etiological criterion is adopted by Irena Styczek (1983) in describing dyslalia as "a delay in language acquisition as a result of delayed development of the functions of certain brain structures" (p.250).Other definitions refer mainly to the symptomatic criterion, e.g."a symptom of speech disorder related to only one aspect of the language, namely articulation" (Rodak 1992, p. 25).A symptomatic definition may also be considered as "an articulation disorder in which individual sounds are missing as phonemes of native speech or a set of sounds, or they are replaced by other sounds or created in a faulty manner" (Pruszewicz 1992, p. 242).In a similar current, dyslalia is defined by Genowefa Demel (1996) as "an irregularity in pronouncing one sound, many sounds, and even all or almost all sounds at once (gibberish)" (p.32), and by Leon Kaczmarek (1977) as "the implementation of phonemes that deviates from the norm established by tradition" (p.102).
In the article, we adopt, after Halina Mierzejewska and Danuta Emiluta-Rozya, the understanding of dyslalia as "determining the abnormal state of elementary segments of speech, i.e. speech sounds (sounds that are phonemes)" (Emiluta-Rozya 2006, p. 132).Emiluta-Rozya (2008) states that these are "disturbances in speech sounds" (p.26) and as such can only be a narrow range of speech difficulties (disturbed articulation) or co-occur with difficulties in using complex linguistic structures (difficulties in both reception, i.e. in understanding as well as in expression).Hence, it seems the most justified to clarify the definition of dyslalia and include in it, along with the symptomatic criterion, the etiological criterion, indicating the causes and pathomechanisms of irregularities.In this approach, dyslalia can occur in almost all forms of speech disorder (cf.List of Forms of Speech Disorder, Emiluta-Rozya 2008), but it has other causes.
The term dyslalia is therefore not a diagnosis, but only a description of the symptoms of speech disturbance, the cause and pathomechanisms of which must be precisely determined in the process of speech therapy diagnosis (cf.Emiluta-Rozya 2006, p. 102;2008, pp. 29-31).After adding an adjective specifying the causes of speech disturbance, dyslalia becomes a nosological unit.As understood this can have peripheral, environmental or cerebral causes.Emiluta-Rozya (2008) includes anatomical, auditory and functional dyslalia as peripheral dyslalia (p.29).The cause of anatomic dyslalia (dysglosia) are congenital or acquired defects in the structure of the organs of the articulatory apparatus, and the pathomechanism is the limitation or inability to perform precise movements of these organs during articulation.The auditory dyslalia is caused by defects in the structure or functioning of the hearing organ, leading to hearing loss, which results in a reduc-tion of auditory control both when receiving and making speech.The causes of functional dyslalia may include reduced efficiency of the articulation apparatus, parafunctions and endogenous dysfunctions (e.g.respiratory dysfunction due to allergies) and abnormal movement habits in the course of biting off, biting and chewing, swallowing or breathing, usually caused by care errors (e.g.long-term bottle feeding), sucking an empty teat, giving the child food of powdery consistency for too long).The pathomechanism here is the abnormal movement habits of the organs of the articulation apparatus during articulation and/or limiting or preventing precise articulation movements.In turn, environmental dyslalia is conditioned by incorrect pronunciation patterns occurring in the immediate vicinity of the child, and the pathomechanism of imitating them.Emiluta-Rozya (2008, p. 30) also mentions subcortical and cortical dyslalia in the etiological classification.Subcortical dyslalia as a nosological unit is an articulation disorder without associated respiratory, phonation and prosody disorders.It can also be a term for speech distortion in dysarthria.The cause is damage to the subcortical structures of the central nervous system causing paresis of the muscles of the articulatory apparatus, i.e. usually discrete disorders of muscle tone and strength, most often of the tongue, less often the lips and soft palate.This leads to difficulties in making precise articulation movements.Cortical dyslalia is not a diagnostic unit and means disturbances in the implementation of phonemes in cortical speech disorders: aphasia and cortical speech distortion.The cause is damage or dysfunction of the cortical structures of the central nervous system, and the pathomechanism of various intensified difficulties in performing intentional movements and their joining during the implementation of phonological structures (instability in aphasia or inability to stabilize cortical speech sounds in cortical speech deformation) (Emiluta-Rozya 2008).
In the article we present the possibility of occurrence of a different aetiology of dyslalia in children with hearing impairment.Similarly to children with normal hearing, the conditions of abnormal articulation in children with hearing impairment can be multiple.Thus, children with hearing impairment may have anatomical abnormalities in the structure of the organs of the articulatory apparatus, which may be the cause of articulatory abnormalities.Also, disturbances in the course of primary functions or reduced efficiency of the articulation apparatus may be present in this group of children and may affect the realization of sounds of the Polish language.One should not overlook the extremely important environmental factor (environmental pronunciation patterns), which may also result in pronunciation irregularities.
In speech therapy diagnosis, the causes of incorrect articulation should be determined and, if possible, the leading cause should be determined.Thus, the diagnosis may be, for example, anatomic, anatomic-functional or auditory-anatomic-functional dyslalia.It is worth referring to Kaczmarek's quantitative classification, specifying the number of incorrectly implemented speech sounds, adding information on whether the dyslalia is singular (incorrect articulation of one sound), multiple (incorrect articulation of several sounds) or total (total lack of pronunciation of sounds, only prosodic elements remain) (Kaczmarek 1966, p. 81).A description of the symptoms should indicate the type of interference: elision (lack of phoneme implementation in the form of a separate segmentsound), paralalia (phoneme implementation falls within the field of implementation of another phoneme), deformation (phoneme implementation goes beyond the proper norm of the implementation of this phoneme) or a deformed substitute (the resulting sound is not systemic and is in the field of implementation of another phoneme) (Kania, 1982, pp. 12-15).It is also necessary to determine what sounds are affected by irregularities (e.g., sigmatism, rotacism, lamdacism, kappacism) with an exact specification of the type of deformation or a description of what sound is changed into another.An example diagnosis could therefore be: ■ Singular environmental dyslalia; uvular specific rotacism; ■ Multiple anatomical and functional dyslalia; parasigmatism: /s/ and /z/ sounds pronounced as hissing sounds; interdental lambdacism; ■ Hearing and anatomic dyslalia; specific sigmatism: /s/ and /z/ sounds pronounced as dorsal.

Auditory dyslalia -the meaning of the term
Due to the subject of the article, attention was focused on one of the types of articulation irregularities -auditory dyslalia.It is a speech disorder in children with hearing impairment due to the limitation or lack of access to acoustic speech patterns and the limitation or lack of auditory auto-control (Emiluta-Rozya 2008, pp. 29-31).
The causes can be: ■ narrowed auditory field; ■ limitation of the range and intensity of auditory perception (dB and Hz); ■ sound compression in hearing aids (implants).
Articulatory abnormalities in children with hearing impairment are often a priori referred to as auditory dyslalia (audiogenic).Such a diagnosis is offered without prior, in-depth interview or speech therapy examination.It is somehow "assigned" to small, hearing-impaired patients.However, the diagnostic procedure should be reviewed, because hearing loss alone does not explain certain irregularities in pronunciation among this group of children.In a situation where early audiological diagnosis and prosthesis, and as a result surdological therapy, are possible, it is necessary to ensure the development of the language system, including in the phonological and phonetic aspect.Some years ago, when the diagnosis took place after the age of three (or later), most speech therapists focused on building a language system so that the child received a communication tool as soon as possible.In the current, altered "audiological reality" one should take care of reference speech.In this process, it is important to take actions to prepare the ground for the formation of proper articulation.

Methodological assumptions of the research
The main objective of this study is to verify the aetiology of articulation disorders occurring in patients with severe and profound prelingual hearing loss (detected and provided with prosthetics in infancy), in whom audiogenic dyslalia has been diagnosed.The following specific objectives have been identified: ■ assessment of the structure and efficiency of the articulation apparatus and the course of orofacial activities in people diagnosed with auditory dyslalia; ■ verification of the aetiology of the observed articulation disorders.
For the purposes of this work, the following questions were asked: 1.What abnormalities in the anatomical structure of the articulatory apparatus were found in the examined persons? 2. What is the efficiency of the articulation apparatus of the subjects?3. What disorders in the course of orofacial functions occur in people in the studied group? 4. What parafunctions occur in the examined persons?

Characteristics of the study group
From a group of children from the Association of Parents and Friends of Children with Hearing Impairment in Krosno (APFCHI), 20 people were selected from the age of 11 to 17 (min.10;6 max.17;2; average 13;9) with diagnosed auditory dyslalia.
All of the children had deep hearing impairment detected early (in the Neonatal Hearing Screening Program) and were provided with prosthetics with one cochlear implant before the age of 30 months.Five of them were later implanted counter-laterally.Eleven of the children use a hearing aid in the other ear and the remaining four do not have a second prosthesis.From the time of optimal sound processor setting (after the first implantation), all of these children have had hearing in the free hearing field of at least 40 dB.From the moment hearing impairment was detected, the examined persons underwent intensive speech therapy -mainly by the method of auditory-verbal education.All of the subjects come from hearing families that use phonic language, so speech improvement also took place in the home environment.Environmental conditions for incorrect articulation were excluded in all subjects.The examined subjects are within the intellectual norm, without additional disabilities.
At the time of entering this study, all of the subjects had only articulation disorders due to hearing impairment (in the Summary of Forms of Speech Disorder by H. Mierzejewska and D. Emiluta-Rozya referred to as auditory dyslalia (Emiluta-Rozya 2008).

Description of the test procedure
The research, the results of which are presented in this article, was carried out in February 2019 during the weekly rehabilitation visit for children with hearing impairment organized by the Association of Parents and Friends of Children with Hearing Disorders in Krosno (APFCHD).The structure, efficiency and functions of the articulation apparatus were examined by: ■ questionnaire for assessing the structure of the articulation apparatus; ■ questionnaire for assessing the articulation and muscle tone of the articulation apparatus; ■ questionnaire for the assessment of functions (physiological functions) within the articulation apparatus (Lipiec, Więcek-Poborczyk) 1 .In order to ascertain the aetiology of articulation disorders, the detailed structure was analysed: ■ nose: general appearance, symmetry (approximate assessment of the nasal septum -with visible curvature), shape of the nostrils, patency (both nostrils), height of the column; ■ lips: continuity, symmetry, length and thickness of the gingular frenulum, length and shape of the upper lip (possibly scars, cavities, shape changed as a result of breathing dysfunction or other reasons); ■ lower jaw: size, position relative to the upper jaw (or displacement); ■ tongue: size (possibly macroglossy, microglossy), symmetry (symmetrical/ asymmetrical tongue, or tongue tissue defects), surface (presence of a tongue groove, tongue folding, so-called geographic tongue), shape (assessment and description of apex, shape of the tongue), sublingual frenulum (length, thickness, places of upper and lower attachments); ■ hard palate: symmetry (symmetrical, asymmetrical), shape (normative, highly arched palate, gothic, flattened), surface (normative, possibly defects or scars, presence of submucosal cleft); ■ soft palate: length (in proportion to the hard palate), symmetry, surface (normative, possibly defects or scars, submucosal cleft), length and symmetry of the uvula; ■ throat: palatine tonsils (size, symmetry); ■ teeth: general dentition (healthy/carious teeth), missing teeth, tooth displacement, and supernumerary teeth; ■ bite: normal (norm) / malocclusion (type).
Next the muscle tone and fitness were assessed: ■ lips: wide opening of the mouth -maximum extension of the lips, tightening and protrusion of the lips (pursing) -lips tight, smacking, alternating: smile (with lips joined together) and pursing, protrusion of lips and arrangement in a window/ring (with closed teeth), alternating: smile and ring/window (with visible joined teeth), tightness of stretched lips (lips are tight), taking air into the mouth like a balloon and holding it for a moment, biting the lower lip with upper teeth (upper teeth are visible) wheezing/vibration of the lips; ■ tongue: maximum sticking out of the tongue on the chin, raising the tongue towards the nose (lower jaw down), alternating: sticking the tongue on the chin and raising towards the nose (lower jaw down), touching tip of the tongue on the corners of the lips with the lower jaw down (the tongue moves in the air, without touching the lower lip, the lower jaw should not move sideways), raising and holding the tongue near the gingival shaft (lower jaw lower), positioning the tongue in the shape of a ridge (tip of the tongue behind the inner surface of the lower teeth, lower jaw down), protrusion of the tongue in the shape of an arrowhead -sharp apex, the tongue does not touch the teeth or lips (lower jaw lower), positioning of the tongue in the shape of a teaspoon (the tongue does not touch the teeth or lips, lower jaw down), licking the hard palate from back to front -to the teeth (lower jaw down), licking with the tongue around the lips (lower jaw down), licking the area behind the lower teeth -sweeping movements (lower jaw down), pushing out each cheek in turn with the tongue (the tip of the tongue makes an up-down movement; closed lips), moving the tip of the tongue with circular motions in the buccal cavity (closed lips), licking the tip of the tongue of the upper dental arch (lower jaw down), clicking (sticking the tongue mass several times to the hard palate with the lower jaw down, followed by dynamic detachment with accompanying characteristic sound effect); ■ lower jaw: making chewing movements with closed lips, alternating raising and lowering of the lower jaw several times, dynamic (loud and short) pronunciation of the vowel [a], lower jaw down, yawning.
The following assessment criteria were taken into account in the tests of muscle fitness and tone: ■ muscle tone of individual organs of the articulatory apparatus; ■ precision and speed of movements; ■ ability to switch from one system to another (applies to alternating exercises); ■ presence of additional movements (e.g.jaw, lips).
A final assessment of functions within the articulation apparatus was carried out.The following physiological functions were investigated: ■ resting breathing: nasal (normal)/oral (abnormal); ■ dynamic breathing: oral-nasal track -normal (breathing in mainly through the mouth, breathing out through the mouth when pronouncing oral sounds, nose when pronouncing nasal sounds)/abnormal (type) -shallow inhalation, attempts to speak on inhalation, shortening of the exhalation phase, disturbance of the ratio between length of inspiration and exhalation; ■ biting off: anterior (normal)/lateral (abnormal), cutting off the food (normal)/ breaking off the food or keeping the food in the interdental space until its softening (abnormal); ■ biting, chewing: crushing and grinding of food by means of lower jaw movements -abduction, sideways movement, adduction with closed mouth (normal)/vertical chewing with closed or open mouth (abnormal)/alternating chewing: circular and vertical with changing lip system (abnormal); ■ swallowing: infantile -flat arrangement of the front of the tongue, the tongue slides between the teeth or presses on them, the mouth muscles tense (normal until the age of 4 years, abnormal after that time)/mature -verticalisation of the wide tongue of which the front part is located near the gums, teeth close to each other, lips loosely closed, flexion and mandibular muscles tighten (normal after 3-4 years of age); ■ parafunctions: finger sucking/tongue sucking/sucking the inside of the cheek/ lip sucking/biting nails/biting pencils/biting the lip/lip pulling on the teeth/ munching with empty mouth (without food)/unnecessary licking of lips/ other.

Findings
The analysis of the research results obtained was divided into three parts.The first concerns the assessment of the structure of the articulatory apparatus, the second its fitness and muscle tone, the third -the course of functions (physiological activities) within the articulatory apparatus.

The results of the assessment of the structure of the articulation apparatus
The structure of individual parts of the apparatus, i.e. nose, lips, jaw and teeth, was assessed.■ Nose structure -the general appearance of the nose, its symmetry and patency were 94% assessed as normal.The nose shape and height of the column were 100% appropriate.■ Lip structure -lip continuity and symmetry, as well as the length and thickness of the gingular frenulum were correct in all subjects.In 6% of the subjects, abnormal lip symmetry, length and shape of the upper lip were found.■ Lower jaw structure -the lower jaw size was 100% assessed as adequate; however, nearly 20% of the subjects had an incorrect position relative to the upper jaw (horizontal shift laterally and/or anteriorly/intralesional). ■ Tongue structure -tongue size, surface and symmetry were 100% assessed as appropriate.A shortened sublingual frenulum that simultaneously changed the shape of the tongue occurred in 12% of subjects.■ Structure of the hard palate -symmetry and surface in 100% of subjects were correct, while the shape was correct in 83% of subjects.■ Structure of the soft palate -velum length and surface as well as uvula length and symmetry were 100% correct, while velum symmetry was correct in 94% of subjects.■ Teeth -no supernumerary teeth were found, 20% of the examined patients had missing teeth, 33% had teeth displacement.■ Occlusion -occlusion defects were found in 35% of subjects.

The results of the assessment of muscle articulation and muscle tone
The efficiency of the lips, tongue, jaw and soft palate was assessed.As part of the assessment of lip dexterity, the results2 were obtained (test-result normal %): wide mouth opening: 100%, lip pull-out and extension: 94%; smacking: 94%; alternation of lip tightening and stretching (smile and pursing) 94%; protrusion of the lips and arrangement in a circle: 97%; alternating smile and circle -97%; tightness of stretched lips -97%; taking air into the mouth -94%; biting the lower lip -100%; vibration of the lips -97%.
Assessment of tongue efficiency: maximum protrusion onto chin: 92%; raising towards the nose: 78%; alternating protrusion onto the chin and lifting towards the nose: 72%; touching the tip of the tongue on the corners of the lips with the lower jaw down: 83%; tongue lift and retention at the gingival shaft 94%; positioning the tongue in the shape of a ridge: 97%; protrusion of the tongue in the shape of an arrowhead: 75%; positioning of the tongue in a spoon shape: 75%; licking the hard palate from back to front: 92%; licking the lips: 92% correct assessments; licking the area behind the lower teeth -92%; pushing out the cheeks: 97%; tongue movements in a circular motion: 97%; licking the tip of the buccal cavity: 100%; licking the upper dental arch: 94%; clicking: 100%.
Assessment of lower jaw efficiency -92% chewing; raising/lowering: 100% and assessment of the soft palate efficiency -pronouncing the vowel [a] -lower jaw down 88% of people performed this test correctly, and yawning 97%.The above figure shows that 10% of the subjects performed the efficiency test for the tongue incorrectly, 7% -for the soft palate and lower jaw, and 3% -for the lips.It should be remembered that the examined adolescents are people who have been provided with speech therapy3 since the detection of a hearing defect (from early childhood), hence the high results obtained in assessing the fitness and muscle tone of the articulatory apparatus are probably the result.

The results of the assessment of functions (physiological functions) within the articulation apparatus
The following orofacial functions were assessed: breathing, swallowing, biting off, biting, chewing, and the possible presence of parafunctions (Fig. 2).The following results were obtained: ■ 89% of subjects received a positive assessment of resting breathing; ■ 83% of subjects received a positive assessment of dynamic breathing; ■ 100% of subjects bite off correctly; ■ 83% of subjects received a positive assessment in the biting and chewing test; ■ 67% of subjects received a positive assessment of swallowing -persistent infant swallowing was found; ■ parafunctions were found in 6% of subjects.
Figure 2 illustrates the results of the assessment of physiological functions within the articulation apparatus in the group of examined children.

An indication of other potential aetiologies of articulatory disorders after trials
After completing the test procedure, 60% of the subjects were found to have factors other than hearing damage alone which may affect the state of articulation of the children.In 30% of the subjects these were anatomical and functional conditions, in 20% -functional and in 10% -anatomical.In 40% of subjects, there were no other determinants of improper articulation other than hearing impairment.
The results confirm the hypothesis adopted in the work that in a group of children with significant and profound hearing impairment, articulation difficulties may arise, which have their source in the abnormal structure, efficiency and function of the articulation apparatus.

Conclusions
The following analysis assumes that existing disorders in the articulation area may also have anatomical and/or functional causes, not necessarily only perceptual ones.Diagnosis must be precise and speech therapy must be targeted.
The conducted research showed that when assessing the state of speech in children with hearing impairment, all possible conditions should be taken into account.The subjects found: abnormal nose structure (6%); lips (6%); abnormal position of the jaws relative to each other (20%); shortened sublingual frenulum (12%); abnormal construction of the hard (17%) and soft (6%) palate; missing teeth (20%), tooth displacement (33%), malocclusions were found in 35% of the patients.
In tests of the efficiency and muscle tone of the organs of the articulatory apparatus, a slightly reduced efficiency of the tongue, soft palate, lips and lower jaw was found (tongue -11% of tests performed, soft palate -7% of tests performed, lips -3% of tests performed, lower jaw -7% of tests performed).

Discussion and practical implications
The present, high level of audiological intervention has forced changes to the current approach to the therapy of children with hearing impairment (Lorenc, 2014).A large proportion of children with profound prelingual hearing loss given implants in the early period achieve good hearing of basic speech frequencies and develop partial acoustic control over their speech, so that in many cases it becomes possible to control articulation (Seifert, Oswaldi et al. 2002).The existing assumptions of surdological speech interactions are valid, but it is worth implementing actions in the area of broadly understood preventative speech therapy.Particular attention should be paid to the course of reflexes, followed by orofacial functions, the assessment of which should not be omitted during the initial period after audiological diagnosis.It is a difficult time for parents who are just learning about the damage to their children's hearing and are starting activities related to prosthetics, taking speech therapy, etc.Therefore, they may overlook the correct feeding method, food calendar, proper course of functions within the articulation apparatus, or even the negative impact of using empty teats.Therefore, the specialist's tasks include drawing attention to this aspect in the field of preventative speech therapy.
The tests were intended to indicate possible, co-existing causes of articulation defects, other than hearing field limitation, in children with hearing impairment.It is the case that there is a "diagnostic generalization" and the term audiogenic dyslalia is used for all children with hearing impairment, without an in-depth analysis of the nature of the origin of articulatory irregularities, assuming a priori that their cause is the limitation of the auditory field and the lack of auditory self-control.

Figure 1 .
Figure 1.Results the tests of the efficiency of the articulation apparatus -abnormal realisations Source: Own study.
Figure. 2. Results of the assessment of functions (physiological functions) within the articulation apparatus (percentage of correctly performed functions and parafunctions in the examined persons) Source: Own study.