Eastern Journal of Medicine 17 (2012) 171-177

Review Article Speech and communication in

Lindsay Pennington

Institute of Health and Society, Newcastle University, England, UK

Abstract. Children communicate using speech, vocalisation, facial expression, gesture and body movement. The motor disorders of cerebral palsy (CP) may affect the movements needed to produce any type of communication signal. Movements intended to be the same may vary in range, speed, strength and accuracy and as a result communication signals may be difficult to understand. Children’s communication development may also be affected by cognitive or sensory disturbances, which are also common in CP (1). This paper will describe the speech and communication difficulties often experienced by children with CP and will summarise the interventions that have been found to be clinically effective with this population of children. Key words: Cerebral palsy, speech, communication, language, children

into sound (acoustic energy) in the process 1. Speech disorders known as phonation. The resonance of the vocal Motor speech disorders () are tract is determined by its shape, and is altered by associated with all types of CP-spastic, dyskinetic movements of the jaw, soft palate, lips and and ataxic. However, little is known about the tongue. For example, if the nasal cavity is not prevalence of dysarthria in CP. We know that it is closed off during speech, nasal resonance is more common in dyskinetic CP than spastic produced and speech sounds nasalised. forms (2, 3), and that estimates of the overall Articulation refers to the movements of the jaw, prevalence of dysarthria in children with CP are tongue and lips, which further shape acoustic around 50% (2, 4). However, exact prevalence energy to create vowels and consonants. When figures for the presence and severity of dysarthria describing the components of speech production are not currently available, as speech is not researchers and clinicians also talk about currently measured in CP surveillance registers. prosody, which refers to the rhythm, stress and Children with different types of CP share many intonation patterns of connected speech. Prosody speech characteristics and it is difficult for is created by changes in pitch, syllable duration clinicians to differentiate between the CP types and loudness, which in turn depend on respiratory when listening to speech recordings (5). The and laryngeal control. perceptual similarities may be due to the Movements for speech are rapid and demand developmental nature of the disorders or the considerable coordination and control. Dysarthria presence of mixed disorders. in children with CP often affects all processes - Speech production relies on several underlying respiration, phonation, resonance, articulation processes-respiration, phonation, resonance and and prosody. Children may have difficultly articulation. To produce speech respiration is controlling their breathing for speech. They may controlled so that exhaled air is forced from the have shallow breathing and may speak on short lungs through the vocal folds and into the oral bursts of air, which might make their voices and nasal cavities. At the larynx, the vocal folds quiet, especially in longer utterances (6). vibrate to turn air pressure (aerodynamic energy) Children may also have difficulty in coordinating exhalation with phonation. They may exhale and *Correspondence: Dr. Lindsay Pennington then start to speak when a significant proportion Institute of Health and Society of their breath has been exhaled. This may lead to Newcastle University them running out of breath and speaking on England, UK residual air. The vibration of their vocal folds Email: [email protected] may be slow or irregular, which can create low Tel: 00 44 191 282 1360 pitched, monotone and breathy voices (7). Children’s voices may sound harsh or vary

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rapidly in pitch. Reduced control of the soft production of loud, clear voice starts with the palate may lead to speech sounding nasalised, and production of isolated vowels and moves to reduced control of the tongue and lip muscles is words and phrases so that children can practice evident from reduced range of consonants and controlling their voice in functional speech. vowels that can be produced in speech (8-11). Children are taught to maintain sufficient breath Difficulties in controlling the vocal tract can support for words or phrases and to breathe at range from mild, with slight imprecision of appropriate points in phrases. For some children speech in words and phrases, to profound, with a this might be between each phrase in a sentence: complete inability to produce any intelligible “The man” “is feeding” “the dog”. Other speech. children may be able to produce longer utterances Children with CP and communication between breaths “The man is feeding” “the difficulties are at risk of lower quality of life and dog”. Therapy may also include modulating reduced participation (12-14). The aim of speech pitch, loudness and timing for prosody (20, 21). and language therapy is to help children to As this type of therapy aims to help children to communicate effectively and independently in all learn new motor behaviours it should follow situations, thereby increasing their access to motor learning principles: therapists should education and social life. For children with severe provide frequent feedback to facilitate the or profound disorders speech may not be production of the target behaviour and then fade effective as the main means of communication feedback once the target has been reached, in and alternative and augmentative communication order to aid retention; therapy should be given (AAC) systems should be implemented to enable intensively so that children can practise of target children to express themselves and their ideas behaviours frequently; targets should be clearly. For children with less severe disorders randomised in practice, rather single behaviours therapy may serve to increase the intelligibility of being practiced repetitively; and children should their speech. be given provided with knowledge of their results (22-25). 2. Speech intervention Therapy focusing on breathes support and voice Research has shown the different motor control production, which follows the motor learning needed to produce movements for sucking, principles above, has been associated with chewing and speech (15). Motor learning theory changes in the ICF levels of body function and also tells us that motor learning is task specific activity. Increased lung volume and greater (16). Therapy to improve speech production muscular effort (26) have been observed post should therefore focus on speech, rather than oral therapy. Changes to children's voices with exercises that use the same body structures. reduced fluctuations in pitch and increased As dysarthria affects all processes involved in volume have also been observed (27, 28). More speech production, from respiration to importantly clinically, however, is change to articulation, therapy needs to address each of children's speech intelligibility. For a group of these processes. Clinicians and researchers children with mild to severe disorder average recommend that intervention focuses on increases in intelligibility post therapy of 15% controlling respiratory effort and coordinating have been observed. For some children with more exhalation and phonation, as these processes severe disorders this represented a doubling in underpin the production of a robust acoustic the number of words that are understandable in signal (3,17,18). Treatment for articulation is single word and connected speech (21). The only advised when other aspects of speech above studies suggest that intervention focusing production have been/are being addressed, as on clear voice production is effective in changing imprecise “production of speech sounds (which is speech and intelligibility in clinical settings. It is the most common perceptual characteristic of now important that research includes measures of dysarthria) is not simply an oral articulatory change at the ICF participation level, and to problem, and is usually the result of laryngeal, investigate if the intervention has a positive velopharyngeal, respiratory and oral articulatory impact on children’s involvement in social and problems” (18). Thus, more precise articulation educational activities and facilitates everyday and improved intelligibility is achieved through interaction (29). developing control of breathing for speech, Following or in conjunction with therapy to increasing background effort and slowing speech maintain breath support and increase control of rate (3,18,19). the coordination of exhalation and phonation, Therapy to increase respiratory effort and intervention may also address nasality and coordination of exhalation and phonation for the articulation. Behavioural therapy for nasality has

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Review Article been described in text books and includes motor people. Communication signals can be sent using exercises to raise the soft palate and close off the speech, vocalisation, facial expression, gesture nasal cavities (19). However, there is currently and whole body movements. Each of these modes insufficient evidence to evaluate the effectiveness of communication can be affected by the motor of this type of intervention (30). The fitting of disorders of CP as the underlying movements palatal lifts (acrylic prosthetic orthodontic may vary in range, strength, speed and precision. appliances, which extend from the hard to the soft Consequently, children’s verbal and nonverbal palate to close the velopharynx) has been signals may be difficult for their communication recommended for some people with CP (30), but with partners to understand. Because CP often is not widely practiced. results from very early damage to the developing Therapy to improve articulation may involve nervous system, communication difficulties may slowing speech rate, which allows children time be evident from infancy, and there may never be to make the precise movements for speech sound a time in the child’s life when communication production (19). Slower rate could be an follows the usual pattern of development. additional focus of therapy targeting breath Early interaction between parents and infants support and voice, and may have generalised without motor disorders is positively reinforcing. effect on articulation. However, the effects of rate Nondisabled infants produce communication change have not been addressed specifically for signals that their parents can interpret and the children with CP. parents then respond in the manner predicted by Therapy may also address the production of the child. For instance, a preverbal infant may individual speech sounds. Some children may be look at a toy, reach towards it and vocalise. The able to produce sounds in some but not all places parent will watch them associate the child’s within words. For example, they may be able to attention with the object and when they see that produce ‘d’ at the end of a word, but may say ‘g’ the child cannot physically obtain the object and instead of ‘d’ at the beginning of words. In these it is given to the child. The children will thus cases therapy may focus of producing contrasting obtain the object they desired and parents will be words that begin with’d and ‘g’; e.g. ‘gate’ satisfied that they have acted appropriately (33). versus ‘date’. If children are not able to make a Children with motor disorders may also try to target sound (usually a consonant) therapy that reach an object and vocalise. However, due to includes visual feedback may help them to learn primitive reflexes they may not be able to reach to move their lips and tongue to produce the towards an object and look at it at the same time. target sound or an approximation of it. Furthermore, they may not be able to coordinate Electroplatography (EPG) has been tried with the timings of their movements so that they reach successfully for a child with CP (31), but has not and vocalise at the same time. Communication been widely evaluated for this group. EPG signals may therefore be difficult for the parents involves the fitting of a removable acrylic plate to interpret and they may give the child a on the hard palate. The plate has electrodes different toy. In such an instance the child will embedded within it. When the tongue touches the not probably appear content and communication electrodes a visual display shows the where will satisfy neither the child nor the parents (34). contact has been made. Bite blocks, which are To accommodate their child’s difficulties and small blocks held between the upper and lower to enable interaction to be completed smoothly teeth to stabilise the jaw, have also been used to and parents may manipulate interaction help children to learn to move their tongue successfully so that their child has opportunities independently of the jaw to produce speech to produce the communication signals that are sounds (32). intelligible. However, for many children with Increases in intelligibility associated with severe motor disorders intelligible signals may be therapy may help children communicate solely by limited to ‘yes’, ‘no’ and requesting objects or speech, or may mean that they need to use AAC activities within view. As a result of this, parents systems less frequently to augment verbal are restricted to asking children closed questions communication. In either of these cases, children or questions that demand children point to an may become more rapid in their communication object nearby. For example, they may hold up a exchanges and interaction may proceed more video and then a toy car and ask ‘Do you want the smoothly. video? Or the car?’ Restricted patterns of conversation, in which parents choose topics and 3. Communication ask questions to which children make simple Communication depends on the sending and responses, conveying limited information have receiving of messages between at least two

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been observed for children who vary widely in skills. Some children with intellectual age and motor disorder severity (35,36). impairments, for example, are able to express In addition to their difficulties controlling the only a limited number of simple comments and movements for communication children with CP may not be able to repair conversation by may also have cognitive impairments, delayed selecting an alternative way of communicating a language development, and sensory impairments message. (1), which will affect all their processing of Skills that are elicited through testing, but not spoken language and further delay their observed in general conversation, can be expressive communication development. generalised by changing the communication environment. This will involve training of 4. Communication intervention children’s conversation partners, most notably The goal of communication therapy for children their parents and nursery workers, teachers etc, in is to become active and independent order to provide wider communication communicators in all of their daily environments. opportunities for children. Training for To do this they need to develop as full a range of conversation partners covers the process of communication skills as possible and to have an interaction, the importance of letting children intelligible means of expressing all their needs lead conversation and directing others in order to and ideas. help them to become active and independent By two and a half years of age non-disabled communicators, and how to encourage children to children have usually acquired most of the skills use individual communication skills. Training can that they need to engage in conversation (37). be provided to parents and children on an They take an equal role in interaction, starting individual basis (42) or to groups of parents (43). about half of all exchanges with their parents, and Training has been successful in helping parents to can negotiate communication breakdown. They direct interaction less and become more use communication to: responsive to their children’s communication, and • Request attention has been associated with children taking more • Request objects or actions turns in conversation, starting more exchanges • Request information within interaction and asking more questions and • Request clarification of a speaker’s making more statements (42,43). The training utterance when they have not heard or not programmes can be intensive and demanding in understood terms of time and commitment for parents. For example, in the Hanen parent programme, it takes • Provide information / make comments two to talk (44) which was investigated by • Provide clarification by repeating or Pennington et al (43). Group is comprised eight revising their utterance when they have not sessions over twelve weeks, each session lasting been understood between two to two and half hours. In addition to • Signal ‘yes’ and ‘no’ the group training sessions, three individual home • Express their personality e.g. humour, visits are made for this programme to enable sarcasm therapists to coach the parents in the techniques they have learned in the group sessions. In early childhood, speech and language However, the commitment is seen as an therapy assessment should include observation of acceptable and useful investment in their child’s the child in everyday settings to observe which future, as parents continue to use the strategies skills they regularly use in conversation and they learn on the programme as their children testing of the child through play to investigate grow and communication develops (Pennington which of the above skills they can use if given and Noble, in press). the opportunity to do so. It should also be noted Most of the communication skills listed in the how the children convey these communication bullet points above can be used without language. skills, e.g. by gesture, vocalisation or speech (38, For example, children may comment on the size 39). of an object by using gesture and they may signal Skills that are neither elicited through testing that they have not understood someone by nor observed in usual settings may be taught by vocalising using falling and rising pitch and modelling and behavioural techniques. For looking quizzical. However, the range and example, children may be taught to request complexity of ideas that may be expressed objects by eye pointing to them and / or without language can be very limited. Children vocalising (40,41). However, not all children may whose speech is often unintelligible may require be expected to acquire a full range of the above augmentative and alternative systems of

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Review Article communication (AAC) to supplement their and adoption of new communication systems so natural modes. that children can truly express all their ideas The aim of AAC is to provide children all the effectively and take a full and active role in all vocabulary they need to communicate areas of their lives (52,53). independently. AAC systems are divided into aided – where a separate piece of communication 5. Conclusion equipment is provided, such as a picture chart or Children with CP have specific but varied voice out put communication aid - and unaided, communication difficulties which require an where no separate equipment is needed, e.g. sign. individualised approach to intervention. Aided systems include objects, photographs, Difficulties may range from mild speech disorder pictures, pictorial symbols, letters and words. to profound difficulty controlling any movements Children who require aided AAC usually start for verbal or nonverbal communication and with a light tech system, such as a chart or book severe language delay. The aim of all speech and containing symbols or words etc. They may also language therapy should be help children develop benefit from high tech systems which have voice as a full a range of communication skills as output. There are now many high tech devices possible and to be able to express their ideas available, ranging from a single switch to intelligibly. Depending on the severity of produce a single message to complex devices children’s motor difficulties and other storing thousands of words and phrases which can accompanying disturbances intervention may be built up into sentences. The choice of system focus on the teaching of individual is dependent on children’s physical, cognitive and communication skills, speech production or on sensory skills (45), and it is important that the the provision of AAC to supplement children’s AAC system is provided appropriately for the natural forms of communication. As child’s developmental level. communication involves at least two people, it is AAC systems will be usually new to children’s important that therapy involves not only the parents, family and teachers as well as the children with CP but also their parents and other children themselves. Like early communication frequent communication partners if children are therapy, AAC intervention needs to involve both to become active and independent communicators the children and their conversation partners. in all of their daily environments. Children need to be taught how to access the vocabulary in their new systems and produce Acknowledgements words and phrases at the appropriate points in Lindsay Pennington holds a National Institute conversation. Conversation partners need to be of Health Research Career Development taught how to incorporate the system into spoken Fellowship. This report is independent research interaction, how to model its use in conversation, arising from a Career Development Fellowship where words/phrases are located in aided supported by the National Institute for Health systems, and how to add words and phrases to Research. The views expressed in this publication allow children to keep abreast of changing are those of the author(s) and not necessarily vocabulary needs. Detailed discussion of the those of the NHS, the National Institute for implementation of AAC is beyond the scope of Health Research or the Department of Health. this paper but can be found in many excellent text books (e.g.(46-49). References It should also be remembered that communication is a highly emotive issue for 1. Rosenbaum P, Paneth N, Leviton A, et al. A report: parents and the introduction of technology to the definition and classification of cerebral palsy April 2006. Dev Med Child Neurol Suppl 2007; 109: supplement communication may not be always 8-14. welcomed initially (Pennington and Noble, in 2. Bax M, Tydeman C, Flodmark O. Clinical and MRI press). However, there is now a body of evidence correlates of cerebral palsy: the European Cerebral to support the introduction of AAC and to suggest Palsy Study. JAMA 2006; 296: 1602-1608. that AAC may facilitate speech rather than hinder 3. Love RJ, Childhood motor speech disability, Boston: its development (50, 51), which may allay some Allyn & Bacon 1992. parents’ fears. Furthermore, research involving 4. Kennes J, Rosenbaum P, Hanna SE, et al. Health status of school-aged children with cerebral palsy: parents and users of AAC systems also suggests information from a population-based sample. Dev that a family centred model of intervention, with Med Child Neurol 2002; 44: 240-247. AAC systems provided to meet the specific 5. Workinger MS, Kent RD. Perceptual analysis of the communication needs as expressed by parents and dysarthrias in children with athetoid and spastic familiar caregivers, may increase acceptability cerebral palsy, in Dysarthria and apraxia of speech:

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perspectives on management, C.A. Moore, K.M. 24. Wulf G, Lee TD, Schmidt RA. Reducing Knowledge Yorkston, and D.R. Beukelman, Editors. Paul of Results About Relative Versus Absolute Timing: Brookes: Baltimore 1991p. 109-126. Differential Effects on Learning. J Mot Behav 1994; 6. Solomon NP, Charron S. Speech breathing in able- 26: 362-369. bodied children and children with cerebral palsy: A 25. Wulf G, Shea JB, Rice M. Type of KR and KR review of the literature and implications for clinical frequency effects on motor learning. Journal of intervention. American Journal of Speech-Language Human Movement Science 1996; 30: 1-18. Pathology 1998; 7: 61-78. 26. Boliek C. Changes in trunk muscle activation and 7. Patel R. Acoustic characteristics of the question- respiratory kinematics during speech following statement contrast in severe dysarthria due to cerebral intensive voice treatment (LSVT-Loud) for chidlren palsy. J Speech Lang Hear Res 2003; 46: 1401-1415. with , in Motor Disorders 8. Ansel BM, Kent RD. Acoustic-phonetic contrasts and Symposium 2009 Paris. intelligibility in the dysarthria associated with mixed 27. Fox CM, Boliek C, Ramig LO, et al. Intensive voice cerebral palsy. J Speech Hear Res 1992; 35: 296-308. treatment (LSVTR LOUD) for children with spastic 9. Platt LJ, Andrews G, Young M, Quinn PT. Dysarthria cerebral palsy. Movement Disorders 2008; 23: 378. of adult cerebral palsy: I. Intelligibility and 28. Robson S. Associations between speech intelligibility articulatory impairment. J Speech Hear Res 1980; 23: of children with cerebral palsy and the loudness and 28-40. clarity of their voice, in Royal College of Speech and 10. Platt LJ, Andrews G, Howie PM. Dysarthria of adult Language Therapists Conference 2008, London. cerebral palsy: II. Phonemic analysis of articulation 29. Hidecker MJC. Building the evidence for errors. J Speech Hear Res 1980; 23: 41-55. communication interventions. Developmental 11. Kent RD, Netsell R. Articulatory abnormalities in Medicine & Child 2009. athetoid cerebral palsy. Journal of Speech and Hearing 30. Yorkston KM. Evidence-based practice guidelines for Disorders 1978; 43: 353-373. dysarthria: management of velopharyngeal function. 12. Dickinson HO, Parkinson KN, Ravens-Sieberer U, et Journal of Medical Speech-Language Pathology 2001; al. Self-reported quality of life of 8-12-year-old 9: 257-273. children with cerebral palsy: a cross-sectional 31. Gibbon FE, Wood SE. Using electropalatography European study. Lancet 2007; 369: 2171-2178. (EPG) to diagnose and treat articulation disorders 13. Arnaud C, White-Koning M, Michelsen SI, et al. associated with mild cerebral palsy: a case study. Clin Parent-reported quality of life of children with Linguist Phon 2003; 17: 365-374. cerebral palsy in Europe. Pediatrics 2008; 121: 54-64. 32. Hodge MM. Interventions for children with 14. Fauconnier J, Dickinson HO, Beckung E, et al. developmental dysarthria, in Treatment of speech Participation in life situations of 8-12 year old sound disorders in children, L. Williams, R. children with cerebral palsy: cross sectional European McCauley, and S. MacLeod, Editors. 2010, Brookes study. BMJ 2009; 338: 1458. Ltd: Baltimore, MD. 15. Wilson EM, Green JR, Yunusova Y, Moore CA. Task 33. Dunst CJ. Infant learning: A cognitive-linguistic specificity in early oral motor development. Semin intervention strategy. 1982, Hingham, MA: Teaching Speech Lang 2008; 29: 257-266. Resources Corp. 16. Schmidt RA, Lee TD. Motor Control and Learning: A 34. Pennington L, McConachie H. Mother-child Behavioral Emphasis. 4th ed 2005, Leeds: Human interaction revisited: communication with non- Kinetics Europe Ltd. speaking physically disabled children. Int J Lang 17. Hodge MM, Wellman L. Management of dysarthria in Commun Disord 1999; 34: 391-416. children, in Clinical management of motor speech 35. Pennington L, McConachie H. Interaction between disorders in childhood, A.J. Caruso and E. Strand, children with cerebral palsy and their mothers: the Editors Thieme: New York 1999p. 209-280. effects of speech intelligibility. Int J Lang Commun Disord 2001; 36: 371-393. 18. Strand EA. Treatment of motor speech disorders in children. Seminars in Speech and Language 1995; 16: 36. Dahlgren-Sandberg A, Liliedahl M. Patterns in early 126-139. interaction between young preschool children with 19. Yorkston KM. Management of motor speech disorders severe speech and physical impairments and their parents. Child Language Teaching and Therapy 2008; in chidlren and adults Austin: Pro-ed. 1999. 24: 9-30. 20. Pennington L, Smallman CE, Farrier F. Intensive 37. Clarke-Stewart KA, Hevey CM. Longitudinal dysarthria therapy for older children with cerebral relations in repeated observations of mother-child palsy: findings from six cases. Child Language interaction between 1 and 2 1/2 years. Developmental Teaching & Therapy 2006; 22: 255-273. Psychology 1981; 17: 127-145. 21. Pennington L. Speech and language therapy for older 38. Pennington L. Assessing the communication skills of children with cerebral palsy: a systems approach. Developmental Medicine & Child Neurology, 2009. children with cerebral palsy: does speech intelligibility make a difference? Child Language Published Online: Sep 16 2009 4:48AM; DOI: Teaching & Therapy 1999; 15: 159-169. 10.1111/j.1469-8749.2009.03366.x. 22. Schmidt RA, Wulf G. Continuous concurrent feedback 39. McConachie H, Ciccognani A. "What's in the box?" Assessing physically disabled children's degrades skill learning: implications for training and simulation. Hum Factors 1997; 39: 509-525. communication skills. Child Language Teaching and Therapy 1995; 11: 253-263. 23. Shea CH, Lai Q, Wright DL, Immink M, Black C. 40. Schlosser RW, Sigafoos J. Selecting graphic symbols Consistent and variable practice conditions: effects on for an initial request lexicon: An integretive review. relative and absolute timing. J Mot Behav 2001; 33: Augmentative and Alternative Communication 2002; 139-152. 18: 102-123.

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Review Article

41. Pinder GL, Olswang LB. Development of research to effective practice 2003, Baltimore: Paul H. communicative intent in young children with cerebral Brookes. palsy: a treatment efficacy study. Infant Toddler 48. Light J, Binger C. Building communicative Intervention 1995; 5: 51-69. competence with individuals who use augmentative 42. McCollum JA. Social interaction between parents and and alternative communication 1998, Baltimore: Paul babies: Validation of an intervention procedure. H. Brooks. Child: Care, Health and Development 1984; 10: 301- 49. Reichle J, Beukelman D, Light J. Exemplary practices 315. for beginning communicators: Implications for AAC 43. Pennington L, Thomson K, James P, Martin L, McNally 2002, Baltimore: Paul H. Brookes. R. Effects of it takes two to talk--the hanen program 50. Schlosser RW. ed. The efficacy of augmentative and for parents of preschool children with cerebral palsy: alternative communication: toward evidence-based findings from an exploratory study. J Speech Lang practice. Augmentative and alternative communication Hear Res 2009; 52: 1121-1138. perspectives, ed. L.L. Lloyd 2003, Academic Press: 44. Pepper J, Weitzman E. It Takes Two to Talk: A San Diego. practical guide for parents of children with language 51. Schlosser RW, Wendt O. Effects of augmentative and delays. 2004, Toronto: The Hanen Centre. alternative communication intervention on speech 45. Cockerill H. Carroll-Few L. eds. Communicating production in children with autism: a systematic without speech: Practical Augementative and review. Am J Speech Lang Pathol 2008; 17: 212-230. Alternative Communication 2001, MacKeith Press: 52. Marshall J, Goldbart J. 'Communication is everything London. I think.' Parenting a child who needs Augmentative 46. Collier B. Communicating Matters: A training guide and Alternative Communication (AAC). International for personal attendants working with people who have Journal of Language and Communication Disorders enhanced communication needs 2000, Baltimore: Paul 2008; 43: 77-98. H. Brookes. 53. Lund SK, Light J. Long-term outcomes for individuals 47. Light J, Beukelman D, Reichle J. Communicative who use augmentative and alternative communication: competence for individuals who use AAC: From Part III--contributing factors. Augment Altern Commun 2007; 23: 323-335.

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