Project of psycholinguistics

Dysarthria

The reason of research was to find the reasons and causes of the disease (Dysarthria)

Group Leader : Faiqa Rafique

Group Members Sadaf syeda Iqra Khan Iram Naqvi Adeena Anwaar Tahira Parveen

Table of contents:

Sr.# Topic Page #1. Abstract 2

2. Introduction 3

3. Aim of study 8

4. Purpose statement 8

5. Research procedure 8

6. Literature Review 9

7. Research Methodology 13

8. Findings and Data analysis 14

9. Suggestions and Recommendation 36

10. Conclusion 38

11. References 39

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Abstract

There are several problems which disturbs the sentence structure. One of them is

language disorder. It totally disturbs the language structure, pronunciation,

sentence pattern or in simple words the overall language disorder can be created

due to several reasons.

There are several reasons for the language disorders , one of them is Dysarthria, In

this study it is focused the causes and symptoms due to which language disorders

are created in a human brain.

After the complete discussion and detailed study about the Dysarthria, it is

suggested how it can be improved. So that language disorder could be minimized.

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Introduction:

What is dysarthria?

Dysarthria is a motor speech disorder. The muscles of the mouth, face, and

respiratory system may become weak, move slowly, or not move at all after a

stroke or other brain injury. The type and severity of dysarthria depend on which

area of the nervous system is affected.

Some causes of dysarthria include stroke, head injury, cerebral palsy, and muscular

dystrophy. Both children and adults can have dysarthria.

What are some signs or symptoms of dysarthria?

A person with dysarthria may experience any of the following symptoms,

depending on the extent and location of damage to the nervous system:

"Slurred" speech

Speaking softly or barely able to whisper

Slow rate of speech

Rapid rate of speech with a "mumbling" quality

Limited tongue, lip, and jaw movement

Abnormal intonation (rhythm) when speaking

Changes in vocal quality ("nasal" speech or sounding "stuffy")

Hoarseness

Breathiness

Drooling or poor control of saliva

Chewing and swallowing difficulty

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How is dysarthria diagnosed?

A speech-language pathologist (SLP) can evaluate a person with speech difficulties

and determine the nature and severity of the problem. The SLP will look at

movement of the lips, tongue, and face, as well as breath support for speech, voice

quality, and more.

Another motor speech disorder is apraxia. An important role of the SLP is to

determine whether the person's speech problems are due to dysarthria, apraxia, or

both.

SLPs work in many places, including hospitals, clinics, nursing homes, and

schools. Sometimes an SLP can come to a person's home. To contact a speech-

language pathologist visit ASHA's Find a Professional.

What treatment is available for people with dysarthria?

Treatment depends on the cause, type, and severity of the symptoms. An SLP

works with the individual to improve communication abilities.

Possible Goals of Treatment

Slowing the rate of speech

Improving the breath support so the person can speak more loudly

Strengthening muscles

Increasing mouth, tongue, and lip movement

Improving articulation so that speech is more clear

Teaching caregivers, family members, and teachers strategies to better

communicate with the person with dysarthria

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In severe cases, learning to use alternative means of communication (e.g., simple

gestures, alphabet boards, or electronic or computer-based equipment)

What can I do to communicate better with a person with dysarthria?

It is important for both the person with dysarthria and the people he or she

communicates with to work together to improve interactions. Here are some tips

for both speaker and listener.

Tips for the Person With Dysarthria

Introduce your topic with a single word or short phrase before beginning to

speak in more complete sentences

Check with the listeners to make sure that they understand you

Speak slowly and loudly; pause frequently

Try to limit conversations when you feel tired, when your speech will be harder

to understand

If you become frustrated, try to use other methods, such as pointing or gesturing,

to get your message across, or take a rest and try again later

Children may need additional help to remember to use these strategies.

Tips for the Listener

Reduce distractions and background noise

Pay attention to the speaker

Watch the person as he or she talks

Let the speaker know when you have difficulty understanding him or her

Repeat only the part of the message that you understood so that the speaker does

not have to repeat the entire message

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If you still don't understand the message, ask yes/no questions or have the

speaker write his or her message to you

What other organizations have information on dysarthria and services for

people with dysarthria?

This list is not exhaustive and inclusion does not imply endorsement of the

organization or content of the Web site by ASHA.

Mayo Clinic

FCC speech-to-speech services access numbers

Speech Communication Assistance by Telephone, Inc.

What causes dysarthria?

Dysarthria is caused by many different conditions that involve the nervous system,

including the following:

Stroke

Brain injury

Tumors

Cerebral palsy

Parkinson's disease

Lou Gehrig's disease/amyotrophic lateral sclerosis (ALS)

Huntington's disease

Multiple sclerosis

Medications

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How common is dysarthria?

Information about the incidence and prevalence of motor speech disorders is

available in the ASHA report, Incidence and Prevalence of Speech, Voice, and

Language Disorders in Adults in the United States.

What are the types of dysarthria?

The following Web sites explain and define the many types of dysarthria.

Cognitive Science Initiative: Language Lexicon

The Neuroscience on the Web Series

How effective are speech-language pathology treatments for dysarthria?

ASHA produced a treatment efficacy summary on dysarthria [PDF] that describes

evidence about how well treatment works. This summary is useful not only to

individuals with dysarthria and their caregivers but also to insurance companies

considering payment for much needed services for dysarthria.

In addition, practice guidelines for dysarthria have been developed by the

Academy of Neurologic Communication Disorders & Sciences (ANCDS).

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Aim of study

Through this study the aim was to find out the language disorders in the dysarthria

patients, its causes, reason and the effects.

Its aim was also to find out the reasons and back ground causes which were the

main reasons of language disorders in the patients and how the patients were

affected to this disease.

Purpose Statement:

The purpose of this research was to identify “the causes and reasons of the

language disorders in the dysarthria patients”.

Research Means and Procedure

The hypotheses enunciated above entail the resort to several means of data

collection. To begin with, this research work is led through a qualitative analysis.

To inquire into the patients' relatives and doctors’ beliefs and viewpoints about the

approach, cause and the reasons of the disease, detail discussions were made with

them.

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Literature Review

Dysarthria is a frequent and persisting sequel to stroke and arises from varied

lesion locations. Although the presence of dysarthria is well documented, for

stroke there are scant data on presentation and intervention outcome. A literature

search was undertaken to evaluate

(a) The features of dysarthria in adult stroke populations relative to the

conventional Mayo system for classification, which was developed from diverse

pathological groups, and

(b) The current status of evidence for the effectiveness of intervention in dysarthria

caused by stroke. A narrative review of results is presented. The limited data

available indicate that, regardless of stroke location, imprecise articulation and

slow speaking rate are consistent

This review summarizes and discusses the literature on speech deficits in cerebellar

diseases and on the topography of cerebellar dysarthria. Clinical descriptions of

dysarthric features in cerebellar diseases, parametric investigations of ataxic

dysarthria, and experimental studies in animals concerning the effects of lesions on

vocalization and the representation of sensorimotor orofacial functions in the

cerebellum are considered. Signs of cerebellar dysarthria include a slowing down

of articulatory movements, increased variability of pitch and loudness, monotonous

and "scanning" speech, and articulatory impreciseness. The available data indicate

that the paramedian regions of the superior cerebellar hemispheres are relevant for

the development of cerebellar dysarthria.

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Dysarthria is more prevalent in left than in right hemisphere lesions. There is a

need for comprehensive, thorough analysis of dysarthria features, involving larger

populations, with stroke and other variables controlled and with appropriate age-

referenced control data. There is low level evidence for benefits arising from

intervention in stroke-related dysarthria. Because studies involve few participants,

without external control, and sometimes include stroke with other aetiologies, their

results lack the required weight for confident evidence-based practice.

The search and review of sourced material was carried out by the author. The

search was confined to publications in English between 1985 and May 2010 for

question a) and between January 2007 and May 2010 for question b). This shorter

time period for the latter was selected because of the existence of two

comprehensive intervention reviews on non-progressive dysarthria which

encompass, but are not confined to stroke (Sellars et al., 2005; Palmer & Enderby,

2007).

An initial search was conducted using MEDLINE. To address question a) stroke

was used in combination with dysarthria. To address question b) therapy was

added as a search term. MEDLINE applies additional related terms: stroke

(apoplexy; apoplexies; cerebral stroke; cerebrovascular accident; cerebrovascular

apoplexy; cerebrovascular stroke; strokes; vascular accident brain; cva); dysarthria

(dysarthrias; dysarthosis); therapy (therapeutic; management; treatment;

intervention; remedy; relief; amelioration; alleviation). For question a) 30290

references were raised, of which 586 were classified as 5*, having all search terms,

or their applied related terms, present and complete. For question b) 5298

references were raised of which 86 were classified as having all search terms

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present and complete. Abstracts of all 5* references were evaluated to determine

their relevance to the questions, according to the following inclusion criteria:

o Data confined to participants with stroke or from which stroke specific

data could be clearly distinguished;

1) adult population;

2) Dysarthria diagnosis without accompanying apraxia of speech or aphemia

and clearly differentiated from any co-existing aphasia.

Additionally for question a):

3) Description of a range of speech parameters derived from specified tasks,

including connected speech: data confined to one parameter such as

articulation or phonation, or obtained from a single task, such as vowel

prolongation or rapid syllable repetition provides a narrow focus without

necessarily identifying the dimensions most commonly associated with

stroke;

4) Data from a minimum of 10 stroke participants, as the representativeness of

single case and small group descriptions cannot be determined. No lower

limit as to the number of participants was set for question b) because of the

small amount of outcome research.

Where more than one publication reported on the same participant group or a

subset thereof, the publication with the most complete and comprehensive data was

used. From the MEDLINE search, six discrete studies met the criteria for question

a) and six for question b). Applying the same inclusion criteria and timeframe,

Ingentaconnect, PsycINFO, LLBA and ANCDS databases were examined with a

view to sourcing any additional publications not indexed in MEDLINE. Additional

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search terms of vascular, CVA, infarction, intervention, speech, treatment and

rehabilitation were applied.

Reference lists for all qualifying material were also scanned and electronic and

hand searches were undertaken of relevant communication disorders journals

which may not be fully referenced in the databases through the time period.

Beyond the material sourced from MEDLINE these further searches provided one

additional source for question a) and one for question b), thus totalling seven

sources for questions a) and seven for b). Suitable to the heterogeneous nature of

the available data, the findings are presented in the form of a narrative review, with

associated discussion of key issues arising from the data. Such overviews of the

literature are defined as “comprehensive narrative syntheses of previously

published information” (Green, Johnson & Adams, 2006, p)

Speech and language therapy treatments for people with dysarthria have not been

tested in large clinical trials. Dysarthria is a speech problem which can be caused

by a number of brain disorders including conditions such as stroke and head injury.

Typical features of dysarthria include slurring of speech and quiet voice volume.

Psychological distress is often experienced by people with dysarthria. Speech and

language therapists employ a range of treatments to help people with dysarthria.

There are no large clinical trials which have tested whether these treatments are

effective.

Research Methodology

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Population

All the patients and the doctors of that government institution considered to be the

population for the study.

Sampling

6 patients and 3 teachers were considered to be the sample for the study

Instrument

Qualitative research was made for this purpose. Patients and doctors were

interviewed to collect the data.

Findings and Data Analysis:

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The research was conducted to find out the causes and the reasons of the language

disorders in the dysarthria patients. For this purposes the researchers were visited

to a medical institute and the several patients were visited and the discussions were

made with the patients, their relatives and the doctors in order to find out the

causes and the reasons of the dysarthria disease and then the language disorders

due to this disease. Furthermore observations were made by observing the patients

their behavior, way of talking, the use of language and the selections of the words.

After that a detail reports were made for each patient, in which their causes,

symptoms of disease, their treatment and their overall language disorders were

discussed. These reports are given as;

Patient: 1

Name of Institute

The name of institute was General Hospital Lahore

Name of Patient

Ehsan Elahi

Gender

Male

Age

22 years

Family status of disorder

Not Present

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Medical Examination

Blood pressure = 130/80

Pulse = 88

Disorder

Aphasia and paralysis

History of Patient

The patient went out with his friends in a night. He didn’t come back on that

night. Next day he was found in very serious condition. His friends had beaten

him with the back of pistol and he was sexually assorted by them badly. The

patient was admitted in NISHTAR hospital for 10 days, the doctors told that his

stomach was filled with a huge amount of poison. His poisonous material was

washed out and he stayed there for 10 days. Then they referred him to the

GENERAL hospital Lahore. Here in this hospital he spent 10 days in unit 1 of

neurology and then he was shifted to the unit 3 of neurology.

Diagnoses

CNS = S1+S2

Power =5/15

Brain edema

Kidney damage

Duration in Hospital

Previous 2 months

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Admitted on 24th December 2012

Causes of disorder

Poison

Stroke on the brain by the back of pistol

Sexual assort

Symptoms

Body paralyze

Unconsciousness

Vomiting

Urine blockage

Abuses

Voice Quality

Slurred speech

Pitch

Low

Stress

On lateral words

Narration

Half sentences

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Sentence Pattern

Wrong according to speaking

Sound

Loud

Language Disability

Unable to speak properly

Can’t produce complete sentences

Gestures

He watches at the right side mostly

He answered to that questions which are not asked by him

He start laugh suddenly without any reason

He starts weep and cry suddenly

Emotion

He could understand all the things and answered to the questions

Medication

Tablet ziapine 100mg

Tablet Rivoril 20mg

Injection Methecobal

Injection Clopex

Treatment

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Medicines and injections

Improvement

Now his right side of body is working properly. Left leg is also working

properly. His left arm has also some movement. He answered to the questions

in chunks of sentences.

The above overall detail of this patient shows that he speaks himself, during

his speak he eats the words and give the stress on the lateral words of the

sentence. He speaks in the chunks. The emotions and the feelings can be

observed in his language. When he starts crying or laughing, the sentences

are broken into small chunks and the stress was put on the lateral words. The

sentence structure was totally wrong. He was producing high sounds and his

pitch was low. All these things show how his disease has affected his

language; how language disorders have been produced in his speak. His lip

movement, gestures, way of narration, his voice, pitch, sound and voice

quality all were defected due to his disease, these all are language disorders.

Patient: 2

Name of Institute

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Name of Patient

Mohammad Yusuf

Gender

Male

Age

75 years


Not present

Disorder

Aphasia and paralysis

History of Patient

The Patient is diabetic for 20 years and got CVA one year back of left side. One

of his legs is cut because of diabetes. He got first stroke a month ago for 5 to 6

minutes. The patient is unconscious and doesn’t recognizing anyone. He is also

not replying if someone talks to him, his eyes movement is also weird. He

stares at a point and doesn’t response at any voice. The patient is uttering

incomplete words which are not understandable he is just producing sounds.

Sometimes he moves his right arm while making sounds. Patient’s condition is

very serious.

Diagnoses

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CNS

Causes of disorder

Diabetes

Stroke

Hypertension

Symptoms

Left side paralyzed

Unconsciousness

Abuses

Voice Quality

Slurred speech

Pitch

High

Stress

There is no stress on any word

Narration

Just producing few sounds which are not understandable

Sentence Pattern

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No pattern

Language Disability

Yes

Gestures

He watches at the same point only

He doesn’t answer to any questions

Sometimes he tries to speak but he can’t

His tongue position is same he is unable to move his tongue that’s why he can’t

speak or utter words

Emotion

He is behaving like emotionless he isn’t recognizing anyone not even his own

son.

Medication

Tab: Maxolon,

Inj : Dianpam,

Tab: Rovator.

Treatment


Improvement

Patient is very serious.

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The above overall detail of this patient shows that the patient was not able to

speak properly. It was his 2nd attack of stroke. He was trying to produce the

sounds but he was unable. He was only uttering the sound not complete

words, chunks, phrases or sentences. He was producing low sounds with high

pitch. All these things show how his disease has affected his language badly.

His all qualities of speaking have been damaged badly. These all are

language disorders.

Patient: 3

Name of Institute


Name of Patient

Sarwar

Gender

Male

Age

54 years


Not signified

Disorder

Stroke with paralysis

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History of Patient

According to attending patient was admitted from previous 10 days, in a usual

status of health one day back then he developed right side weakness and patients

fell down on right side. Patient is also unable to speak for 1 day.

Diagnoses

CNS

Causes of disorder

Smoking

Stroke

Hypertension

Symptoms

Left leg or right arm paralysis for 12 hours

Vomiting=1 day

Abuses

Voice Quality

Zero movement of lips

Pitch

Very low and not able to hear

Stress

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No stress on words

Narration

He was able to narrate some sounds but not properly

Sentence Pattern

No pattern

Language Disability

Yes

Gestures

Only seeing

He doesn’t answer to any questions

Speaking is very poor

Response is zero

Emotion

No understanding and No recognition

Medication

Tab=Disprine

Tab=Sane. 20g

Tab=Ulcerex

Tab= Ceftriaxone 1 gm.

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Tab= Zestil 5mg

Treatment


Improvement

Not satisfied

Analysis

The above overall details of this patient show that he was a patient of

language disorder. He was trying to answer the question but he was unable to

answer in complete sense and sentences. He was only able to utter the words only

for example “a” “ba”etc. He was watching to all but not understanding anything.

He was only watching to his surroundings. He was unconscious and unable to

speak. All these things show how his disease has affected his language and his

language disorders.

Patient: 4

Name of Institute


Name of Patient

Ismail khan

Gender

Male

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Age

60


Not present

Disorder

SOB

History of Patient

The patient he was in usual state of health two days back then he developed

fever palpitation than took medicine for fever and was relived. But the

patient was not comfortable so he went to a local doctor next day. His blood

pressure was 220/116. He took medicines for the blood pressure yesterday.

When the patient awoke up in the morning his left (R+) side weakness and

Aphasia

Diagnoses

Aphasia

Paralysis

Causes of disorder

Heart attack

Blood pressure

Body Itchy

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Symptoms

Fever

R+ weakness

Voice Quality

Slurred

Pitch

Low

Stress

Balance

Narration

He was not able to narrate the complete sentences

Sentence Pattern

Wrong

Language Disability

Yes

Gestures

He was able to understand only few things

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He was smiling without reason

Emotion

Strange

Medication

Tab Ciproflex

Tab dispreen

Tab Ceftriancone

Tab Illcerene

Tab Rovata

Treatment

Chest,

Paralyze

Nebulization

Position change

Improvement

He was recovering very slowly

The above overall detail of the patient shows that he was suffering from the

language disorder. Patient’s speech was slurred and he was producing

complete sentences but that were grammatically wrong. His sound was high

and pitch was low. His body language was strange. He was smiling himself

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and doing strange things. He was restless and moving continuously. His

tongue movement was disturbed. These all are the language disorders.

Patient: 5

Name of Institute


Name of Patient

Imtiaz Ali

Gender

Male

Age

15


Not present

Disorder

Stroke

History of Patient

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The patient came in emergency with complaints of fits from last 25 days for

5-7 minutes

Diagnoses

CVA

Paralysis

Causes of disorder

Fits

Blood pressure

Water in kidneys

Symptoms

Unconscious

Right side paralyze

Voice Quality

Slurred

Pitch

Low

Stress

Balance

Narration

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He was not able to narrate the complete sentences

Sentence Pattern

Wrong

Language Disability

Yes

Gestures

He was able to understand everything

Emotion

Good

Medication

Tab Tenormin

Tab Asprin

Treatment

3 months course of prescribed medicine

Improvement

He was recovering very fastly

The above overall detail of the patient shows that he was suffering from

language disorder. When he was admitted he was passing through fits those

effects his speech badly. He was not able to speak the words or sentences

early. His speech was slurred. His sound was high and pitch was low. For the

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short duration he wasn’t able to speak any word. These all are language

disorders

Patient: 6

Name of Institute


Name of Patient

Karamat Ali

Gender

Male

Age

35

Family status

Not Present

Disorder

Stroke

Brain injury

History of Patient

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The patient fell in this disease due to an accident on road. He is suffering

from brain injury due to the road accident after that this brain injury lead

him toward dysarthria (It is a speech disorder resulting from weakness,

paralysis, that is of neurological etiology).

Diagnoses

Brain damage

Causes

Accident

Symptoms

Slurred speed

Vomiting with blood

Voice quality

Low

Pitch

High

Stress

No stress

Narration

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No

Sentence Pattern

No

Language Disability

He was unable to speak

Gestures

He was telling his things by hands

He was answering the questions by hands

Emotions

He was able to understand everything

He was able to move to move his lip, tongue and body.

Medication

Cefspan 400mg ( BID)

Omega 40mg (BID)

Voren Ing. ( BID)

Dicloran 40mg (TID)

Panadol 500mg( TID)

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Treatment

To avoid conversation when you are tired.

Computer to type out words.

Flip cards with words or symbols.

It’s important to maintain a relaxed, calm environment reduce noise music

and other stimuli during communication.

Improvement

When he was admitted, he was restless and did not understanding anything.

He was not answering to anyone. He was unconscious first. Now he was

able to understand and answer the things. Now he was in his senses.

The above overall detail of the patient shows that he was suffering from

language disorder. During his speak he was unable to speak complete

sentences. He was uttering the chunks of sentences. His damage of language

muscles was very severing so that doctors advised him to give rest to his

mouth (language muscles) for a little duration. His sound was loud and pitch

was low.

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Suggestions and Recommendations:

According to the overall it is suggested as;

Suggestions for Teachers:

Learn as much as you can about the student’s specific disability. Speech-

language impairments differ considerably from one another, so it’s

important to know the specific impairment and how it affects the student’s

communication abilities.

Recognize that you can make an enormous difference in this student’s life!

Find out what the student’s strengths and interests are, and emphasize them.

Create opportunities for success.

If you are not part of the student’s IEP team, ask for a copy of his or her IEP.

The student’s educational goals will be listed there, as well as the services

and classroom accommodations he or she is to receive.

Make sure that needed accommodations are provided for classwork,

homework, and testing. These will help the student learn successfully.

Consult with others (e.g., special educators, the SLP) who can help you

identify strategies for teaching and supporting this student, ways to adapt the

curriculum, and how to address the student’s IEP goals in your classroom.

Find out if your state or school district has materials or resources available to

help educators address the learning needs of children with speech or

language impairments. It’s amazing how many do!

Communicate with the student’s parents. Regularly share information about

how the student is doing at school and at home.

Suggestions for Parents

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Learn the specifics of your child’s speech or language impairment. The more

you know, the more you can help yourself and your child.

Be patient. Your child, like every child, has a whole lifetime to learn and

grow.

Meet with the school and develop an IEP to address your child’s needs. Be

your child’s advocate. You know your son or daughter best, share what you

know.

Be well informed about the speech-language therapy your son or daughter is

receiving. Talk with the SLP, find out how to augment and enrich the

therapy at home and in other environments. Also find out what not to do!

Give your child chores. Chores build confidence and ability. Keep your

child’s age, attention span, and abilities in mind. Break down jobs into

smaller steps. Explain what to do, step by step, until the job is done.

Demonstrate. Provide help when it’s needed. Praise a job (or part of a job)

well done.

Listen to your child. Don’t rush to fill gaps or make corrections. Conversely,

don’t force your child to speak. Be aware of the other ways in which

communication takes place between people.

Talk to other parents whose children have a similar speech or language

impairment. Parents can share practical advice and emotional support. Visit

NICHCY’s State Sheets and find a parent group near you. Look in the

Disability-Specific section, under “speech-language.”

Keep in touch with your child’s teachers. Offer support. Demonstrate any

assistive technology your child uses and provide any information teachers

will need. Find out how you can augment your child’s school learning at

home.

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Conclusion:

Speech and language skills develop in childhood according to fairly well-defined

milestones Parents and other caregivers may become concerned if a child’s

language seems noticeably behind (or different from) the language of same-aged

peers. This may motivate parents to investigate further and, eventually, to have the

child evaluated by a professional. The language disorders affect the language

totally which affects the personality of a person completely. Without a language

any person is nothing and with the language disorders he/she completely or

partially feels a sort of hopeless and misery.

The most of the language disorders are developed in the childhood or in the young

age mostly, especially in those who cannot control their emotions. So there should

be such type of efforts done at the domestic, social and government level to wash

the mind of such persons.

References

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1 |Minnesota Department of Education. (2010). Speech or language impairments. Online at:http://education.state.mn.us/MDE/EdExc/SpecEdClass/DisabCateg/SpeechLangImpair/index.html

2 | Boyse, K. (2008). Speech and language delay and disorder. Retrieved from the University of Michigan Health System website: http://www.med.umich.edu/yourchild/topics/speech.htm

3 | Ibid.

4 | American Speech-Language-Hearing Association. (n.d.). Speech sound disorders: Articulation and phonological processes. Online at: http://www.asha.org/public/speech/disorders/speechsounddisorders.htm

5 | Cincinnati Children’s Hospital. (n.d.). Speech conditions and diagnoses. Online at: http://www.cincinnatichildrens.org/health/info/speech/diagnose/speech-disorder.htm

6 | National Institute on Deafness and Other Communication Disorders. (2002). What is voice? What is speech? What is language? Online at:http://www.nidcd.nih.gov/health/voice/pages/whatis_vsl.aspx

7 | American Academy of Otolaryngology — Head and Neck Surgery. (n.d.). Fact sheet: About your voice. Online at: http://www.entnet.org/HealthInformation/aboutVoice.cfm

8 | Boyse, K. (2008). Speech and language delay and disorder. Retrieved from the University of Michigan Health System website: http://www.med.umich.edu/yourchild/topics/speech.htm

9 | Encyclopedia of Nursing & Allied Health. (n.d.). Language disorders. Online at: http://www.enotes.com/nursing-encyclopedia/language-disorders

10 | Ibid.

11 | U.S. Department of Education. (2010, December). Twenty-ninth annual report to Congress on the Implementation of the Individuals with Disabilities Education Act: 2007. Online at: http://www2.ed.gov/about/reports/annual/osep/2007/parts-b-c/index.html

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Sharp HM, Hillenbrand K. Speech and language development and disorders in children. Pediatr Clin North Am. 2008;55:1159-1173.

Simms MD. Language disorders in children: classification and clinical syndromes. Pediatr Clin North Am. 2007;54:437-467.

Simms MD, Schum RL. Language development and communication disorders, In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 19th ed. Philadelphia, Pa: Saunders Elsevier; 2011:chap32.

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