Children with Developmental Apraxia of Speech Communication Profiles and Interventions - PowerPoint PPT Presentation

Loading...

PPT – Children with Developmental Apraxia of Speech Communication Profiles and Interventions PowerPoint presentation | free to download - id: 3d578-YWU4Y



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

Children with Developmental Apraxia of Speech Communication Profiles and Interventions

Description:

Robin et.al., (1993) noted that children had disordered prosody, suggesting that ' ... Garn-Nunn & Katz, 2000. Obtained postings daily from APRAXIA-KIDS ... – PowerPoint PPT presentation

Number of Views:575
Avg rating:3.0/5.0
Slides: 113
Provided by: munroemyer
Learn more at: http://aac.unl.edu
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Children with Developmental Apraxia of Speech Communication Profiles and Interventions


1
Children with Developmental Apraxia of Speech
Communication Profiles and Interventions
  • Laura J. Ball, Ph. D.
  • Munroe-Meyer Institute for Genetics and
    Rehabilitation
  • University of Nebraska Medical Center, Omaha

2
Demographics
  • Onset
  • Course
  • Gender
  • Prevalence
  • Aggregation

3
Research Classifications
  • Unitary Entity isolate one characteristic that
    differentiates DAS from other childhood speech
    problems.
  • Syndrome does not require one necessary and
    sufficient dx criterion.
  • Subtypesbehavioral characteristics are
    associated with dx criteria for each of 2
    subtypes of the disorder.

4
Theoretical Perspective
  • Shriberg et.al., (1997a, 97b, 97c) present a
    schema for speech production in DAS with
    linguistic processing stages.
  • 1. Input processes (auditory-temporal,
    perceptual)
  • 2. Organizational processes ( representational,
    transformational)
  • 3. Output processes (selection-retrieval,
    pre-articulatory sequencing)
  • 4. Articulatory execution.

5
DAS Deficit in Input Processes?
  • Auditory-Temporal Perceptual input processes
    are usually proposed from 2 general perspectives.
    Children with DAS have
  • 1. Across-the-board deficits in language
    processes.
  • 2. Specific deficits in either formulation or
    transformation of appropriate phonological
    representations.

6
  • Robin et.al., (1993) noted that children had
    disordered prosody, suggesting that impaired
    temporal perception could impact ability to gain
    information about durational aspects of prosody
    and add to the observed prosodic difficulties.

7
DAS Deficit in Organizational Processes?
  • Representational Perceptual Organization
  • Velleman Strand (1994) implicate
    representational processing. They suggest that
    children with DAS could be seen as impaired in
    their ability to generate utilize frames, which
    would otherwise provide the mechanisms for
    analyzing, organizing, utilizing information
    from their motor, sensory, linguistic systems
    for the production of spoken language.

8
  • Maassen, Thoonen, Gabreels (1993) Children
    with DAS demonstrate a phonological encoding
    disorder.

9
  • Snow, Marquardt, Davis (1992) Children with
    DAS demonstrate an apparent breakdown in the
    ability to perceive syllableness and access
    compare syllable representations with regard to
    position structure.

10
  • Groenen, Crul, Maassen, Thoonen (1993) weaker
    auditory memory traces suggest perceptual
    discrimination tasks have diagnostic value. The
    degree of dysfunction in speech production is
    related to the degree of dysfunction in speech
    perception.

11
  • Transformational Organization
  • Morphophonemic, allophonic sociolinguistic
    rules appear to be intact.

12
DAS Deficit in Output Processes?
  • Pre-articulatory Sequencing
  • (most prevalent) attributes the variability
    observed in speech output to deficits in
    pre-articulatory sequencing of the
    spatio-temporal movements for speech sounds.

13
Selection-Retrieval
  • Phonetic variability involves a lower-level
    deficit in motor programming, rather than
    retrieval of phonemic units.
  • Walton Pollack (1991) motor theory Although
    one could argue that there is a phonemic
    confusion in the speech of these children, one
    could also argue that their ability to
    demonstrate these contrasts is lost when their
    motor systems are taxed or challenged.

14
DAS is a disorder of movement

15
Diagnostic Features
  • Speech Errors
  • Differ from errors of children with developmental
    delay, phonological processes.
  • Resemble errors of adult acquired apraxia
    (contrast between voluntary and involuntary
    performance, variability of errors).
  • Differ from dysarthria, which has errors in
    phonation, resonance, articulation prosody.

16
  • DAS impacts
  • all aspects
  • of communication

17
Why do we Communicate?
  • Light (1988) identified four purposes of social
    communication
  • 1. expression of wants or needs,
  • 2. transfer of information,
  • 3. social closeness, and
  • 4. social etiquette.

18
Important Aspects
  • 1. DAS as a disorder of movement
  • 2. DAS as a disorder impacting all aspects of
    communication

19
DAS Defined
  • Typically defined in terms of sound production
    error patterns, actually a disorder of movement.
  • Difficulty is noted with purposeful voluntary
    movements for speech, creating an inability to
    sequence speech movements in the absence of
    paralysis.

20
DAS is a disorder of movement

21
Survey of SLPs
  • Participants
  • regional SLPs treating DAS
  • Profiles
  • children actually in treatment
  • Perspective
  • clinical awareness vs. pure research version

22
Profiles
23
DAS Communication Characteristics
  • Decreased intelligibility
  • Disordered language
  • Social withdrawal
  • Behavioral aggression
  • Academic failure

24
Important Aspects… gee, notice a pattern here?
  • 1. DAS as a disorder of movement
  • 2. DAS as a disorder impacting all aspects of
    communication

25
Screening for DAS
  • Address increase in referrals diagnoses of DAS
    among preschool population
  • Short administration time
  • Organize, streamline assessment process
  • Increase assessment efficiency
  • Morehouse Linderman, 2000

26
Screening for Developmental Apraxia of Speech
(SDAS)
  • Oral Motor Movements
  • Phoneme Stimulability
  • Intelligibility
  • Checklist of DAS Characteristics
  • Increasing Word Length
  • Multisyllabic Words Across Trials
  • Interpretation Recommendations
  • Morehouse Linderman, 2000

27
Assessment of DAS (Strand, 1998)
  • Neuromuscular
  • Muscle strength, tone, coordination
  • Reflexes
  • Sensory function
  • Structural Function
  • Structures, tissue characteristics, sensation
  • Range of motion, strength, coordination, speed,
    ability to vary muscle tension.

28
  • Motor Speech Production
  • Simple to complex phonetic sequencing
  • CV, VC, CVC (vary the vowel)
  • monosyllabic words
  • multisyllabic words
  • phrases
  • sentences of increasing length

29
Assess at Level of Breakdown
  • Examine any vowels NOT heard in spontaneous
    speech
  • Examine CV/VC combinations, also omitting those
    heard in spontaneous speech
  • Examine CVC productions, omitting those heard in
    spontaneous speech
  • same 1st last phoneme
  • different 1st last phoneme

30

Examine Words of Increasing Length
  • simultaneous production with examiner
  • direct imitation
  • delayed imitation

31
Examine Multisyllabic Words
  • simultaneous production with examiner
  • direct imitation
  • delayed imitation

32

Physiological functioning for speech production
  • Respiration
  • Laryngeal function
  • Resonance Large number
  • hyper- nasal
  • hypo- nasal
  • mixed nasality

33
Articulation Phonology
  • What evaluation procedures would be most
    appropriate to address the needs of children with
    DAS?
  • What evaluation procedures would be most
    appropriate to address the needs of children with
    motor-based speech disorders?

34
Intelligibility Comprehensibility
  • What are the most appropriate means of assessing
    intelligibility in young children?
  • How might you get a measure of a childs
    comprehensibility vs. intelligibility?

35
Intelligibility/Comprehensibility
  • Index of Augmented Speech Comprehensibility in
    Children (I-ASCC) (Dowden, 1997)
  • A non-standardized clinical measure to assess
    comprehensibility.

36
I-ASCC Hierarchy
  • Present a picture with a verbal cue such as What
    is this?
  • Present a picture and provide contextual cues
    such as Its a food you might eat. What is it?
  • Present a picture plus an embedded model such as
    Its pizza. Now you say it.

37

38
Intelligibility
  • Judge listens to taped utterances without
    contextual cues and transcribes.

39
Comprehensibility
  • After listening to judging the entire set of
    utterances without contextual cues, the listener
    rewinds the tape, reads a contextual cue and
    transcribes again.

40
Contextual Cues
  • Something children eat at snack time.
  • Something children use during craft time.
  • Something children eat for lunch.
  • Clothing young girls wear outside.
  • What you see children doing with a book.

41
Language
  • What current methods exist to measure expressive
    language in unintelligible children?
  • What are the most appropriate assessment
    procedures for assessing both receptive and
    expressive language in children with DAS?

42
Clinically, consider of ALL of the following
  • Movement skills
  • Receptive expressive language skills
  • Physical structures and functions
  • Comprehensibility
  • Communication repertoires in use

43
Differential Diagnosis
  • Determine which characteristics are most readily
    apparent. Are there dominant speech
    characteristics?
  • Dysarthria vs. DAS
  • Fluency disorder vs. DAS
  • Phonological disorder vs. DAS
  • Developmental articulation vs. DAS

44
Research Questions
  • What attributes of overall communication
    disabilities are found in children with DAS?
  • Do clusters based on communication disabilities
    exist for children with DAS?

45
Methods
  • N36 children with DAS
  • Screening
  • DAS Screening Instrument (Blakeley, 1980)
  • Child Social Interaction Scales (Adapted from
    Booth-Butterfield and Gould, 1986 Duran, 1992
    Wiemann, 1977 Canary and Spitzberg, 1987
    McCrosky, 1982 Christophel, 1990 and Burgoon,
    1976.)

46
Criteria for Inclusion
  • Committee of 3 DAS experts rated degree of DAS
  • A mean score ? 3, considered DAS

47
  • Articulation and Phonology
  • Do children with DAS use phonological processes?
    Examine consistency of productions.
  • Khan-Lewis Phonological Analysis
  • Articulation prosody
  • Goldman-Fristoe Test of Articulation
  • Consider impact on language skills reading
    development

48

Language
  • Language sample if intelligibility allows
  • Comprehensive receptive expressive
  • Morphology syntax
  • Test of Auditory Comprehension of
  • Language (III) (1998)
  • Peabody Picture Vocabulary Test (IIIA/B)

49
Communication
  • Social communication skills
  • Behavioral communication repertoires
  • Academic communication skills
  • Social Skills Rating System (Gresham and
    Elliott, 1990)

50
Assessment Procedures Contributing to DAS Profile
Identification

51
Profile Communication Aspects
  • Intelligibility Comprehensibility
  • Language (receptive expressive)
  • Social
  • Behavioral
  • Academic

52
Cluster Analysis
  • Measure used to examine large data set and
    determine if there are patterns of similarity
    among the variables.
  • Results in dendrogram (see diagram) which
    depicts the total data set and each stage of
    grouping the most similar data points (or in this
    case, children with DAS) into clusters.

53
Cluster Analysis
  • Confirmatory measure of profiles previously
    obtained (Ball Beukelman, 1998).
  • Classifies sample into smaller number of mutually
    exclusive groups based on similarity.
  • Variables analyzed simultaneously to discover
    underlying structure.

54
Significant Discriminant Functions
55
Profile Identification Procedures
Discriminant Function Structure
Weights Articulation-oriented Function
1 Articulation -.531 DAS .488
Intelligibility .481 MLU .452
PCC .413 Language-oriented Function
2 Parent/behavior -.453 Language
comprehension .434 Receptive Vocabulary
.363 Phonological skills .347

56
Cluster One, n 12
  • high articulation errors
  • high social skill ratings
  • high DAS scores (very DAS)
  • few consistent phonological processes
  • low intelligibility
  • low vocabulary scores
  • high disruptive behaviors
  • low receptive language scores
  • small MLU
  • low PCC

57
Cluster Two, n 12
  • high articulation errors
  • high social skills ratings
  • less DAS
  • many consistent phonological processes
  • low intelligibility
  • high vocabularyscores
  • few disruptive behaviors
  • high receptive language scores
  • high MLU
  • high PCC

58
Cluster Three, n 1
  • high articulation errors
  • many consistent phonological processes
  • more DAS
  • low intelligibility
  • low vocabulary scores
  • less socially interactive
  • many behavioral disruptions
  • low receptive language skills
  • low MLU
  • low PCC

59
Cluster Four, n 11
  • low articulation errors
  • few consistent phonological processes
  • less DAS
  • high intelligibility
  • high vocabulary scores
  • less socially interactive
  • few behavioral disruptions
  • high receptive language scores
  • high MLU
  • high PCC

60

Cluster Status on Significant Variables
  • I II
    IV
  • High Articulation Err Low Language X
    X
  • Low Articulation Err High Language
    X
  • High Behavior Probs. Low Language X
    X
  • Low Behavior Probs. High Language
    X

61
(No Transcript)
62
Intervention
63
Motor Learning Theory
  • Motor learning occurs as a result of experience
    practice
  • Relevant factors
  • Precursors to Motor Learning
  • Conditions of Practice
  • Knowledge of Results
  • Effects of Rate

64
Motor Learning Prepractice
  • The prepractice portion of a therapy session
    involves
  • Motivation
  • make the tasks seem important
  • set goals with the child with standard to achieve
  • not just do the best you can
  • Focused Attention

65
General Idea of Task
  • understand task clearly
  • ways they will learn
  • keep instructions simple focus on 1-2 important
    aspects of movement.
  • DO NOT OVERINSTRUCT

66
Observational Learning
  • modeling demonstration with pictures,
    videotapes, and live demos
  • show the child the movements a few times covering
    all stimuli being targeted in the session
  • be wary of verbal instructions

67
Establish Reference of Correctness
  • auditory feedback
  • i.e., for /pa/, may have lip closure as correct
    to begin, then later move to correct articulation

68
Motor Learning Practice
  • Knowledge of Performance
  • Knowledge of Results
  • summary
  • immediate
  • Repetitive Practice
  • mass
  • distributed

69
Knowledge of Performance (KP)
  • Feedback about the correctness of a particular
    movement pattern re accuracy of production.
  • e.g., I heard you say ….

70
Knowledge of Results (KR)
  • Feedback about the outcome of a movement pattern
    re environmental goal.
  • e.g., Yes, you got it! No, thats not quite
    it.

71
  • Avoid extraneous activity (speaking, movements by
    clinician/child) during the period between the
    response when you deliver KR, also after KR

72
  • Summary KR is better than immediate KR, better to
    wait until several (easier wait 15, difficult
    wait 3-5) responses are obtained

73
Conditions of Motor Speech Practice (DAS)
  • Repetitive Practice
  • need enough trials/session to allow motor
    learning to occur become habituated to
    automatic
  • use reinforcements that dont take time
  • develop activities that facilitate repeated
    opportunities for production of target movement
    patterns

74
  • Mass vs. Distributed Practice
  • decision depends on severity and type
  • mass yields quick development of accurate
    production
  • distributed requires longer time, but get better
    generalization
  • direct imitation
  • delayed imitation

75
  • Examine Sentences of Increasing Length
  • direct imitation
  • with repeated attempts

76
Speech Practice for DAS
  • Intensive treatment is required
  • Large number of movement repetitions required (no
    fewer than 20)
  • Come to neutral position between attempts (rest),
    do NOT divide into component parts
  • Progress through hierarchy of task difficulty
  • Treat rhythm, stress intonation to coincide
    with articulation drills

77
Augmentative and Alternative Communication
Children with DAS

78
Integrating AAC and Natural Speech
  • Extent of AAC use depends upon the communication
    load that can be carried by natural speech.
  • Extent of AAC use will vary from child to child.
  • Extent of AAC use will vary for a child depending
    on the communication goal.

79
Lindblom Model of Mutuality
  • Rich
  • Information
  • from the
  • acoustic signal
  • (Intelligibility)
  • Poor
  • Poor Signal-Independent Rich
  • Information

Higher Comprehensibility
Lower Comprehensibility
80
Intelligibility Estimates
  • Mother 85
  • Grandmother 30
  • School SLP 30
  • Classroom teacher 50
  • AAC Specialist 25-30

81
AAC Use Intelligibility of Children with DAS
  • N 36 children confirmed with DAS
  • M 6 years, 1 month age
  • M 44 intelligibility
  • Range of intelligibility from 0 to 97
  • N 1 child using AAC at time of evaluation for
    DAS

82
Use of AAC systems by Children with DAS
(Cumley, 1997)
  • Participants were children with severe
    phonological disorder and/or DAS
  • N 16 Children
  • 3 yrs, 5 months to 7 yrs, 5 months

83
Procedures
  • DAS children with a range of intelligibility were
    taught to use an AAC technique
  • Children engaged in play situations
  • Interactions were video recorded and analyzed

84
Research Design
  • ABA Design
  • 1. No AAC Board Present
  • 2. Treatment Condition with AAC Board Present
  • 3. Post-treatment Condition with AAC Board
    Present

85
Results
  • Increase comprehensible messages
  • Increased successful communication repairs
  • Children with most severe speech disorders used
    AAC most frequently

86
  • AAC use did not decrease the number of speech
    attempts!!!
  • AAC use reduced the number of gestures.
  • AAC was used primarily to resolve communication
    breakdowns.

87
Communication Goals
  • Conversation
  • Small talk
  • Information sharing
  • Language learning
  • Participation
  • Education Recreation
  • Social memberships
  • Establishing maintaining
  • Wants Needs

88
Multimodal Considerations
  • Communicative contexts
  • Communicative goals
  • Intent of communication situation
  • Immediate future communication needs
  • Support development of skills

89

Focus on Communicative Competence
  • Theme-specific boards
  • Picture/symbol dictionary
  • Remnant books
  • Voice output communication aids
  • Collaborate roles responsibilities for each
    partner
  • Establish initiation repair of breakdowns)

90
AAC Strategies
  • Sign
  • Low-tech (situation specific)
  • Portable digitized speech devices (situation
    specific)
  • Portable general purpose devices

91
AAC Evaluation
  • Why children with DAS are difficult to augment
  • typically ambulatory
  • have developed alternative, often unique
    communication strategies
  • may have intact cognitive skills
  • language development ongoing
  • may have poor literacy skills

92
AAC Device Specifications
  • Portability
  • Comprehensive system
  • high tech
  • low tech
  • Cover extensive vocabulary demands
  • Minimize sequencing demands
  • Teach sequencing skills
  • Allow facilitate language development

93
Family Concerns re DAS
  • Qualitative Research Project
  • Garn-Nunn Katz, 2000
  • Obtained postings daily from APRAXIA-KIDS
    listserve
  • Apparent Themes
  • Diagnosis
  • Treatment
  • Securing Treatment
  • Personal

94
Family Diagnostic Concerns
  • 26 of postings
  • Varying descriptive terms
  • Nature of problem
  • Concomitant problems
  • Importance of Early Diagnosis
  • SLP crucial to success
  • Garn-Nunn Katz, 2000

95
Family Treatment Concerns
  • 28 of postings
  • Importance of speech motor practice
  • Sign language, AAC facilitate speech early
  • Parents intensively involved with treatment
  • Changing nature of treatment
  • Educational concerns
  • Garn-Nunn Katz, 2000

96
Family Concerns Securing Treatment Services
  • 22 of postings
  • Intensive treatment, long period of time
  • Secure different sources of treatment
  • IEP procedures, goals, availability of services
  • Private insurance issues
  • Parent advocacy training, IDEA
  • Garn-Nunn Katz, 2000

97
Family Personal
  • 17 of postings
  • Success stories, thanks, encouragement
  • Failures, venting
  • Explaining DAS to others to child
  • Local support groups
  • Garn-Nunn Katz, 2000

98
Case Study
  • Walt, 10 year 6 month old male
  • Regular 4th grade classroom Intelligibility lt50
    to unfamiliar listener
  • Diagnosed with DAS in 1998
  • 8 years of traditional articulation-oriented
    speech therapy
  • Past evaluation, recommendations

99
Assessment Results
  • Language
  • TACL-3
  • PPVT-III
  • Receptive subtests from CELF-R
  • MLU

100
  • Articulation/Phonology
  • GFTA
  • KLPA
  • Screening Test for Developmental Apraxia of
    Speech (Blakeley, 1980)
  • Percent of Consonants Correct
  • Motor Speech Tasks

101
  • Social Communication
  • Social Skills Rating System(Gresham Elliott,
    1990) (AGS)
  • Child Social Interaction Scale
  • Intelligibility/Comprehensibility
  • I-ASCC

102
AAC Assessment for Walt
  • Examine current communication and communication
    needs
  • parent child interview
  • speech evaluation results
  • communication abilities
  • understands symbols for communication
  • emerging literacy skills

103
  • Physical Status
  • ambulatory, active
  • good fine motor control
  • hearing and vision WNL

104
Walts Communication Device
  • Lightweight portable
  • Durable
  • Extensive vocabulary
  • Support emerging literacy skills
  • Support developing language
  • Allow for novel message generation
  • Good quality voice output for communication in a
    variety of contexts

105
Walts Communication System
  • DynaMyte (DynaVox Systems, Inc)
  • Topic Boards
  • Letter Board
  • Remnant book
  • Natural speech

106
Classroom Recommendations
  • Provide multiple avenues of communication
  • Computer supported literacy options
  • Phonetic based word generation (Intellikeys)
  • Story reading (Living Books, Intellikeys)
  • Story writing (WriteOutloud, CoWriter)
  • Organizational software (Inspiration)

107
Speech Therapy Recommendations
  • Frequent treatment sessions (daily)
  • Brief treatment sessions (15 min)
  • Motor learning concepts stressed
  • knowledge of results
  • knowledge of performance
  • distributed practice
  • Provide tactile, visual, verbal feedback

108
References
  • Bradford Dodd (1996). Do all speech-disordered
    children have motor deficits? Clinical
    Linguistics and Phonetics, 10(2), 77-101.
  • Davis, B. (1998a). Differential diagnosis of
    developmental apraxia. Newsletter ASHA Special
    Interest Division 1 Language Learning and
    Education, 5(2), 4-7.
  • Hayden, D.(1994). Differential diagnosis of motor
    speech dysfunction in children. Clinics in
    Communication Disorders, 4(2), 119-141.
  • Hayden Square (1999). Verbal Motor Production
    Assessment for Children (VMPAC). The
    Psychological Corporation A Harcourt Assessment
    Company

109
More References
  • Cumley, G. (1997). Introduction of an
    augmentative and alternative modality Effects on
    the quality and quantity of communication
    interactions of children with severe phonological
    disorders. Unpublished Doctoral Dissertation,
    University of Nebraska-Lincoln.
  • Davis, B., Jakielski, K., Marquardt, T. (1998).
    Developmental apraxia of speech Determiners of
    differential diagnosis. Clinical Linguistics and
    Phonetics, 12(1), 25-45.
  • Dowden, P. (1997). Augmentative and Alternative
    Communication Decision Making for Children with
    Severely Unintelligible Speech. AAC, 13(1), 48-58.

110
More References
  • Hall, P., Jordan, L., Robin, D. (1993).
    Developmental apraxia of speech Theory and
    clinical practice. Austin, TX Pro-ed.
  • McNeil, M., Robin, D., Schmidt, R. (1997).
    Apraxia of Speech Definition, differentiation,
    and treatment. In M. McNeil (Ed.), Clinical
    management of sensorimotor speech disorders (p.
    394). New York Thieme.
  • Shriberg, L., Austin, D., Lewis, B., McSweeny,
    J., Wilson, D. (1997a). The Percentage of
    Consonants Correct (PCC) metric Extensions and
    reliability data. JSLHR, 40(4), 708-722.

111
More References
  • Shriberg, L., Aram, D., Kwiatkowski, J.
    (1997a). Developmental apraxia of speech I
    Descriptive and theoretical perspectives. JSLHR,
    40(2), 273-285.
  • Shriberg, L., Aram, D., Kwiatkowski, J.
    (1997b). Developmental apraxia of speech II
    Toward a diagnostic marker. JSLHR, 40(2),
    286-312.
  • Shriberg, L., Aram, D., Kwiatkowski, J.
    (1997c). Developmental apraxia of speech III A
    subtype marked by inappropriate stress. JSLHR,
    40(2), 313-337.
  • Strand, E. (1998). Treatment of developmental and
    acquired apraxia of speech. In D. Beukelman K.
    Yorkston (Eds.), Motor speech disorders.
    Baltimore Brookes.

112
More References
  • Strand, E. A. (1995). Treatment of motor speech
    disorders in children. Seminars in Speech and
    Language, 16(2), 126-139.
  • Shriberg, L., Austin, D., Lewis, B., McSweeny,
    J., Wilson, D. (1997b). The Speech Disorders
    Classification System (SDCS) Extensions and
    lifespan reference data. JSLHR, 40(4), 723-740.
  • Caruso Strand (1999). Clinical Management of
    Motor Speech Disorders in Children. NY Thieme.
  • Beukelman, D., Mirenda, P. (1998). Augmentative
    and Alternative Communication. (2nd ed.).
    Baltimore Brookes.
About PowerShow.com