From the Editor Change

was recently asked to give a guest lecture in a colleagues class on the topic of languagelearning disabilities. To prepare for the lecture, I went back to old course files on my computer from when I taught the course Language Disorders: School-Age Populations back in 2001. To my surprise, among my course files, there were no PowerPoint slideshows for me to review and (hopefully) borrow content fromrather, I found lecture notes written in longhand that corresponded to a set of overhead transparencies. It is almost impossible for me to recall teaching from lecture notes and transparencies, despite it only being a relatively short time ago when apparently I did! I dont recall the transparency-to-PowerPoint transition as being particularly difficult, although I do recall there being a period where I would bring overhead transparencies of my PowerPoint slides as a backup when giving conference presentations. And, Ill admit, occasionally I feel nostalgic for my transparencies, particularly in those perennial instances when technology lets me down. My experience reflects a broader social shift as we transition from relying on print to electronic media in many facets of life. Presently, I use online resources to pay my bills, book hotel accommodations and airline travel, register for conferences, research restaurant menus and movie schedules, print airline boarding passes, track my spending, sample and purchase music, correspond with family and friends, and shop for books, clothing, and household merchandise. Just last year, I finally transitioned from a paper calendar to an online Outlook-based calendar; of all the transitions from paper to electronic media, the shift to online scheduling was the most challenging for me (and the one I most strongly resisted). There is yet another impending print-to-electronic-media transition that will affect not only me but all the readers of ASHA journals, and that is the upcoming shift to online-only journals scheduled to happen with the 2010 volumes. The benefits of going to online-only journals are numerous and include cost-effectiveness and sensitivity to the environment, to name just a few. Currently, I suspect that many readers of this column already utilize ASHA resources available

online at www.asha.org, to include not only the comprehensive archives of all previous issues of AJSLP but also a variety of other key archival documents (e.g., the online Leader, Code of Ethics, and cardinal documents of the Association). Importantly, the shift to online-only journals will allow integration of new features and tools that could only be possible by going online. Specifically, efforts are under way to offer enhanced online supplementary content linked to journal articles, such as videos, sound clips, and images designed to help readers better understand content presented in articles. For instance, a research article involving presentation of auditory stimuli to adult listeners could be coupled with sound clips so that readers could hear the exact stimuli used in the study. Because replication of study findings is critical to the process of scientific accumulation, the possibilities presented by attaching enhanced online content to articles are particularly exciting. Over the next months, I encourage readers of AJSLP to begin to prepare for the transition from paper to online-only journals so that it is as seamless as possible. You can do this by familiarizing yourself with the available online version of the current issue of the journal as well as the entire archive at the journals home page (http://ajslp.asha.org/). Additionally, go ahead and follow the Sign Up for E-mail Alerts link on the AJSLP home page so that you can receive the table of contents directly to your inbox as each AJSLP issue is released. When you begin to receive these alerts, follow the link and browse the journal online so that you become accustomed to examining the online version of the journal rather than the print version, which in the near future will no longer be available. I recognize that change is difficult, yet it is also the pathway to possibility. While many of us will lament the loss of our print journals for some time once they go away, I suspect there will be a time not far into the future when we reflect on those old print journals in the same way that I reflected on the overhead transparencies with which I used to lecture: slightly nostalgic but glad we moved on.

Laura Justice Editor

114 American Journal of Speech-Language Pathology Vol. 18 May 2009

DOI: 10.1044/1058-0360(2009/ed-02)

Viewpoint

Is Expressive Language Disorder an Accurate Diagnostic Category?

Laurence B. Leonard
Purdue University, West Lafayette, IN
Purpose: To propose that the diagnostic category of expressive language disorder as distinct from a disorder of both expressive and receptive language might not be accurate. Method: Evidence that casts doubt on a pure form of this disorder is reviewed from several sources, including the literature on genetic findings, theories of language impairments, and the outcomes of late talkers with expressive language delays. Areas of language that are problematic in production but not readily amenable to comprehension testing are also discussed. Conclusions: The notion of expressive language disorder has been formalized in classification systems and is implicit if not explicit in the organization of many standardized tests. However, a close inspection of the evidence suggests that deficits in language expression are typically accompanied by limitations in language knowledge or difficulties processing language input. For this reason, the diagnostic category of expressive language disorder should be used with considerable caution. This view has implications for both research and clinical practice. Key Words: expressive language disorder, specific language impairment, language disorders

n the literature on children with language impairments, it is common to find reference to the heterogeneity of this population. Although some patterns of strengths and weaknesses are more common than others, exceptions to the common patterns can easily be found. These differences among children have encouraged attempts to identify subgroups of children with language impairments (Aram & Nation, 1975; Conti-Ramsden, Crutchley, & Botting, 1997; Korkman & Hkkinen-Rihu, 1994; Rapin, 1996; Rapin & Allen, 1983, 1987; van Daal, Verhoeven, & van Balkom, 2004; Wilson & Risucci, 1986; Wolfus, Moscovitch, & Kinsbourne, 1980). Often these subdivisions reflect domains of language (e.g., grammar, vocabulary) that may be especially weak in some but not other subgroups. However, just as frequently, subdivisions are based on the modality comprehension and/or productionthat may be affected. This modality distinction is most often a division between children with expressive language deficits and children with receptive-expressive language deficits. Children in

the first category have problems that are principally confined to language output; children in the latter category exhibit significant weaknesses in language comprehension as well as language expression. The distinction between expressive language disorder and receptive-expressive language disorder is not simply an informal clinical sorting of children; it has been formalized. Expressive language disorder and (mixed) receptiveexpressive language disorder constitute categories in the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision; American Psychiatric Association, 2000) and carry different codes (315.31 and 315.32 for the expressive and receptive-expressive forms of the disorder, respectively). In the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10; World Health Organization, 2005), the two subtypes are referred to as expressive language disorder and receptive language disorder (with codes of F80.1 and F80.2, respectively). Although the latter term does not include the word expressive, the ICD-10 definition of this subtype specifies that in almost all cases expressive language is markedly disturbed (p. 238). To avoid confusion, the term receptive-expressive language disorder will be used here. An inspection of standardized language tests can give the impression that the distinction between expressive language disorder and receptive-expressive disorder should be part of a clinicians a priori assessment strategy. Many tests have a separate score for expressive and receptive language, and those tests with multiple subtests have provisions for combining scores of particular subtests to arrive at an expressive language composite score and a receptive language composite score. Tests that provide separate expressive and receptive scores include the Clinical Evaluation of Language FundamentalsPreschool, Second Edition (Wiig, Secord, & Semel, 2004), the Clinical Evaluation of Language Fundamentals, Fourth Edition (Semel, Wiig, & Secord, 2003), the Comprehensive Assessment of Spoken Language (Carrow-Woolfolk, 1999), the Oral and Written Language Scales (Carrow-Woolfolk, 1995), the Preschool Language Scale, Fourth Edition (Zimmerman, Steiner, & Pond, 2002), the Reynell Developmental Language Scales (U.S. edition; Reynell & Gruber, 1990), the Sequenced Inventory of Communication Development, Revised Edition (Hedrick, Prather, & Tobin, 1995), the Test of Adolescent and Adult Language, Third Edition (Hammill, Brown, Larsen, & Wiederholt, 1994), the Test of Early Language Development, Third Edition (Hresko, Reid, & Hammill, 1999), the Test of Language DevelopmentIntermediate, Fourth Edition (Hammill & Newcomer, 2008), the Test of Language Development Primary, Fourth Edition (Newcomer & Hammill, 2008), 115

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and the Test of Narrative Language (Gillam & Pearson, 2004). The distinction between expressive and receptive language has also become highly relevant to evidence-based practice. For example, Law, Garrett, and Nye (2004) made use of this distinction in their meta-analysis of intervention studies meeting the criteria for randomized controlled trials. One of their conclusions from their secondary analyses was that there may be a differential effect of intervention for expressive syntax, with intervention being effective for those children who do not also have receptive language difficulties (p. 931). In this article, I point out significant limitations in the expressive versus receptive-expressive dichotomy as applied to vocabulary, grammar, and narrative skills. I recognize that children with weak expressive language ability in these areas can vary widely in their language comprehension ability. I also acknowledge that, using psychometric criteria, it is often possible to group children into expressive and receptiveexpressive categories. However, I question whether, at a deeper level, the distinction is accurate. A simple example can be used to introduce this idea. Mainstream American English-speaking children with language impairments often produce not in contexts requiring doesnt (e.g., Mommy not like carrots). It is highly likely that children making this error in production can understand sentences such as Mommy doesnt like carrots, as the form doesnt will have been heard before in similar contexts. (One can imagine that, in response to Show me Mommy doesnt like carrots, children might select a picture of a woman who is frowning while looking at a plate of carrots rather than a picture that depicts a woman smiling at the carrots.) I would argue that the childrens failure to produce the correct form is due to insufficient knowledge; the children may have sufficient familiarity with doesnt and the contexts in which it appears to interpret its meaning, but not know this form well enough to recognize that it should be retrieved for use in their own speech. It is important to stress that such children might well earn age-appropriate scores on sentence comprehension tests and low scores on sentence production tests. This pattern of performance might give us license in a technical sense to say that these children have an expressive language disorder. However, this is not the same as saying that their problems in using forms such as doesnt are limited to output. Insufficient knowledge is also a factor. In making my case, I will try to keep separate the concept of psychometrically defined gaps between expressive and receptive scores on the one hand and the concept of limitations in language knowledge on the other. Children showing gaps between scores on expressive and receptive language tests might be described differently from children showing low scores on both types of tests, but it seems risky to describe the output problems of the first group as a limitation in expressive language only. I will pursue these issues more fully below. I begin with some of the pitfalls in defining expressive language disorder based on differences between expressive and receptive language test scores, and then follow with a more extended discussion of how expressive language disorder may be an inaccurate characterization because the

degree or type of language knowledge needed for language expression may differ from that needed to succeed in language comprehension.

Empirical Discrepancies and Gaps in the Data

There is little doubt that early methods of defining children as exhibiting an expressive or receptive-expressive language disorder were fraught with problems. Bishop (1979) pointed out some of these difficulties in a now-classic study. She administered both the Peabody Picture Vocabulary Test (PPVT; Dunn, 1965) and the Test for Reception of Grammar (Bishop, 1977) to children who had been classified as showing either an expressive language disorder or a receptive-expressive language disorder. Bishop found that both groups of children scored well below the level of agematched typically developing children on both tests. The typically developing children in this study were not unrepresentative; their standard scores averaged approximately 100. Given the lower scores of the expressive language disorder group on two different comprehension measures, Bishop argued that there was no clear justification for giving these children a clinical label that excluded reference to receptive language. We now have greater sophistication in using test scores as a basis for classifying children as exhibiting an expressive language disorder or a receptive-expressive language disorder. Factors now considered include the need to select only those expressive and receptive language tests that have acceptable levels of sensitivity and specificity, and the need to ensure that the standard errors of measurement of the expressive and receptive language tests are taken into account before concluding that the two types of scores are truly different. Of course, it is also important to take into account the domains of language that are assessed. For example, Deevy and Leonard (2004) studied a group of children with language impairments who earned low-average scores on the PPVT, Third Edition (PPVTIII; Dunn & Dunn, 1997), a receptive vocabulary test, but scored poorly on tests of expressive language. When tested for their understanding of wh-questions of the type Who was the happy brown dog chasing? the children performed significantly below the level of a group of slightly younger typically developing children who were matched according to raw scores on the PPVTIII. Even though these childrens low-average receptive vocabulary scores were not clinically significant, their poorer understanding of wh-questions relative to younger typically developing children would seem to render a classification of expressive language disorder quite insufficient. Perhaps the greatest obstacle to using test scores to classify children as showing an expressive language disorder rests in the fact that some of the details of expressive language that are most problematic for children with language impairmentsand are often of great diagnostic importance are extremely difficult to test in comprehension. A clear example is seen in the area of grammatical morphology. In production, morphemes that reflect tense and agreement, such as auxiliary is, third person singular s, and

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past tense ed, often pose significant problems for children with language impairments. These children often use these morphemes inconsistently for an extended period. This inconsistency represents an especially good means of distinguishing children with language impairments from their typically developing peers; sensitivity and specificity values approximate or exceed 80% (Bedore & Leonard, 1998; Rice & Wexler, 2001). However, tests of the comprehension of these morphemes are difficult to develop, for several reasons. First, given the structure of English, verb morphemes that reflect subject-verb agreement (e.g., auxiliary and copula be forms, third person singular s) are accompanied by the subject of the sentence that provides a supporting (or, in the case of testing, a confounding) cue. To control for this fact, items with invariant nouns must be employed. Unfortunately, children may not know that nouns such as fish, deer, and moose are identical in singular and plural. Thus an item on a picture-pointing task such as Show me The fish are swimming may be difficult either because the child does not understand that auxiliary are marks third person plural or because the child does not know that fish is the form used for plural as well as singular. (In contrast, in languages such as Spanish and Italian in which the subject is optional when the referent is clear, the item can be presented without the subject, thus avoiding subject number cues and the need for invariant nouns.) Johnson, deVilliers, and Seymour (2005) avoided this problem in a picture-pointing task with the clever innovation of using verbs with word-initial /s/. By ensuring that there were no pauses between the subject and the verb, contrasts such as The duck swims in the water and The ducks swim in the water could be used without providing confounding cues. Unfortunately, typically developing children do not appear to perform above the level of chance until 5 years of age on this type of task. As noted by Johnson et al., typically developing children produce third person singular s to a greater degree than their performance on this task would predict. Therefore, the type of knowledge required for production must be somewhat different than the knowledge required to succeed on this task. As children reach 4 years of age, the assessment of their understanding of certain agreement morphemes is possible through the use of grammaticality judgment tasks. In the Rice/Wexler Test of Early Grammatical Impairment (Rice & Wexler, 2001), childrens judgments of sentences with missing agreement morphemes (e.g., He running away or Now the bear want a drink) and agreement morphemes reflecting incorrect agreement (e.g., He are mad or I drinks milk) are evaluated, along with sentences possessing correct use of these morphemes. The advantage of this assessment tool is that a separate evaluation can be made of the childrens judgments of sentences most likely to resemble their own production errors (notably, the omission of agreement markers) and their judgments of sentences whose errors are not those likely to be used by the children (those with overt agreement errors such as I drinks milk). However, because grammaticality judgment tasks require some degree of metalinguistic skill, high levels of both sensitivity and specificity are not seen until approximately 6 years of age.

The assessment of childrens comprehension of past tense poses a different type of problem. When assessed by means of a picture-pointing task, past tense is typically distinguished from present tense by contrasting a drawing of an action that was just completed with a drawing of an action still in progress. For example, the drawing for an item assessing comprehension of The girl jumped could depict a girl landing after having just jumped over a fence, contrasted with a drawing of a girl still in the air. However, such a past tense item conflates past tense with completion or perfective aspect. Within a picture-pointing format, it would be very difficult to test for past tense without providing cues of this type, yet the absence of such cues is necessary to determine whether the child understands past tense independent of perfective aspect. I suspect that our limited ability to assess certain language details in comprehensionor the older ages at which we have had to assess themhas contributed to the impression that some children have deficits restricted to language expression. Quite possibly, this complication has been responsible in part for the apparent instability of this diagnostic category. For example, using the categories of expressive and receptive-expressive language deficits, Conti-Ramsden and Botting (1999) found that many of the children who were classified as exhibiting an expressive language disorder were reclassified as showing a receptive-expressive language disorder when tested 12 months later. Tomblin and Zhang (2006) tested alternative models for their suitability in accounting for childrens scores on standardized language test batteries at four different ages. They found that a singledimension modelin which all language tests were treated as a single factorwas superior to a model that treated expressive and receptive scores as separate factors. There was some evidence that, across time, grammatical abilities and vocabulary abilities became differentiated, but an expressive versus receptive distinction did not emerge.

Limitations in Language Knowledge Underlying Seemingly Pure Cases of Expressive Language Disorder
With further development and refinement of testing procedures, it is likely that we will move toward a greater understanding of childrens language comprehension. However, I believe that problems in expressive language may be due in part to limitations in the degree of childrens language knowledge, and this graded level of knowledge may prove very difficult to measure given current methods of testing in which a response to any receptive test item is either correct or incorrect. The subtle but important role played by language knowledge can be seen if we consider those operations that are most often associated with expressive language disorders. These operations include those involved in retrieving and preparing linguistic material for output. (The problematic operations cannot be confined to the physical act of speaking. If this were the case, all children with expressive language disorders would have significant phonological difficulties and there would be no way to distinguish problems in a
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domain such as grammar from those in a domain such as vocabulary.) I believe that the difficulties that children with expressive language disorder have with operations of retrieval and preparation for output are exacerbated by limitations in language knowledge. I consider the operations of word retrieval and sentence formulation in turn.

Word Retrieval Problems

Word retrieval difficulty is usually defined as a problem in accessing words that are already known by the child. However, the word-finding literature offers an alternative interpretation. McGregor, Newman, Reilly, and Capone (2002) provided an illustrative study in this regard. These investigators performed a comprehensive examination of the semantic knowledge possessed by a group of children with specific language impairment (SLI) who were found to commit a substantial number of naming errors for ageappropriate objects. They found that the childrens drawings, definitions, and recognition responses were also relatively poor for objects that were incorrectly or inadequately named. Most of the children earned age-appropriate scores on the PPVTIII. McGregor et al. summarized their findings succinctly: This study demonstrates that the degree of knowledge represented in the childs semantic lexicon makes words more or less vulnerable to retrieval failure and that limited semantic knowledge contributes to the frequent naming errors of children with SLI (p. 998). Limitations in degree of word knowledge can also affect naming response time (RT), even when children produce the correct name for an object (e.g., Kail & Leonard, 1986). The typical explanation for this view is that repeated encounters with a word lead to stronger and more numerous associations in semantic memory. Words with stronger and more numerous associations can be retrieved more quickly than words that are represented in semantic memory with fewer and weaker associations. For this reason, typically functioning adults show faster RTs for names that have high frequency of occurrence in the language than for names with lower frequency of occurrence. Obviously, these adults do not have selective retrieval deficits; rather, the RT differences reflect differences in the degree to which the highand low-frequency words are known. It would follow that the slower RTs for children with language impairments that have been reported in some picture-naming studies might well be attributable to limitations in the degree to which the children knew the words.

Sentence Formulation Problems

Another possible deficit of a strictly expressive nature is a problem of sentence formulation, that is, a deficit in preparing already-acquired language material into sentences for output. One relevant line of evidence is the study of speech disruptions in children with language impairments. If children insert pauses or fillers (e.g., uh or well ) or repeat syllables or words in the sentences they produce, they may be having difficulties with sentence formulation, even when the sentences contain no grammatical errors. Finneran, Leonard, and Miller (in press) found that a group

of 9-year-olds with SLI produced grammatical sentences with significantly more speech disruptions than a group of same-age peers. Similar results were reported by Guo, Tomblin, and Samelson (2008), who found that children with SLI had a significantly higher number of pauses than sameage peers in their production of narratives. The fact that the rate of pauses was higher at phrase boundaries led these investigators to conclude that these pauses may have been due to lexical and/or syntactic weaknesses in the children with SLI. As we saw in the discussion of word retrieval problems, speech disruptions occurring during sentence production could reflect words or syntactic structures that are simply not as well known by children with language impairments as by typically developing peers, thus requiring more of a struggle to accurately retrieve. The source of the difficulty, then, may occur prior to the point of preparing the utterance for production. Another look at sentence formulation is provided by studies that employ syntactic priming. Leonard et al. (2000) found that children with language impairments who were inconsistent in using auxiliary is were more likely to describe a target picture with this morpheme (e.g., The Grinch is reading the book) if they had just repeated a prime sentence such as The cats are drinking the milk than if they had just repeated a sentence such as The bird flew away. The difference between these two priming conditions was greater in the group of children with language impairments than in a group of younger typically developing children who were also inconsistent in their use of auxiliary is. The priming effects seen in both groups were interpreted as reflecting the prior activation of a syntactic frame. In the case of The cats are drinking the milk, the frame is appropriate for use when describing the target picture, and its prior activation renders it easier to retrieve. Once retrieved, the content words and function words (including the specific auxiliary form, is) can be retrieved and inserted into the frame. The fact that the priming effects were larger in the group with language impairments led Leonard et al. to propose that these children had greater difficulty with sentence formulation, and this process was greatly assisted through prior activation of an applicable syntactic frame. Similar results were obtained in a subsequent study by Leonard et al. (2002). Although formulation of an utterance seems to fall on the expressive side of language, it is not an insulated process. More recent work provides a strong indication that priming crosses modalities. In children (Shimpi, Gmez, Huttenlocher, & Vasilyeva, 2007) as well as adults (Branigan, Pickering, Stewart, & McLean, 2000), simply hearing prime sentences without repeating them also leads to increased use of the syntactic frame in production. The fact that production is influenced by prime sentences that are heard but not repeated has led to the view that language production relies on the same type of structural knowledge as language comprehension (Bock, Dell, Chang, & Onishi, 2007). It would follow that, in the Leonard et al. studies, the prime sentences facilitated the childrens knowledge of the sentence structure, not just their ability to call on the structure for use in a target sentence. It can be seen, then, that the findings from word retrieval and sentence formulation studies do not provide sufficient

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evidence to conclude that the problem lies exclusively in language expression. Limitations in language knowledge are also implicated.

The Expressive Versus Receptive-Expressive Distinction in the Identification, Prediction, and Explanation of Language Impairments
There are additional reasons to question the notion of expressive language disorder. An inspection of the literature on the identification of language impairments, the prediction of later language impairments, and theories of language impairments provides very little (if any) evidence that expressive language problems occur in isolation. Instead, they seem to be accompanied by weaknesses in language comprehension and/or knowledge.

Genetic Studies and the Expressive Versus Receptive-Expressive Distinction

Twin studies have provided valuable information concerning the genetic and environmental influences on childrens language abilities. Bishop, Adams, and Norbury (2006) employed the twin-study methodology and identified two heritable weaknesses associated with risk for language impairment. One was a limitation seen on a nonword repetition task. The other was a weakness in grammatical computation, as reflected on tasks of tense and agreement morpheme production and syntactic comprehension. Although heritable, these two weaknesses were separable; one could occur without the other. Neither of these weak ability areas suggests a division between receptive and expressive skills. The grammatical computation measure involved tasks of both production and comprehension. The nonword repetition task, although requiring a production response, is often taken to be a measure of verbal short-term memory (e.g., Gathercole & Baddeley, 1990), and thus cannot be viewed as a purely expressive task.

Theories of Grammatical Impairment and the Expressive Versus Receptive-Expressive Distinction

There are several prominent explanations for the types of grammatical difficulties experienced by children with language impairments. However, all of these accounts seem to assume that the problem is not limited to language expression but extends to the childrens incomplete grasp of particular linguistic principles, or to their inability to process linguistic information in the input. Although there is debate among researchers about the descriptive and explanatory adequacy of some of these accounts, most of these accounts would have been dealt a fatal blow if a significant minority of the children serving as participants in these studies performed adequately on the comprehension or receptive language-processing tasks that were used to test these accounts. For example, the extended optional infinitive account of Rice, Wexler, and their colleagues holds that children with language impairments fail to grasp the notion that tense and agreement are obligatory in main clauses (Rice, 2003;

Rice & Wexler, 1996; Rice, Wexler, & Hershberger, 1998). Instead, they treat tense and agreement as optional. In production, this problem leads to inconsistency in the use of tense and agreement morphemes. In comprehension, it is seen when the children judge sentences such as The boy am running as wrong but treat both The boy is running and The boy running as acceptable. Similarly, in the Representational Deficit for Dependent Relationships account of van der Lely, children with language impairments have difficulty not only in the use of certain grammatical details but also in comprehending them (van der Lely, 1998; van der Lely & Battell, 2003). Thus wh-questions that require movement of wh-words and auxiliary verbs, as in Who was the girl kissing? are more difficult for these children in both comprehension and production than wh-questions that can be produced or interpreted with no such movement, as in Who was kissing the girl? Recent approaches that describe the movement deficit somewhat differently nevertheless find that comprehension is affected (Friedmann & Novogrodsky, 2007). Ullman and Pierpoint (2005) propose that many children with SLI have a deficit in the neural circuitry responsible for procedural memory, the system involved in the learning and execution of sequential cognitive (including linguistic) information. This procedural deficit is assumed to affect comprehension as well as production. Although more research is needed to test this proposal, recent evidence on procedural learning difficulties in children with language impairments indicates that the problem is not limited to language expression (Tomblin, Mainela-Arnold, & Zhang, 2007). Accounts that assume processing capacity limitations in children with language impairments also implicate comprehension as well as production. Put more precisely, these accounts assume that the problem of these children rests in a limited processing capacity that restricts the amount and timeliness of information that can be taken in, thus impeding the development of comprehension as well as production. Perhaps the dominant proposal of this type is that these children have significant limitations in verbal working memory (e.g., Hoffman & Gillam, 2004; Leonard et al., 2007; Montgomery, 2000). Studies that have examined verbal working memory in children with language impairments consistently report difficulties in this population. It is tempting to treat differences between linguistically based accounts and those that assume processing limitations as equivalent to a difference in competence versus performance. A limitation in competence can easily be viewed as a receptive-expressive problem given that language knowledge is affected. However, a processing limitation affects more than online performance; if the information is not adequately processed, it cannot serve to form or strengthen an underlying representation in the childs developing language system. As a result, knowledge is affected, not simply the childs performance in the moment. It is striking that there are no theories of expressive (only) language disorder apart from proposals that pertain to segmental phonology or prosody (e.g., Gerken & McGregor, 1998; Goffman, 2004). Despite the fact that the expressive component has been front and center in the existing theories of grammatical impairments, the proponents of all theories
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have seen the need to assume deficits that extend beyond language output.

Late Talkers and the Prediction of Outcomes

Several excellent prospective studies have been conducted that follow late talkers for several years with the aim of determining which factors represent risk factors for language impairment at a later age. Children are defined as late talkers according to expressive language criteria, specifically, as producing fewer than 50 words and no word combinations (e.g., Rescorla, 1989, 2005), or as falling below the 10th percentile in word use at 24 to 30 months (e.g., Ellis Weismer, 2007; Thal, 2005; Thal, Tobias, & Morrison, 1991). Many of the late talkers in these studies earned age-appropriate scores on tests of language comprehension. A careful review of this literature reveals one puzzling fact. The percentage of late talkers with outcomes that lead to a diagnosis of SLI at a later age is consistently much lower than would be expected given that the prevalence of SLI is approximately 7% at 5 years of age (Tomblin et al., 1997). For example, Thal (2005) found that only 8.8% of the late talkers in her prospective study met the criteria for SLI when the children were 5 years old. Ellis Weismer (2007) found that only 7.5% of the late talkers in her investigation met the criteria for SLI when they reached age 5. These percentages are close to the prevalence figures for SLI among 5-year-olds in the general population and suggest that an early pattern of slow expressive language development is not a good predictor of later language impairment. Instead, early, slow expressive language development seems to predict later language functioning that is below average but within normal limits (e.g., Rescorla, 2005). Importantly, when 24-month-olds are found to have low comprehension as well as production ability, their outcomes are poorer (Thal et al., 1991). Ellis Weismer (2007) reported that late talkers comprehension at 30 months was the strongest single predictor of these childrens language production scores at 66 months. In a more recent investigation, Rice, Taylor, and Zubrick (2008) assessed the language abilities of 7-year-olds who had been identified as exhibiting either late language emergence or language emergence at a typical age. Late language emergence was defined as a small expressive vocabulary (70 words or fewer) or no word combinations at 24 months of age. At age 7 years, a higher percentage of the late language emergence group met the criterion for affectedness on 7 of the 17 language measures obtained. The percentage of children in this group who met the criterion ranged from 4 to 23, depending on the language measure. These percentages are somewhat higher than those of previous studies. However, it should be noted that the criterion used for affectedness for each language measure was 1 SD. Such a criterion is not especially stringent, as it represents the lowest 16% of a distribution.

conventional distinctions be far behind? For example, ever since the influential work of Bloom and Lahey (1978), the distinction among content, form, and use (including areas of overlap) has been viewed as important for the description of language impairments in children, even making its way into the definition of language disorder by the American Speech-Language-Hearing Association (1993). This distinction has served as a useful heuristic, by focusing our attention on broad dimensions of language that might be adversely affected. However, to my knowledge, it has not yet been demonstrated that children can be reliably placed into subtypes that conform to these particular divisions. The degree to which these and other conventional distinctions can be substantiated would seem to be an important topic for future investigation. It is possible that meaningful subtypes might be identified through genetic studies of potential endophenotypes (clusters of related abilities) that arise from theoretical proposals of causal factors in language impairment (Bishop, 2006). For example, if weaknesses in several theoretically related abilities appear to cluster together in monozygotic twins to a greater extent than in dizygotic twins, this cluster might constitute a meaningful subtype of language impairment. Additional clusters might also be discovered in this way, and these might prove to be genetically distinct from each other. Still other weaknesses may prove to be rather frequent but unreliable in their patterning. The latter weaknesses might be regarded as secondary deficits that may accompany one or more of the core subtypes but not enter into a formal classification scheme.

Implications for Clinical Research and Practice

One goal for future clinical research would be to develop or refine methods for assessing childrens understanding of language details that are often problematic for these children in production but have proven to be difficult to assess in comprehension. As noted earlier, one such language detail is subject-verb agreement. Current methods are suitable for ages 5 years and older, but less than ideal for younger children. However, it might be possible to assess childrens sensitivity to subject-verb agreement at a younger age. McNamara, Carter, McIntosh, and Gerken (1998) found that preschool-age children with SLI were more likely to point to a correct picture (e.g., a picture of a bird) in response to a sentence containing an appropriately used article (e.g., Find the bird for me) than in response to a sentence containing an inappropriate morpheme (e.g., Find was bird for me). Sentence contexts appropriate for a subject-verb agreement morpheme were not employed (e.g., contrasting Mom is running with Mom the running), but it seems that this task might allow for items of this type. Of course, as I argued earlier, an awareness that a morpheme seems to be in an appropriate (or inappropriate) context is no assurance that the child has sufficient knowledge to use the morpheme. Additional forms of assessing childrens receptive command of subject-verb agreement will still be needed. The assessment of childrens comprehension of past tense has also proven to be challenging. However, it may be possible to develop informative tests of past tense comprehension

Implications for the Study of Heterogeneity

If a conventional distinction such as the expressive versus receptive-expressive distinction becomes suspect, can other

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by adapting existing procedures seen in the normal child language literature. Wagner (2001) developed a task used with young typically developing children in which a toy character is made to proceed along a path, performing actions in the middle of the path and then again at the end of the path. The actions performed in the first location can have definable endpoints (e.g., filling a toy bucket with small toy apples). In some items, this action might be completed before the character moves on to the next location (e.g., all the apples are placed in the bucket), and in other items, the action might not be completed before the character resumes the journey along the path (e.g., some of the apples remain on the ground next to the bucket). The action at the end of the path is identical to the first action. While the character is performing the action at the end of the path, the examiner can ask the child to point to the location of the named action. A request such as Show me where the girl filled up the bucket is most appropriate when the first action had been completed (all apples were placed in the bucket). A request such as Show me where the girl was filling up a bucket can be made both when the first action had been completed and when it was left incomplete, because the past progressive does not entail completion, only past time. To contrast past with present tense, the request Show me where the girl is filling up a bucket can be made. In this instance, of course, the correct response is the location of the action being performed at the end of the path. The views expressed in this article also carry implications for clinical practice. When children show a significant gap between their expressive and receptive language test scores, clinicians should carefully examine the details of expressive language that are problematic for the children. If these details are not reflected adequately in the receptive language tests that were administered, there is a possibility that the children lack the prerequisite knowledge for successful production. If receptive measures that do tap into these details are available, clinicians might then employ them to supplement the receptive language testing of the children. Treatment decisions, too, might be influenced by the views conveyed here. Treatment focused on details of expressive language for which the childrens prerequisite knowledge has not been established should involve an approach that provides the children with information about meaning, grammatical function, and/or contexts of use along with any production practice that is provided. For young children, of course, such information might have to be provided through examples rather than through formal instruction. I think it rather paradoxicaland consistent with the views expressed herethat approaches such as recasting have proven promising as a method for facilitating young childrens expressive language (e.g., Camarata & Nelson, 2006; Camarata, Nelson, & Camarata, 1994; Leonard, Camarata, Pawowska, Brown, & Camarata, 2008). In this approach, clinicians respond to childrens utterances with conversationally appropriate utterances that resemble the childrens preceding utterances but contain the language target. Such an approach provides children with contextual information and contrasts between their own utterance and the recast utterance, yet no expressive use of the target is even required of the children. Of course, future research may

reveal that some children require practice in producing the language target. However, I suspect that any treatment approach that is found to meet the highest levels of evidence will have a significant component devoted to providing children with information that goes well beyond the act of production.

Conclusions
At the outset of this article, I introduced the idea that children may exhibit deficits in expressive language that are caused by limitations in knowledge that extend beyond a problem with the retrieval and preparation of language material for output. These limitations might not be reflected in the childrens scores on language comprehension tests. As I have tried to show, current methods of assessing comprehension abilities do not yet allow us to test childrens grasp of certain details of language that are known to be problematic in language expression. It is also difficult to demonstrate that a pure expressive language disorder can even exist, given the types of language knowledge that seem to underlie operations such as word retrieval and sentence formulation. I am also struck with how little the notion of expressive language disorder enters into attempts to explain grammatical impairments. Outside of the realm of segmental phonology and prosody, there seems to be no theory of expressive language problems that does not also assume a limitation in language knowledge or a problem in processing language input. Furthermore, it does not seem plausible that the existing theories would remain viable if many of the children with language impairments in these studies could succeed in the comprehension and receptive language-processing tasks that were employed to test these theories. Genetic evidence, too, seems to point to weaknesses in ability areas that incorporate receptive as well as expressive language. Finally, early delays in expressive language (only) do not serve as good predictors of later language impairment; on the other hand, if comprehension delays are also seen at a young age, later problems in language are more likely. It may be that the term expressive language disorder is useful in particular circumstances, as a type of shorthand to refer to children whose receptive language test scores are demonstrably higher than their expressive language test scores. However, considering the questions that remain about this diagnostic category, we should be alert to the possibility that children may lack the knowledge needed to produce language adequately even when their receptive language scores might suggest otherwise.

Acknowledgments
This work was supported in part by National Institute on Deafness and Other Communication Disorders Grant R01 DC00458. Many thanks to Patricia Deevy and Jeanette S. Leonard for their very helpful comments on earlier versions of this article.

References
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: Author.
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American Speech-Language-Hearing Association. (1993). Definitions of communication disorders and variations [Relevant paper]. Available from www.asha.org /policy. Aram, D., & Nation, J. (1975). Patterns of language behavior in children with developmental language disorders. Journal of Speech and Hearing Research, 18, 229241. Bedore, L., & Leonard, L. (1998). Specific language impairment and grammatical morphology: A discriminant function analysis. Journal of Speech, Language, and Hearing Research, 41, 11851192. Bishop, D. V. M. (1977). Comprehension of grammar: Normal and abnormal development. Doctoral thesis, Oxford University, Oxford, England. Bishop, D. V. M. (1979). Comprehension in developmental language disorders. Developmental Medicine and Child Neurology, 21, 225238. Bishop, D. V. M. (2006). What cause specific language impairment? Current Directions in Psychological Science, 15, 217221. Bishop, D. V. M., Adams, C., & Norbury, C. F. (2006). Distinct genetic influences on grammar and phonological short-term memory deficits: Evidence from 6-year-old twins. Genes, Brain and Behavior, 5, 158169. Bloom, L., & Lahey, M. (1978). Language development and language disorders. New York: Wiley. Bock, K., Dell, G., Chang, F., & Onishi, K. (2007). Persistent structural priming from language comprehension to language production. Cognition, 104, 437458. Branigan, H., Pickering, M., Stewart, J., & McLean, J. (2000). Syntactic priming in spoken production: Linguistic and temporal interference. Memory and Cognition, 28, 12971302. Camarata, S., & Nelson, K. E. (2006). Conversational recast intervention with preschool and older children. In R. McCauley & M. Fey (Eds.), Treatment of language disorders in children ( pp. 237264). Baltimore: Brookes. Camarata, S., Nelson, K. E., & Camarata, M. (1994). Comparison of conversational recasting and imitative procedures for training grammatical structures in children with specific language impairment. Journal of Speech and Hearing Research, 37, 14141423. Carrow-Woolfolk, E. (1995). Oral and Written Language Scales. Circle Pines, MN: AGS. Carrow-Woolfolk, E. (1999). Comprehensive Assessment of Spoken Language. Circle Pines, MN: AGS. Conti-Ramsden, G., & Botting, N. (1999). Classification of children with specific language impairment: Longitudinal considerations. Journal of Speech, Language, and Hearing Research, 42, 11951204. Conti-Ramsden, G., Crutchley, A., & Botting, N. (1997). The extent to which psychometric tests differentiate subgroups of children with SLI. Journal of Speech, Language, and Hearing Research, 40, 765777. Deevy, P., & Leonard, L. (2004). The comprehension of whquestions in children with specific language impairment. Journal of Speech, Language, and Hearing Research, 47, 802815. Dunn, L. (1965). Expanded Manual for the Peabody Picture Vocabulary Test. Circle Pines, MN: AGS. Dunn, L., & Dunn, L. (1997). Peabody Picture Vocabulary Test Third Edition. Circle Pines, MN: AGS. Ellis Weismer, S. (2007). Typical talkers, late talkers, and children with specific language impairment: A language endowment spectrum? In R. Paul (Ed.), Language disorders from a developmental perspective ( pp. 83101). Mahwah, NJ: Erlbaum. Finneran, D., Leonard, L., & Miller, C. (in press). Speech disruptions in the sentence formulation of school-age children

with specific language impairment. International Journal of Language and Communication Disorders. Friedmann, N., & Novogrodsky, R. (2007). Is the movement deficit in syntactic SLI related to traces or to thematic role transfer? Brain and Language, 101, 5063. Gathercole, S., & Baddeley, A. (1990). Phonological memory deficits in language disordered children: Is there a causal connection? Journal of Memory and Language, 29, 336360. Gerken, L. A., & McGregor, K. (1998). An overview of prosody and its role in normal and disordered child language. American Journal of Speech-Language Pathology, 7, 3848. Gillam, R., & Pearson, N. (2004). Test of Narrative Language. Austin, TX: Pro-Ed. Goffman, L. (2004). Kinematic differentiation of prosodic categories in normal and disordered language development. Journal of Speech, Language, and Hearing Research, 47, 10881102. Guo, L.-Y., Tomblin, J. B., & Samelson, V. (2008). Speech disruptions in the narratives of English-speaking children with specific language impairment. Journal of Speech, Language, and Hearing Research, 51, 722738. Hammill, D., Brown, V., Larsen, S., & Wiederholt, J. (1994). Test of Adolescent and Adult Language, Third Edition. Austin, TX: Pro-Ed. Hammill, D., & Newcomer, P. (2008). Test of Language DevelopmentIntermediate, Fourth Edition. Austin, TX: Pro-Ed. Hedrick, D., Prather, E., & Tobin, A. (1995). Sequenced Inventory of Communication Development, Revised Edition. Los Angeles: Western Psychological Services. Hoffman, L., & Gillam, R. (2004). Verbal and spatial information processing constraints in children with specific language impairment. Journal of Speech, Language, and Hearing Research, 47, 114125. Hresko, W., Reid, K., & Hammill, D. (1999). Test of Early Language Development, Third Edition. Austin, TX: Pro-Ed. Johnson, V., deVilliers, J., & Seymour, H. (2005). Agreement without understanding? The case of third person singular /s/. First Language, 25, 317330. Kail, R., & Leonard, L. (1986). Word-finding abilities in language-impaired children. ASHA Monographs, 25. Korkman, M., & Hkkinen-Rihu, P. (1994). A new classification of developmental language disorders. Brain and Language, 47, 96116. Law, J., Garrett, Z., & Nye, C. (2004). The efficacy of treatment for children with developmental speech and language delay/ disorder: A meta-analysis. Journal of Speech, Language, and Hearing Research, 47, 924943. Leonard, L., Camarata, S., Pawowska, M., Brown, B., & Camarata, M. (2008). The acquisition of tense and agreement morphemes by children with specific language impairment during intervention: Phase 3. Journal of Speech, Language, and Hearing Research, 51, 120125. Leonard, L., Ellis Weismer, S., Miller, C., Francis, D., Tomblin, J. B., & Kail, R. (2007). Speed of processing, working memory, and language impairment in children. Journal of Speech, Language, and Hearing Research, 50, 408428. Leonard, L., Miller, C., Deevy, P., Rauf, L., Gerber, E., & Charest, M. (2002). Production operations and the use of nonfinite verbs by children with specific language impairment. Journal of Speech, Language, and Hearing Research, 45, 744758. Leonard, L., Miller, C., Grela, B., Holland, A., Gerber, E., & Petucci, M. (2000). Production operations contribute to the grammatical morpheme limitations of children with specific language impairment. Journal of Memory and Language, 43, 362378.

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McGregor, K., Newman, R., Reilly, R., & Capone, N. (2002). Semantic representation and naming in children with specific language impairment. Journal of Speech, Language, and Hearing Research, 45, 9981014. McNamara, M., Carter, A., McIntosh, B., & Gerken, L. (1998). Sensitivity to grammatical morphemes in children with specific language impairment. Journal of Speech, Language, and Hearing Research, 41, 11471157. Montgomery, J. (2000). Verbal working memory and sentence comprehension in children with specific language impairment. Journal of Speech, Language, and Hearing Research, 43, 293308. Newcomer, P., & Hammill, D. (2008). Test of Language DevelopmentPrimary, Fourth Edition. Austin, TX: Pro-Ed. Rapin, I. (1996). Developmental language disorders: A clinical update. Journal of Child Psychology and Psychiatry, 37, 643656. Rapin, I., & Allen, D. (1983). Developmental language disorders: Nosologic considerations. In U. Kirk (Ed.), Neuropsychology of language, reading and spelling ( pp. 155184). New York: Academic Press. Rapin, I., & Allen, D. (1987). Developmental dysphasia and autism in preschool children: Characteristic and subtypes. In J. Martin, P. Fletcher, R. Grunwell, & D. Hall (Eds.), Proceedings of the First International Symposium on Specific Speech and Language Disorders in Children ( pp. 2035). London: AFASIC. Rescorla, L. (1989). The Language Development Survey: A screening tool for delayed language in toddlers. Journal of Speech and Hearing Disorders, 54, 587599. Rescorla, L. (2005). Age 13 language and reading outcomes in late-talking children. Journal of Speech, Language, and Hearing Research, 48, 459472. Reynell, J., & Gruber, C. (1990). Reynell Developmental Language Scales ( U.S. Edition). Los Angeles: Western Psychological Services. Rice, M. (2003). A unified model of specific and general language delay: Grammatical tense as a clinical marker of unexpected variation. In Y. Levy & J. Schaeffer (Eds.), Language competence across populations: Toward a definition of SLI ( pp. 6394). Mahwah, NJ: Erlbaum. Rice, M., Taylor, C., & Zubrick, S. (2008). Language outcomes of 7-year-old children with or without a history of late language emergence at 24 months. Journal of Speech, Language, and Hearing Research, 51, 394407. Rice, M., & Wexler, K. (1996). Toward tense as a clinical marker of specific language impairment in English-speaking children. Journal of Speech, Language, and Hearing Research, 39, 12391257. Rice, M., & Wexler, K. (2001). Rice/Wexler Test of Early Grammatical Impairment. San Antonio, TX: The Psychological Corporation. Rice, M., Wexler, K., & Hershberger, S. (1998). Tense over time: The longitudinal course of tense acquisition in children with specific language impairment. Journal of Speech, Language, and Hearing Research, 41, 14121431. Semel, E., Wiig, E., & Secord, W. (2003). Clinical Evaluation of Language Fundamentals, Fourth Edition. San Antonio, TX: The Psychological Corporation. Shimpi, P., Gmez, P., Huttenlocher, J., & Vasilyeva, M. (2007). Syntactic priming in 3- and 4-year-old children: Evidence for abstract representations of transitive and dative forms. Developmental Psychology, 43, 13341346.

Thal, D. (2005, November). Early detection of risk for language impairment. Paper presented at the Annual Convention of the American Speech-Language-Hearing Association, San Diego, CA. Thal, D., Tobias, S., & Morrison, D. (1991). Language and gesture in late talkers: A 1-year follow-up. Journal of Speech and Hearing Research, 34, 604612. Tomblin, J. B., Mainela-Arnold, E., & Zhang, X. (2007). Procedural learning in adolescents with and without specific language impairment. Language Learning and Development, 3, 269293. Tomblin, J. B., Records, N., Buckwalter, P., Zhang, X., Smith, E., & OBrien, M. (1997). The prevalence of specific language impairment in kindergarten children. Journal of Speech, Language, and Hearing Research, 40, 12451260. Tomblin, J. B., & Zhang, X. (2006). The dimensionality of language ability in school-age children. Journal of Speech, Language, and Hearing Research, 49, 11931208. Ullman, M., & Pierpoint, E. (2005). Specific language impairment is not specific to language: The procedural deficit hypothesis. Cortex, 41, 399433. van Daal, J., Verhoeven, L., & van Balkom, H. (2004). Subtypes of severe speech and language impairments: Psychometric evidence from 4-year-old children in the Netherlands. Journal of Speech, Language, and Hearing Research, 47, 14111423. van der Lely, H. (1998). SLI in children: Movement, economy, and deficits in the computational-syntactic system. Language Acquisition, 7, 161192. van der Lely, H., & Battell, J. (2003). Wh-movement in children with grammatical SLI: A test of the RDDR hypothesis. Language, 79, 153181. Wagner, L. (2001). Aspectual influences on early tense comprehension. Journal of Child Language, 28, 661681. Wiig, E., Secord, W., & Semel, E. (2004). Clinical Evaluation of Language FundamentalsPreschool, Second Edition. San Antonio, TX: Psychological Corporation. Wilson, B., & Risucci, D. (1986). A model for clinical-quantitative classification. Generation I: Application to language-disordered preschool children. Brain and Language, 27, 281309. Wolfus, B., Moscovitch, M., & Kinsbourne, M. (1980). Subgroups of developmental language impairment. Brain and Language, 10, 152171. World Health Organization. (2005). International Statistical Classification of Diseases and Related Health Problems, Tenth Revision. Geneva, Switzerland: Author. Zimmerman, I., Steiner, V., & Pond, R. (2002). Preschool Language Scale, Fourth Edition. San Antonio, TX: The Psychological Corporation. Received August 27, 2008 Accepted October 21, 2008 DOI: 10.1044/1058-0360(2008/08-0064) Contact author: Laurence B. Leonard, Department of Speech, Language, and Hearing Sciences, 500 Oval Drive, Heavilon Hall, Purdue University, West Lafayette, IN 47907. E-mail: xdxl@purdue.edu.

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Clinical Focus

Consensus Auditory-Perceptual Evaluation of Voice: Development of a Standardized Clinical Protocol

Gail B. Kempster
Rush University, Chicago

Bruce R. Gerratt
University of California, Los Angeles

Katherine Verdolini Abbott

University of Pittsburgh, Pittsburgh, PA

Julie Barkmeier-Kraemer
University of Arizona, Tucson

Robert E. Hillman
Massachusetts General Hospital, Boston

Purpose: This article presents the development of the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) following a consensus conference on perceptual voice quality measurement sponsored by the American SpeechLanguage-Hearing Associations Special Interest Division 3, Voice and Voice Disorders. The CAPE-V protocol and recording form were designed to promote a standardized approach to evaluating and documenting auditory-perceptual judgments of vocal quality.

Method: A summary of the consensus conference proceedings and the factors considered by the authors in developing this instrument are included. Conclusion: The CAPE-V form and instructions, included as appendices to this article, enable clinicians to document perceived voice quality deviations following a standard (i.e., consistent and specified) protocol. Key Words: Consensus Auditory-Perceptual Evaluation of Voice, voice, voice assessment

he Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) is a clinical and research tool developed to promote a standardized approach to evaluating and documenting auditory-perceptual judgments of voice quality. The tool was created as a direct outcome of the Consensus Conference on Auditory-Perceptual Evaluation of Voice, held in June 2002 and sponsored by the American Speech-Language-Hearing Associations (ASHA) Special Interest Division 3, Voice and Voice Disorders and the University of Pittsburgh. The purpose of this article is to document the development of the CAPE-V protocol and form, and provide a rationale for each of the elements included in the protocol. The consensus conference brought together an international group of voice scientists, experts in human perception, and speech-language pathologists to explore solutions to a 124

long-standing need in clinical voice pathology: to apply scientific evidence about psychophysical measurement to the clinical practice of judging auditory-perceptual features of voice quality. (See Appendix A for a list of conference participants.) Following 2 days of presentations and discussion, recommendations from these participants informed and guided the development of the CAPE-V tool. The CAPE-V authors (the authors of this article) approached the task of psychophysical measurement and the scaling of voice quality by adhering to the consensus opinions of scientists and clinicians. From its inception, the CAPE-V was intended to become a standardized protocol, useful to clinicians and researchers, that incorporates multiple recommendations for best practices in assessing perceived abnormal vocal quality (Barkmeier, Verdolini, & Kempster, 2002). The word standardized is used throughout this article to refer to a

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procedure that is administered and scored in a consistent way; it does not here denote norm-referencing. The continuum of normal to abnormal voice quality is inextricably related to vocal health. While auditory-perceptual judgments of voice and speech can never be accomplished with perfect validity or reliability (Gerratt & Kreiman, 2000; Gerratt, Kreiman, Antonanzas-Barroso, & Berke, 1993; Kent, 1996; Kreiman & Gerratt, 1998, 2000; Kreiman, Gerratt, Kempster, Erman, & Berke, 1993; Kreiman, Gerratt, Precoda, & Berke, 1992; Shrivastav, 2006; Shrivastav, Sapienza, & Nandur, 2005), perceptual appraisal of voice quality remains a key standard for judgment of vocal impairments, both for patients who experience vocal changes and for the clinicians who treat them (Carding, Carlson, Epstein, Mathieson, & Shewell, 2000; Hirano, 1981; Oates & Russell, 1998; Wilson, 1987). Simply stated, auditory-perceptual measures of voice quality define the presence or absence of a voice disorder clinically. Voice clinicians who treat these patients make auditory-perceptual judgments. Thus, there is a clear need for a way to make such judgments that is sound theoretically, is clinically meaningful, and can be consistently administered.

scale(s), type and amount of user training needed, and whether to use anchors in training. The establishment of an ideal method also requires that some well-known obstacles be overcome. These include the lack of standard terminology for describing or scaling disordered voice quality, the absence of a standard definition of normal voice, inherent poor reliability of auditory-perceptual judgments of voice quality, and inherent variability of an individuals voice production. Although Kent conceded that the perceptual assessment of voice quality has been an uncertain endeavor, vexed by disagreements among authorities and variability in data, he cited reasons for some optimism, based on a growing international interest in developing a standardized procedure, as evidenced by the international representation at the Consensus Conference. He also pointed to emerging consensus points on some basic issues, including what kind of scale to use and how many and which attributes to rate. Moreover, recent demonstrations suggest that computer modeling and interactive synthesis of disordered voice quality can assist in developing improved methods for auditoryperceptual assessment (Callan, Kent, Roy, & Tasko, 2000; Gerratt & Kreiman, 2001; Kreiman & Gerratt, 2000).

Consensus Conference Issues and Summary

The 2-day conference began with a statement of the problem, that of creating valid and reliable measures of auditory-perceptual features of voice quality. Four invited scientists explored issues surrounding the difficult task of psychophysical measurement and scaling, as understood from relevant areas of human perception. The presentations reviewed the historical background of auditory-perceptual evaluation of voice and speech and described the state of the art in human auditory perception, with particular emphasis on how such information might affect the auditory-perceptual assessment of voice disorders. Several voice researchers, from the United States and elsewhere, added information from their investigations of voice quality. Finally, a report on routine clinical practice in the United States was included to relate current practice patterns to conclusions drawn from the scientific discussion. Throughout the conference, the scientists and clinicians reacted to the clinical and research conundrums in auditory-perceptual judgments of voice quality and the challenge of developing a new assessment instrument. At the conclusion of the conference, the authors of this article collaborated to draft the CAPE-V form and procedures.

Psychoacoustic Principles and Human Perception

Lawrence Feth reviewed current psychoacoustics-based perspectives on human perception and the discrimination of sound (Houtsma, 1995; Zwicker, Fastl, & Frater, 1999). He presented a brief review of the anatomy and physiology of the ear, as well as an overview of how sound is processed going from peripheral to central auditory mechanisms. He described (a) the peripheral influences of the outer and middle ear as manifested by the audibility curve, (b) the frequency selectivity/critical bandwidth processing and intensity compression that are initially the result of cochlear morphology and biomechanics, and (c) integration of acoustic information (e.g., spectral integration) that takes place at higher levels of the central nervous system. Feth also summarized what is currently known about how humans perceive and discriminate acoustic parameters of sound. Most of the work in this area has focused on pitch and loudness perception, which has influenced the scaling methods and theoretical constructs for both of these phenomena. Much less effort has been expended in formally studying the perception of sound quality, primarily because it is a more complex (multidimensional) and difficult to quantify perceptual phenomenon. Two sounds that are judged to have equal pitch and loudness but can still be discriminated from each other are said to differ in timbre or quality. By way of example, Feth briefly summarized some of the work by Zwicker et al. (1999) in which they attempted to explore the perception of quality-related concepts such as sharpness, pleasantness, fluctuation, strength, and roughness.

Auditory-Perceptual Evaluation: Exploring the Elusive Ideal

Raymond Kent provided a broad review of auditoryperceptual assessment of voice and speech and outlined the challenges and assumptions associated with establishing an ideal perceptual evaluation method. In voice assessment, such an ideal method would (a) provide a reliable means of differentiating normal and disordered voices, and tracking changes in a patients vocal status across time; (b) correlate with underlying pathophysiology and objective measures; and (c) be clearly established, including type of

Psychophysical Issues Related to Scaling

George Gescheider and Lawrence Marks each gave presentations dealing with the psychophysical bases of perceptual scaling and measurement (Gescheider & Marks, 2002; Marks & Algom, 1998). Gescheider briefly reviewed 125

Kempster et al.: Consensus Auditory-Perceptual Evaluation of Voice

the classic work of some well-known pioneers in psychophysics (Fechner, Weber, Stevens, and Thurstone) in discussing basic approaches for determining absolute and difference (just noticeable differences or difference limens) thresholds for sensory systems. He concluded with an overview of additional scaling methods, including partition, ratio, and multidimensional approaches. Marks addressed the methodological issues in perceptual scaling and measurement more specifically, explaining that the general process of psychophysical analysis involves (a) definition of the stimuli (What properties of stimuli are pertinent to perception?), (b) definition of the perceptual experiences (What are the attributes/features/dimensions of perception and how do these attributes/features/dimensions interrelate?), and (c) determination/modeling of the processes that relate percepts to stimuli (sensory, decisional, cognitive processes: encoding, transforming, recoding, etc.). Marks also commented on the concepts of internal and external validity, sensitivity, and reliability of scaling procedures, as well as differences between direct as compared with indirect scaling methods. Direct methods, which are considered more appropriate than indirect approaches for clinical applications, make use of interval or ratio scaling procedures. To optimize direct scaling, consideration should be given to the actual range and distribution of the stimuli being used, whether standard or anchor stimuli are employed, whether there are sequential/order effects, and whether training improves performance (Gescheider & Marks, 2002; Marks & Algom, 1998). Marks made two specific recommendations with respect to developing a clinical instrument for auditory-perceptual assessment of voice quality. First, he recommended using numerical rating scales with at least 15 subcategories/ divisions or, alternatively, employing continuous graphical/ visual analog scales. Second, he recommended that the location of anchors (e.g., normal or most severe) be adjusted to provide extra room at the ends of the scale to avoid end effects.

schemes for voice assessment and concluded that the most widely used was the Buffalo Voice Profile (Wilson, 1987). Work in Belgium by DeBodt and his colleagues includes clinical recommendations about appropriate use of various options based on a review of contemporary perceptual rating scales.

Consensus Points
The conference attendees agreed that there is no single, best way to approach the task of measuring perceived vocal quality. The current knowledge base is inadequate for designing a clinical tool that resolves all of the relevant scientific issues. Indeed, efforts to do so have reflected an array of problems of reliability, utility, and validity, and these limitations are also true in the development of the CAPE-V. Nonetheless, the CAPE-V authors incorporated multiple perspectives, from scientific data to clinical practice, to develop both a protocol to follow and a form to document auditory-perceptual features of abnormal quality. Conference participants agreed that constructing a consistent and specified set of evaluation procedures and a documentation format would, at a minimum, improve communication and consistency among clinicians. In this context, the authors agreed on the following orienting principles: 1. Perceptual dimensions should reflect a minimal set of clinically meaningful, perceptual voice parameters. 2. Procedures and results should be obtainable expediently. 3. Procedures and results should be applicable to a broad range of vocal pathologies and clinical settings. 4. Ratings should be demonstrated to optimize reliability within and across clinicians through later validation studies. 5. Ultimately, exemplars may be considered for future use as anchors and possibly for training.

Current Practice
Reports from international experts present at the conference reviewed the utilization of auditory-perceptual scales in clinical practice and research, including interactive training models and the use of training scales and anchors (Chan & Yiu, 2002; Oates & Russell, 1998) and other formalized perceptual scaling instruments and procedures including Vocal Profile Analysis by Laver (Carding et al., 2000) and the Stockholm Voice Evaluation Approach (Hammarberg, 2000). Carding reviewed current methods in Britain and noted that while most clinicians in the United Kingdom are trained in Lavers Vocal Profile Analysis, the GRBAS (grade, rough, breathy, asthenic, and strained) method (Hirano, 1981) is recommended as the minimum standard for practicing voice clinicians in the United Kingdom. Several participants referred to other influential sources of information related to the perception of vocal quality: Kreiman et al. (1993) and DeBodt, Wuyts, Van de Heyning, and Croux (1997). Kreiman et al. identified 57 different perceptual

Specific Elements of the CAPE-V

The CAPE-V instructions are included as Appendix B, and the form for documenting the assessment is presented in Appendix C.

Tasks
The CAPE-V stipulates that the individual whose voice is to be assessed (hereafter referred to as the patient) perform three specific vocal tasks: (a) sustain the vowels /a / and /i / three times each; (b) read six specific sentences with different phonetic contexts; and (c) converse naturally in response to the standard question (Tell me about your voice problem). Rationale for the tasks. The first task elicits vowel prolongations. Vowel prolongations (at a steady and comfortable pitch level) provide an opportunity to listen to a patients voice without articulatory influences. Vowels can also be analyzed acoustically, for which some normative data are available. The second task elicits six sentences of varied

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speech contexts from which to assess different elements of vocal quality. Sentence 1 (The blue spot is on the key again) is a commonly used stimulus sentence to examine the coarticulatory influence of three vowels (/a, i, u / ). Sentence 2 (How hard did he hit him?) provides a context to assess soft glottal attacks and voiceless to voiced transitions. Sentence 3 (We were away a year ago) features all voiced phonemes and provides a context to judge possible voiced stoppages/spasms and ones ability to link (i.e., maintain voicing) from one word to another. Sentence 4 (We eat eggs every Easter) includes several vowel-initiated words that may provoke hard glottal attacks and provides the opportunity to assess whether these occur. Sentence 5 (My mama makes lemon jam) includes numerous nasal consonants, thus providing an opportunity to assess hyponasality and possible stimulability for resonant voice therapy. Finally, Sentence 6 (Peter will keep at the peak) contains no nasal consonants and provides a useful context for assessing intraoral pressure and possible hypernasality or nasal air emission. The third task elicits conversational speech and is the most important and relevant to both patient and clinician. Although, in the CAPE-V protocol, conversation is assessed after the vowels and sentences, it is expected that this aspect of the patients voice is under close observation throughout the evaluation session.

Scale
A 100-mm line scale with unlabeled anchors, commonly known as a visual analog scale, is used to assess each of the six quality features. The leftmost portion of the scale reflects normal voice (in the case of judging severity, pitch, or loudness) or none of the quality being judged (in the case of roughness, breathiness, and strain). The right end of the scale is to reflect the listeners judgment of the most extreme example of deviance. A tick mark for each of the three tasks, with the subscript 1 (for vowels), 2 (for sentences), and/or 3 (for conversation) is drawn onto the scale to reflect a listeners judgment for each scale. Measurement from the left end of the scale to each tick mark, in millimeters, is denoted on the blank to the far right of the scale (___ /100). Rationale for the scale. Marks recommends that auditoryperceptual judgments of voice quality be made on a visual analog scale (or set of scales), using open-ended anchor points at either end as a way to inhibit end effects of the scale. Visual analog scales are easy for raters to use and appear to have become more commonplace in voice research in the past 2 decades.

Verbal Descriptor Degree of Deviance

While the primary measurement index is an interval scale provided by the 100-mm visual analog line, the CAPE-V also includes the ordinal ratings of mild, moderate, and severe, printed below the measurement line, to serve as a supplemental severity indicator. These qualitative terms are positioned in a nonequidistant fashion, based on Markss recommendations, and reflect the range of voice severity using terminology more familiar to clinicians than the discrete intervals measured on the 100-mm visual analog scale.

Quality Features to be Assessed

The CAPE-V protocol specifies six quality features to be evaluated consistently and allows flexibility to add other perceptual features of interest. The six voice quality features selected for consistent appraisal are labeled and defined as follows: Overall Severity: global, integrated impression of voice deviance Roughness: perceived irregularity in the voicing source Breathiness: audible air escape in the voice Strain: perception of excessive vocal effort (hyperfunction) Pitch: perceptual correlate of fundamental frequency Loudness: perceptual correlate of sound intensity Rationale for the quality features. Despite much debate over the description, validity, and independence of any list of voice quality features, these six have consistently appeared in both national and international voice literature for decades (DeBodt et al., 1997; Fairbanks, 1960; Hirano, 1981; Wilson, 1987). Thus, the rationale for including these six voice quality features is the belief that both clinicians and researchers find these attributes meaningful. Another common descriptor, hoarse, was excluded from the list of terms because the authors agreed with Fairbanks (1960) that hoarseness is perceived by many as a combination of roughness and breathiness. The CAPE-V form also includes two unlabeled scales. These allow the clinician to document other salient perceptual features of a patients voice, such as degree of nasality, spasm, tremor, intermittent aphonia, falsetto, glottal fry, or weakness.

Additional CAPE-V Elements

A nominal rating judgment allows the clinician to classify the consistency or intermittent presence of the voice quality feature within and across evaluation tasks. Sections devoted to resonance or other features supplement the CAPE-V protocol by allowing other salient descriptors to document a patients voice quality. This flexibility is needed to capture the spectrum of voice disorders and associated conditions or features. The list of terms provided on the form is not inclusive, meant only as examples of specific features that may help describe auditory-perceptual attributes.

Rating Procedures
The CAPE-V judgments are intended to reflect the clinicians direct observations of the patients performance during the evaluation and should not take into account patient report or other sources. Standard audio-recording procedures should be used, such as recording in a quiet environment and using a standard mouth-to-microphone distance with the highest possible sampling rate for digital conversion. If a patient returns following an initial assessment, the clinician may compare the initial voice sample and 127

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CAPE-V ratings directly to any subsequent recordings, to optimize the internal consistency or reliability of repeated sequential ratings, particularly for assessing treatment outcomes. As always, clinicians are encouraged to minimize bias in all ratings. The CAPE-V form and instructions have been available to affiliates of Special Interest Division 3 on the protected portion of the divisions Web site since 2003. The tool was presented at national conventions as early as 2002 (Barkmeier, 2003; Barkmeier et al., 2002; Hillman, 2003; Shrivastav, Kempster, & Zraick, 2006; Zraick et al., 2007). The instrument is already used in more than 20 clinics and some laboratories throughout the United States, and using the CAPE-V protocol as directed has been shown to add no more than a few minutes to a voice evaluation session (M. Spencer, personal communication, June 16, 2005). A national, multi-institutional validation study examining the reliability of the instrument has also begun (Zraick et al., 2007).

scale measures of voice quality by incorporating millimeter measures on visual analog scales. Such scales are shown to better accommodate the task of measurement of multidimensional features, such as vocal quality (Chan & Yiu, 2002; Gerratt et al., 1993). The GRBAS scale, however, only allows ordinal judgments on a four-point scale of normal (1), mild (2), moderate (3), or severe (4), which severely limits its application to research design and statistical analysis. Finally, the CAPE-V attempts to document more voice quality features than the GRBAS, across more speech tasks, while allowing room for supplemental feature scales and comment areas.

Summary and Conclusions

The CAPE-V is the result of an effort sponsored by ASHA Special Interest Division 3 to create a clinical protocol that can be used for making auditory-perceptual judgments of voice quality in a standardized way. The CAPE-V form and procedures represent the consensus recommendations from experts in human perception, speech and voice scientists, and speech-language pathologists who specialize in voice disorders. Although there is no known ideal method for obtaining reliable and valid judgments of auditory-perceptual features, the CAPE-V derives its protocol and measurement scales from a state-of-the-art understanding of the multidimensional factors that underlie psychophysical measurement and human perception. As such, the authors hope it serves to support and encourage best clinical practices in the auditory-perceptual evaluation of voice.

Concurrent Validity and the CAPE-V

A masters thesis (Berg & Eden, 2003) directed by Hammarberg and Holmberg compared aspects of the CAPE-V to the Stockholm Voice Evaluation Approach on patients with three different voice pathologies (E. Holmberg, personal communication, December 1, 2003). This study involved a translation of the CAPE-V into Swedish. The authors determined that intra- and interrater reliability was acceptably high in both protocols, and no obvious differences were found between the two approaches in terms of listener variability. Both protocols were able to separate the three disorders from each other and showed significant pre-to-posttreatment changes in voice quality. Karnell et al. (2007) published a preliminary report comparing the reliability of clinician-based auditory-perceptual judgments using the CAPE-V to those made with the GRBAS voice-rating scheme (Hirano, 1981) and two other quality of life scales. Among other findings, Karnell et al. found comparable estimates of interrater reliability for the two scales, both at high levels. They suggest that the CAPE-V may offer more sensitivity to small differences within and among patients than the GRBAS scale (p. 1). A second preliminary investigation has suggested that the CAPE-V results meet or exceed the GRBAS in measurement reliability (Zraick et al., 2007). The CAPE-Vs similarity to the GRBAS scale is obvious to anyone familiar with both scales. In fact, the CAPE-V uses all of the GRBAS percepts (except aesthenic) for judging voice quality, and the definitions of the quality features are also similar. However, three important factors discriminate the CAPE-V from the GRBAS scale. First, the GRBAS has no published, standardized protocol to follow in English. The Hirano (1981) reference most often cited for the GRBAS provides no guidelines for clinical administration, speech material, or rating calibration. In contrast, the CAPE-V includes a specific protocol that designates the tasks, procedures, and scaling routine, toward the larger goal of improving the consistency of clinical assessment from one clinician to another, without excessive demands on clinician time or learning. Second, the CAPE-V provides interval

Acknowledgments
The CAPE-V was developed under the auspices of ASHA Special Interest Division 3, Voice and Voice Disorders following the Consensus Meeting on Auditory-Perceptual Assessment of Voice Disorders held at the University of Pittsburgh, June 1011, 2002. Funds for support for this meeting came from Division 3 and the University of Pittsburgh. The initial version of the CAPE-V was posted on the Division 3 Web site in late 2002 and has been available to division affiliates since that time. The form and protocol included in this article as Appendices B and C have been modified slightly from the initial version. The authors thank Leslie Glaze for her unwavering support for the publication of this article and critical feedback at important junctures. We also acknowledge, with gratitude, the comments and suggestions of all of the attendees at the consensus meeting, and editorial suggestions for the article made by Richard Peach.

References
Barkmeier, J. (2003, November). Update on the use of the CAPE-V tool. Presented at the Annual Convention of the American Speech-Language-Hearing Association, Chicago. Barkmeier, J., Verdolini, K., & Kempster, G. (2002, November). Report of the consensus conference on auditory-perceptual evaluation of voice. Presented at the Annual Convention of the American Speech-Language-Hearing Association, Atlanta, GA. Berg, B., & Edn, S. (2003). Perceptuell bedmning av rstkvalitet hos tre organiska rststrningarjmfrelse mellan Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) och Stockholm Voice Evaluation Approach ( SVEA). [Perceptual evaluation of

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voice quality in three organic voice disordersa comparison between Consensus Auditory Perceptual Evaluation of Voice (CAPE-V) and Stockholm Voice Evaluation Approach (SVEA)]. Unpublished masters thesis, Karolinska Institute, Stockholm, Sweden. Callan, D., Kent, R., Roy, N., & Tasko, S. (2000). The use of self-organizing maps for the classification of voice disorders. In R. Kent & M. Ball ( Eds.), Voice quality measurement ( pp. 103116). San Diego, CA: Singular. Carding, P. N., Carlson, E., Epstein, R., Mathieson, L., & Shewell, C. (2000). Formal perceptual evaluation of voice quality in the United Kingdom. Logopedics, Phoniatrics, Vocology, 25(3), 133138. Chan, K., & Yiu, E. (2002). The effect of anchors and training on the reliability of perceptual voice evaluation. Journal of Speech, Language, and Hearing Research, 45, 111126. DeBodt, M. S., Wuyts, F. L., Van de Heyning, P. H., & Croux, C. (1997). Test-retest study of the GRBAS scale: Influence of experience and professional background on perceptual rating of voice quality. Journal of Voice, 11(1), 7480. Fairbanks, G. (1960). Voice and articulation drillbook. Philadelphia: Harper & Row. Gerratt, B. R., & Kreiman, J. (2000). Theoretical and methodological development in the study of pathological voice quality. Journal of Phonetics, 28(3), 335342. Gerratt, B. R., & Kreiman, J. (2001). Measuring vocal quality with speech synthesis. Journal of the Acoustical Society of America, 110, 25602566. Gerratt, B., Kreiman, J., Antonanzas-Barroso, N., & Berke, G. (1993). Comparing internal and external standards in voice quality judgments. Journal of Speech and Hearing Research, 36, 1420. Gescheider, G. A., & Marks, L. E. (2002). Psychophysical scaling. In H. E. Pashler & S. S. Stevens ( Eds.), Stevens handbook of experimental psychology (3rd ed., pp. 91138). Indianapolis, IN: Wiley. Hammarberg, B. (2000). Voice research and clinical needs. Folia Phoniatrica et Logopaedica, 52, 93102. Hillman, R. (2003, June). Overview of the Consensus AuditoryPerceptual Evaluation of Voice (CAPE-V) instrument developed by ASHA Special Interest Division 3. Presented at the Annual Symposium on the Care of the Professional Voice, Philadelphia. Hirano, M. (1981). Clinical examination of voice. New York: Springer Verlag. Houtsma, A. J. M. (1995). Pitch perception. In B. C. J. Moore ( Ed.), Handbook of perception and cognition (2nd ed., pp. 276295). San Diego, CA: Academic Press. Karnell, M., Melton, S., Childes, J., Coleman, T., Dailey, S., & Hoffman, H. (2007). Reliability of clinician-based (GRBAS and CAPE-V) and patient-based (V-RQOL and IPVI) documentation of voice disorders. Journal of Voice, 21, 576590.

Kent, R. D. (1996). Hearing and believing: Some limits to the auditory-perceptual assessment of speech and voice disorders. American Journal of Speech-Language Pathology, 5(3), 723. Kreiman, J., & Gerratt, B. R. (1998). Validity of rating scale measures of voice quality. Journal of the Acoustical Society of America, 104, 15981608. Kreiman, J., & Gerratt, B. R. (2000). Sources of listener disagreement in voice quality assessment. Journal of the Acoustical Society of America, 108, 18671876. Kreiman, J., Gerratt, B. R., Kempster, G. B., Erman, A., & Berke, G. S. (1993). Perceptual evaluation of voice quality: Review, tutorial, and a framework for future research. Journal of Speech, Language, and Hearing Research, 36, 2140. Kreiman, J., Gerratt, B. R., Precoda, K., & Berke, G. (1992). Individual differences in voice quality perception. Journal of Speech and Hearing Research, 35, 512520. Marks, L., & Algom, D. (1998). Psychophysical scaling. In M. H. Birnbaum ( Ed.), Measurement, judgment, and decision making. San Diego, CA: Academic Press. Oates, J., & Russell, A. (1998). Learning voice analysis using an interactive multi-media package: Development and preliminary evaluation. Journal of Voice, 12, 500512. Shrivastav, R. (2006). Multidimensional scaling of breathy voice quality: Individual differences in perception. Journal of Voice, 20, 211222. Shrivastav, R., Kempster, G., & Zraick, R. (2006, November). Now hear this: Improving perceptual evaluations of voice quality. Paper presented at the Annual Convention of the American Speech-Language-Hearing Association, Miami Beach, FL. Shrivastav, R., Sapienza, C. M., & Nandur, V. (2005). Application of psychometric theory to the measurement of voice quality using rating scales. Journal of Speech, Language, and Hearing Research, 48, 323335. Wilson, D. K. (1987). Voice problems of children (3rd ed.). Baltimore: Williams and Wilkins. Zraick, R., Klaben, B., Connor, N., Thibeault, S., Glaze, L., Thrush, C., & Bursac, Z. (2007, November). Results of the CAPE-V validation study. Paper presented at the Annual Convention of the American Speech-Language-Hearing Association, Boston. Zwicker, E., Fastl, H., & Frater, H. (1999). Psychoacoustics: Facts and models. New York: Springer-Verlag. Received March 8, 2008 Accepted August 14, 2008 DOI: 10.1044/1058-0360(2008/08-0017) Contact author: Gail B. Kempster, Department of Communication Disorders and Sciences, Rush University Medical Center, 1653 W. Congress Parkway, 203 Senn, Chicago, IL 60612. E-mail: gail_b_kempster@rush.edu.

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Appendix A Participants at the Consensus Conference on Auditory-Perceptual Assessment of Voice Disorders, University of Pittsburgh, June 1011, 2002
Julie Barkmeier Diane Bless Paul Carding Karen Chan Raymond Colton Mary Erickson Michelle Ferketic Lawrence Feth Bruce Gerratt George Gescheider Leslie Glaze Douglas Hicks James Hillenbrand Robert Hillman Eva Holmberg Celia Hooper Michael Karnell Gail Kempster Raymond Kent Jody Kreiman Rebecca Leonard Lori Lombard Christy Ludlow Lawrence Marks Malcolm McNeil Thomas Murry Jennifer Oates Kristin Pelczarski Lorraine Ramig Doug Roth Mary Sandage Christine Sapienza Lana Shekim Rahul Shrivastav Kim Steinhauer Joseph Stemple Johann Sundberg Micheal Trudeau Katherine Verdolini Edwin M-L. Yiu

The authors regret if they have inadvertently omitted a participant from this list.

Appendix B (p. 1 of 2) CAPE-V Procedures

Developed by Gail Kempster, Bruce Gerratt, Katherine Verdolini, Julie-Barkmeier-Kraemer, and Robert Hillman (June 2002) ASHA Special Interest Division 3, Voice and Voice Disorders Description and Instructions General description of the tool. The CAPE-V indicates salient perceptual vocal attributes, identified by the core consensus group as commonly used and easily understood. The attributes are: (a) Overall Severity; (b) Roughness; (c) Breathiness; (d) Strain; (e) Pitch; and (f) Loudness. The CAPE-V displays each attribute accompanied by a 100-mm line forming a visual analog scale (VAS). The clinician indicates the degree of perceived deviance from normal for each parameter on this scale, using a tick mark. For each dimension, scalar extremes are unlabeled. Judgments may be assisted by referring to general regions indicated below each scale on the CAPE-V: MI refers to mildly deviant, MO refers to moderately deviant, and SE refers to severely deviant. A key issue is that the regions indicate gradations in severity, rather than discrete points. The clinician may place tick marks at any location along the line. Ratings are based on the clinicians direct observations of the patients performance during the evaluation, rather than patient report or other sources. To the right of each scale are two letters, C and I. C represents consistent, and I represents intermittent presence of a particular voice attribute. The rater circles the letter that best describes the consistency of the judged parameter. A judgment of consistent indicates that the attribute was continuously present throughout the tasks. A judgment of intermittent indicates that the attribute occurred inconsistently within or across tasks. For example, an individual may consistently exhibit a strained voice quality across all tasks, which include sustained vowels and speech. In this case, the rater would circle C to the right of the strain scale. In contrast, another individual might exhibit consistent strain during vowel production, but intermittent strain during one or more connected speech task. In this case, the rater would circle I to the right of the strain scale. Definitions of vocal attributes. The features of voice that are to be rated are defined as follows: Overall Severity: global, integrated impression of voice deviance Roughness: perceived irregularity in the voicing source Breathiness: audible air escape in the voice Strain: perception of excessive vocal effort (hyperfunction) Pitch: perceptual correlate of fundamental frequency. This scale rates whether the individuals pitch deviates from normal for that persons gender, age, and referent culture. The direction of deviance (high or low) should be indicated in the blank provided above the scale. Loudness: perceptual correlate of sound intensity. This scale indicates whether the individuals loudness deviates from normal for that persons gender, age, and referent culture. The direction of deviance (soft or loud) should be indicated in the blank provided above the scale. Blank scales and additional features. The six standard vocal attributes included on the CAPE-V are considered the minimal set of parameters for describing the auditory-perceptual characteristics of disordered voices. The form also includes two unlabeled scales. The clinician may use these to rate additional prominent attributes required to describe a given voice. The clinician may indicate the presence of other attributes or positive signs not noted elsewhere under Additional features. If an individual is aphonic, this should be noted under Additional features, and no additional marks should be made on the scales.

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Appendix B (p. 2 of 2) CAPE-V Procedures

Data Collection The individual should be seated comfortably in a quiet environment. The clinician should audio-record the individuals performance on three tasks: vowels, sentences, and conversational speech. Standard recording procedures should be used that incorporate a condenser microphone placed at an azimuth of 45 from the front of the mouth and at a 4-cm microphone-to-mouth distance. Audio recordings are recommended to be made onto a computer with 16 bits of resolution and a signal-sampling rate of no less than 20 KHz. Task 1: Sustained vowels. Two vowels were selected for this task. One is considered a lax vowel (/a /) and the other tense (/i /). In addition, the vowel, /i/, is the sustained vowel used during videostroboscopy. Thus, the use of this vowel during this task offers an auditory comparison to that produced during a stroboscopic exam. The clinician should say to the individual, The first task is to say the sound, /a/. Hold it as steady as you can, in your typical voice, until I ask you to stop. (The clinician may provide a model of this task, if necessary.) The individual performs this task three times for 3 to 5 s each. Next, say the sound, /i /. Hold it as steady as you can, in your typical voice, until I ask you to stop. The individual performs this task three times for 3 to 5 s each. Task 2: Sentences. Six sentences were designed to elicit various laryngeal behaviors and clinical signs. The first sentence provides production of every vowel sound in the English language, the second sentence emphasizes easy onset with the /h/, the third sentence is all voiced, the fourth sentence elicits hard glottal attack, the fifth sentence incorporates nasal sounds, and the final sentence is weighted with voiceless plosive sounds. The clinician should give the person being evaluated flash cards, which progressively show the target sentences (see below) one at a time. The clinician says, Please read the following sentences one at a time, as if you were speaking to somebody in a real conversation. (Individual performs task, producing one exemplar of each sentence.) If the individual has difficulty reading, the clinician may ask him or her to repeat sentences after verbal examples. This should be noted on the CAPE-V form. The sentences are: (a) The blue spot is on the key again; (b) How hard did he hit him? (c) We were away a year ago; (d) We eat eggs every Easter; (e) My mama makes lemon jam; and (f) Peter will keep at the peak. Task 3: Running speech. The clinician should elicit at least 20 s of natural conversational speech using standard interview questions such as Tell me about your voice problem or Tell me how your voice is functioning. Data Scoring The clinician should have the individual perform all voice tasksincluding vowel prolongation, sentence production, and running speech, before completing the CAPE-V form. If performance is uniform across all tasks, the clinician should mark the ratings indicating overall performance for each scale. If the clinician notes a discrepancy in performance across tasks, he or she should rate performance on each task separately, on a given line. Only one CAPE-V form is used per individual being evaluated. In the case of discrepancies across tasks, tick marks should be labeled with the task number. Tick marks reflecting vowel prolongation should be labeled #1 (see form). Tick marks reflecting running speech should be labeled #2. Tick marks reflecting story retelling should be labeled #3. In the rare event that the clinician perceives discrepancies within task type (e.g., /a/ vs. /i/ ), he or she may further label the ratings accordingly, such as 1/a/ versus 1/i/ to reflect the different vowels, or 2(a)-(b)-(c)-(d)-(e)- or (f) for the different sentences. Unlabeled tick marks indicate uniform performance. See examples below. (Note: Using labels to indicate discrepancies/variation across tasks in the severity of an attribute is different than indicating that an attribute is displayed intermittently [I]. If an attribute is judged to have equal severity whenever it appears, but it is not present all the time, I should be circled to indicate that the attribute is intermittent, and no additional labeling needs to be done.) After the clinician has completed all ratings, he or she should measure ratings from each scale. To do so, he or she should physically measure the distance in millimeters from the left end of the scale. The millimeters score should be written in the blank space to the far right of the scale, thereby relating the results in a proportion to the total 100-mm length of the line. The results can be reported in two possible ways. First, results can indicate distance in millimeters to describe the degree of deviancy, for example 73/100 on strain. Second, results can be reported using descriptive labels that are typically employed clinically to indicate the general amount of deviancy, for example moderate-to-severe on strain. We strongly suggest using both forms of reporting. It is strongly recommended that for all rating sessions following the initial one, the clinician have a paper or electronic copy of the previous CAPE-V ratings available for comparison purposes. He or she should also rate subsequent examinations based on direct comparisons between earlier and current audio recordings. Such an approach should optimize the internal consistency/reliability of repeated sequential ratings within a patient, particularly for purposes of assessing treatment outcomes. Although difficult, clinicians are encouraged to make every effort to minimize bias in all ratings. We acknowledge that this solution is imperfect. Other Elements The clinician can indicate prominent observations about resonance phenomena under Comments about resonance. Examples include, but are not limited to, hyper- or hyponasality and cul-de-sac resonance.

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Appendix C CAPE-V Form

Note. This form may be photocopied for clinical purposes. Also available online at http://ajslp.asha.org.

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Clinical Focus

When Simon Says Doesnt Work: Alternatives to Imitation for Facilitating Early Speech Development
Laura S. DeThorne Cynthia J. Johnson
University of Illinois at Urbana-Champaign

Louise Walder
Private Practice, Mahomet, IL

Jamie Mahurin-Smith
University of Illinois at Urbana-Champaign

Purpose: To provide clinicians with evidencebased strategies to facilitate early speech development in young children who are not readily imitating sounds. Relevant populations may include, but are not limited to, children with autism spectrum disorders, childhood apraxia of speech, and late-talking toddlers. Method: Through multifaceted search procedures, we found experimental support for 6 treatment strategies that have been used to facilitate speech development in young children with developmental disabilities. Each strategy is highlighted within this article through a summary of the underlying rationale(s), empirical support, and specific examples of how it could be applied within intervention.

Conclusions: Given the relatively sparse experimental data focused on facilitating speech in children who do not readily imitate, theoretical support emerges as particularly key and underscores the need for clinicians to consider why they are doing what they are doing. In addition, this review emphasizes the need for the research community to bridge the gap between pressing clinical needs and the limited evidence base that is currently available.

Key Words: speech treatment, toddlers, preschool children, apraxia

speech-language pathologist sits on the floor across from Micah, a 2-year-old boy with few intelligible words and a limited repertoire of speech sounds. Despite Micah s speech-language difficulties, there is no direct evidence of any neuromuscular difficulties. In the clinicians attempt to engage Micah, she pulls two of his favorite toys out of her baglittle plastic animals. She holds up a dog in one hand and a cat in the other. Which one do you want, Micah? He reaches for the dog. You want the dog? she inquires, stressing the name of the desired object. Micah silently reaches again for the desired toy. The clinician pulls it just out of his reach and instructs, Say dog. Micah is silent. The clinician prompts him again, this time with a simplified version of the word, Watch my mouth. Say da, but before she is able to finish, Micah has wandered off. The

clinician is frustrated. Although Micah has a small repertoire of speech sounds, including /d/, which he uses in spontaneous jargon, he will not imitate any of them. How is she supposed to help him talk intelligibly? Children like Micah, who are not readily imitating sounds despite typical strength and structure of oral neuromusculature, are not uncommon on the caseloads of practicing speechlanguage pathologists, particularly those in early intervention. Relevant populations may include children with apraxia of speech, autism spectrum disorders (ASD), or those referred to descriptively as late-talking toddlers. Although goals for language development are primary in many of these children, speech sound development may also be key. Recent research in the treatment of speech sound disorders has focused primarily on how to select target speech sounds (e.g., Kamhi, 2006) and relied heavily on traditional practices of speech sound elicitation that build on imitation abilities. For example, 133

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Van Ripers hierarchy of production training begins by attempting to elicit imitation of isolated speech sounds ( Van Riper & Erickson, 1996). Similarly, Strand and Skinder (1999) note that integral stimulation, one of the most common approaches to treating childhood speech disorders, requires children to imitate models by the clinician. This void between the literature that emphasizes imitation as a basic strategy for facilitating speech sound production and the skills of young children who do not readily imitate leaves clinicians struggling to determine best practice through a process of trial and error. From this rich experience base, a few clinicians have taken the initiative to share their strategies through books, videos, Web sites, and conference presentations (e.g., Boshart, 2004; Hammer, 2006; Marshalla, 2003). In addition, the marketplace for practicing clinicians has been flooded with materials, such as whistles and chewy tubes, that are advertised as products to facilitate early speech production. Despite the wealth of good ideas embedded in many of these resources, they are rarely grounded within a solid theoretical framework or linked to the small repository of empirical research on treatment efficacy that is available. Consequently, clinicians are left to filter through such products and advice without much guidance in regard to evidence-based practice (EBP). EBP has been defined as a framework for clinical decision making that integrates scientific evidence with clinical expertise and client values (American Speech-Language-Hearing Association [ASHA], 2004; Dollaghan, 2007; Johnson, 2006). The importance of EBP has recently been emphasized in multiple ASHA publications (e.g., ASHA, 2004, 2005; Mullen, 2007). Although the gold standard for evidence of treatment efficacy is empirical data from randomized experimental designs emerging from a variety of independent investigators (ASHA, 2004; Johnson, 2006; Mullen, 2007; Odom et al., 2005), few treatment approaches in speechlanguage pathology have accumulated this form of support. How then do clinicians answer pressing questions regarding the treatment of children on their caseloads? Fortunately, EBP encompasses varied forms of evidence, including theoretical grounding and clinical expertise, and does not preclude use of experimental interventions. However, EBP dictates that we be aware of what evidence does or does not exist for our practices and that we give thought to why certain strategies and techniques might be successful. Without an understanding of why something works, there is always the danger that it will be misapplied, and we will be left unable to build on the strategy to form new and potentially better ideas. The purpose of the present article is to highlight strategies for facilitating early speech sound development based on the current evidence base. Although the strategies may apply more broadly, the focus is on young children who are not readily imitating early speech sounds despite typical strength and structure of peripheral oral musculature. The clinical goal is to facilitate speech development through eliciting relevant child vocalizations, whether imitative or spontaneous. We began the process by generating a list of strategies with an established theoretical framework that were being promoted by prominent clinical authorities in the treatment of speech in children with developmental disabilities (e.g.,

Hammer, 2006; Manolson, 1992; Marshalla, 2003; Square, 1999; Strand, 1995). We then used multifaceted search procedures to identify relevant intervention studies, including electronic keyword searches of relevant databases (e.g., PsycInfo, ERIC, PubMed) and ancestral searches of references in identified sources. Based on this review, we identified six strategies with Level II empirical support (see ASHA, 2004; Johnson, 2006; Justice & Fey, 2004, for a review of evidence levels). Specifically, we selected strategies that were supported by at least one experimental or quasi-experimental study on a relevant population. Consistent with criteria outlined in Dollaghan (2007) in regard to the evaluation of treatment studies, we considered a study as experimental if it actively manipulated treatment in order to examine its effect on meaningful speech outcomes in a relevant pediatric population using either a comparison group or condition. Due to the relatively sparse literature, we have included semiexperimental studies that lack the random group assignment or naBve evaluation usually associated with the gold standard in experimental design. To be considered a relevant population, the treatment study had to include children with substantial speech impairment associated with developmental disability. Table 1 lists the six treatment strategies that met our criteria of evidential support. The remaining document serves to summarize the theoretical and empirical support for each of these strategies as well as to underscore important areas for future intervention research. Before proceeding, we want to emphasize our focus on eliciting speech-like vocalizations in young children who are not readily imitating speech sounds. If and when speech imitation skills emerge, additional strategies for shaping speech productions are likely to apply. In addition, the present strategies do not explicitly address important goals related to vocabulary and pragmatic development that will also be key in many of these children. In sum, this article is not intended as a cookbook for how to provide intervention. On the contrary, the focus on theoretical frameworks and the empirical research related to each strategy is intended to encourage clinicians to think independently and critically about how each strategy may or may not apply to an individual case.

Evidence-Based Strategies for Eliciting Speech-Like Vocalizations

1. Provide Access to Augmentative and Alternative Communication (AAC) Rationale. AAC encompasses the use of manual signs, communication boards/books, high-tech electronic devices, and other forms of unaided and aided communication (Binger & Light, 2006, p. 200). We highlight the use of AAC as the first strategy because of its relatively strong empirical support and its underappreciated role in natural speech development. Although AAC can serve as a compensatory means of facilitating social interactions for children with substantial speech-language difficulties (e.g., Charlop-Christy, Carpenter, Le, LeBlanc, & Kellet, 2002; Cumley & Swanson, 1999), we want to stress its utility in facilitating natural speech development. Although counterintuitive to many, AAC can serve as a critical tool in facilitating speech development

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TABLE 1. Summary of six strategies for facilitating speech sounds development in children who are not readily imitating. Primary rationale Successful communication enhances the development of relevant semantic and syntactic networks (i.e., it provides a meaningful framework for production of new words, syllables, and sounds), and in the case of voice output devices, provides a timely auditory model. Anxiety and stress can have a negative impact on motor performance. Imitation may serve as a model for eliciting imitation itself. Neural mechanisms devoted to melodic production can be used to bootstrap speech production. Children with speech sound disorders may be less able to capitalize on the sensory feedback typically available. Sensory motor control for speech is somewhat distinct from nonspeech oromotor behaviors. Utilize puppet play to model target sounds or movements. If the child babbles baba, repeat this back and use it to begin the song Baa Baa Black Sheep. Produce meaningful words and phrases with exaggerated prosody, such as an elongated rising intonation for the word more when used as a request. Enhance visual/tactile feedback by providing a light tap on your own or the childs lips while modeling production of a /b/ sound. If alveolar speech sounds are being targeted, incorporating tongue clicks into meaningful play would be more appropriate than tongue wagging or protrusion. Provide a child with a core vocabulary book: a small album that includes photos of meaningful objects, people, and places. Example Key empirical evidence Millar et al. (2006)

Strategy

1. Provide access to AAC

2. Minimize pressure to speak

Baskett (1996), Kouri (2005) Field et al. (2001), Snow (1989), Tamis-LeMonda et al. (2001) Kouri & Winn (2006), Wade (1996)

3. Imitate the child

4. Utilize exaggerated intonation and slowed tempo

5. Augment auditory, visual, tactile, and proprioceptive feedback

Bernard-Opitz et al. (1999), Hailpern et al. (2008) Braislin & Cascella (2005)

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by enhancing childrens ability to build relevant semantic and syntactic networks, and in the case of voice output devices, by providing a consistent acoustic model of target sounds and words that children can select as needed (see Millar, Light, & Schlosser, 2006). Evidence. A review of evidence regarding the impact of AAC on speech-language development in individuals with disabilities is provided by Millar et al. (2006). Of the six studies identified by the authors as demonstrating experimental control, 89% of the individual cases demonstrated increases in speech production with the introduction of AAC, and the remaining 11% of the cases showed no change. None of the 27 cases demonstrated a deleterious effect on speech production; however, a study by Yoder and Layton (1988) highlighted the potential importance of providing verbal models in conjunction with sign if the ultimate goal is to facilitate speech production. On a related note, a singlesubject design by Iacono and Duncum (1995) found that the use of sign in conjunction with a speech output device was more effective in eliciting word productions from a 2-year-old child with Down syndrome than use of sign alone. In sum, the literature suggests rather convincingly that AAC not only provides a compensatory mechanism for speech difficulties but can also serve as a powerful tool in facilitating natural speech development. Examples. The many issues involved in successfully selecting and implementing AAC are beyond the scope of this article, and readers are referred to the variety of more comprehensive resources (e.g., Beukelman & Mirenda, 2005; Light, Beukelman, & Reichle, 2003; Reichle, Beukelman, & Light, 2002). However, we offer a few examples of low- and mid-tech options that have been successfully implemented with young children. For example, meaningful signs can be modeled directly by the examiner or through hand-over-hand facilitation of the childs hands, if he or she is receptive to this. Blacklin and Crais (1998) stress the importance of beginning with survival words that are likely to be motivating and powerful, such as words that facilitate requesting and protesting (see also Bondy & Frost, 1994). Considerations for selecting signs, especially for children with cognitive or motor coordination constraints, include the iconic and motoric complexity of the signs, with symmetrical contact gestures with high iconicity being easiest. Specific examples include modeling the sign for more when a child is reaching for another cookie or open when a child is struggling to open a container of interest. Given the possibility that children with substantial articulation difficulties may also experience difficulties coordinating manual communication, AAC devices that utilize picture symbols and voice output provide another potentially helpful modality. Hammer (2006) suggests a core vocabulary book that could include photos or symbols of favored objects, people, and activities. A child who is searching for a favorite toy or wondering where Mom is could point to the relevant item or person in his or her book. As another example, options for snacks and mealtime could be pictorially represented on the refrigerator door, so that a child could point to what he or she wanted to eat either as an initiation or at the prompt of a caregiver. Bondy and Frost (1994) provide a concrete hierarchy of steps that can be implemented

to help children discover the power of using pictures to communicate. Voice output devices might also be appropriate for some children. Examples are varied and range from talking key chains that offer up to 10 s of voice recording to dynamic displays with word prediction and synthetic speech output. Examples for how to incorporate the simpler devices include encouraging a childs use of a speech output device to take his or her turn in reading reoccurring words or phrases from a repetitive book. A one-button speech output device with a belt clip could be worn throughout the day and used to participate in a common social routine, such as saying hello, or in making a frequent request, such as going to the bathroom. In addition to the texts cited earlier, the following Web sites are useful in understanding the options and issues surrounding AAC: http://aac.unl.edu/, where the University of Nebraska at Lincoln provides a collection of resources and links related to AAC; www.wati.org/, where the Wisconsin Assistive Technology Initiative sponsors a loaning library, training events, and related resources; and www.attainmentcompany.com/xcart/home.php, the Web site for the Attainment Company, which is known for its variety of relatively low-cost AAC systems. 2. Minimize Pressure to Speak Rationale. In addition to building childrens linguistic networks, AAC may actually facilitate speech in part by reducing pressure to speak in the traditional sense. The general strategy of reducing communicative pressure is based on the premise that high-pressure situations can have a negative impact on motor performance in both adults and children across a variety of tasks, including speaking (e.g., Beuter & Duda, 1985; I. M. Blood, Wertz, Blood, Bennett, & Simpson, 1997; Caruso, Chodzko-Zajko, Bidinger, & Sommers, 1994; Hardy, Mullen, & Martin, 2001; Milne, 1970; Tolkmitt & Scherer, 1986). Consider the difference between conversing with a friend versus delivering a public speech, or singing in the shower versus performing a solo. The precise mechanism through which anxiety affects motor performance is complex, although the general response to stress involves activation of the sympathetic nervous system paired with inhibition of the parasympathetic system (G. W. Blood, Blood, Bennett, Simpson, & Susman, 1994; Robertson, 2004; Weber & Smith, 1990). Relevant effects on speech may include disruption of respiratory function, increased muscular tremor, and altered sensitivity of sensory receptors within articulatory regions (Weber & Smith, 1990). Evidence. Experimental evidence in support of decreasing communicative pressure comes from studies that have compared childrens communicative behavior across conditions in two different populations: children with autism and children late to talk. Specifically, a group design by Baskett (1996) directly compared the amount of vocalizations in 8 children with autism, age 46 years, during two conditions: one in which the child and examiner were in the same room together, and one in which the examiner was in a separate room but could be viewed live by the child through a video monitor. Both conditions included a scripted pseudoconversation intended to elicit interaction. The video condition was expected to increase communicative behaviors by decreasing the stress associated with direct interpersonal interaction. In

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support of this prediction, the childrens mean vocal behavior paired with eye gaze toward the examiner was higher in the video condition than in person. The study also provided preliminary support for the idea that using a puppet as a conversational partner might decrease communicative pressure in some children, as evidenced by increased eye gaze and vocal behaviors (see also Bishop, Hartley, & Weir, 1994). Additional support for the use of lower-pressure techniques comes from a recent study by Kouri (2005), a group design comparing the effect of two treatment approaches, mand-elicited imitation and modeling with auditory bombardment, on word production in 29 late-talking preschoolers. Although the mand-elicitation condition, which utilized mands (e.g., What do you want? ) and prompted imitations (e.g., Tell me bubble) of lexical items, elicited more target words within the treatment setting, the number or percentage of target words generalized to the home setting did not differ between conditions. The study suggests that higherpressure techniques, such as direct requests for imitation, do not enhance word learning outside the treatment setting to any greater extent than lower-pressure strategies, such as modeling (see also Camarata, Nelson, & Camarata, 1994, for a similar study focused on grammatical targets). Examples. Attempts to reduce communicative pressure can take a variety of forms, depending in large part on what circumstances an individual child finds stressful. Examples might include avoiding direct requests for imitation, minimizing time pressure, avoiding test questions, following the childs lead, and utilizing familiar interactions and naturalistic settings (e.g., Girolametto, 1988). Additional clinical strategies include simultaneous vocalization (Velleman, 2006) or vocal contagion (Marshalla, 2003) in which children vocalize in conjunction with others, thereby creating less focus on their own voice. We also recommend the use of puppets as interactive partners. Puppet play reduces the potential power differential associated with adultchild interactions and minimizes the pressure of certain social conventions such as eye contact and conversational turn-taking. Children can either interact directly with the puppet or simply observe interactions between the puppet and clinician. Such interactions can be used to model target sounds (e.g., using a bumblebee puppet to model syllable-initial /b/: Bumblebee, you had better not eat my banana. Beware bumblebee, if you bite my banana Ill bop you with my bean bag!), elicit imitations of relevant oral motor movements (e.g., encouraging a reticent puppet to open its mouth and say ah while pretending to play doctor), or provide a comfortable context in which to use unfinished carrier phrases ( Lets tell the bee when to start ready, set I go! to encourage spontaneous production of /go /). 3. Imitate the Child Rationale. In addition to being a low-pressure strategy, the primary rationale for imitating the child is that it serves as a means to model the skill of imitation itself. In short, being imitated may teach a child to imitate, and imitation is a useful strategy in learning to use spoken language (see Masur & Eichorst, 2002; Schwartz & Leonard, 1985; Snow, 1989). Recent evidence of mirror neurons is also consistent with the importance of developing imitation skills (Nishitani,

Avikainen, & Hari, 2004; Rizzolatti & Craighero, 2004). Mirror neurons fire when an observer sees someone perform a familiar action, and their firing activates relevant motor neurons. A clinicians imitation of a childs speech may trigger mirror neuron firing (Oberman & Ramachandran, 2007), thereby serving as a form of involuntary rehearsal on the childs part. Of interest, neural imaging studies indicate that the mirror neuron system is impaired in children with ASD (Iacoboni & Dapretto, 2006); in fact, Dapretto et al. (2006) found an inverse relationship between symptom severity and mirror neuron activity in their functional magnetic resonance imaging study of 9 boys with ASD. Whether or not the adults example of imitation leads to imitation by the child in the short term, focusing on the childs spontaneous activity within his or her natural environment is likely to be more engaging for the child (e.g., Lewy & Dawson, 1992), facilitate generalization of any elicited speech sounds (Koegel, Camarata, Koegel, Ben-Tall, & Smith, 1998), and simplify the speaking task by using a familiar form to elicit the unfamiliar function of imitation (Velleman, 2006). Evidence. Imitating the child is incorporated as a single thread in several multifaceted therapy programs (e.g., The Hanen Program for Parents or Greenspans Floortime approach). The Hanen Program, for instance, stresses the importance of imitation, specifying one of the best ways to connect with very young children who are just beginning to communicate is to imitate their sounds, actions, facial expressions and words (Manolson, 1992, p. 18). Despite relatively widespread use of this strategy in conjunction with other techniques, we focus here on evidence to support its use in isolation. For example, Field, Field, Sanders, and Nadel (2001) examined the effect of adult imitation of child behavior in a sample of 20 nonverbal children with autism, age 4 6 years. Specifically the investigators compared childrens behavior across two conditions: one in which the adult imitated a childs behaviors, including vocalizations, and the other in which the adult was simply asked to play with the child. The children exposed to the imitation condition demonstrated a significant increase in vocalizations across sessions, whereas the children in the play condition did not. In addition, work by Snow (1989) including 100 children age 1420 months demonstrated associations between the frequency with which mothers imitated their children and the frequency with which the children used imitation. As maternal imitation increased, spontaneous imitative behavior increased in their childrens speech as well. Although correlation designs do not specify causal influence, Snow used such data to make the point that imitation is a skill that can be learned, rather than a less mutable personality trait. Similarly, a prospective longitudinal study of 40 motherchild dyads by Tamis-LeMonda, Bornstein, and Baumwell (2001) found the extent to which mothers imitated their 13-monthold children predicted the timing of the childrens later child language milestones even after controlling for child language differences at 13 months. For instance, a mother might respond Ball! to a childs vocalization of ba; such a response was found to predict the timing of developments including the childs acquisition of his or her first 50 words,
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the use of combinatorial speech, and first references to the past. Finally, a study by L. B. Leonard et al. (1982) supported the idea of selecting targets from the childs current productions, which is a key element of imitation (see also Stoel-Gammon, 1998). Leonard et al. found that young children (age 2;8 [years; months] to 3;1) were significantly more likely to produce new words with phonological characteristics they had already acquired than to produce phonologically challenging words. The authors introduced 16 unfamiliar words to 28 children, 14 with normal language development and 14 with specific language impairment. Half of the items were out-of-phonology words containing initial consonants or clusters not yet acquired by the child, and half were in-phonology words. Both groups showed a clear preference for the in-phonology words. The intervention strategy employed in this study, in which the in-phonology targets presented to the child were determined by the childs prior productions, could be viewed as a form of delayed imitation of the child, which in turn facilitated the childs word production. Examples. A clinicians imitation of the child might include verbal or nonverbal actions. In regard to the latter, imitating a childs nonverbal actions, especially oral motor movements, could provide a useful springboard for facilitating verbal interaction. For example, if the child yawns, the clinician might pretend to yawn (with an exaggerated vowel-like sound) and wait to see how the child responds. Similarly, if a child were to make a lip-spreading movement (e.g., to smile for a photo or to show off something he or she did), the clinician might imitate the action and pair with a relevant speech sound, like a prolonged /i / for See! Clinicians can also imitate a childs spontaneous verbalizations; for example, if the child says baba, the adult conversational partner might imitate baba and then use it as a start for the song Baa Baa Black Sheep. As mentioned by Marshalla (2003), this strategy also allows a clinician to assign meaning to vocalizations that are already in a childs repertoire. For example, the child may regularly vocalize dih-uh in his spontaneous jargon. If he happens to say it while pointing to a desired object, the clinician might imitate and assign meaning (which may or may not be there already in the childs mind) by saying, Dih-uh. Oh, this one. You want this one, and then pausing to give the child a chance to respond verbally or otherwise. Once a child is producing recognizable words, incorrect pronunciations need not be imitated. Instead, imitation could serve as an opportunity to model the adult form of the word in conjunction with additional strategies for facilitating language development, such as expansion, which fall outside the scope of this article (see McCauley & Fey, 2006). 4. Utilize Exaggerated Intonation and Slowed Tempo Rationale. Whether imitating the child or initiating interaction, exaggerated intonation is a commonly employed technique (e.g., J. S. Leonard, 1992; Macaluso-Haynes, 1985). Although the slower tempo that often characterizes phrases with exaggerated intonation may be facilitatory in its own right, we suggest that the primary rationale for this strategy is that neural mechanisms involved in singing can be used to bootstrap speech production due to partially distinct but also overlapping neural networks. In a 2003 article,

Patel hypothesized that linguistic and musical syntax share certain syntactic processes (instantiated in overlapping frontal brain areas) that apply over different domain-specific syntactic representations in posterior brain regions (p. 679). Similarly, research into the neural bases of pitch processing indicates that both right and left cerebral hemispheres, as well as some subcortical structures, are involved in evaluating pitch changes in both speech and music (Baum & Pell, 1999). However, some imaging studies have described distinct patterns of brain activity for speech and singing. Jeffries, Fritz, and Braun (2003) concluded that speech involved relatively greater neural activation in left-hemisphere structures, while singing the same text resulted in a relative increase in right-hemisphere activity. For children in the target populations, a focus on tasks that emphasize right-hemisphere activation could prove to be a valuable compensatory mechanism. In addition to the idea of neurological bootstrapping, a secondary rationale for modeling exaggerated prosody is that prosodic features may be key in facilitating speech intelligibility. Even children without clear speech sound production may be able to increase their communicative success by utilizing familiar intonational patterns, such as a rising intonation to mark a question versus a falling intonation to mark a comment (see Hargrove, Roetzel, & Hoodin, 1989). In other words, even if exaggerated intonation does not help with the accuracy or fluency of speech production, it may highlight important features of the speech signal for intelligibility. Evidence. While the neural pathways involved have yet to be labeled conclusively, the use of music in speech therapy has a long history. Clinicians have used singing in therapy for patients with acquired apraxia (Wambaugh & Doyle, 1994), and the fluency-inducing effects of singing are well documented in the stuttering literature (Alm, 2004). In fact, Melodic Intonation Therapy, developed by Albert, Sparks, and Helm (1973) for adults with aphasia, has been frequently applied to young children with speech and language difficulties. The approach focuses on (a) the addition of a melodic line, (b) slowed tempo, and (c) exaggerated rhythm and stress (Wade, 1996). Although exaggerated prosody has been used in the treatment of adult communication disorders (Hyland & McNeil, 1987), we focus here on its use to facilitate speech production in young children. Wade (1996) conducted a singlesubject alternating-treatment design to compare the effects of Melodic Intonation Therapy versus oral motor treatment on the initial consonant production of a 3-year-old girl with apraxia of speech. When the study began, she had been in treatment for a year and evidenced more than a 1-year delay in the areas of expressive language and phonology. A 2-month therapy program targeted phonemes at varying levels of difficulty, classed as easy, intermediate, or hard. When results were compared for Melodic Intonation Therapy and oral motor therapy, the former was found to be significantly more effective for phonemes at all three difficulty levels (see also Helfrich-Miller, 1984). Additional studies with weaker experimental designs have also noted gains in verbal imitation (Krauss & Galloway, 1982) and general intelligibility (Grube, Spiegel, Buchhop, & Lloyd, 1986) as a function of exaggerating intonational patterns.

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In the realm of child language, a recent study by Kouri and Winn (2006) compared the use of sung versus spoken stories to facilitate learning of nonsense words by 16 preschoolage children with language difficulties. Although the sung condition did not differentially facilitate word comprehension, it was associated with more unsolicited attempts at imitation of the target forms during the second of the two experimental sessions. In sum, converging evidence supports the use of melody and exaggerated prosody to facilitate childrens attempts and accuracy at speech production. Examples. Exaggerated prosody can be overlaid onto any meaningful word or phrase. For example, the word hi could be produced with an elongated falling intonation, or the word more could be modeled with a rising intonation to denote a request. Frequent two-syllable phrases could be presented with exaggerated two-tone patterns (e.g., high-low) and later used as an unfinished carrier phrase (e.g., Allllll I done or Light I on). Phrases might be practiced with or without musical accompaniment, such as striking two keys on a keyboard. Similarly, pauses could be inserted into familiar songs to tempt children into completing the anticipated piece (e.g., Like a diamond in the I or Row row row your I). 5. Augment Auditory, Visual, Tactile, and Proprioceptive Feedback Rationale. Though established speech production is usually highly automatic and accomplished without attention to sensory feedback (Lof, 2007; see also Todorov, 2004), the latter likely plays an important role in establishing new speech behaviors (Clark, Robin, McCullagh, & Schmidt, 2001). Consequently, when imitation of a new speech movement is challenging under natural circumstances, we recommend enhancing sensory feedback to guide the new movement. The rationale is that children with speech difficulties may be less able to capitalize on sensory feedback due to one or more of the following reasons: (a) the need to focus the bulk of their attention on the movement itself, (b) a lack of sensory receptors or good sensory function in certain feedback domains, such as audition, or (c) the tendency to experience more sensory or motor noise (Todorov, 2004, pp. 910911) than typically developing children. In any case, augmented sensory data may then be needed to develop internal models for speech sound production. Internal models refer to the neural mechanisms that associate motoric plans with their sensory consequences (Brass & Heyes, 2005; Iacoboni, 2005; Iacoboni & Wilson, 2006; Kawato, 1999). Evidence. The small literature on the benefits of enhancing sensory input or feedback focuses largely on manipulation of four domains: auditory, visual, tactile, and proprioceptive. In the auditory domain, the Fast ForWord Program (Scientific Learning Corporation, 1997) was developed to provide children with exposure to acoustically modified speech that involves slowed consonant-vowel transitions; we do not review this literature here due to its focus on language outcomes in school-age children who are likely to have already acquired speech imitation skills (Gillam, Loeb, & Friel-Patti, 2001; Gillam et al., 2008; Merzenich et al., 1996; Tallal et al., 1996, 1997). In addition, there is a small literature regarding the use of visual feedback to facilitate speech sound production using real-time spectrographic displays, ultrasound, and electromagnetic articulography in older children and adults

(Adler-Bock, Bernhardt, Gick, & Bacsfalvi, 2007; Barry, 1989; Carter & Edwards, 2004; Katz, Bharadwaj, & Carstens, 1999; Katz et al., 2007; Meredith, 2007; Shuster, Ruscello, & Smith, 1992). We focus here on two treatment studies that have utilized mixed forms of augmented feedback to facilitate speech development in young children with significant developmental speech disabilities. First, a study by Hailpern, Karahalios, Halle, DeThorne, and Coletto (2008) examined the role of computerized contingent auditory and visual feedback on the vocalizations of 2 nonverbal children with autism, age 5 and 7 years, using an adapted within-subject experimental design. Visual feedback included colorful circles, fireworks, or jagged lines that appeared on a computer screen in response to the loudness, pitch, and duration of the childs voice. Auditory feedback included pitch-shifted replay of the childs vocalizations, reverberation, or segments of familiar musical tunes. Results found that computerized feedback increased vocalizations significantly in one child and demonstrated a promising trend toward increasing speech-like vocalizations in the other (see also BernardOpitz, Sriram, & Sapuan, 1999). Despite its promise, results from this line of research are extremely preliminary. The extent to which results will generalize across children and across contexts is an area for further investigation. In the tactile and proprioceptive realms, another more established means of providing augmented feedback to facilitate speech is a cuing system referred to as PROMPT, which stands for Prompts for Restructuring Oral Muscular Phonetic Targets (Chumpelik, 1984; Square, 1999). This system uses a different tactile prompt for each English phoneme according to its place, manner, and voicing in conjunction with providing auditory and visual models (Chumpelik, 1984). Most cited research using PROMPT with children has been disseminated outside of peer-reviewed venues and comes from a single set of investigators (www.promptinstitute.com/; see Smit, 2004, as a potential exception). We will draw attention here to a study by Square, Bose, Goshulak, and Hayden (n.d.) that was accessible online. This pilot study utilized a single-subject design to target production accuracy of trained lexical items in 6 boys, all age 4, with substantial language and phonological disabilities. The authors noted gains in target production accuracy as well as in overall communication and social interaction (see also Rogers et al., 2006). Examples. Enhanced feedback has been advocated for many years by prominent clinical authorities (e.g., Boshart, 2004; Marshalla, 2005, 2007), with techniques such as speaking more loudly and facing the child to accentuate the auditory and visual characteristics of target sounds (Ertmer et al., 2002, p. 193). Focusing first on the auditory realm, target words and sounds can be delivered with slight amplification through headphones (e.g., Hodson & Paden, 1991). Low-tech options, such as talking into an echo microphone, a section of PVC pipe, a mailbox, or any chamber that creates an echo, can be used to attract the childs interest to the targets. Enhanced visual feedback can be promoted by face-to-face interaction, mirror work, and gestures. Similarly, a puppet with a movable mouth can provide visual input for speech in a way that may be less threatening to children than being asked to attend directly to an adult (see Strategy 2). Currently
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available computer programs that provide real-time visual feedback in response to vocalization are limited to specialized instruments, such as the Visi-Pitch IV by KayPentax, which includes voice games designed for children. In the tactile and proprioceptive domains, touch-pressure cues, such as a light tap on the clinicians or childs lips while modeling bilabial plosives, have been utilized (Bleile, 2004). Similarly, brushes (e.g., a toothbrush or cotton swab) and snack foods (e.g., frosting or a lollipop on the alveolar ridge) have all been used to draw attention to key articulator locations. 6. Avoid Emphasis on Nonspeech-Like Articulator Movements: Focus on Function Rationale. One current controversy in the area of speech motor control involves the relative task-specificity of speech production (see Ballard, Granier, & Robin, 2000; G. Weismer, 2006; Ziegler, 2003). One view, referred to as the taskindependent view or the hypothesis of body part coding, postulates a general sensory motor mechanism that underlies movement regardless of function, thereby suggesting that the neural basis of imitation is body part-specific (e.g., Goldenberg & Karnath, 2006). Lof (2006) reports that some of the most commonly used oral motor activities include blowing, tongue wagging, and smiling, in which a body part such as the lips or tongue is the focus, yet the direct relation to speech sound production is unclear. Despite the prevalence of such techniques, converging evidence supports a more task-dependent model, in which the sensory motor control of speech is somewhat distinct from nonspeech oral motor behaviors, such as emotional expression and vegetative functions (see G. Weismer, 2006; Ziegler, 2003). Although the same muscles may be employed for speech and nonspeech oral motor tasks, different muscle fibers may be recruited and in markedly different ways depending on the goal of the action (Iacoboni, 2005; Iacoboni & Wilson, 2006; Moore & Ruark, 1996; Ruark & Moore, 1997). In sum, the task-dependent view stresses the importance of helping individuals form an internal model of the target in regard to motor plans and sensory consequences, and emphasizes the goal or purpose of the motor task as critical to its generalization. Evidence. In regard to experimental evidence, studies related to the effectiveness of nonspeech activities have generally not supported their use for facilitating speech in children without gross neurological deficits (see reviews by Forrest, 2002; Lof, 2006); however, few studies have been published in peer-reviewed journals. As a notable exception, Braislin and Cascella (2005) published a brief research report on the effect of oral motor treatment on the articulation errors of 4 first-grade students. Treatment included gross motor activities, body positioning, and various articulator movements and resistance exercises. The outcome variable, scores on a standardized articulation test, did not improve substantially after 7 weeks of intervention, which included a total of 15 half-hour sessions (see also Gommerman & Hodge, 1995). Although to date most studies of oral motor activities have focused on older children who are already attempting speech sound imitation, we recommend utilizing nonspeech activities judiciously and only when a child is not yet imitating speech sounds. In addition, the nonspeech activity should mimic the position, movement, and function

of the target speech sound(s) as closely as possible. One final note: It is important to distinguish between the use of nonspeech oral motor activities, such as blowing bubbles or licking a lollipop, for therapeutic versus motivational purposes. Such activities may serve as motivating materials through which to implement the strategies we discuss, but may not in and of themselves facilitate speech sound production. Examples. Examples of incorporating relevant and functional nonspeech activities into therapy vary based on the target. For example, if alveolar sounds are being targeted, modeling tongue clicks would be more suitable than tongue protrusion or tongue wagging, particularly if it could be paired with a meaningful activity, such as a sound effect for a clock or knocking on doors in a lift-the-flap book. Similarly, if a clinician wanted to target fricatives, attempting to elicit airflow paired with constriction in the vocal tract is likely to be more facilitative than blowing exercises. For example, one might produce bilabial raspberries during vehicle play to simulate a motor noise. Similarly, velars could be targeted through coughing sounds (e.g., make a kangaroo puppet cough and then ask it, Kangaroo, do you have a cold? Let me get you a Kleenex. Heres a Kleenex, Kangaroo. Can you cough in the Kleenex? Ready, set I oh no, Kangaroo is keeping his cough inside. Lets help him cough). As a final example, attempts to elicit /m / may be better facilitated through use of a kazoo than a whistle because use of a kazoo involves bilabial closure and the initiation of voicing (see Marshalla, 2003).

Strategies for Future Research

Although all of the strategies we have reviewed are in need of additional investigation, this section focuses on four promising strategies that have not received direct examination within a treatment study of childhood speech outcomes. We highlight each of these strategies in conjunction with its theoretical rationale in hopes that it will elicit additional experimental investigation. First, a common strategy in the treatment of children with motor speech disorders is utilizing carrier phrases (Macaluso-Haynes, 1985; Strand, 1995; Yoss & Darley, 1974). The rationale is that carrier phrases provide a rich linguistic context for priming relevant semantic (e.g., Ferrand & New, 2004), structural (e.g., Kemp, Lieven, & Tomasello, 2005; Miller & Deevy, 2006; Savage, Lieven, Theakston, & Tomasello, 2003), and prosodic (e.g., Church & Schacter, 1994; Niedenthal, Krauth-Gruber, & Ric, 2004) networks. As an example, the repetitive phrase Brown bear, brown bear, what do you ____ ? (Martin & Carle, 1967) offers a syntactic frame that may prime the target word see via its grammatical properties (i.e., the phrase requires a verb). In addition, it offers a context that activates semantic properties (e.g., the concept of a bear elicits properties of animacy), and the prosodic pattern elicits the opportunity to close the intonational phrase or melody. Indeed, theories on the role of prosody in language development and disorders propose that a prosodic hierarchy of feet, prosodic words, and phonological phrases determines young childrens abilities to produce strong and weak syllables (Gerken & McGregor, 1998). Despite widespread use, the effect of using carrier phrases on speech production has not been isolated within a treatment

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study, though their use in language treatment has been documented. For example, Bradshaw, Hoffman, and Norris (1998) found that the cloze procedure paired with expansions facilitated childrens language use more than a combined paradigm of direct questions and direct modeling during book reading in two 4-year-old children with language delay (see also Girolametto, Pearce, & Weitzman, 1996, 1997). Future research needs to evaluate the independent effects of carrier phrases on speech production in children from a variety of relevant populations. A second strategy worthy of study is pairing vocalizations with analogous cross-modality movements. For example, Hammer (2006) suggests modeling fricative sounds, such as /s/, by pulling ones fingers along a string or pairing specific vowel sounds with gross arm movements that mimic lip positioning, such as spreading arms wide for /i/ or putting arms in a circle for /o/. Key to this strategy is utilizing movements that are relatively automatic and analogous to the target vocalization so as not to compete with the attempted speech production for motoric or cognitive resources. We propose that coordinating or synchronizing movements may simplify motor control for the nervous system (see Beheshti, 1993; Chang & Hammond, 1987; Getchell, 2006; Peters, 1977). To our knowledge, this strategy has not been directly examined in regard to facilitating childrens speech development. However, there is a long tradition in vocal music pedagogy of analogous cross-modality movement as a teaching tool (e.g., Gruhn, 2002; Wis, 1998). A third strategy for consideration is encouraging vocal play, particularly play that involves articulator movement relevant to speech sound production (see Strategy 6 above), such as turning on and off voicing with a vowel-like production or exploring variations in pitch. The rationale for encouraging vocal play is based on the hypothesized importance of experience and sensory feedback in forming internal models for speech sound production (Max, Guenther, Gracco, Ghosh, & Wallace, 2004; Mussa-Ivaldi, 1999). Once children learn to associate specific motor commands with their sensory consequences, motor control can be executed in a pure feedforward manner (Kawato, 1999, p. 718; see also Kent, 1998). Although not evaluated within an experimental treatment study, support for this strategy comes from links between infants vocal play and their early speech development (Oller, 1980; Stark, 1980; Stoel-Gammon, 1998). In addition, a number of studies have documented early speech difficulties in children whose vocal exploration was limited by tracheostomy (Hill & Singer, 1990; Kamen & Watson, 1991; Locke & Pearson, 1990; Ross, 1982). Finally, for children with early metacognitive abilities, incorporating metaphoric devices to solidify emergent speech sound knowledge should receive investigation. By metaphoric devices, we refer to the pairing of specific speech sounds with meaningful environmental sounds, objects, or events (e.g., referring to /s/ as the snake sound). As children try to acquire new speech sounds, they are essentially attempting to store, recall, and consistently produce a new form that for the moment carries little meaning. Motor learning theorists speculate that imagery analogies or metaphors might help to relieve the load on abstract working memory during complex motor tasks by allowing individuals to use

visual processing skills or episodic memory and limiting reliance on phonological processing (Baddeley & Hitch, 1974; Liao & Masters, 2001; Poolton, Masters, & Maxwell, 2006). This strategy may be particularly powerful for children with limited verbal working memory capacity (S. E. Weismer, Evans, & Hesketh, 1999) or slowed learning ability (Windsor & Hwang, 1999). Additional examples of such metaphors for new target sounds include referring to /m/ as the yummy food sound, /p/ as the popcorn sound, or /u/ as the monkey sound (cf. Bleile, 2004; Ertmer et al., 2002; Lindamood & Lindamood, 2003; Mawhinney & McTeague, 2004; Sindrey, 1997).

Concluding Remarks
In sum, many children who do not readily attempt sound imitation pose a significant clinical challenge in regard to targeting speech development. When experimental support is not readily available, clinicians need to give conscious consideration to the rationale for their techniques, and the research community needs to take seriously the charge to fill current gaps in the clinical knowledge base. Due to the paucity of explicit and comprehensive resources on facilitating speech sound development in young children who do not readily imitate, we considered theoretical frameworks and empirical research findings to emphasize six strategies to guide intervention. With this in mind, the following text rewrites the opening vignette using some of the evidence-based strategies outlined in this article. In the clinicians attempt to engage Micah, she pulls two of his favorite toys out of her baglittle plastic animals. She holds up a dog in one hand and a cat in the other. Which one do you want Micah? He reaches for the dog. You want the dog? she inquires, stressing the name of the desired object with exaggerated intonation (Strategy 4). Micah silently reaches again for the desired toy. You want the dog, she says as she touches the picture of the dog on Micahs voice output device (Strategy 1). The clinician hands him the dog and says the word one more time, this time with a light touch to Micahs upper lip as she pronounces the /d / and a light touch to the underside of his chin as she pronounces the /g / (Strategy 5). With the dog in hand, Micah begins to walk it across the floor while vocalizing gogogogo. The clinician imitates Micah (Strategy 3) by saying, Go go go. Go dog go. When Micah abandons his dog in search of more toys, the clinician uses exaggerated falling intonation followed by a pause (Strategy 4) to say, All I done. Were all I done. Bye-bye dog. Buh-buh, adds Micah.

Acknowledgments
This project was supported in part by the U.S. Department of Education, Project FOCAL (Grant H325D070061). Thanks to Amie King and Julie Hengst for sharing their expertise in AAC, Ashley Sharer and Lauren Mueller for their frequent trips to the library (online and in person), and Bonnie Johnson, Pamela Hadley, and Pamela Marshalla for their feedback on earlier drafts of the manuscript. Finally, thanks to Z for inspiration.
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References
Adler-Bock, M., Bernhardt, B. M., Gick, B., & Bacsfalvi, P. (2007). The use of ultrasound in remediation of North American English /r/ in 2 adolescents. American Journal of SpeechLanguage Pathology, 16, 128139. Albert, M. L., Sparks, R. W., & Helm, N. A. (1973). Melodic intonation therapy for aphasia. Archives of Neurology, 29, 130131. Alm, P. A. (2004). Stuttering and the basal ganglia circuits: A critical review of possible relations. Journal of Communication Disorders, 37, 325369. American Speech-Language-Hearing Association. (2004). Evidence-based practice in communication disorders: An introduction [Technical report]. Available from www.asha.org /policy. American Speech-Language-Hearing Association. (2005). Evidence-based practice in communication disorders [Position statement]. Available from www.asha.org/policy. Baddeley, A., & Hitch, G. (1974). Working memory. In C. H. Bower (Ed.), The psychology of learning and motivation (pp. 4789). New York: Academic Press. Ballard, K., Granier, J., & Robin, D. (2000). Understanding the nature of apraxia of speech: Theory, analysis, and treatment. Aphasiology, 14, 969995. Barry, R. M. (1989). EPG from square one: An overview of electropalatography as an aid to therapy. Clinical Linguistics and Phonetics, 3, 8191. Baskett, C. (1996). The effect of live interactive video on the communicative behavior in children with autism. Unpublished masters thesis, University of North Carolina, Chapel Hill. Baum, S. R., & Pell, M. D. (1999). The neural bases of prosody: Insights from lesion studies and neuroimaging. Aphasiology, 13, 581608. Beheshti, Z. (1993). Effect of imposed auditory rhythms on human interlimb coordination. Australian Physiotherapy, 39, 135144. Bernard-Opitz, V., Sriram, N., & Sapuan, S. (1999). Enhancing vocal imitations in children with autism using the IBM SpeechViewer. Autism, 3, 131147. Beukelman, D. R., & Mirenda, P. (2005). Augmentative and alternative communication: Supporting children and adults with complex communication needs (3rd ed.). Baltimore: Brookes. Beuter, A., & Duda, J. L. (1985). Analysis of the arousal /motor performance relationship in children using movement kinematics. Journal of Sport Psychology, 7, 229243. Binger, C., & Light, J. (2006). Demographics of preschoolers who require AAC. Language, Speech, and Hearing Services in Schools, 37, 200208. Bishop, D., Hartley, J., & Weir, F. (1994). Why and when do some language-impaired children seem talkative? A study of initiation in conversations of children with semantic-pragmatic disorder. Journal of Autism and Developmental Disorders, 24, 177197. Blacklin, J., & Crais, E. (1998, November). Severe expressive output disorders: A treatment protocol for young children. Paper presented at the Annual Convention of the American SpeechLanguage-Hearing Association, San Antonio, TX. Bleile, K. (2004). Manual of articulation and phonological disorders: Infancy through adulthood (2nd ed.). Clifton Park, NY: Delmar Cengage Learning. Blood, G. W., Blood, I. M., Bennett, S., Simpson, K. C., & Susman, E. J. (1994). Subjective anxiety measurements and cortisol responses in adults who stutter. Journal of Speech and Hearing Research, 37, 760768. Blood, I. M., Wertz, H., Blood, G. W., Bennett, S., & Simpson, K. C. (1997). The effects of life stressors and daily stressors on stuttering. Journal of Speech, Language, and Hearing Research, 40, 134143.

Bondy, A. S., & Frost, L. A. (1994). The Picture Exchange Communication System. Focus on Autistic Behavior, 9, 119. Boshart, C. (2004, October). Oral-motor analysis and remediation techniques. Presented at the One-Day Inservice, Speech Dynamics, Champaign, IL. Bradshaw, M. L., Hoffman, P. R., & Norris, J. A. (1998). Efficacy of expansions and cloze procedures in the development of interpretations by preschool children exhibiting delayed language development. Language, Speech, and Hearing Services in Schools, 29, 8595. Braislin, M. A. G., & Cascella, P. W. (2005). A preliminary investigation of the efficacy of oral motor exercises for children with mild articulation disorders. International Journal of Rehabilitation Research, 28, 263266. Brass, M., & Heyes, C. (2005). Imitation: Is cognitive neuroscience solving the correspondence problem? Trends in Cognitive Sciences, 9, 489495. Camarata, S. M., Nelson, K. E., & Camarata, M. N. (1994). Comparison of conversational-recasting and imitative procedures for training grammatical structures in children with specific language impairment. Journal of Speech and Hearing Research, 37, 14141423. Carter, P., & Edwards, S. (2004). EPG therapy for children with long-standing speech disorders: Predictions and outcomes. Clinical Linguistics and Phonetics, 18, 359372. Caruso, A. J., Chodzko-Zajko, W. J., Bidinger, D. A., & Sommers, R. K. (1994). Adults who stutter: Responses to cognitive stress. Journal of Speech and Hearing Research, 37, 746754. Chang, P., & Hammond, G. R. (1987). Mutual interactions between speech and finger movements. Journal of Motor Behavior, 19, 265274. Charlop-Christy, M. H., Carpenter, M., Le, L., LeBlanc, L. A., & Kellet, K. (2002). Using the Picture Exchange Communication System (PECS) with children with autism: Assessment of PECS acquisition, speech, social-communicative behavior, and problem behavior. Journal of Applied Behavior Analysis, 35, 213231. Chumpelik, D. (1984). The PROMPT system of therapy: Theoretical framework and applications for developmental apraxia of speech. Seminars in Speech and Language, 5(2), 139156. Church, B. A., & Schacter, D. L. (1994). Perceptual specificity of auditory priming: Implicit memory for voice intonation and fundamental frequency. Journal of Experimental Psychology, 20, 521533. Clark, H. M., Robin, D. A., McCullagh, G., & Schmidt, R. A. (2001). Motor control in children and adults during a non-speech oral task. Journal of Speech, Language, and Hearing Research, 44, 10151025. Cumley, G. D., & Swanson, S. (1999). Augmentative and alternative communication options for children with developmental apraxia of speech: Three case studies. Augmentative and Alternative Communication, 15, 110125. Dapretto, M., Davies, M. S., Pfeifer, J. H., Scott, A. A., Sigman, M., Bookheimer, S. Y., & Iacoboni, M. (2006). Understanding emotions in others: Mirror neuron dysfunction in children with autistic spectrum disorders. Nature Neuroscience, 9, 2830. Dollaghan, C. A. (2007). The handbook for evidence-based practice in communication disorders. Baltimore: Brookes. Ertmer, D. J., Young, N., Grohne, K., Mellon, J. A., Johnson, C., Corbett, K., & Saindon, K. (2002). Vocal development in young children with cochlear implants: Profiles and implications for intervention. Language, Speech, and Hearing Services in Schools, 33, 184195.

142 American Journal of Speech-Language Pathology Vol. 18 133145 May 2009

Ferrand, L., & New, B. (2004). Semantic and associative priming in the mental lexicon. In P. Bonin (Ed.), Mental lexicon: Some words to talk about words (pp. 2543). New York: Nova Science. Field, T., Field, T., Sanders, C., & Nadel, J. (2001). Children with autism display more social behaviors after repeated imitation sessions. Autism, 5, 317323. Forrest, K. (2002). Are oral-motor exercises useful in the treatment of phonological /articulatory disorders? Seminars in Speech and Language, 23, 1525. Gerken, L. A., & McGregor, K. (1998). An overview of prosody and its role in normal and disordered child language. American Journal of Speech-Language Pathology, 7, 3848. Getchell, N. (2006). Age and task-related differences in timing stability, consistency, and natural frequency of childrens rhythmic, motor coordination. Developmental Psychobiology, 48, 675685. Gillam, R. B., Loeb, D., & Friel-Patti, S. (2001). Looking back: A summary of five exploratory studies of Fast ForWord. American Journal of Speech-Language Pathology, 10, 269273. Gillam, R. B., Loeb, D. F., Hoffman, L. M., Bohman, T., Champlin, C. A., Thibodeau, L., et al. (2008). The efficacy of Fast ForWord language intervention in school-age children with language impairment: A randomized controlled trial. Journal of Speech, Language, and Hearing Research, 51, 97119. Girolametto, L. E. (1988). Improving the social-conversational skills of developmentally delayed children: An intervention study. Journal of Speech and Hearing Disorders, 53, 156167. Girolametto, L., Pearce, P. S., & Weitzman, E. (1996). Interactive focused stimulation for toddlers with expressive vocabulary delays. Journal of Speech and Hearing Research, 39, 12741283. Girolametto, L., Pearce, P. S., & Weitzman, E. (1997). Effects of lexical intervention on the phonology of late talkers. Journal of Speech and Hearing Research, 40, 338348. Goldenberg, G., & Karnath, H. (2006). The neural basis of imitation is body part specific. The Journal of Neuroscience, 26, 62826287. Gommerman, S. L., & Hodge, M. M. (1995). Effects of oral myofunctional therapy on swallowing and sibilant production [Abstract]. International Journal of Orofacial Myology, 21, 922. Grube, M. M., Spiegel, B. B., Buchhop, N. A., & Lloyd, K. L. (1986). Intonational training as a facilitator of intelligibility. Human Communication Canada, 10, 1724. Gruhn, W. (2002). Phases and stages in early music learning: A longitudinal study on the development of young childrens musical potential. Music Education Research, 4, 5171. Hailpern, J., Karahalios, K., Halle, J., DeThorne, L., & Coletto, M. (2008, April). Visualization: Speech, language & autistic spectrum disorder. Work in Progress poster presented at the Computer Human Interaction 2008 Conference, Florence, Italy. Retrieved April 17, 2008, from www.chi2008.org /works_in_ progress.html. Hammer, D. W. (2006). Treatment strategies for childhood apraxia of speech [DVD]. Pittsburgh, PA: CASANA. Hardy, L., Mullen, R., & Martin, N. (2001). Effect of taskrelevant cues and state anxiety on motor performance. Perceptual and Motor Skills, 92, 943946. Hargrove, P. M., Roetzel, K., & Hoodin, R. B. (1989). Modifying the prosody of a language-impaired child. Language, Speech, and Hearing Services in Schools, 20, 245258. Helfrich-Miller, K. R. (1984). Melodic intonation therapy with developmentally apraxic children. Seminars in Speech and Language, 5, 119125. Hill, B. P., & Singer, L. T. (1990). Speech and language development after infant tracheostomy. Journal of Speech and Hearing Disorders, 55, 1520.

Hodson, B. W., & Paden, E. P. (1991). Targeting intelligible speech (2nd ed.). Austin, TX: Pro-Ed. Hyland, J., & McNeil, M. R. (1987). The effects of intoning therapy and the speech of a developmentally apraxic adult. In R. Brookshire (Ed.), Clinical aphasiology (pp. 288299). Minneapolis, MN: BRK. Iacoboni, M. (2005). Neural mechanisms of imitation. Current Opinion in Neurobiology, 15, 632637. Iacoboni, M., & Dapretto, M. (2006). The mirror neuron system and the consequences of its dysfunction. Nature, 7, 942951. Iacoboni, M., & Wilson, S. M. (2006). Beyond a single area: Motor control and language within a neural architecture encompassing Brocas area. Cortex, 42, 503506. Iacono, T. A., & Duncum, J. E. (1995). Comparison of sign alone and in combination with an electronic communication device in early language intervention: Case study. Augmentative and Alternative Communication, 11, 249259. Jeffries, K. J., Fritz, J. B., & Braun, A. R. (2003). Words in melody: An H215O PET study of brain activation during singing and speaking. Neuroreport, 14, 749754. Johnson, C. J. (2006). Getting started in evidence-based practice for childhood speech-language disorders. American Journal of Speech-Language Pathology, 15, 2035. Justice, L. M., & Fey, L. (2004, September 21). Evidence-based practice in schools: Integrating craft and theory with science and data. The ASHA Leader, 9, pp. 45, 3032. Kamen, R. S., & Watson, B. C. (1991). Effects of long-term tracheostomy on spectral characteristics of vowel production. Journal of Speech and Hearing Research, 34, 10571065. Kamhi, A. G. (2006). Treatment decisions for children with speechsound disorders. Language, Speech, and Hearing Services in Schools, 37, 271279. Katz, W. F., Bharadwaj, S. V., & Carstens, B. (1999). Electromagnetic articulography treatment for an adult with Brocas aphasia and apraxia of speech. Journal of Speech, Language, and Hearing Research, 42, 13551366. Katz, W. F., Garst, D. M., Carter, G. S., McNeil, M. R., Fossett, T. R., Doyle, P. J., & Szuminsky, N. J. (2007). Treatment of an individual with aphasia and apraxia of speech using EMA visually-augmented feedback. Brain and Language, 103, 213214. Kawato, M. (1999). Internal models for motor control and trajectory planning. Current Opinion in Neurobiology, 9, 718727. Kemp, N., Lieven, E., & Tomasello, M. (2005). Young childrens knowledge of the determiner and adjective categories. Journal of Speech, Language, and Hearing Research, 48, 592609. Kent, R. D. (1998). Normal aspects of articulation. In J. E. Bernthal & N. W. Bankson (Eds.), Articulation and phonological disorders (pp. 162). Boston: Allyn & Bacon. Koegel, R. L., Camarata, S., Koegel, L. K., Ben-Tall, A., & Smith, A. E. (1998). Increasing speech intelligibility in children with autism. Journal of Autism and Developmental Disorders, 28(3), 241251. Kouri, T. A. (2005). Lexical training through modeling and elicitation procedures with late talkers who have specific language impairment and developmental delays. Journal of Speech, Language, and Hearing Research, 48, 157171. Kouri, T. A., & Winn, J. (2006). Lexical learning in sung and spoken story script contexts. Child Language Teaching and Therapy, 22, 293313. Krauss, T., & Galloway, H. (1982). Melodic intonation therapy with language delayed apraxic children. Journal of Music Therapy, 19, 102113. Leonard, J. S. (1992). Intervention with young children at risk for specific communication disorders. Seminars in Speech and Language, 13, 223236.
DeThorne et al.: Alternatives to Imitation

143

Leonard, L. B., Schwartz, R. G., Chapman, K., Rowan, L. E., Prelock, P. A., Terrell, B., et al. (1982). Early lexical acquisition in children with specific language impairment. Journal of Speech and Hearing Research, 25, 554564. Lewy, A. L., & Dawson, G. (1992). Social stimulation and joint attention in young autistic children. Journal of Abnormal Child Psychology, 20, 555566. Liao, C., & Masters, R. S. W. (2001). Analogy learning: A means to implicit motor learning. Journal of Sports Sciences, 19, 307319. Light, J. C., Beukelman, D. R., & Reichle, J. (2003). Communicative competence for individuals who use AAC: From research to effective practice. Baltimore: Brookes. Lindamood, P., & Lindamood, P. (2003). Lindamood phoneme sequencing program for reading, spelling and speech (LiPS) (3rd ed.). Bloomington, MN: Pearson Education. Locke, J. L., & Pearson, D. M. (1990). Linguistic significance of babbling: Evidence from a tracheostomized infant. Journal of Child Language, 17, 116. Lof, G. L. (2006, November). Logic, theory and evidence against the use of non-speech oral motor exercises to change speech sound productions. Paper presented at the Annual Convention of the American Speech-Language-Hearing Association, Miami, FL. Lof, G. L. (2007, November). Reasons why non-speech oral motor exercises should not be used for speech sound disorders. Seminar presented at the Annual Convention of the American SpeechLanguage-Hearing Association, Boston. Macaluso-Haynes, S. (1985). Developmental apraxia of speech: Symptoms and treatment. In D. Johns (Ed.), Clinical management of neurogenic communication disorders (pp. 259266). Boston: Little, Brown. Manolson, A. (1992). It takes two to talk: A parents guide to helping children communicate. Toronto, Ontario, Canada: The Hanen Centre. Marshalla, P. (2003). Becoming verbal with childhood apraxia: New insights on Piaget for todays therapy. Kirkland, WA: Marshalla Speech and Language. Marshalla, P. (2005). Successful r therapy. Kirkland, WA: Marshalla Speech and Language. Marshalla, P. (2007, March). Practical therapy techniques for apraxia and dysarthria: Innovative strategies for developing more intelligible speech (Grades PreK-6). Workshop conducted by the Bureau of Education and Research, Champaign, IL. Martin, B., & Carle, E. (1967). Brown bear, brown bear, what do you see? New York: Holt. Masur, E. F., & Eichorst, D. L. (2002). Infants spontaneous imitation of novel versus familiar words: Relations to observational and maternal report measures of their lexicons. MerrillPalmer Quarterly, 48, 405426. Mawhinney, L., & McTeague, M. S. (2004). Early language development: Handouts and activities with bonus CD-ROM. Greenville, SC: Super Duper. Max, L., Guenther, F. H., Gracco, V. L., Ghosh, S. S., & Wallace, M. E. (2004). Unstable or insufficiently activated internal models and feedback-biased motor control as sources of dysfluency: A theoretical model of stuttering. Contemporary Issues in Communication Science and Disorders, 31, 105112. McCauley, R. J., & Fey, M. E. (2006). Treatment of language disorders in children. Baltimore: Brookes. Meredith, A. (2007, June). Implementing electropalatography in the treatment of a child with a persistent speech sound disorder. Paper presented at the 2007 International Child Phonology Conference, Seattle, WA. Merzenich, M. M., Jenkins, W. M., Johnston, P., Schreiner, C., Miller, S. L., & Tallal, P. (1996). Temporal processing deficits of language-learning impaired children ameliorated by training. Science, 271, 7781.

Millar, D. C., Light, J. C., & Schlosser, R. W. (2006). The impact of augmentative and alternative communication intervention on the speech production of individuals with developmental disabilities: A research review. Journal of Speech, Language, and Hearing Research, 49, 248264. Miller, C. A., & Deevy, P. (2006). Structural priming in children with and without specific language impairment. Clinical Linguistics and Phonetics, 20, 387399. Milne, D. C. (1970). The relation between anxiety and motor performance in young children. Unpublished doctoral dissertation, Michigan State University, East Lansing. Moore, C. A., & Ruark, J. L. (1996). Does speech emerge from earlier appearing oral motor behaviors? Journal of Speech and Hearing Research, 39, 10341047. Mullen, R. (2007, March 6). The state of the evidence: ASHA develops levels of evidence for communication sciences and disorders. The ASHA Leader, 12(3), pp. 89, 2425. Mussa-Ivaldi, F. A. (1999). Modular features of motor control and learning. Current Opinion in Neurobiology, 9, 713717. Niedenthal, P. M., Krauth-Gruber, S., & Ric, F. (2004). A role for emotion in lexical access. In P. Bonin (Ed.), Mental lexicon: Some words to talk about words (pp. 147166). New York: Nova Science. Nishitani, N., Avikainen, S., & Hari, R. (2004). Abnormal imitation-related cortical activation sequences in Aspergers syndrome. Annals of Neurology, 55, 558562. Oberman, L. M., & Ramachandran, V. S. (2007). The simulating social mind: The role of the mirror neuron system and simulation in the social and communicative deficits of autism spectrum disorders. Psychological Bulletin, 133, 310327. Odom, S. L., Brantlinger, E., Gersten, R., Horner, R. H., Thompson, B., & Harris, K. R. (2005). Research in special education: Scientific methods and evidence-based practices. Exceptional Children, 71(2), 137148. Oller, D. K. (1980). The emergence of the sounds of speech in infancy. In G. H. Yeni-Komshian, J. F. Kavanagh, & C. A. Ferguson (Eds.), Child phonology (pp. 93112). New York: Academic Press. Patel, A. D. (2003). Language, music, syntax and the brain. Nature Neuroscience, 6, 674681. Peters, M. (1977). Simultaneous performance of two motor activities: The factor of timing. Neuropsychologia, 15, 461465. Poolton, J. M., Masters, R. S. W., & Maxwell, J. P. (2006). The influence of analogy learning on decision-making in table tennis: Evidence from behavioural data. Psychology of Sport and Exercise, 7, 677688. Reichle, J., Beukelman, D. R., & Light, J. C. (2002). Exemplary practices for beginning communicators. Baltimore: Brookes. Rizzolatti, G., & Craighero, L. (2004). The mirror-neuron system. Annual Review of Neuroscience, 27, 169192. Robertson, D. (2004). Primer on the autonomic nervous system (2nd ed.). New York: Elsevier. Rogers, S. J., Hayden, D., Hepburn, S., Charlifue-Smith, R., Hall, T., & Hayes, A. (2006). Teaching young nonverbal children with autism useful speech: A pilot study of the Denver Model and PROMPT interventions. Journal of Autism and Developmental Disorders, 36, 10071024. Ross, G. S. (1982). Language functioning and speech development of six children receiving tracheotomy in infancy. Journal of Communication Disorders, 15, 95111. Ruark, J. L., & Moore, C. A. (1997). Coordination of lip muscle activity by 2-year-old children during speech and nonspeech tasks. Journal of Speech, Language, and Hearing Research, 40, 13731385.

144 American Journal of Speech-Language Pathology Vol. 18 133145 May 2009

Savage, C., Lieven, E., Theakston, A., & Tomasello, M. (2003). Testing the abstractness of childrens linguistic representations: Lexical and structural priming of syntactic constructions in young children. Developmental Science, 6, 557567. Schwartz, R. G., & Leonard, L. B. (1985). Lexical imitation and acquisition in language-impaired children. Journal of Speech and Hearing Disorders, 50, 141149. Scientific Learning Corporation. (1997). Fast ForWord [Computer software]. Oakland, CA: Author. Shuster, L. I., Ruscello, D. M., & Smith, K. D. (1992). Evoking /r/ using visual feedback. American Journal of Speech-Language Pathology, 4(2), 3744. Sindrey, D. (1997). Listening games for littles. London, Ontario, Canada: Wordplay. Smit, A. B. (2004). Articulation and phonology resource guide for school-age children and adults. Clifton Park, NY: Delmar Cengage Learning. Snow, C. E. (1989). Imitativeness: A trait or a skill? In G. E. Speidel & K. E. Nelson (Eds.), The many faces of imitation in language learning (pp. 7390). New York: Springer-Verlag. Square, P. A. (1999). Treatment of developmental apraxia of speech. In A. Caruso & E. Strand (Eds.), Clinical management of motor speech disorders in children (pp. 149185). New York: Thieme. Square, P. A., Bose, A., Goshulak, D., & Hayden, D. (n.d.). Effects of articulatory subsystem treatment for developmental neuromotor speech disorders: A pilot study. Retrieved April 17, 2008, from http://promptinstitute.com /. Stark, R. E. (1980). Stages of speech development in the first year of life. In G. H. Yeni-Komshian, J. F. Kavanagh, & C. A. Ferguson (Eds.), Child phonology (pp. 7392). New York: Academic Press. Stoel-Gammon, C. (1998). Role of babbling and phonology in early linguistic development. In A. M. Wetherby, S. F. Warren, & J. Reichle (Eds.), Transitions in prelinguistic communication (pp. 87110). Baltimore: Brookes. Strand, E. A. (1995). Treatment of motor speech disorders in children. Seminars in Speech and Language, 16, 126139. Strand, E. A., & Skinder, A. (1999). Treatment of developmental apraxia of speech: Integral stimulation methods. In A. J. Caruso & E. A. Strand (Eds.), Clinical management of motor speech disorders in children (pp. 109148). New York: Thieme. Tallal, P., Miller, S. L., Bedi, G., Byma, G., Wang, X., Nagarajan, S. S., et al. (1996). Language comprehension in languagelearning impaired children improved with acoustically modified speech. Science, 271, 8184. Tallal, P., Saunders, G., Miller, S., Jenkins, W. M., Protopapas, A., & Merzenich, M. M. (1997, October). Rapid trainingdriven improvement in language ability in autistic and other PDD children. Paper presented at the annual meeting of the Society for Neuroscience, New Orleans, LA. Tamis-LeMonda, C. S., Bornstein, M. H., & Baumwell, L. (2001). Maternal responsiveness and childrens achievement of language milestones. Child Development, 72, 748767.

Todorov, E. (2004). Optimality principles in sensorimotor control. Nature Neuroscience, 7, 907915. Tolkmitt, F. J., & Scherer, K. R. (1986). Effect of experimentally induced stress on vocal parameters. Journal of Experimental Psychology: Human Perception and Performance, 12, 302313. Van Riper, C., & Erickson, R. (1996). Speech correction: An introduction to speech pathology and audiology (9th ed.). Englewood Cliffs, NJ: Prentice-Hall. Velleman, S. (2006, November). Childhood apraxia of speech: Assessment/treatment for the school-aged child. Paper presented at the Annual Convention of the American Speech-LanguageHearing Association, Miami, FL. Wade, C. A. (1996). A case study: The effects of Melodic Intonation Therapy and oral-motor treatment on initial consonant production by a child with developmental verbal dyspraxia. Unpublished masters thesis, Kansas State University, Manhattan. Wambaugh, J. L., & Doyle, J. R. (1994). Treatment for acquired apraxia of speech: A review of efficacy reports. Clinical Aphasiology, 22, 231243. Weber, C. M., & Smith, A. (1990). Autonomic correlates of stuttering and speech assessed in a range of experimental tasks. Journal of Speech and Hearing Research, 33, 690706. Weismer, G. (2006). Philosophy of research in motor speech disorders. Clinical Linguistics & Phonetics, 20, 315349. Weismer, S. E., Evans, J., & Hesketh, L. J. (1999). An examination of verbal working memory capacity in children with specific language impairment. Journal of Speech, Language, and Hearing Research, 42, 12491260. Windsor, J., & Hwang, M. (1999). Testing the generalized slowing hypothesis in specific language impairment. Journal of Speech, Language, and Hearing Research, 42, 12051218. Wis, R. M. (1998). Invite, instruct, inspire. Teaching Music, 5(6), 3840. Yoder, P. J., & Layton, T. L. (1988). Speech following sign language training in autistic children with minimal verbal language. Journal of Autism and Developmental Disorders, 18, 217229. Yoss, K. A., & Darley, F. L. (1974). Therapy in developmental apraxia of speech. Language, Speech, and Hearing Services in Schools, 5, 2331. Ziegler, W. (2003). Speech motor control is task-specific: Evidence from dysarthria and apraxia of speech. Aphasiology, 17, 336. Received December 11, 2007 Revision received May 28, 2008 Accepted September 19, 2008 DOI: 10.1044/1058-0360(2008/07-0090) Contact author: Laura S. DeThorne, University of IllinoisSpeech & Hearing Science, 901 South Sixth Street, Champaign, IL 61820. E-mail: lauras@illinois.edu.

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Clinical Focus

A Noninvasive Imaging Approach to Understanding Speech Changes Following Deep Brain Stimulation in Parkinsons Disease
Shalini Narayana Adam Jacks
Research Imaging Center, The University of Texas Health Science Center, San Antonio

Donald A. Robin
Research Imaging Center, The University of Texas Health Science Center, San Antonio, and Honors College, The University of Texas, San Antonio

Howard Poizner
Institute for Neural Computation, The University of California, San Diego

Wei Zhang Crystal Franklin

Research Imaging Center, The University of Texas Health Science Center, San Antonio

Mario Liotti
Simon Fraser University, Burnaby, British Columbia, Canada

Deanie Vogel
Our Lady of the Lake University, San Antonio

Peter T. Fox
Research Imaging Center, The University of Texas Health Science Center, San Antonio, and South Texas Veterans Health Care Center, San Antonio

Purpose: To explore the use of noninvasive functional imaging and virtual lesion techniques to study the neural mechanisms underlying motor speech disorders in Parkinsons disease. Here, we report the use of positron emission tomography (PET) and transcranial magnetic stimulation (TMS) to explain exacerbated speech impairment following subthalamic nucleus deep brain stimulation (STN-DBS) in a patient with Parkinsons disease. Method: Perceptual and acoustic speech measures, as well as cerebral blood flow during speech as measured by PET, were obtained with STN-DBS on and off. TMS was applied to a region in the speech motor network found to be abnormally active during DBS. Speech disruption

by TMS was compared both perceptually and acoustically with speech produced with DBS on. Results: Speech production was perceptually inferior and acoustically less contrastive during left STN stimulation compared to no stimulation. Increased neural activity in left dorsal premotor cortex (PMd) was observed during DBS on. Virtual lesioning of this region resulted in speech characterized by decreased speech segment duration, increased pause duration, and decreased intelligibility. Conclusions: This case report provides evidence that impaired speech production accompanying STN-DBS may result from unintended activation of PMd. Clinical application of functional imaging and

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TMS may lead to optimizing the delivery of STNDBS to improve outcomes for speech production as well as general motor abilities.

Key Words: Parkinsons disease, neuroimaging, deep brain stimulation, transcranial magnetic stimulation

he primary aim of this clinical forum is to explore the role of modern, noninvasive, multimodality brain imaging in understanding motor speech disorders and to demonstrate their utility by presenting a brain imaging case study of one patient with Parkinsons disease who underwent deep brain stimulation (DBS) of the subthalamic nucleus (STN). As with many individuals with Parkinsons disease and STN-DBS, stimulation in this patient resulted in speech deterioration while limb function improved (Pinto, Ozsancak, et al., 2004). We use this case as a proof-ofprinciple experiment that utilizes brain imaging to inform a clinical problem. We first present a brief literature review of DBS, including its mechanism of action and effects on speech in Parkinsons disease as well as a recently developed technique used in studying brain function, transcranial magnetic stimulation (TMS). Then we provide data from this case study of the speech changes associated with STN-DBS, as well as application of imaging techniques to better understand the underlying reasons for such a change. Finally, we offer interpretation of the findings in this case and a more general discussion of how imaging may guide clinical decision making and the development of new treatment approaches.

Literature Review: DBS and Parkinsons Disease

Speech symptoms. Speech symptoms typically found in Parkinsons disease include voice problems (e.g., hypophonia), imprecise articulation, impaired intelligibility, and disrupted prosody (Duffy, 2005; Ramig, Fox, & Sapir, 2004). While levodopa is widely used in the pharmacological treatment of Parkinsons disease to restore the balance of dopamine in the basal ganglia and reduce Parkinsonian symptoms, its effect on speech is mixed (Pinto, Ozsancak, et al., 2004). It has been shown to initially improve articulation and voice quality while phonatory parameters remain unchanged (Pinto, Ozsancak, et al., 2004). In a recent study, levodopa has been shown to increase the rate and intensity of speech parallel with limb movements in patients with Parkinsons disease (Ho, Bradshaw, & Iansek, 2008). However, these patients could not maintain speech intensity over the breath span while on levodopa. In a study examining handwriting and speech changes across the levodopa cycle in patients with Parkinsons disease, improvements were found only in handwriting, with no changes observed in speech across the medication cycle (Poluha, Teulings, & Brookshire, 1998). Over time, many individuals with Parkinsons disease develop levodopa-induced dyskinesias, including uncontrolled choreiform movements. Surgical interventions. Various surgical interventions are performed to alleviate the symptoms of Parkinsons disease as well as the unwanted side effects of pharmacological treatment (e.g., hyperkinesias). Among them, thalamotomy and pallidotomy (specifically globus pallidus) are common techniques (Schulz, Greer, & Friedman, 2000; Scott et al.,

1998). While limb motor function has been shown to improve following these surgical treatments, their effects on speech have been variable. Most patients continue to experience speech disorders postoperatively, with only those with mild dysarthria showing significant improvements (Schulz et al., 2000; Schulz, Peterson, Sapienza, Greer, & Friedman, 1999; Scott et al., 1998). There are also reports of postoperative cognitive / linguistic deficits such as decreased verbal fluency that may further complicate the assessment of the speech motor system in these patients (Scott et al., 1998; Witjas et al., 2007). DBS of thalamus or pallidum has also been performed to alleviate symptoms of Parkinsons disease. Similar to dopaminergic replacement and surgical therapies, these procedures improve limb function but result in no improvement or worsening of speech (Pinto, Ozsancak, et al., 2004). DBS. Recently, STN-DBS has emerged as a viable and common treatment for Parkinsons disease when drug therapies result in unacceptable side effects (Kleiner-Fisman et al., 2006). DBS is thought to act as a reversible and adjustable lesion to the targeted region (Obeso et al., 2000), allowing for fine-tuning of settings to achieve the optimal outcome with regard to motor function (Moro, Poon, Lozano, Saint-Cyr, & Lang, 2006). To date, it is estimated that more than 35,000 patients with Parkinsons disease have been implanted with STN-DBS worldwide (Benabid, Deuschl, Lang, Lyons, & Rezai, 2006; Kleiner-Fisman et al., 2006). In addition to treating the general motor symptoms of Parkinsons disease, STN-DBS has been found to ameliorate the drug related dyskinesias and motor fluctuations (Baron et al., 1996; Kumar, Lozano, Montgomery, & Lang, 1998). A meta-analysis of 22 studies of STN-DBS in Parkinsons disease found greater than 50% improvement on the Unified Parkinsons Disease Rating Scale (UPDRS; Fahn et al., 1987) and in motor function and activities of daily living, and a 69% reduction in dyskinesias (Kleiner-Fisman et al., 2006). Although general motor function and dyskinesia in patients with Parkinsons disease improve following STNDBS, motor speech abilities often do not respond or respond negatively to this treatment (DAlatri et al., 2008; Pinto, Ozsancak, et al., 2004). Increased severity of speech impairment is reported as one of the most common side effects of this procedure. Reports of new or worsened dysarthria range widely from 5% (Krack et al., 2003), 20% (RodriguezOroz et al., 2005), 53% (Gan et al., 2007), and up to 61% of implanted patients (Guehl et al., 2006). Specific motor speech symptoms associated with STN-DBS include decreases in speech intelligibility (Rousseaux et al., 2004), difficulty with speech initiation (Moretti et al., 2003), and greater impairment in prosody, articulation, and intelligibility (Santens, De Letter, Van Borsel, De Reuck, & Caemaert, 2003) in the presence of improved limb and body movements. Gan et al. (2007), Krack et al. (2003), and Rodriguez-Oroz et al. (2005)
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found that speech with STN-DBS declined or remained unchanged when assessed during on-medication cycles at follow-up sessions 1 year or more after implantation. Unfortunately, speech performance measures in many studies have limitations. These include limited perceptual rating of speech (only a single perceptual dimension on UPDRSItem 18) and failure to assess speech with stimulation on and off (Gan et al., 2007; Krack et al., 2003; Rodriguez-Oroz et al., 2005) or assessment of speech during on-medication cycles as well as when off medication (Gentil, Chauvin, Pinto, Pollak, & Benabid, 2001; Gentil, GarciaRuiz, Pollak, & Benabid, 1999, 2000; Gentil, Pinto, Pollak, & Benabid, 2003). In these studies, the comparison measures for DBS off consisted of presurgical baseline performance measures and therefore are confounded by possible variations due to disease progression or potential microlesions resulting from the surgical procedure. There are reports of overall improvement in speech performance with DBS on compared to off in a series of four studies (during off-medication cycle only; Gentil et al., 1999, 2000, 2001, 2003). These researchers found speech improvements as measured with UPDRS Item 18 ( perceptual rating of speech impairment), as well as changes in acoustic measures of voice with DBS on (e.g., increased vowel duration and pitch variation; Gentil et al., 2001). Finally, increased oral force measures also have been associated with DBS stimulation (Gentil et al., 1999, 2003). Although these studies show that some improvements are possible in speech subsystems related to STN stimulation, the lack of measures during on-medication cycles precludes generalization to typical speaking situations in patients with Parkinsons disease, who generally continue dopaminergic replacement therapy along with STN stimulation for optimal clinical benefit. Furthermore, while the inclusion of quantitative measures (e.g., F0 variation and maximal phonation duration) are steps in the right direction for studies of speech with STN-DBS, oral force measures and the single dimension perceptual rating scale from the UPDRS provide little information about the nature of the functional speech deficit in speakers with Parkinsons disease and STN-DBS. Existing studies examining speech effects of STN-DBS in Parkinsons disease highlight the need for more comprehensive measures of speech performance, including detailed multidimensional perceptual ratings as well as quantitative measures of acoustic parameters of speech production. One of the goals of the present work was to provide a more detailed picture of the speech consequences of STN-DBS. We used Darley, Aronson, and Browns (1975) classical rating scheme with 38 perceptual dimensions of speech and voice characteristics, in addition to acoustic measures shown to be sensitive to speech characteristics in hypokinetic dysarthria secondary to Parkinsons disease (Rosen, Kent, Delaney, & Duffy, 2006). A clearer understanding of the nature of speech deficit in this population will help in making clinical decisions to improve functional outcomes. Potential neural mechanisms. The neural mechanisms underlying the differential response of limb and body versus speech function in patients with Parkinsons disease who receive STN-DBS are not yet understood. Hypotheses include variations in electrode placement or an inadequate

recruitment of surrounding neural structures and possible existence of separate motor programs for limbs and speech (Pinto, Thobois, et al., 2004). Farrell, Theodoros, Ward, Hall, and Silburn (2005) hypothesized that the differences in speech response to DBS might relate to different innervation patterns in which cranial nuclei for laryngeal systems receive bilateral cortical input as opposed to primarily unilateral innervation of the limbs. In contrast to the dopaminergic imbalance that results in limb symptoms, a nondopaminergic origin of speech disorder in Parkinsons disease has also been proposed (DAlatri et al., 2008). This difference has been attributed as a reason for the differences in speech and limb motor response to levodopa and DBS treatments in Parkinsons disease. Another interesting observation has been the differential effect of left- and right-sided DBS on speech. Articulatory accuracy and syllable rates have been shown to decrease with active left STN stimulation when compared to presurgical measurements. Conversely, STN stimulation on the right side resulted in improvement or no change in these speech parameters (Wang, Metman, Bakay, Arzbaecher, & Bernard, 2003; Wang et al., 2006). These authors propose that motor asymmetry, that is, more damaged basal ganglia in the language-dominant hemisphere (left hemisphere in 98% of the population), may result in worse speech outcome in Parkinsons disease. It is important to further examine the causes of any differential effects on speech, especially if speech deterioration following STN-DBS can be minimized or avoided altogether. One way to gain an understanding of the mechanisms of action of motor and speech responses (positive or negative) to STN-DBS is to use noninvasive imaging to quantify the neurobiology of stimulation effects. While there are a few imaging studies examining the effect of STN-DBS on limb and executive functions (Asanuma et al., 2006; Carbon & Eidelberg, 2006; Trot et al., 2006), there has been only one such study examining speech following STN-DBS (Pinto, Thobois, et al., 2004). We examined the neural mechanisms underlying the decreased capacity for speech production following STN-DBS in a single case by using positron emission tomography (PET) and extended the investigation to include a virtual lesion study using TMS.

Imaging Techniques: An Overview

Of the many different approaches to brain imaging, some techniques focus on functional activity in the brain (e.g., PET), and others emphasize brain anatomy (structural imaging), such as magnetic resonance imaging (MRI). Here, PET was used to assess regional brain activity associated with STN stimulation. Specifically, while STN-DBS is intended to target the STN, PET imaging was used to determine which brain regions were actually active during DBS stimulation. Anatomical MRI acquired prior to DBS implantation was used to register PET images and target TMS. For more details about imaging brain function with PET and MRI, readers are referred to Cherry and Phelps (2002) and Mandeville and Rosen (2002), respectively. In this article, we describe TMS, a relatively new approach to study brain function. TMS. TMS is a recent methodology that is being used to study neural function by introducing a localized magnetic

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field using coils of wire encased in plastic that are applied on a persons scalp. A magnetic field is induced in the orthogonal direction by passing current through the coils of wire. This magnetic field passes through the scalp and skull, and induces a secondary current in the underlying brain tissue. The neurons in the path of the secondary field depolarize and fire synchronously. When applied to a region such as the primary motor cortex, a single pulse of TMS can elicit an involuntary response from the target muscles. TMS can be applied as a single pulse, paired pulses, or repetitively (rTMS). Single pulse TMS is used to study the time at which the activity in the stimulated area contributes to the task (i.e., chronometric studies). Paired pulse TMS methodology explores the effects of the first TMS pulse on the second pulse and is used to examine corticocortical connectivity and interactions. Researchers have used rTMS to modulate cortical excitability beyond the duration of the pulse application, and it therefore has the potential to be a treatment tool (Pascual-Leone et al., 1998); rTMS has been applied to treat neuropsychiatric disorders such as depression, schizophrenia, tinnitus, Parkinsons disease, and stroke (Ridding & Rothwell, 2007). Both single pulse and rTMS can be used to transiently disrupt activity at the stimulated site, also termed as virtual lesions (described below). The immediate effects of TMS are observed when task performance is affected during TMS application. TMS applied to any cortical region will depolarize a mixture of excitatory and inhibitory neurons that lie in the path of the magnetic field, in both orthodromic (stimulation of the cell body and propagation of action potential along the axon) and antidromic (stimulation of axon and propagation of action potential toward the cell body) directions (Pascual-Leone & Walsh, 2002). The net effect of TMS is an outcome of complex interplay of several factors, such as the cortical area being stimulated, the proportion of excitatory and inhibitory neurons in the stimulated area, the rate, the intensity, and the duration of TMS. For example, TMS can have an excitatory effect by synchronously firing neurons. Stimulation of the pyramidal cells in the primary motor cortex at rest results in involuntary contraction of muscles and a motor evoked potential. Another example of such an excitatory effect is production of phosphenes (perception of flashes of light) following TMS applied to the visual cortex. However, by injecting random or out-of-phase firing and resulting in desynchronization of ongoing activity, TMS can also result in a disruption of the regions typical spontaneous activity. Thus, a single pulse or a train of rTMS can transiently disrupt normal brain activity by introducing out-of-phase neural activity to the stimulated site, and result in a virtual lesion (PascualLeone, Walsh, & Rothwell, 2000). If the stimulated region is necessary for an ongoing task, virtual lesion with TMS results in disruption in the task performance. Such application of TMS enables researchers and clinicians to assess the functional significance of the stimulated region. The major advantages of this method are (a) production of a focal lesion in a cortical region, (b) transient disruption of information processing, (c) absence of cortical reorganization that is seen following a lesion, and (d) assisting in establishing a chain of cause and effect between the activity of the brain and behavior. Virtual lesioning with TMS can

also confirm the functional significance of a specific region that has been suggested through functional imaging using PET or functional MRI. Virtual lesion studies using TMS have outlined the role of inferior frontal gyrus (Brocas area) in speech (Pascual-Leone, Gates, & Dhuna, 1991) and the role of dorsal premotor cortex (PMd) in articulatory planning and execution (Stewart, Walsh, Frith, & Rothwell, 2001; Tandon et al., 2003). Most virtual lesion studies of speech motor system have focused on the disruptive effect of TMS, and the investigators induced a complete arrest of speech by applying TMS at high rates and intensities. In this study, we use stimulation rates and intensities that disrupt but do not completely arrest speech, allowing for quantitative measurement of changes resulting from stimulation. In the case of DBS, a virtual lesion study using TMS is especially advantageous, as both techniques have a similar mechanism of action, that is, stimulation of a cortical region and disruption ongoing neural activity. For a more detailed review of principles and application of TMS, readers are referred to PascualLeone and Walsh (2002) and Paus (2002). Image-guided robotically positioned TMS. Use of anatomical and functional imaging for targeting has improved the accuracy of identifying the target sites for TMS (Brain Sight, Rouge Research; Krings et al., 2001). However, many researchers continue to apply TMS by hand or using passive holding devices, resulting in positioning errors. Another factor that is important is the orientation of the magnetic field in relation to the neurons. Therefore, a system that includes image-guided targeting, optimal orientation for individual sites, and a rigid holding mechanism is needed. For this reason, an image-based robotically positioned TMS (irTMS) system was developed at the Research Imaging Center (Lancaster et al., 2004). This system integrates the corticalcolumn cosine aiming theory for targeting and determining optimal orientation of the TMS coil (P.T. Fox et al., 2004) and holding capabilities of a robotic system. The positioning accuracy of the irTMS system, using a modified NeuroMate robot arm, was similar to that reported for the NeuroMate neurosurgical robot arm: 1.99 0.46 mm. The estimated maximum variation in planned delivery of electric field strength fell within the range of 3% 4%, demonstrating the high level of accuracy and precision of planned TMS achievable by the irTMS system (Lancaster et al., 2004). The advantages of irTMS include precise localization of target, determining the correct orientation of the TMS coil for individual sites, and consistent delivery of TMS over a long period of time and reproducibility across sessions. Safety of TMS with DBS. Since TMS has a potential of inducing current in the wires, it is important to consider the safety of applying TMS on persons who have STN-DBS. The effects of TMS on scalp leads and the implanted stimulator itself were examined in a phantom study (Kumar, Chen, & Ashby, 1999). They concluded that magnetic stimulation even at the maximum machine output directly over the scalp leads did not deliver damaging currents to the brain or to the implanted stimulator. They observed that the stimulator was no longer programmable only when TMS was applied directly over it or in close proximity (<2.5 cm). In the current study, the scalp leads were not near the scalp location of TMS application, and the location of the stimulator was in the
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chest wall. In addition, the stimulator was turned off during TMS. With these precautions, we were confident that TMS application in this participant would be safe. Study overview. Three experiments were conducted with a patient with Parkinsons disease who had electrodes implanted bilaterally in the STN and associated negative changes in speech function. In the first experiment, perceptual and acoustic measures of speech were used to document speech performance related to STN-DBS in four stimulation conditions (bilateral on, left on, right on, and bilateral off ). Experiment 2 was a PET imaging study examining brain regions activated with the stimulators turned on or off (bilaterally). The information from this study allowed us to quantify the regions of the brain that were active during STN-DBS. We found that left PMd (Brodmann Area [BA] 6) was overactive during STN-DBS, while other activity patterns were typical based on known patterns of activity in Parkinsons disease and the location of the stimulator. To confirm that PMd is critical to this patients speech difficulty, Experiment 3 was designed to induce a virtual lesion of this region (with DBS off ) using irTMS, and to determine whether speech symptoms that emerged with irTMS paralleled those found with STN-DBS.

Method
Participant Description
At the time of the case study, the patient was a 59-yearold, right-handed male who had Parkinsons disease for 11 years. He was implanted with DBS electrodes bilaterally in the STN 2 years prior to the study. While his general motor skills improved with STN-DBS, speech had deteriorated. We used the Hoehn and Yahr scaling system (Hoehn & Yahr, 1967) to assess the severity of Parkinsons disease. The Hoehn and Yahr scale is a commonly used system for describing how the symptoms of Parkinsons disease progress. The scale allocates stages from 0 (mild ) to 5 (severe) to indicate the relative level of disability. The participants Hoehn and Yahr level improved from Level 3 to Level 2 following implantation (symptoms on both sides of the body, and no impairment of balance). He was able to walk unassisted and had reduced resting tremor and bradykinesia on clinical examination. The DBS parameters were as follows bilaterally: amplitude 2.6 V, pulse width 90 ms, and frequency of stimulation 185 Hz. The participant was on levodopa medication during the entire length of the study (Experiments 1, 2, and 3), in order to obtain the most representative speech behavior and to isolate the effects of DBS on speech. STNDBS was turned off and on alternatively during Experiments 1 and 2, but remained turned off during the entire duration of Experiment 3. Written informed consent was obtained from the participant, and all procedures were approved by the institutional review board at the University of Texas Health Science Center.

Experiment 1: Perceptual and Acoustic Parameters of Speech and Voice

Stimuli and conditions. To examine changes in speech consequent to STN-DBS, the patient read a standard, phonetically

balanced speech sample (The Rainbow Passage; Fairbanks, 1960) in each of four stimulation conditions (i.e., bilateral on, left on, right on, and bilateral off ). The speech samples were acquired 10 min after turning the DBS off or on. Recording. Reading samples were recorded to a digital video camera with an external lapel microphone positioned 20 cm from the participants mouth. Digital video and audio files were transferred to a personal computer for further analysis. Audio files were filtered using a noise reduction process from Adobe Audition (Version 1.5) to reduce background noise in the signal. Recordings were digitized at 44 kHz and low-pass filtered at 22 kHz. Perceptual rating. Reading samples were rated for perceptual dimensions of speech and voice dysfunction by two speech-language pathologists experienced in the assessment of motor speech disorders (second and third authors). All stimuli across DBS and TMS conditions (see Experiment 3) were randomized and rated by the judges. A 7-point equal interval rating scale, with 1 being most severely impaired and 7 being unimpaired (note that Darley et al., 1975, used the opposite weighting), was employed to rate the 38 perceptual dimensions developed by Darley and colleagues. Perceptual dimensions first were assigned individually, with the two raters blind to experimental condition and to the others perceptual ratings. After completion of the task by each rater, perceptual ratings were compared to assess interrater agreement. The raters agreed on the same 8 aberrant dimensions across all conditions for 97% interjudge agreement. This 97% interrater reliability reflects an agreement on the deviant dimensions, and not the actual rating values. Initial perceptual ratings of the two judges differed by an average of 1.2 points; values reported henceforth represent perceptual ratings determined by consensus following the initial rating. Acoustic analysis. Acoustic measures also were obtained, including three parameters of acoustic contrastivity shown to be sensitive to differentiating speech of individuals with hypokinetic disorders from that of healthy, unimpaired speakers (Rosen et al., 2006) as well as broad durational measures of tone groups (similar to breath groupings, see below) and intergroup intervals. All acoustic analyses were performed using routines developed at the Research Imaging Center for Praat acoustic analysis software (Boersma & Weenink, 2008). First, reading passages were parsed into tone groups, a unit of segmentation similar to breath groups, defined as a group of words bounded by a single intonational contour (see Figure 1). Fast Fourier spectra and intensity contours with a minimum periodicity frequency of 50 Hz and a time step of 16 ms (one quarter of the effective window length) were created in Praat for each tone group. The acoustic contrastivity measures reflect reduced spectral and temporal variation in the speakers with hypokinetic dysarthria and were designed to be used in various speaking conditions, including sentence production or conversation (Rosen et al., 2006). In that study, the three parameters most sensitive to differences in acoustic contrastivity include percentage pause time (PPT), intensity variation (IV), and spectral range (SR). The reported values of these measures, described in more detail below, represent mean values of the multiple tone groups within each stimulation condition.

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FIGURE 1. Visual depiction of the acoustic signal and parsing method in Praat (Boersma & Weenink, 2008). The top two rows show the acoustic signal, including the acoustic waveform and a broad band spectrogram. The third row shows speech and pause segment intervals. The bottom row shows the demarcation among tone groups and intergroup intervals.

For each tone group, an intensity contour was generated in Praat (see trace in Figure 1). Speech and pause segments, respectively, were identified as periods in the intensity contour in which mean spectral energy was above or below a threshold of 15% of maximum spectral energy in the tone group. PPT (i.e., pause portion) was the percentage of time frames identified as pauses by the above criteria, thus reflecting extreme intensity drops in Parkinsons disease. IV was calculated as the standard deviation of intensity values of frames in the intensity envelope (i.e., root-mean-square energy contour) and reflects variation in prosody and articulatory closure. SR was the range of acoustic energy occurring across frequency bandwidths in an utterance. Specifically, acoustic energy was measured in 28 consecutive 300-Hz frequency bands from the fast Fourier spectrum (08100 Hz). SR was calculated as the difference in decibels between maximum and minimum energy values across the spectrum. This measure is an indicator of homogeneity of acoustic energy distribution and is related to a reduction in the distinction between consonants and vowels frequently found in speakers with hypokinetic dysarthria (Rosen et al., 2006). In addition to the acoustic contrastivity measures, broad durational analysis of tone group intervals and intergroup intervals was performed. Note that the acoustic contrastivity measures were based only on the acoustic signal within tone group boundaries, thus excluding large silent periods (i.e., intervals) between groups. Analysis of tone group duration and intergroup duration was used to better understand the timing of phrase groups more globally, which

is particularly important for examining differences in speech in the TMS conditions (see Figure 1).

Experiment 2: Functional Imaging Study

PET image acquisition. The second experiment involved cerebral blood flow (CBF) measurements using PET (GE 4096 WB scanner, with 15 slices, each 6.5 mm) while the patient performed speech tasks or rested with DBS on and off. CBF was measured with 15O-labeled water with a half-life of 123 s. The isotope was administered as an intravenous bolus of 810 ml of saline containing 60 mCi. A 90-s scan was initiated at the point in time the tracer bolus entered the brain. A 10-min interscan interval, sufficient for isotope decay (five half-lives), was used. Two speech task conditions were employed, including reading aloud (Rainbow Passage; Fairbanks, 1960) and phonation (prolonged ah). The participant received a total of 12 injections of 15O-labeled water for the following conditions: two repetitions each of rest, reading, and phonation conditions during DBS on (six scans with DBS on), and two repetitions each of rest, reading, and phonation conditions during DBS off (six scans with DBS off ). There was a 10-min interval after turning DBS on and off prior to the subsequent imaging condition. MRI. An anatomical MRI obtained prior to DBS implantation was used to optimize spatial normalization of PET images. MRI was acquired on a 1.9-Tesla Elscint Prestige scanner using a high-resolution 3D gradient-recalled acquisitions in the steady state (GRASS) sequence: repetition time = 33 ms;
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echo time = 12 ms; flip angle = 60; voxel size = 1 mm3; matrix size = 256 192 192; acquisition time = 15 min. Image preprocessing. PET images were reconstructed into 60 slices, each 2 mm thick with an image matrix size of 60 128 128, using a 5-mm Hann filter, resulting in images with a spatial resolution of approximately 7 mm (full width at half-maximum) and value normalized to a whole-brain mean of 1,000. MRI and PET data were spatially normalized using Spatial Normalization software (Lancaster et al., 1995). This software performs global (nine-parameter) spatial normalization and registers the images to the target shape provided by the Talairach and Tournoux atlas (Talairach & Tournoux, 1988). Image analysis. Images were analyzed by creating voxelwise statistical parametric images (SPIs) using the Medical Image Processing Station (Research Imaging Center) software validated for PET data analysis (Mintun, Fox, & Raichle, 1989). Z-score images (SPI{z}) with z values above 1.96 and corrected for multiple comparisons by applying Bonferroni correction calculated from an image-wise standard deviation were created by contrasting (a) all DBS off phonation conditions with DBS off resting conditions, (b) all DBS on phonation conditions with DBS on resting conditions, (c) all DBS off reading conditions with DBS off resting conditions, (d) all DBS on reading conditions with DBS on resting conditions, (e) all DBS on rest conditions with DBS off rest conditions, and (f ) all DBS on conditions with all DBS off conditions. Images were displayed using MANGO (Multi-Image Analysis GUI) developed at the Research Imaging Center ( http:// ric.uthscsa.edu/mango/).

volunteers while stimulating left PMd (Tandon et al., 2003). A TMS train consisted of a series of TMS pulses delivered over 5 s (4 pulses/s 5 s = 20 pulses), followed by no TMS for 5 s. The study consisted of 10 sessions, with 20 TMS trains applied in each session. The participant received a total of 4,000 pulses during the study. The participant read either the Grandfather Passage or Rainbow Passage during TMS on and off conditions. As mentioned above, the deep brain stimulators were always off during this experiment. The entire session was videotaped. Perceptual and acoustic analyses. Speech recordings were analyzed using the same perceptual and acoustic analytical methods described in Experiment 1. Prior to acoustic analysis, a custom software tool was used to reduce the impact of TMS noise on acoustic measures (TMS Denoiser; S. Ghosh, personal communication, August 27, 2007). In addition, speech intelligibility during TMS on and off conditions was assessed perceptually as the percentage of produced words that were identifiable to listeners (the second and third authors).

Results
Experiment 1: Perceptual and Acoustic Parameters of Speech and Voice
Ratings for the eight aberrant perceptual dimensions are shown in Table 1 and Figure 2 for each of the four experimental conditions. As expected, findings indicate that this patient with long-standing Parkinsons disease had impaired speech production in all conditions. Lower perceptual ratings were found during conditions that included stimulation of the left STN (i.e., mean rating across dimensions for left stimulation = 2.65; bilateral stimulation = 3.1) as opposed to conditions when the right STN was stimulated as well as when there was no stimulation (i.e., mean rating across dimensions for right stimulation = 4.25; no stimulation = 3.98). Interestingly, right STN stimulation resulted in higher (less impaired) ratings than no stimulation for three dimensions
TABLE 1. Perceptual speech and limb measurements during deep brain stimulation (DBS) on and off conditions. Measures Limb Hoehn and Yahr level Facial masking Tremor Pill rolling movement Perceptual speech Monopitch Monoloud Harsh Breathy Strained/strangled Short phrases Imprecise consonants Intelligibility DBS on 2 4 3 3 3 3 2 4 3 2 3 3 2 2 2 3 3 4 4 4 5 5 4 4 4 LH DBS RH DBS DBS off 3 + + + 4 4 4 4 4 3 4 4

Experiment 3: TMS Virtual Lesion Study

Use of irTMS. To verify the outcome of Experiment 2, a TMS virtual lesion was induced in this patient with DBS off. The Cadwell High Speed Magnetic Stimulator (Cadwell Laboratories) controlled by a pulse generator (Grass Technologies) was used. An irTMS system developed at the Research Imaging Center (Lancaster et al., 2004) was applied to the target site, namely left PMd corresponding to BA 6 (Talairach coordinates x = 46, y = 2, and z = 42). The irTMS system was used to (a) determine target sites using coregistered anatomical (3D MRI) and PET images, (b) plan the TMS coil pose for the site of interest based on cortical columnar orientation (P. T. Fox et al., 2004), (c) register the participants head to his 3D MRI image, (d) register the robots coordinate system to the participants head, and (e) robotically position the TMS coil to the planned pose. TMS delivery. The participant was seated in a dental chair and his head immobilized with a thermoplastic face mask. Resting motor threshold (rMT) was defined as the minimum level of stimulation that evoked a movement in the first dorsal interossii muscle of the right hand in 50% of trials. In this case, with TMS applied to the left primary hand motor cortex, the rMT was determined to be 68% of the machine output. Once rMT was determined, the TMS coil was positioned at the target site using the irTMS system. TMS stimulation then was applied to left PMd at 110% of the motor threshold (75% machine output) at a frequency of 4 Hz. These parameters were based on a previous study in healthy

Note. LH = left hemisphere; RH = right hemisphere; perceptual measures range from 7 (normal ) to 1( profoundly impaired ); + = present; = absent.

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FIGURE 2. Perceptual ratings for each of the eight aberrant speech dimensions for each experimental condition. Lower values reflect greater impairment.

(breathy, strained/strangled, short phrases). In the remaining five dimensions, right stimulation and no stimulation conditions were equivalent. With left-only stimulation, all scores dropped and generally ranged from 2 to 3 with none of the eight dimensions reaching a score of 4. Acoustic measures are shown in Table 2 for IV, PPT, and SR in the four DBS conditions, with comparison data from unimpaired speakers and those with hypokinetic dysarthria from Rosen et al. (2006). The mean values of these measures were compared across different conditions. Each of the three measures changed as a function of experimental condition. In particular, lower measures of IV and SR were evident in conditions with DBS on bilaterally or left only. In contrast, these measures were higher with DBS off or on only to the right side. These higher values are indicative of more normal production, although they are still below comparison measures from comparison speakers (unimpaired or those with hypokinetic dysarthria; see Table 2). The pattern for PPT was less consistent, with the lowest value for LH only (3.87), a moderate value of 5.99 for RH only, and similar PPT of 9.52 and 8.21 for bilateral on and off conditions, respectively. The acoustic contrastivity measures were employed because they reflect articulatory closure and distinct intersegment boundaries. Furthermore, they have been shown to be useful in differentiating speech of participants with hypokinetic

dysarthria due to Parkinsons disease from that of healthy participants (Rosen et al., 2006). Our results indicate reduced acoustic contrastivity with STN-DBS on, particularly to the left hemisphere. Additional acoustic measures included broad durational measures of tone groups compared with intergroup intervals as a means of assessing the global temporal structure of utterances (see Figure 3). This analysis was particularly useful in contrasting the temporal structuring of speech during TMS conditions in Experiment 3 (also shown in Figure 3). Findings indicated slightly shorter duration of tone group intervals in conditions with bilateral DBS or left hemisphere stimulation only, relative to DBS off or to the right hemisphere only. The findings for bilateral and left hemisphere only DBS are consistent with the results due to TMS, discussed in greater detail in Experiment 3. Intergroup interval durations were little affected by DBS condition, staying relatively stable at 600 ms across conditions. In contrast to its effects on speech, STN-DBS improved the patients general motor function, as judged by three authors (third, fourth, and eighth authors) viewing videotapes of the patient. For example, turning the stimulators off bilaterally resulted in increased facial masking and the emergence of limb tremor. This worsening of general motor function with DBS turned off stands in marked contrast to the concomitant improvement in speech. A 10-min wait period between on and off conditions was sufficient to elicit the behavioral responses described above. Moreover, as the stimulator remained off during the TMS study reported below, facial masking, bilateral pill-rolling, and resting tremor worsened (see Table 1).

Experiment 2: Functional Imaging Study

Task-related activation patterns for phonation contrasted with rest (both during DBS off and DBS on) primarily involved activation of the supplementary motor area (SMA, Region 1 in Figure 4). Task-related activation patterns for reading contrasted with rest (during DBS off) involved activation of SMA, bilateral primary motor cortices (M1; Regions 2 and 3 in Figure 4), bilateral anterior cingulate cortices (regions 4 and 5 in Figure 4), and posterior cingulate cortex, insula, thalamus, basal ganglia, cerebellum, and primary and secondary auditory and visual cortices. Similar activations were also seen during reading in DBS on condition, but in the primary motor cortices these did not reach

TABLE 2. Spectral contrast measures in four subthalamic nucleus DBS conditions and TMS conditions. Comparison data (Rosen et al., 2006) DBS condition Measure Intensity variation (dB) Percentage pause time Spectral range (dB) LH + RH on 3.92 (0.42) 9.52 (4.16) 46.93 (3.10) LH on 3.63 (0.24) 3.87 (2.38) 39.46 (3.06) RH on 4.54 (0.30) 5.99 (1.80) 67.03 (6.02) Off 4.47 (0.29) 8.21 (2.37) 62.18 (5.54) TMS condition TMS on 3.09 (0.25) 2.72 (0.12) 40.28 (2.02) TMS off 3.82 (0.22) 9.92 (1.35) 40.56 (1.77) Healthy controls 6.5 25.0 94.0 Hypokinetic dysarthria 5.4 14.0 84.0

Note. TMS = transcranial magnetic stimulation. Values represent means, with standard errors in parentheses.

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FIGURE 3. Acoustic measures: average speech and pause interval durations with deep brain stimulation (DBS) and transcranial magnetic stimulation (TMS) on and off during paragraph reading.

FIGURE 4. Activations during speech tasks contrasted with rest during DBS on and off conditions. Activations during reading in DBS off condition are shown in red, activations during reading with DBS on are in green, and activations common across both conditions are shown in yellow. Numerals indicate the following specific locations: 1 = supplementary motor cortex; 2 = left primary motor cortex mouth; 3 = right primary motor cortex mouth; 4 = left cingulate cortex; and 5 = right cingulate cortex. The peak activations for both cingulate cortices were at z = 34.

significance during reading in the DBS on condition (see Figure 4). The contrast of DBS on and off conditions demonstrated significant blood flow increases in several brain regions (see Tables 3 and 4 and Figure 5). Increase in blood flow was seen at the site of DBS (left STN) implant (see Table 3 and Region 1 in Figure 5) and in the neighboring thalamus. The activation in the left STN was identified at Talairach coordinates of x = 10, y = 10, and z = 2, but the volume of activation was contiguous with the nearby thalamic activation centered at x = 6, y = 14, and z = 2, with a cluster size of 416 mm3. In addition, increased blood flow was observed in bilateral lentiform nuclei of the putamen (Regions 3 and 4 in Figure 5). Significant increase in blood flow was also seen in remote regions such as left PMd (BA 6; Region 2 in Figure 5), frontal eye field (BA 8), and dorsolateral prefrontal cortex (BA 11), bilateral cingulate cortex (BA 32), and inferior frontal gyri (BA 44, 45, 46, and 47; see Table 4). The left PMd, which had the most significant increase in CBF, was chosen as a target site for TMS virtual lesion. Significant decreases in CBF in left M1-hand and SMA were noted during the DBS on condition (see Table 4). We did not consider regions that showed decreases in CBF (such as SMA) as targets for TMS-induced virtual lesion. Contrast of DBS on and off during the rest condition revealed activations in the same regions. However, due to the fewer number of

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TABLE 3. Coordinates of significant cerebral blood flow increases during DBS on contrasted with DBS off. Coordinates Brain region Left lateral globus pallidus Left VPMN thalamus Left putamen Left STN/thalamus Left thalamus (pulvinar) Right putamen x 24 16 24 6 10 32 y 16 19 8 14 34 20 z 2 7 6 2 2 0 Cluster size (mm3) 704 400 528 416 280 528 Z score 3.99 3.87 3.6 3.48 3.43 4.14 p value .00003 .00005 .00016 .00025 .0003 <.00003

Note. Coordinates (x, y, and z) represent brain coordinates in Talairach Atlas (Talairach & Tourneux, 1988). VPMN = ventral posterior medial nucleus; STN = subthalamic nucleus.

scans (4 vs. 12 scans used in all DBS on vs. all DBS off analysis), the areas had smaller significance values and cluster sizes. This indicates that the speech motor network can be identified using few scans, but the findings are more robust when more scans are included in the analysis. Therefore, including more scans assists in accurate targeting of a region with irTMS.

Experiment 3: TMS Virtual Lesion Study

The participant tolerated 4-Hz repetitive TMS (irTMS) without any adverse effects. While speech was affected by TMS, there were no overt effects on the oromotor system. The patient did not demonstrate any abnormal tongue, jaw, or lip movements during TMS. Further, no effects were observed on the limb motor system. Complete speech arrest was observed in 60% of the trials. On the other trials, speech production was possible but disrupted, as shown in Figure 6. When TMS was applied, speech altered immediately, with increased pause length between words (see Figure 3). Specifically, average duration of tone group intervals was reduced from 1.1 s with TMS off to 0.6 s with TMS on. In accordance with this finding,

average duration of intergroup intervals increased from 0.9 s (TMS off ) to 1.4 s (TMS on). The average lengths of tone group durations and intergroup intervals with and with out TMS are shown in Figure 3, alongside durational data from Experiment 1. With TMS off, 97% of words were intelligible; when TMS was applied, intelligibility dropped to 57%. Perceptual analyses of speech data with TMS were performed to assess whether TMS stimulation of left PMd produces similar effects as bilateral or left STN stimulation (see Experiment 1; Figure 2). Critically, the same eight deviant perceptual dimensions found in Experiment 1 were also found to change as a result of TMS stimulation to the left PMd (see Figure 2). It was also the case that three other aberrant perceptual dimensions consistently emerged with TMS stimulation, including reduced stress (rating of 2), inappropriate silences (rating of 1), and phoneme prolongation (rating of 1). The average rating across the eight perceptual dimensions hovered around 1 (the lowest possible score), showing that TMS stimulation of left BA 6 had devastating effects on speech production in the same perceptual dimensions as with left STN stimulation. In addition to these perceptual measures, acoustic contrastivity measures also were obtained for comparison

TABLE 4. Coordinates of significant cerebral blood flow increases in remote sites during DBS on contrasted with DBS off. Coordinates Brain region Left frontal eye field (BA 8) Left PMd (BA 6) Left middle frontal gyrus (BA 11) Left anterior cingulate cortex (BA 32) Left inferior frontal gyrus (BA 45/46) Right inferior frontal gyrus (BA 47) Right anterior cingulate cortex (BA 24/32) Right inferior frontal gyrus (BA 44/47) Right anterior cingulate cortex (BA 32) Right BA 24/SMA Left M1 hand (BA 4) Left SMA (BA 6) x 22 46 5 6 39 35 20 58 10 7 36 3 y 36 2 48 32 38 28 2 18 19 20 26 14 z 40 42 18 8 0 6 40 2 42 42 42 62 Cluster size (mm3) 360 480 400 656 272 328 296 224 200 240 280 240 Z score 4.31 3.67 3.36 3.35 3.28 3.65 3.63 3.62 3.38 3.26 2.65 3.02 p value <.00003 .00012 .00039 .00041 .00052 .00013 .00014 .00015 .00036 .00056 .004 .001

Note. BA = Brodmann area; M1 = primary motor cortex; SMA = supplementary motor area; PMd = dorsal premotor cortex.

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FIGURE 5. Activation of local (z plane) and remote (y plane) brain regions by DBS. Marker 1 corresponds to left subthalamic nucleus (STN)/ventral posterior nucleus of the thalamus; 2 = left dorsal premotor cortex (Brodmann area 6); 3 = left putamen; and 4 = right putamen.

measures did not show as great a difference due to TMS stimulation as was found for DBS conditions, with the exception of PPT, which was much reduced with TMS on compared to off. This result may seem contradictory, as the previous section (see Figure 6) described increased pause duration during TMS stimulation (which might be construed to correspond to higher PPT). Note, however, that PPT represents percentage of time within a tone group (see Figure 1) that is under 15% of the maximum spectral energy. Note also that the values of SR and IV for both TMS on and off conditions were similar to those found in DBS on condition. We speculate that these might reflect residual effects of TMS even during the off segments (see below).

Discussion
In this report, we highlight the use of multimodality imaging to gain knowledge about speech deterioration following STN-DBS in a single participant with Parkinsons disease on levodopa medication. Unique in this report is the combination of objective measures of speech (perceptual and acoustic) with PET imaging and virtual lesion techniques to understand the underlying neural mechanisms responsible for speech impairment due to DBS. Similar to previous studies (e.g., Pinto, Ozsancak, et al., 2004), speech was found to deteriorate with stimulation to the left STN in this patient. The use of Darley et al.s (1975) multidimensional rating system in this study provided greater specificity to the nature of the speech impairment than has been previously reported, revealing deficits characteristic of hypokinetic dysarthria in Parkinsons disease (e.g., short phrases, monopitch, monoloud, imprecise consonants, intelligibility) as well as others that are not typically found in individuals with Parkinsons disease (harsh, strained/ strangled vocal quality). Multidimensional perceptual ratings may provide clues to the nature of the mechanism underlying speech deterioration sometimes found in Parkinsons disease patients with STN-DBS. For example, harsh and strained/ strangled vocal qualities typically are associated with spastic dysarthria. These perceptual findings suggest that STN-DBS in this patient is stimulating not only the STN and connected basal ganglia, but may be inadvertently stimulating fibers in the corticospinal tract as well (see Figure 7). Speech changes associated with STN-DBS were assessed with acoustic measures previously used in speakers with hypokinetic dysarthria due to Parkinsons disease (Rosen et al., 2006). These measures provided evidence of STN effects on speech, resulting in blurred acoustic boundaries (PPT), reduced differentiation between consonant and vowel sounds (SR), and decreased acoustic contrastivity (i.e., variation in the intensity envelope, important for normal prosody). In contrast, with DBS off or on only to the right side, acoustic contrastivity measures were more similar to reported data from speakers with Parkinsons disease and hypokinetic dysarthria (Rosen et al., 2006). Overall, this pattern of acoustic results indicates a loss of acoustic contrastivity when DBS was applied to the left STN, while absence of stimulation or stimulation to the right STN resulted in a higher degree of contrast. Similar differential effects of left and right DBS on speech have been previously reported (Wang et al.,

with effects due to DBS (see Experiment 1). Table 2 shows results of measures that were reduced in speakers with hypokinetic dysarthria ( Rosen et al., 2006) and in left hemisphere STN stimulation, including IV, PPT, and SR. These
FIGURE 6. Real time representation of speech acoustic signal and TMS stimulation in Praat (Boersma & Weenink, 2008). The top row shows the acoustic waveform, with vertical boundaries marking the segments with and without TMS. The middle row includes a gloss transcription of the participants speech, and the bottom row indicates the TMS condition.

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FIGURE 7. Schematic representation of effects of STN-DBS in Parkinsons disease. Orange lines represent excitatory connections, and gray and black lines represent inhibitory connections. Direct and indirect stimulation of STN by DBS is indicated by the boxes with dashed lines. The dashed lines indicate disrupted connections following STN-DBS. Orthodromic disruption of globus pallidus by STN is shown in the green box, and antidromic propagation along the corticosubthalamic fibers is shown in the red box.

2003, 2006), where the intensity of maximally sustained vowel phonation was shown to be improved only during right DBS on when compared to both baseline and left DBS on. Furthermore, it might be expected that spectral contrast measures during DBS off and TMS off should be more similar than found (see Table 2). However, IV, PPT, and SR for TMS off did not vary appreciably compared to TMS on and were generally more comparable with the DBS on conditions. This pattern of effects may indicate that the disrupted articulatory plans generated in left PMd during TMS on were carried out by the motor cortex during TMS off and resulted in a spillover of TMS-induced disruption into the TMS off period. The speech-related functional activation patterns for reading contrasted with rest (DBS on and off) found in this participant are similar to the previously reported pattern in Parkinsons disease (Liotti et al., 2003; Narayana et al., 2008; Pinto, Thobois, et al., 2004). Local and remote increases in CBF with DBS on that were found in this participant are also consistent with published literature (Haslinger, Kalteis, Boecker, Alesch, & Ceballos-Baumann, 2005; Hershey et al., 2003). Unilateral activity at the site of stimulation even when both stimulators are on as seen in this participant has been reported in other STN-DBS studies (Asanuma et al., 2006; Hershey et al., 2003). Further, decreases in CBF seen in M1 and the SMA following STN stimulation with DBS are consistent with the published literature (Haslinger et al., 2005; Hershey et al., 2003). These studies also report decreased CBF in left PMd when DBS is on. The neural mechanism

of these CBF changes is not well characterized. However, we found that the DBS on versus off contrast revealed an unexpected area of hyperactivation in the left PMd (see Figure 5). Therefore, we investigated the role of left PMd in speech production and whether the abnormal activation of this region could explain the speech disorder in this participant. Various functional studies also have shown activation of PMd in normal speech (Bookheimer, Zeffiro, Blaxton, Gaillard, & Theodore, 2000; Petersen, Fox, Posner, Mintun, & Raichle, 1988; Price, Moore, & Frackowiak, 1996; Schulz, Varga, Jeffires, Ludlow, & Braun, 2005; Watkins, Gadian, & Vargha-Khadem, 1999; Wise et al., 1991; Wise, Greene, Bchel, & Scott, 1999), as well as in motor speech disorders such as stuttering (Brown, Ingham, Ingham, Laird, & Fox, 2005) and Parkinsons disease (Narayana et al., 2008). Several lesion studies indicate that PMd is important in speech programming (R. J. Fox, Kasner, Chatterjee, & Chalela, 2001; Robin, Jacks, & Ramage, 2008; Watkins, Dronkers, & Vargha-Khadem, 2002), phonemic speech production (Larner et al., 2004), and phonetic perceptual processing (Demonet et al., 1992; Zatorre, Evans, Meyer, & Gjedde, 1992; Zatorre, Myer, Gjedde, & Evans, 1996). Previous work in our center has also shown that TMS stimulation to this area disrupts speech in healthy, unimpaired speakers (Robin, Guenther, et al., 2008; Tandon et al., 2003). The role of PMd in normal speech production is thought to involve working memory storage of units/programs for speech production (Maas et al., 2008; Robin, Jacks, Hageman, et al., 2008; Wright et al., in press). The increased blood flow in
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PMd during normal speech therefore can be thought to be a result of neurons firing in a temporal hierarchical and synchronous pattern. However during DBS on, the neurons in left PMd are stimulated continuously, also resulting in an increased blood flow. Functional imaging methods such as PET do not have the temporal resolution to differentiate the timing of cortical processes involved in speech that usually occur in milliseconds. Therefore in PET, neuronal firing during normal speech (i.e., periodic) and DBS on (i.e., continuous) appears as activations. Further, continuous stimulation or out-of-phase firing resulting from direct antidromic stimulation from DBS (or TMS) and the resulting desynchronization of ongoing activity disrupts the normal function of left PMd. Therefore, speech disruption seen during DBS as well as TMS is a direct result of desynchronization of ongoing activity in the left PMd. Verification of left PMd as critical to the worsening of speech in this patient was obtained with irTMS when the stimulators were turned off. As noted, stimulation of this area in this patient produced a speech deficit that was perceptually similar to that found with STN-DBS. It is not well understood how STN-DBS increases CBF in PMd. Recently, using MR tractography, connections have been shown between STN and several cortical areas such as PMd, SMA, M1-hand, M1-trunk, and M1-fore upper limb (Aravamuthan, Muthusamy, Stein, Aziz, & Johansen-Berg, 2007). An upstream antidromic (i.e., propagation of action potential from the axon to the cell body) modulating effect of STN stimulation on these direct corticosubthalamic projections has been proposed (Haslinger et al., 2005). Highfrequency stimulation within the STN has been shown to induce negative frontal cortical potentials, further supporting the direct antidromic stimulation of corticosubthalamic axons (Ashby et al., 2001). Therefore, one potential explanation of this finding is that bilateral or left-sided stimulation of STN in this participant resulted in antidromic activation of left PMd, thereby causing speech to deteriorate with STNDBS. This is depicted in Figure 7. Stimulation of STN by DBS results in orthodromic (i.e., the propagation of action potential from cell body to the axon) disruption of excitatory effect of STN on the internal segment of globus pallidus. The net outcome of this disruption is the release of inhibition on the thalamus and motor cortex and improvement in limb motor symptoms of Parkinsons disease. However, at the same time, stimulation of STN can propagate in the antidromic direction along the corticosubthalamic fibers and result in speech impairment. The notion of Farrell and colleagues (2005) that speech motor planning /programming may be disrupted as a result of STN-DBS is in line with our findings, as stimulation of PMd only disrupts speech attempts and not silent reading (Tandon et al., 2003). Thus, we hypothesize that DBS disrupts ongoing processes in left PMd (e.g., during speech) by adding noise to the system vis--vis antidromic stimulation. Virtual lesioning by TMS also resulted in such disruption of ongoing activity in left PMd during overt speech. This finding points to the role of PMd in speech motor programming. Furthermore, DBS could result in speech deficit not only by direct disruption of PMd activity but also indirectly by interfering with the interactions between PMd and the

primary motor cortex. Excitability of PMd has been shown to directly modulate the primary motor cortex (Reis et al., 2008). As noted in the introduction, explanations for the differential responses to stimulation observed for speech versus general motor behavior are speculative, ranging from hypotheses about electrode placement to differential neural organization of speech and limb motor systems. Relative to electrode placement, appropriate increases in CBF in STN, thalamus, and basal ganglia were demonstrated bilaterally using PET imaging with DBS on (see Table 3). Further, improvement in limb motor performance when DBS was on indicates appropriate positioning of electrodes. However, the exact site of stimulation in this patient is not known, as postoperative MRI was not performed. Topographically, there is evidence that the STN regions connected to the cortex (i.e., motor cortex, SMA, and PMd) are located in close proximity and are more lateral and anterior to the STN regions connected to other brain regions (i.e., basal ganglia and thalamus; Aravamuthan et al., 2007). Therefore, DBS can directly stimulate areas in STN connected to the premotor cortices as well as the primary hand, trunk, and upper limb motor areas. In the superior-inferior dimension (z plane), STN regions connected to PMd and SMA were segregated from those parts of STN connected to the motor cortex (Aravamuthan et al., 2007). Thus, even a small displacement of the DBS in the z direction can stimulate not only regions in STN connected to the primary motor cortex but also areas of STN connected to SMA and PMd. Therefore, while improving motor function by lesioning the connections of STN to the motor cortex, DBS might incidentally lesion its connections to the premotor areas. This can also explain the speech disturbances found in our participant with Parkinsons disease and STN-DBS. Such differences in the location of the implanted electrodes can explain why some patients with DBS have speech problems. Farrell and colleagues (2005) have argued that disruption of speech due to STN-DBS results from activation differences in local neuronal population responses and fundamental differences in their role in the regulation of speech and limb movements. The argument that speech planning and execution are driven by different neural organization schemes than other motor systems has been challenged in the literature, particularly for high-level motor organization and programming (Ballard, Robin, & Folkins, 2003). Another point made by Farrell et al. is that limb systems receive unilateral (contralateral) innervation via corticospinal inputs, whereas speech structures, which project to corticobulbar systems, include bilateral innervation patterns of some muscle groups. It is unclear how these differences in innervation patterns would lead to poorer or no response of speech to DBS in the face of positive limb responses, particularly given our finding that right-sided stimulation has minimal or no detrimental effects on speech. Our findings support similar findings by others (Wang et al., 2003, 2006) and their argument about motor asymmetry. In summary, one patient with long-standing Parkinsons disease who was implanted bilaterally with STN-DBS was studied. Unique in this report was the combination of objective measures of speech ( perceptual and acoustic) with

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PET and MRI as well as virtual lesion methods using TMS to understand the underlying neural mechanisms responsible for speech impairment due to DBS. Although these data are based on only one patient, they provide a strong direction for future research efforts. We have provided preliminary evidence to explain the neural mechanism underlying speech deterioration in patients with Parkinsons disease and STNDBS. The finding that right-sided stimulation resulted in speech that was in many ways perceptually better than when the stimulators were off might allow for balancing the intensity of stimulation between hemispheres as a successful treatment strategy. If these findings hold for other patients with STN-DBS, then image-guided adjustment of STNDBS parameters may promote improvement in all motor functions.

Acknowledgments
This research was supported in part by grants from the National Institutes of Health, including National Institute of Neurological Disorders and Stroke Grants NS43738 to Peter T. Fox and NS36449 to Howard Poizner, and National Institute of Mental Health Grant MH60246 to Peter T. Fox. We offer sincere thanks to Dr. Charles Wilson of the University of Texas at San Antonio for thoughtful discussion and insightful comments on this work. Finally, we thank our patient for participation in this study.

References
Aravamuthan, B. R., Muthusamy, K. A., Stein, J. F., Aziz, T. Z., & Johansen-Berg, H. (2007). Topography of cortical and subcortical connections of the human pedunculopontine and subthalamic nuclei. NeuroImage, 37, 694 705. Asanuma, K., Tang, C., Ma, Y., Dhawan, V., Mattis, P., Edwards, C., et al. (2006). Network modulation in the treatment of Parkinsons disease. Brain, 129, 2667. Ashby, P., Paradiso, G., Saint-Cyr, J. A., Chen, R., Lang, A. E., & Lozano, A. M. (2001). Potentials recorded at the scalp by stimulation near the human subthalamic nucleus. Clinical Neurophysiology, 112, 431437. Ballard, K. J., Robin, D. A., & Folkins, J. W. (2003). An integrative model of speech motor control: A response to Ziegler. Aphasiology, 17(1), 37 48. Baron, M. S., Vitek, J. L., Bakay, R. A., Green, J., Kaneoke, Y., Hashimoto, T., et al. (1996). Treatment of advanced Parkinsons disease by posterior GPi pallidotomy: 1-year results of a pilot study. Annals of Neurology, 40, 355366. Benabid, A. L., Deuschl, G., Lang, A. E., Lyons, K. E., & Rezai, A. R. (2006). Deep brain stimulation for Parkinsons disease. Movement Disorders, 21(Suppl. 14), S168S170. Boersma, P., & Weenink, D. (2008). Praat: Doing phonetics by computer (Version 5.0.22) [Computer program]. Retrieved April 27, 2008, from www.praat.org/. Bookheimer, S. Y., Zeffiro, T. A., Blaxton, T. A., Gaillard, W., & Theodore, W. H. (2000). Activation of language cortex with automatic speech tasks. Neurology, 55, 11511157. Brown, S., Ingham, R. J., Ingham, J. C., Laird, A. R., & Fox, P. T. (2005). Stuttered and fluent speech production: An ALE meta-analysis of functional neuroimaging studies. Human Brain Mapping, 25(1), 105117. Carbon, M., & Eidelberg, D. (2006). Functional imaging of sequence learning in Parkinsons disease. Journal of the Neurological Sciences, 248(12), 7277.

Cherry, S. R., & Phelps, M. E. (2002). Imaging brain function with positron emission tomography. In A. W. Toga & J. C. Mazziotta (Eds.), Brain mapping: The methods (pp. 485511). San Diego, CA: Academic Press. DAlatri, L., Paludetti, G., Contarino, M. F., Galla, S., Marchese, M. R., & Bentivoglio, A. R. (2008). Effects of bilateral subthalamic nucleus stimulation and medication on Parkinsonian speech impairment. Journal of Voice, 22(3), 365372. Darley, F., Aronson, A., & Brown, J. (1975). Motor speech disorders. Philadelphia: Saunders. Demonet, J. F., Chollet, F., Ramsay, S., Cardebat, D., Nespoulous, J. L., Wise, R., et al. (1992). The anatomy of semantic and phonological processing in normal subjects. Brain, 115, 17531768. Duffy, J. R. (2005). Motor speech disorders: Substrates, differential diagnosis, and management (2nd ed.). St. Louis, MO: Elsevier Mosby. Fahn, S., Elton, R. L., & Members of the UPDRS Development Committee. (1987). Unified Parkinsons Disease Rating Scale. In S. Fahn, C. D. Marsden, D. B. Calne, & M. Goldstein (Eds.), Recent developments in Parkinsons disease (Vol. 2, pp. 153163). Florham Park, NJ: Macmillan Healthcare Information. Fairbanks, G. (1960). Voice and articulation drill book (2nd ed.). New York: Harper & Row. Farrell, A., Theodoros, D., Ward, E., Hall, B., & Silburn, P. (2005). Effects of neurosurgical management of Parkinsons disease on speech characteristics and oromotor function. Journal of Speech, Language, and Hearing Research, 48, 520. Fox, P. T., Narayana, S., Tandon, N., Sandoval, H., Fox, S. P., Kochunov, P., et al. (2004). Column-based model of electric field excitation of cerebral cortex. Human Brain Mapping, 22(1), 114. Fox, R. J., Kasner, S. E., Chatterjee, A., & Chalela, J. A. (2001). Aphemia: An isolated disorder of articulation. Clinical Neurology and Neurosurgery, 103(2), 123126. Gan, J., Xie-Brustolin, J., Mertens, P., Polo, G., Klinger, H., Mollion, H., et al. (2007). Bilateral subthalamic nucleus stimulation in advanced Parkinsons disease: Three years follow-up. Journal of Neurology, 254(1), 99106. Gentil, M., Chauvin, P., Pinto, S., Pollak, P., & Benabid, A. L. (2001). Effect of bilateral stimulation of the subthalamic nucleus on parkinsonian voice. Brain and Language, 78(2), 233240. Gentil, M., Garcia-Ruiz, P., Pollak, P., & Benabid, A. L. (1999). Effect of stimulation of the subthalamic nucleus on oral control of patients with parkinsonism. Journal of Neurology, Neurosurgery & Psychiatry, 67, 329333. Gentil, M., Garcia-Ruiz, P., Pollak, P., & Benabid, A. L. (2000). Effect of bilateral deep-brain stimulation on oral control of patients with parkinsonism. European Neurology, 44(3), 147152. Gentil, M., Pinto, S., Pollak, P., & Benabid, A. L. (2003). Effect of bilateral stimulation of the subthalamic nucleus on parkinsonian dysarthria. Brain and Language, 85(2), 190196. Guehl, D., Cuny, E., Benazzouz, A., Rougier, A., Tison, F., Machado, S., et al. (2006). Side-effects of subthalamic stimulation in Parkinsons disease: Clinical evolution and predictive factors. European Journal of Neurology, 13, 963971. Haslinger, B., Kalteis, K., Boecker, H., Alesch, F., & CeballosBaumann, A. O. (2005). Frequency-correlated decreases of motor cortex activity associated with subthalamic nucleus stimulation in Parkinsons disease. NeuroImage, 28, 598606. Hershey, T., Revilla, F. J., Wernle, A. R., McGee-Minnich, L., Antenor, J. V., Videen, T. O., et al. (2003). Cortical and subcortical blood flow effects of subthalamic nucleus stimulation in PD. Neurology, 61, 816821. Ho, A. K., Bradshaw, J. L., & Iansek, R. (2008). For better or worse: The effect of levodopa on speech in Parkinsons disease. Movement Disorders, 23, 574580.
Narayana et al.: Imaging Speech Changes in Parkinsons Disease

159

Hoehn, M. M., & Yahr, M. D. (1967). Parkinsonism: Onset, progression and mortality. Neurology, 17, 427442. Kleiner-Fisman, G., Herzog, J., Fisman, D. N., Tamma, F., Lyons, K. E., Pahwa, R., et al. (2006). Subthalamic nucleus deep brain stimulation: Summary and meta-analysis of outcomes. Movement Disorders, 21(Suppl. 14), S290S304. Krack, P., Batir, A., Van Blercom, N., Chabardes, S., Fraix, V., Ardouin, C., et al. (2003). Five-year follow-up of bilateral stimulation of the subthalamic nucleus in advanced Parkinsons disease. The New England Journal of Medicine, 349, 19251934. Krings, T., Chiappa, K. H., Foltys, H., Reinges, M. H., Cosgrove, R. G., & Thron, A. (2001). Introducing navigated transcranial magnetic stimulation as a refined brain mapping methodology. Neurosurgical Review, 24(4), 171179. Kumar, R., Chen, R., & Ashby, P. (1999). Safety of transcranial magnetic stimulation in patients with implanted deep brain stimulators. Movement Disorders, 14(1), 157158. Kumar, R., Lozano, A. M., Montgomery, E., & Lang, A. E. (1998). Pallidotomy and deep brain stimulation of the pallidum and subthalamic nucleus in advanced Parkinsons disease. Movement Disorders, 13(Suppl. 1), 7382. Lancaster, J. L., Glass, T. G., Lankipalli, B. R., Downs, H., Mayberg, H., & Fox, P. T. (1995). A modality-independent approach to spatial normalization of tomographic images of the human brain. Human Brain Mapping, 3, 209223. Lancaster, J. L., Narayana, S., Wenzel, D., Luckemeyer, J., Roby, J., & Fox, P. (2004). Evaluation of an image-guided, robotically positioned transcranial magnetic stimulation system. Human Brain Mapping, 22, 329340. Larner, A. J., Robinson, G., Kartsounis, L. D., Rakshi, J. S., Muqit, M. M. K., Wise, R. J. S., et al. (2004). Clinicalanatomical correlation in a selective phonemic speech production impairment. Journal of the Neurological Sciences, 219(12), 2329. Liotti, M., Ramig, L. O., Vogel, D., New, P., Cook, C. I., Ingham, R. J., et al. (2003). Hypophonia in Parkinsons disease: Neural correlates of voice treatment revealed by PET. Neurology, 60, 432440. Maas, E., Robin, D., Wright, D., & Ballard, K. (2008). Motor programming in apraxia of speech. Brain and Language, 106(2), 107118. Mandeville, J. B., & Rosen, B. R. (2002). Functional MRI. In A. W. Toga & J. C. Mazziotta (Eds.), Brain mapping: The methods (pp. 315350). San Diego, CA: Academic Press. Mintun, M., Fox, P. T., & Raichle, M. E. (1989). A highly accurate method of localizing regions of neuronal activity in the human brain with PET. Journal of Cerebral Blood Flow and Metabolism, 9, 96103. Moretti, R., Torre, P., Antonello, R. M., Capus, L., Gioulis, M., Zambito Marsala, S., et al. (2003). Speech initiation hesitation following subthalamic nucleus stimulation in a patient with Parkinsons disease. European Neurology, 49(4), 251253. Moro, E., Poon, Y. Y. W., Lozano, A. M., Saint-Cyr, J. A., & Lang, A. E. (2006). Subthalamic nucleus stimulation: Improvements in outcome with reprogramming. Archives of Neurology, 63, 12661272. Narayana, S., Fox, P. T., Zhang, W., Franklin, C., Robin, D. A., Vogel, D., & Ramig, L. O. (2008). Neural correlates of efficacy of voice therapy identified by performance-correlation analysis. Manuscript submitted for publication. Obeso, J. A., Rodriguez-Oroz, M. C., Rodriguez, M., Lanciego, J. L., Artieda, J., Gonzalo, N., et al. (2000). Pathophysiology of the basal ganglia in Parkinsons disease. Trends in Neurosciences, 23, 819.

Pascual-Leone, A., Gates, J. R., & Dhuna, A. (1991). Induction of speech arrest and counting errors with rapid-rate transcranial magnetic stimulation. Neurology, 41, 697702. Pascual-Leone, A., Tormos, J. M., Keenan, J., Tarazona, F., Canete, C., & Catala, M. D. (1998). Study and modulation of human cortical excitability with transcranial magnetic stimulation. Journal of Clinical Neurophysiology, 15(4), 333343. Pascual-Leone, A., & Walsh, V. (2002). Transcranial magnetic stimulation. In A. W. Toga & J. C. Mazziotta (Eds.), Brain mapping: The methods (pp. 225290). San Diego, CA: Academic Press. Pascual-Leone, A., Walsh, V., & Rothwell, J. (2000). Transcranial magnetic stimulation in cognitive neurosciencevirtual lesion, chronometry, and functional connectivity. Current Opinion in Neurobiology, 10(2), 232237. Paus, T. (2002). Combination of transcranial magnetic stimulation with brain mapping. In A. W. Toga & J. C. Mazziotta (Eds.), Brain mapping: The methods (pp. 691705). San Diego, CA: Academic Press. Petersen, S. E., Fox, P. T., Posner, M. I., Mintun, M., & Raichle, M. E. (1988). Positron emission tomographic studies of the cortical anatomy of single-word processing. Nature, 331, 585589. Pinto, S., Ozsancak, C., Tripoliti, E., Thobois, S., LimousinDowsey, P., & Auzou, P. (2004). Treatments for dysarthria in Parkinsons disease. Lancet Neurology, 3, 547556. Pinto, S., Thobois, S., Costes, N., Le Bars, D., Benabid, A. L., Broussolle, E., et al. (2004). Subthalamic nucleus stimulation and dysarthria in Parkinsons disease: A PET study. Brain, 127(Pt. 3), 602615. Poluha, P. C., Teulings, H. L., & Brookshire, R. H. (1998). Handwriting and speech changes across the levodopa cycle in Parkinsons disease. Acta Psychologica, 100(12), 7184. Price, C. J., Moore, C. J., & Frackowiak, R. S. J. (1996). The effect of varying stimulus rate and duration on brain activity during reading. NeuroImage, 3, 4052. Ramig, L., Fox, C., & Sapir, S. (2004). Parkinsons disease: Speech and voice disorders and their treatment with the Lee Silverman voice treatment. Seminars in Speech and Language, 25, 169180. Reis, J., Swayne, O. B., Vandermeeren, Y., Camus, M., Dimyan, M. A., Harris-Love, M., et al. (2008). Contribution of transcranial magnetic stimulation to the understanding of cortical mechanisms involved in motor control. The Journal of Physiology, 586(2), 325351. Ridding, M. C., & Rothwell, J. C. (2007). Therapeutic use of rTMS. Nature Reviews Neuroscience, 8, 559567. Robin, D. A., Guenther, F., Narayana, S., Jacks, A., Tourville, J., Ramage, A., et al. (2008, March). Transcranial magnetic stimulation virtual lesion study of speech. Poster presented at the Biennial Conference on Motor Speech, Monterey, CA. Robin, D. A., Jacks, A., Hageman, C., Clark, H. C., & Woodworth, G. (2008). Visuomotor tracking abilities of speakers with apraxia of speech or conduction aphasia. Brain and Language, 106(2), 98106. Robin, D. A., Jacks, A., & Ramage, A. E. (2008). The neural substrates of apraxia of speech as uncovered by brain imaging: A critical review. In R. J. Ingham (Ed.), Neuroimaging in communication sciences and disorders (pp. 129154). San Diego, CA: Plural. Rodriguez-Oroz, M. C., Obeso, J. A., Lang, A. E., Houeto, J. L., Pollak, P., Rehncrona, S., et al. (2005). Bilateral deep brain stimulation in Parkinsons disease: A multicentre study with 4 years follow-up. Brain, 128(Pt. 10), 22402249. Rosen, K. M., Kent, R. D., Delaney, A. L., & Duffy, J. R. (2006). Parametric quantitative acoustic analysis of conversation produced

160 American Journal of Speech-Language Pathology Vol. 18 146161 May 2009

by speakers with dysarthria and healthy speakers. Journal of Speech, Language, and Hearing Research, 49, 395411. Rousseaux, M., Krystkowiak, P., Kozlowski, O., Ozsancak, C., Blond, S., & Destee, A. (2004). Effects of subthalamic nucleus stimulation on parkinsonian dysarthria and speech intelligibility. Journal of Neurology, 251(3), 327334. Santens, P., De Letter, M., Van Borsel, J., De Reuck, J., & Caemaert, J. (2003). Lateralized effects of subthalamic nucleus stimulation on different aspects of speech in Parkinsons disease. Brain and Language, 87(2), 253258. Schulz, G. M., Greer, M., & Friedman, W. (2000). Changes in vocal intensity in Parkinsons disease following pallidotomy surgery. Journal of Voice, 14, 589606. Schulz, G. M., Peterson, T., Sapienza, C. M., Greer, M., & Friedman, W. (1999). Voice and speech characteristics of persons with Parkinsons disease pre- and postpallidotomy surgery: Preliminary findings. Journal of Speech, Language, and Hearing Research, 42, 11761194. Schulz, G. M., Varga, M., Jeffires, K., Ludlow, C. L., & Braun, A. R. (2005). Functional neuroanatomy of human vocalization: An H215O PET study. Cerebral Cortex, 15, 18351847. Scott, R., Gregory, R., Hines, N., Carroll, C., Hyman, N., Papanasstasiou, V., et al. (1998). Neuropsychological, neurological and functional outcome following pallidotomy for Parkinsons disease. A consecutive series of eight simultaneous bilateral and twelve unilateral procedures. Brain, 121, 659675. Stewart, L., Walsh, V., Frith, U., & Rothwell, J. C. (2001). TMS produces two dissociable types of speech disruption. NeuroImage, 13, 472478. Talairach, J., & Tournoux, P. (1988). Co-planar stereotaxic atlas of the human brain. 3-dimensional proportional system: An approach to cerebral imaging. New York: Thieme Medical. Tandon, N., Narayana, S., Lancaster, J. L., Brown, S., Dodd, S., Vollmer, D. G., et al. (2003). CNS Resident Award: Role of the lateral premotor cortex in articulation. Clinical Neurosurgery, 50, 341349. Trot, M., Su, S., Su, P., Yen, R. F., Tseng, H. M., Barnes, A. et al. (2006). Network modulation by the subthalamic nucleus in the treatment of Parkinsons disease. NeuroImage, 31, 301307. Wang, E., Metman, L. V., Bakay, R., Arzbaecher, J., & Bernard, B. (2003). The effect of unilateral electrostimulation of the subthalamic nucleus on respiratory/phonatory subsystems of speech production in Parkinsons diseasea preliminary report. Clinical Linguistics & Phonetics, 17(4), 283289.

Wang, E. Q., Metman, L. V., Bakay, R. A. E., Arzbaecher, J., Bernard, B., & Corcos, D. M. (2006). Hemisphere-specific effects of subthalamic nucleus deep brain stimulation on speaking rate and articulatory accuracy of syllable repetitions in Parkinsons disease. Journal of Medical Speech-Language Pathology, 14, 323334. Watkins, K. E., Dronkers, N. F., & Vargha-Khadem, F. (2002). Behavioural analysis of an inherited speech and language disorder: Comparison with acquired aphasia. Brain, 125, 452464. Watkins, K. E., Gadian, D. G., & Vargha-Khadem, F. (1999). Functional and structural brain abnormalities associated with a genetic disorder of speech and language. American Journal of Human Genetics, 65, 12151221. Wise, R., Chollet, F., Hadar, U., Friston, K., Hoffner, E., & Frackowiak, R. (1991). Distribution of cortical neural networks involved in word comprehension and word retrieval. Brain, 114, 18031817. Wise, R. J., Greene, J., Bchel, C., & Scott, S. K. (1999). Brain regions involved in articulation. Lancet, 353, 10571061. Witjas, T., Kaphan, E., Rgis, J., Jouve, E., Chrif, A. A., Pragut, J.-C., et al. (2007). Effects of chronic subthalamic stimulation on nonmotor fluctuations in Parkinsons disease. Movement Disorders, 22, 17291734. Wright, D. L., Robin, D. A., Rhee, J.-H., Vaculin, A., Jacks, A., Guenther, F. H., & Fox, P. T. (in press). Using the self-select paradigm to delineate the nature of speech motor programming. Journal of Speech, Language, and Hearing Research. Zatorre, R. J., Evans, A. C., Meyer, E., & Gjedde, A. (1992). Lateralization of phonetic and pitch discrimination in speech processing. Science, 256, 846849. Zatorre, R. J., Myer, E., Gjedde, A., & Evans, A. C. (1996). PET studies of phonetic processes in speech perception: Renew, replication and reanalysis. Cerebral Cortex, 6, 2130. Received January 31, 2008 Revision received June 6, 2008 Accepted October 13, 2008 DOI: 10.1044/1058-0360(2008/08-0004) Contact author: Shalini Narayana, Research Imaging Center, The University of Texas Health Science Center, San Antonio, 7703 Floyd Curl Drive MSC 6240, San Antonio, TX 78229-3900. E-mail: narayana@uthscsa.edu. Adam Jacks is now at Texas State UniversitySan Marcos.

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Research

Fundamental Frequency Variation With an Electrolarynx Improves Speech Understanding: A Case Study
Peter J. Watson Robert S. Schlauch
University of Minnesota, Minneapolis

Purpose: This study examined the effect of fundamental frequency (F0) variation on the intelligibility of speech in an alaryngeal talker who used an electrolarynx (EL). Method: One experienced alaryngeal talker produced variable F0 and a constant F0 with his EL as he read sentences aloud. As a control, a group of sentences with variable F0 was flattened at a constant F0. Twenty listeners heard these sentences in background noise and wrote down what they heard. Results: Speech understanding was on average 14% better with variable F0 controlled by the

talker than the sentences produced with a constant F0 and the control sentences resynthesized with flattened F0. Conclusions: Variable F0 contributes to speech understanding in noise. Because speech produced by an EL is considered to have poorer intelligibility in relation to other alaryngeal methods, training alaryngeal talkers to use variable F0 may prove to be of significant benefit for communication for those who use electrolarynges. Key Words: intelligibility, electrolarynx, F0 variability

or as many as 50% of persons with a total laryngectomy, the electrolarynx (EL) is either the sole source of alaryngeal voicing or is used as a supplement (Hillman, Walsh, Wolf, Fisher, & Hong, 1998; Mendenhall et al., 2002). Even though the EL is often used for communication, it is typically ranked as the poorest for producing intelligible speech in relation to other alaryngeal techniques (i.e., esophageal and tracheoesophageal; Holley, Lerman, & Randolph, 1983; Williams & Watson, 1985). Several factors are attributed to poor intelligibility, including confusion of voiced and unvoiced phonemes, competing noise radiating externally from the EL, reduced low-frequency energy in the source-spectrum, and the EL sounding mechanical or robotic because of no fundamental frequency (F0) variation (Eadie, 2003; Espy-Wilson, MacAuslan, Huang, & Walsh, 1998; Meltzner & Hillman, 2005; Weiss & Basili, 1985). For this study, the latter factor of the relation of F0 variation to intelligibility in EL speech was explored. Previous investigations have sought to improve the naturalness of EL speech (e.g., Espy-Wilson et al., 1998; Meltzner

& Hillman, 2005; Qi & Weinberg, 1991), but few studies, to our knowledge, have examined what factors make EL speech more intelligible (Kalb & Carpenter, 1981). Several clinical techniques are suggested to improve speech understanding. These techniques include proper placement of the EL to reduce extraneous noise, overarticulation or exaggeration of oral movement, and slowing rate (Boone, McFarlane, & Berg, 2005; Stemple, Glaze, & Klaben, 2000). Generally, most EL devices allow the user to adjust the frequency so that it is higher for women and lower for men, but they produce only a constant or monotone fundamental frequency. There are, however, a few devices that allow the user to produce variable intonation.1 Recent work has shown that speech with naturally varying intonation yields better intelligibility than the same sentences synthetically flattened to the mean F0 of a normal talkers production (Binns & Culling, 2007; Laures & Bunton, 2003; Laures & Weismer, 1999; Watson & Schlauch, 2008). In light of these
1 To our knowledge, there are two types of EL devices that allow a talker to produce variable fundamental frequency. One type includes two models (Servox and the Nu-Voice III) that produce only two frequencies. For the two-frequency devices, a talker has to alternate between two separate buttons on the EL. The second type includes two models (UltraVoice and the TruTone) in which the talker dynamically produces continuous frequency variation by manipulating a single control.

Disclosure Statement
The authors have no proprietary, financial, professional, or any other personal interest of any nature or kind in any product or service with Griffin Labs that could be construed as influencing the position presented in this article.

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results, it would be important to know if variable intonation yields better understanding in EL speech. Moreover, it is of interest to examine how F0 variation affects intelligibility when speech produced with an EL is heard in noise. Almost all speech is produced in environments where competing noise is present (Bess & Humes, 1995), making the presence of background noise a more ecologically valid testing condition than a measure of speech understanding in quiet. The purpose of this preliminary investigation was to examine the effect of variable intonation on intelligibility in one alaryngeal talker. The talker read aloud sentences while he used a pressure-sensitive button on his EL to produce variable intonation. He also read sentences aloud without using variable intonation using a fixed frequency (flat intonation contour). Following data collection, sentences produced with variable intonation were resynthesized with flat intonation contours as an experimental control. This was done so that if a difference of intelligibility were found between sentences produced with variable and those with flat intonation (resynthesized and fixed frequency), greater confidence in the results could be attributed to variable intonation. For example, the alaryngeal talker knowingly or unknowingly might exaggerate his articulation and modify phrasing when using variable intonation and not do so during the fixed-frequency condition. The prepared sentences were then played back to listeners to test the effect of variable intonation on intelligibility in this one alaryngeal talker.

and decreasing, respectively, the inward pressure on the frequency control button. The device also had an intensity control, but output level was held constant throughout the recording session. To examine speech understanding, we chose to study speech intelligibility. Intelligibility, as defined by Kent, Weismer, Kent, and Rosenbek (1989, p. 483), is the degree to which the speakers intended message is recovered by the listener. For this study, words identified in sentences were selected as the means for determining whether a listener understood the EL talkers message. Identifying words in sentences as opposed to the identification of single spoken words is considered a more functional evaluation of speech performance because talkers typically communicate using phrases (Yorkston, Beukelman, Strand, & Bell, 1999). Sentences are also preferred over words for the study of prosody, which has variations in frequency that are important for speech intelligibility and that are slower than the syllable rate (Binns & Culling, 2007). Six sets of 10 sentences (60 sentences) from the Institute of Electrical and Electronics Engineers (IEEE) corpus (Rothauser et al., 1969) were selected as stimuli. These sentences are widely used in the study of speech perception (e.g. Grant & Seitz, 1998; Hawley, Litousky, & Culling, 2004; Killian, Niquette, Gudrundsen, Revit, & Banerjee, 2004). The 10 sentences within each set are phonetically balanced. All sentences are declarative and have relatively low semantic predictability (Rothauser et al., 1969).

Data Collection

Method
Participants
The talker was a 49-year-old man who underwent a total laryngectomy at 33 years of age because of laryngeal cancer. An EL was his primary means of communication since that time. He began using his current EL (described below) 3 years prior to data collection. The talker reported that he consistently used the variable frequency option of his EL. Other than his laryngectomy, he reported that he was in good general health and had no other history of a communication disorder. He was a monolingual talker of American English. Twenty listeners between 18 and 30 years of age (M = 22, SD = 3.4) participated in the listening portion of the study. None reported any previous exposure to alaryngeal speech. All reported that they were in good general health, had normal hearing, and had no history of any speech or language disorder. All listeners were monolingual talkers of American English.

Data collection took place during the Annual Voice Institute of the International Association of Laryngectomees held in Chicago in June 2006. Audio recording was performed in a quiet hotel room and took approximately 30 min to complete. The talker was seated and wore a head-mounted microphone (AKG, C420) interfaced with a CD audio recorder (Marantz, DRR300). The acoustic data were digitally recorded at a 44.1-kHz sampling rate with 16-bit quantization. The talker was instructed to read the sentences aloud in a conversational manner. He first read four of the six sets of sentences (40 sentences) using variable intonation, which he controlled with the dynamic frequency button on the EL. His base frequency for the variable intonation condition was 50 Hz. A sentence from the first set of IEEE sentences produced with frequency variation was inadvertently not recorded. He then read the remaining two sets of sentences (20) without frequency variation. For this latter condition, he adjusted the base frequency so that it was 65 Hz.

Stimulus Preparation
The digital files were transferred from CD to a personal computer for analysis and stimulus preparation. A separate audio file was made of each sentence. The sentences were divided into three groups. The first two sets of sentences with variable intonation made up List A, and the remaining two sets with variable intonation made up List B. The two sets with no frequency variation made up List C. Because one sentence was missing in List A (see above), one sentence 163

Materials and Procedures

The talker used a TruTone EL (Griffin Laboratories). The baseline (lowest) pitch of the device could be adjusted from 50 Hz to 180 Hz. The device had an adjustable dynamic frequency range of 300 Hz from baseline that could be used to produce variable intonation. Frequency could be raised from baseline and lowered toward baseline by increasing

Watson & Schlauch: F0 Variation and Intelligibility With an Electrolarynx

was randomly selected and dropped from Lists B and C, so that each contained 19 rather than 20 sentences. Acoustic analysis and manipulation were performed using Praat software (Version 4.2.01; Boersma & Weenik, 2005). Prior to resynthesis procedures, selected acoustic variables were calculated for the three sentence lists; these are shown in Table 1. These values represent the acoustic characteristics of the sentences with variable intonation (Lists A and B) and the fixed-frequency intonation (List C). No data for F0 standard deviation and minimum and maximum frequency are shown for the sentences in List C because they were produced without frequency variation. To prepare the sound files for the listening tasks, resynthesis was performed using the Pitch Synchronous Overlap and Add technique implemented by the Praat software. All of the sentences were resynthesized first. This was done to ensure that if the resynthesis procedure degraded the signal in any way, the sentences would be equivalent for this factor. Resynthesis was also performed on the original (without resynthesis) audio recordings for the sentences in Lists A and B. The intonation contour of these sentences was flattened with a constant F0 of 65 Hz. Subsequently, sentences used for the listening task were synthesized only once. As a result of these procedures, five sets of sentences were used for the listening portion of the study: (a) List A with variable intonation, (b) List A with flat intonation, (c) List B with variable intonation, (d) List B with flat intonation, and (e) List C with flat intonation. Figure 1 shows example waveforms, spectrograms, and F0 contours of the prepared stimuli. The F0 contour is shown by the dark lines running through the spectrographic display in each example. The top display shows one sentence from List A, The navy attacked the big task force, with the frequency variation produced by the alaryngeal talker, and the middle display shows the same sentence from List A after the intonation contour was flattened at 65 Hz. The bottom display shows one sentence from List C, A plea for funds seems to come again, with a flat intonation contour at 65 Hz. As shown in this figure, the talker typically was able to turn the device off during voiceless segments and back on during voiced. For example in the top sentence, the /t / in attacked, the /t / in the beginning and the /sk / at the end of task, and the /f/ at the beginning and the /s/ at the end of force were produced without voicing. Following resynthesis, all the audio files were equalized for level by equating the root-mean-square average voltage of each file.

Listening Experiment
Two groups of 10 persons each listened to the same sentences processed differently. Table 2 shows the sentence lists and conditions that were presented to each group. Although both groups of listeners were presented with sentences produced with the EL set to a single frequency (List C), persons from each group heard different lists of sentences with varying intonation and resynthesized-flat intonation. Learning the words in the sentences was not possible because none of the sentences was repeated within a listening group. Alternating the sentence lists that were flattened or intoned improved the chances that observed differences in speech understanding resulted from the stimulus condition (variable intonation or resynthesized flattened) rather than the words composing the sentences or modifications such as articulation or rate change. The prepared audio files were mixed with noise and were played through headphones (Sennheiser, Model HD205) using a 16-bit digital-to-analog converter at a sampling rate of 44100 Hz interfaced with a personal computer. These stimuli were low-pass filtered with a cut-off frequency of 8000 Hz. The speech level was 70 dB SPL. Digitally generated speech-spectrum noise, shaped to match the long-term spectrum of a group of normal talkers, was presented at a +5-dB signal-to-noise ratio. Participants sat in a double-walled sound booth and listened through headphones. The audio files were randomly presented to each listener and could only be heard once. A listener pushed a button on a response box when ready to hear a file. Listeners were instructed to write down orthographically (transcribe) exactly what they heard. Transcription affords better intra- and interlistener reliability than other methods of measuring intelligibility, such as scaling (Yorkston & Beukelman, 1978).

Data Analysis
The number of words from each list of sentences correctly identified by a listener was counted and then converted to the percentage of the total number of words within a list. A word was counted as incorrect if it did not match the original word. If spelling errors were made but the words were phonetically the same, they were counted as correct. The number of correct words was first independently counted by two judges. The proportion of difference of scoring between the two judges was less than 1%. With the differences in scoring, the two judges met and came to a consensus on how the word should be scored.

TABLE 1. Means and standard deviations (in parentheses) for selected acoustic variables. List A B C Note. Syllables per second 2.84 (0.57) 2.57 (0.41) 3.04 (0.58) F0 average 85.47 (18.42) 86.02 (3.91) 65.00 (0.00) F0 SD 21.65 (6.43) 20.42 (4.90) F0 minimum 52.45 (1.23) 53.53 (3.11) F0 maximum 133.66 (25.72) 131.04 (21.70)

Dashes indicate no data because the sentences in List C were produced without frequency variation.

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FIGURE 1. Examples of waveforms, spectrograms, and F0 contours of sentences produced by the alaryngeal talker. The dark line running through the spectrogram display is the F0 contour. The top panel shows intonation controlled by the talker, and the middle panel shows the identical utterance seen in the top panel but with F0 flattened synthetically at 65 Hz. The bottom panel shows a sentence with no F0 variation produced by the talker with the base frequency of 65 Hz.

Before inferential statistical analysis was performed, the data were first scaled using a rationalized arcsine transformation (Studebaker, 1985). Arcsine transformation is used for normalizing the distribution of proportional (percentage) data. The rationalized component of the transformation procedure produces values that are close to the numerical range of the percentage data and are expressed as rationalized arcsine units (Studebaker, 1985). Inferential statistics were performed using a mixed-design analysis of variance (ANOVA) with the listening groups as the between-subjects factor and the intonation conditions as the repeated measures factor. If statistical significance was reached, post hoc testing was performed using a Bonferroni adjustment. The alpha level was set at p < .01.
TABLE 2. The prepared sentences played to the two groups of listeners. Variable intonation List A List B Resynthesized flat List B List A Fixed-frequency flat List C List C

Results
The number of words correctly identified (percentage correct) for Listening Groups 1 and 2 is shown in Figure 2. Box plots show the distribution of listener responses, and also the overlap of responses for the sentences with flatintonation contours. For both listening groups, sentences with variable intonation were at least 10% more intelligible than the sentences with flat intonation. There was essentially no difference in the first listening group between Lists B and C with flat intonation, with an average of 78.7% and 78.5%, respectively, of words correctly transcribed. For the second listening group, there was a larger range of speech understanding between sentences in Lists A and C with flat intonation, with an average of 81.18% and 74.14%, respectively, for words transcribed correctly. The lower score for sentences in List C was because of two low-listener outliers. However, the overlap between the first and third quartiles for the sentences with flat intonation is similar for both listening groups. The ANOVA showed no significant between-factors effect for listening groups, F(1, 18) = 0.01, p = .92, h2 = .005, but a significant within-factors effect was found for the 165

Group 1 2

Watson & Schlauch: F0 Variation and Intelligibility With an Electrolarynx

FIGURE 2. Box plots showing the percentage of correctly transcribed words for the two listening tasks. In each graph, results for the sentences with variable intonation are to the left, sentences with synthetically flat intonation contours are in the middle, and those produced by the talker with no variable intonation are shown to the right.

intonation conditions, F(2, 36) = 112.22, p < .01, h2 = .85. No significant listening group by intonation interaction was observed, F(2, 36) = 3.62, p = .04, h2 = .12. Post hoc testing, using a Bonferroni correction ( p < .003), found a significant difference between the sentences in Lists A and B with variable intonation and sentences in Lists A, B, and C with flat intonation. No statistically significant difference was found between the sentences with flat intonation for Lists A, B, and C ( p = .18).

Discussion
In this investigation, speech intelligibility was significantly better with variable intonation than it was with either the resynthesized flat intonation or the fixed-frequency intonation produced by the EL talker. The difference of intelligibility between speech produced with and without variable intonation in the present study was within the range reported for unimpaired talkers speech with natural intonation as compared to experimentally flattened F0 contours when heard in noise (Laures & Bunton, 2003; Laures & Weismer, 1999; Watson & Schlauch, 2008). It is uncertain whether variable intonation produced by the alaryngeal talker in this study directed listeners to important words or helped them demarcate word boundaries, as suggested by Laures and Weismer (1999). Examination of the variable intonation patterns did not appear to line up with any specific word type, although content words were present in almost all the short phrases produced by the alaryngeal talker. Whatever the mechanism, the ability to vary intonation contributed to speech understanding for at least this alaryngeal talker. Meltzner and Hillman (2005) state that controlling frequency variation with an EL may be hard to implement

because it would be difficult to match the diverse naturalpitch patterns that represent specific linguistic properties in running speech. However, the use of many different F0 patterns may not be required to aid speech intelligibility in users of an EL. Although some variability was observed in the frequency patterns produced by the EL talker, the primary pattern was a rising and falling of F0 in the short segments of speech produced within a sentence. The risingfalling pattern tends to be one of the most common forms of short-term F0 movement found in speech (Gussenhoven, 2004). It may be that listeners have certain expectations of F0 movement (e.g., the rising and falling pattern), and when there is a departure from these patterns listeners have difficulty tracking speech in noise. It is important to note that not just any pattern of frequency variation yields an improvement of speech intelligibility. When the intonation contour of spoken sentences is inverted (having the same amount of variation) or sinusoidally modulated, speech intelligibility suffers (Hillenbrand, 2003; Schlauch, Miller, & Watson, 2005). For both inversion and sinusoidal modulation, intelligibility is worse than for F0 flattened at the mean frequency of a talkers productions. Several factors regarding the results of this study should be mentioned. First, the alaryngeal talker in this study was often successful in turning the EL on and off in many cases to produce phonemic voicing contrasts. Voicing confusion is believed to be one of the most prevalent factors in producing intelligibility errors in EL users (Weiss & Basili, 1985). It is not known whether variable intonation would produce similar results when voicing contrasts were less precise. Additionally, the device used by the alaryngeal talker in this study allows for continuous fluid adjustment of frequency with inward and outward pressure of just one button. It would also be instructive to know if the two-frequency

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devices, with the user having to move between two buttons, would yield similar results. The findings from this preliminary investigation suggest that the incorporation of variable intonation training would be important to those who use an EL. However, further research, incorporating group data with alaryngeal talkers of various degrees of competency, is required to determine which frequency patterns yield the best intelligibility, and the most efficient way to train the use of these intonation patterns in those who use an EL.

References
Bess, F., & Humes, L. (1995). Audiology: The fundamentals. Baltimore: Williams & Wilkins. Binns, C., & Culling, J. (2007). The role of fundamental frequency contours in the perception of speech against interfering speech. Journal of the Acoustical Society of America, 122, 17651776. Boersma, P., & Weenik, W. (2005). Praat: A system for doing phonetics by computer (Version 4.4.30) [Computer software]. Amsterdam: Institute of Phonetic Sciences. Boone, D., McFarlane, S., & Berg, S. (2005). The voice and voice therapy. Englewood Cliffs, NJ: Prentice Hall. Eadie, T. (2003). The ICF: A proposed framework for comprehensive rehabilitation of individuals who use alaryngeal speech. American Journal of Speech-Language Pathology, 12, 189197. Espy-Wilson, C., MacAuslan, J., Huang, C., & Walsh, M. (1998). Enhancement of electrolaryngeal speech by adaptive filtering. Journal of Speech, Language, and Hearing Research, 41, 12531264. Grant, K., & Seitz, P. (1998). Measures of auditory-visual integration in nonsense syllables and sentences. Journal of the Acoustical Society of America, 104, 238250. Gussenhoven, C. (2004). The phonology of tone and intonation. New York: Cambridge University Press. Hawley, M., Litousky, R., & Culling, J. (2004). The benefit of binaural hearing in a cocktail party: Effect of location and type of interference. Journal of the Acoustical Society of America, 115, 833843. Hillenbrand, J. (2003). Some effects of intonation contour on sentence intelligibility. The Journal of the Acoustical Society of America, 114, 2338. Hillman, R., Walsh, M., Wolf, G., Fisher, S., & Hong, W. (1998). Functional outcomes following treatment for advanced laryngeal cancer. Part I: Voice preservation in advanced laryngeal cancer. Part 2: Laryngectomy rehabilitation: The state of the art in the VA System. Annals of Otology, Rhinology and Laryngology, 172, 127. Holley, S., Lerman, J., & Randolph, K. (1983). A comparison of the intelligibility of esophageal, electrolaryngeal, and normal speech in quiet and in noise. Journal of Communication Disorders, 16, 143155. Kalb, M., & Carpenter, M. (1981). Individual speech influence on relative intelligibility of esophageal speech and artificial larynx users. Journal of Speech and Hearing Disorders, 46, 7780. Kent, R., Weismer, G., Kent, J., & Rosenbek, J. (1989). Toward phonetic intelligibility testing in dysarthria. Journal of Speech and Hearing Disorders, 54, 482499.

Killian, M., Niquette, P., Gudrundsen, G., Revit, L., & Banerjee, S. (2004). Development of quick speech-in-noise test for measuring signal-to-noise ratio loss in normal hearing and hearing impaired listeners. Journal of the Acoustical Society of America, 116, 23952405. Laures, J., & Bunton, K. (2003). Perceptual effects of a flattened fundamental frequency at the sentence level under different listening conditions. Journal of Communication Disorders, 36, 449464. Laures, J., & Weismer, G. (1999). The effect of flattened F0 on intelligibility at the sentence-level. Journal of Speech, Language, and Hearing Research, 42, 11481156. Meltzner, G., & Hillman, R. (2005). Impact of aberrant acoustic properties on the perception of sound quality in electrolarynx speech. Journal of Speech, Language, and Hearing Research, 48, 766779. Mendenhall, W., Morris, C., Stringer, S., Amdur, R., Hineman, R., Villaret, D., et al. (2002). Voice rehabilitation after total laryngectomy and postoperative radiation therapy. Journal of Clinical Oncology, 20, 25002505. Qi, Y., & Weinberg, B. (1991). Low-frequency energy deficit in electrolaryngeal speech. Journal of Speech and Hearing Research, 34, 12501256. Rothauser, E., Chapman, W., Guttman, N., Nordby, K., Silbiger, H., Urbanek, G., et al. (1969). IEEE recommended practice for speech quality measurements. IEEE Transactions on Audio Electroacoustics, 17, 225246. Schlauch, R., Miller, S., & Watson, P. (2005). Examining explanations for fundamental frequencys contribution to speech intelligibility in noise. Journal of the Acoustical Society of America, 118, 1933. Stemple, J., Glaze, L., & Klaben, B. (2000). Clinical voice pathology: Theory and management. San Diego, CA: Singular. Studebaker, G. A. (1985). A rationalized arcsine transform. Journal of Speech and Hearing Research, 28, 455462. Watson, P. J., & Schlauch, R. S. (2008). The effect of fundamental frequency on the intelligibility of speech with flattened intonation contours. American Journal of Speech-Language Pathology, 17, 348355. Weiss, M., & Basili, A. (1985). Electrolaryngeal speech produced by laryngectomized subjects: Perceptual characteristics. Journal of Speech and Hearing Research, 28, 294298. Williams, S., & Watson, J. (1985). Differences in speaking proficiencies in three laryngectomee groups. Archives of Otolaryngology, 111, 216219. Yorkston, K. M., & Beukelman, D. R. (1978). A comparison of techniques for measuring intelligibility of dysarthric speech. Journal of Communication Disorders, 11, 499512. Yorkston, K., Beukelman, D., Strand, E., & Bell, K. (1999). Management of motor speech disorders in children and adults. Austin, TX: Pro-Ed. Received March 25, 2008 Accepted August 24, 2008 DOI: 10.1044/1058-0360(2008/08-0025) Contact author: Peter J. Watson, Department of Speech-LanguageHearing Sciences, 164 Pillsbury Drive, Shevlin 115, University of Minnesota, Minneapolis, MN 55455. E-mail: pjwatson@umn.edu.

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Research

Effects of Robust Vocabulary Instruction and Multicultural Text on the Development of Word Knowledge Among African American Children
Sherri Lovelace
Arkansas State University, Jonesboro

Sharon R. Stewart
University of Kentucky, Lexington

Purpose: To examine the effect of a systematic vocabulary instructional technique in African American 2nd-grade children with below average vocabulary skills. An additional goal was to examine the role of book type in the retention of novel vocabulary words. Method: Using an adapted alternating treatments design, storybooks were used as a source for contextualizing vocabulary words in the context of robust vocabulary training. Five childrens productive definitions were used to assess developing word knowledge using a 4-stage continuum ranging from no knowledge to full concept knowledge. Results: Superior word learning for instruction words in comparison with control words replicated across children provided evidence of behavior change that was attributable to robust

vocabulary instruction. Gains in word learning were maintained 2 weeks following conclusion of the study. Use of storybooks that displayed sociocultural images and experiences that were similar to versus different from their own did not have a reliable effect on word learning among these African American children. Conclusions: The findings demonstrate the potential impact of robust vocabulary instruction for facilitating vocabulary development in children with below average vocabulary skills. Analysis of the results indicates that the use of the African American book was not a potent influence in facilitating retention of words. Key Words: cultural and linguistic diversity, vocabulary, storybooks, African American, word knowledge

nowledge of words is highly related to general world knowledge, which is a by-product of sociocultural experiences (Anderson & Freebody, 1983; Hart & Risley, 1995; Nagy & Herman, 1987). Because early word learning is highly related to frequency of input, children growing up with varying input will develop vocabularies that differ (deVilliers, 2004). Consequently, children from socially, culturally, and linguistically diverse backgrounds often struggle in mainstream school settings because their culture gives them exposure not only to different vocabulary but to a different emphasis on which words are central to their life experiences, behaviors, and ways of understanding. Children from low socioeconomic status (SES) backgrounds are often limited in experiences needed to build background knowledge for vocabulary growth because individual choices and experiences provided to these children overall are more limited than for groups with greater 168

economic resources (Heath, 1982, 1989; Kagan & Garcia, 1991). Because experiences are limited, the potential for gaining word knowledge from a variety of opportunities is predictably reduced for these children. These early differences in childrens vocabulary knowledge have shown that even a small disadvantage grows into a larger one and becomes difficult to ameliorate without intervention (Biemiller, 2001b; National Institute of Child Health and Human Development Early Child Care Research Network, 2005). As individuals learn language they learn the meanings of not only their social system but also the ethnic system of their culture. Childrens early word learning is reflective of the values, expectations, and rules transmitted within their microculture, and the preferred language patterns of members within the group will influence the communication patterns that children develop (Battle, 1996). Consequently, this may place many children from ethnically diverse homes

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at risk for academic achievement because their word meanings may be incongruent with those of the school environment. Thus, the resulting conflict between their word usage and expectations of the classroom may hinder their ability to be successful in school-related literacy activities (Washington & Craig, 1999; Wolfram, Adger, & Christian, 1999; Wright, 1983). Although differences develop before entry into school, the gap between students becomes perceptible on standardized tests in later primary grades because they are heavily weighted toward vocabulary knowledge (Campbell, Hombo, & Mazzeo, 2000). To overcome the disadvantage that children with limited vocabularies have, it has been suggested that vocabulary instruction that systematically builds word and world knowledge should accompany instruction in decoding during kindergarten through second grade (Biemiller, 2001a; Champion, Hyter, McCabe, & Bland-Stewart, 2003; Scarborough, 2001).

Robust Vocabulary Instruction

In response to the need for practical strategies to enhance word learning, Beck, Perfetti, and McKeown (1982) identified a systematic vocabulary instruction program called robust vocabulary instruction that has been found to be effective not only for learning the meanings of words but also for improving reading comprehension (McKeown, Beck, Omanson, & Perfetti, 1983; McKeown, Beck, Omanson, & Pople, 1985). With robust vocabulary instruction, students learn how a novel word is similar to and different from related concepts and how the word is used in a variety of situations. The approach provides repeated interactions with opportunities to process new words by making inferences based on meaningful uses and prior experiences. The objective is for students to learn word meanings at a deep level of understanding using a variety of procedures that include word associations, word networks, and sentence completions, among a number of other game-like tasks that stress the relations between target words and previously acquired vocabulary. The extant literature offers evidence of the effectiveness of robust vocabulary instruction, particularly for children from diverse sociocultural backgrounds. In several investigations, Beck, McKeown, and their colleagues (Beck et al., 1982; McKeown et al., 1983, 1985) conducted a program of research that examined the effectiveness of robust vocabulary instruction with predominantly African American (i.e., >70%) fourth-grade students drawn from lower SES populations. Beck et al. (1982) evaluated the effectiveness of robust vocabulary instruction compared with regular reading and language arts activities. The authors measured three outcomes: accuracy of word knowledge, fluency of lexical access, and text comprehension. They found that children who received the vocabulary instruction scored significantly better on the test of word knowledge and performed significantly faster and more accurately on response-timed tasks, but they made only marginal gains in text comprehension. In a replication study that also addressed comprehension, McKeown et al. (1983) found that students receiving the instructional program performed better than their peers in the control group in three ways: (a) they learned the meaning of more instructional words,

(b) they demonstrated greater speed of lexical access as measured by reaction time on a word categorization task, and (c) they had superior comprehension of stories that contained taught words. In a later study, McKeown et al. (1985) examined the effects of the nature of robust vocabulary instruction and the frequency of instructional encounters on word learning. Fourth-grade students in the experimental group received one of three kinds of instruction: learning definitions for words, rich (i.e., robust) instruction, and extended rich instruction. The extended rich instruction encouraged children to be aware of and use the taught words outside of class. Frequency of input was manipulated by providing either 4 or 12 encounters with each word. Results indicated that the three instructional groups performances were superior to the control group on definitional knowledge, but they did not differ from one another. High-frequency encounters resulted in better performance on all measures. In a more recent investigation, Beck and McKeown (2007) found that low-SES kindergarten and first-grade children in the robust instruction group learned more vocabulary as compared with the group that received no instruction. Additionally, they investigated the extent to which more encounters with target words enhanced learning. They found that when kindergarten and first-grade children received robust instruction with 20 encounters in comparison with 5 encounters, they learned significantly more target words. These findings indicated that increasing the amount of instructional time and exposures to targeted words resulted in substantial gains in word learning. In a large-scale, randomized controlled trial study of a robust vocabulary instruction extension program, Apthorp (2006) found significant and positive effects on childrens oral vocabulary and reading achievement for economically disadvantaged third-grade students in which over 78% were at risk for not meeting grade-level expectations in reading. Interestingly, the positive effects of the program were not replicated in the comparison group in which over 70% of the children performed at grade level or above, and only a minority was considered economically disadvantaged. Although not specific to robust vocabulary instruction, the findings here are similar to those of Elley (1989), who found that children with lower vocabulary skills learned more new words as compared with children with higher vocabulary skills. Both authors concluded that ceiling effects may have reduced sensitivity to actual growth among children with higher vocabulary skills. In all five of the aforementioned studies, robust vocabulary intervention was effective in improving word learning in students drawn from school populations with low-SES backgrounds and in which at least 70% of participants were African American. Third- and fourth-grade children in these studies were considered at risk for later literacy difficulty initially on the basis of sociocultural factors and on reading and vocabulary subtests scores of standardized tests of achievement. No standardized tests of vocabulary were administered. Kindergarten and first-grade children in Beck and McKeowns (2007) study were given the Peabody Picture Vocabulary TestIII (Dunn & Dunn, 1997) only to determine whether preintervention verbal knowledge differed
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between experimental and comparison groups. Unfortunately, no analyses were conducted to determine whether prior vocabulary knowledge differentially affected word learning. In one of the few studies examining a priori vocabulary knowledge and the effect of robust vocabulary instruction, Coyne, McCoach, and Kapp (2007) found that extended (i.e., robust) vocabulary instruction resulted in greater word learning than either incidental exposure or embedded instruction on all measures used. In the embedded instruction condition, interventionists provided students with simple definitions of target words when encountered in storybook reading; no postreading activities that encouraged a deep processing of words were completed. Results found that receptive vocabulary knowledge moderated kindergarteners response to instruction, with extended rich instruction favoring students with higher overall receptive vocabulary scores. Although prior level of receptive vocabulary knowledge moderated response to instruction, students with lower Peabody Picture Vocabulary TestIII scores still experienced substantial word learning through extended instruction compared with other conditions. These findings are consistent with several investigations that suggest that a priori vocabulary knowledge influences word acquisition (Justice, Meier, & Walpole, 2005; Penno, Wilkinson, & Moore, 2002; Robbins & Ehri, 1994; Snchal, Thomas, & Monker, 1995). However, Coyne et al. found that the nature and frequency of instructional encounters also contribute significantly to word learning by children regardless of high or low vocabulary skills. Specifically, elaboration of target words with more exposures results in gains in word learning regardless of prior vocabulary knowledge.

Role of Storybooks in Vocabulary Development

Beck, McKeown, and Kucan (2002) have suggested that because direct instruction in word meanings for all words is not feasible, instruction should focus on only those words that are of high frequency and are found across a variety of domains (e.g., frigid and miserable). They suggest that instruction in these so-called Tier 2 words is most productive because knowledge of these words can have a powerful impact on language and academic functioning. The authors also have recommended that for children in the early elementary grades, storybook literature is a good source of vocabulary words. Childrens storybook literature often is used as a starting point for language intervention to create dynamic and interactive learning experiences. For speech-language pathologists, the integration of book reading into clinical service delivery is a way to facilitate novel word learning because it provides exposure to new words regardless of language or reading ability and literacy materials in the home (Brabham & Lynch-Brown, 2002). Several studies show that younger and older children from middle-class backgrounds who likely experience book reading interactions at home, as well as those whose language skills and home experiences are relatively impoverished, benefit from storybooks read aloud (Bus, Van Ijzendoorn, & Pellegrini, 1995; P. S. Dale, CrainThoreson, Notari-Syverson, & Cole, 1996; Hargrave & Snchal, 2000; Snchal, 1997; Snchal & Cornell, 1993; Sulzby, 1985; Whitehurst et al., 1988).

Whereas the role of storybooks in the development of language and literacy has been widely investigated, the influence of multicultural literature and its role in the development of language has received little attention. It has been suggested that utilizing texts that do not activate students prior knowledge can exclude them from understanding the information being presented (Reynolds, Taylor, Steffense, Shirley, & Anderson, 1982). Bell and Clark (1998) provided support for this point, finding that African American childrens comprehension and recall of story events were significantly different for stories depicting Black characters and themes than those consisting of Black characters and EuroAmerican themes or White characters and Euro-American themes. Similarly, Grice and Vaughn (1992) found that the contextual knowledge, prior experiences, and cultural background of African American and Caucasian American third-grade students either facilitated or interfered with their ability to receive the messages from culturally conscious literature (i.e., picture books, novels, biographies, and poetry). In their study, African American students had higher levels of acceptance and identity with the culturally conscious texts than the melting pot texts (i.e., characters were middleclass, and no explicit references were made to their racial identity). These studies suggest that childrens sociocultural experiences provide them with a foundation for interpreting texts, which enables them to make connections to real-life experiences and activate their background knowledge facilitating greater comprehension. Given these findings, it would appear that acknowledging childrens cultural experiences through the use of literature can be a means of bridging the gap between diverse learners word knowledge and their typically developing peers. Thus, the objective of this investigation was twofold. The first was to examine the effects of robust vocabulary instruction for children with below average vocabulary skills as determined by standardized assessments of vocabulary rather than by tests of academic achievement. The second purpose was to examine the influence of book type in the retention of novel vocabulary words among African American children. It was hypothesized that given an empirically sound method of vocabulary instruction, African American children with below average vocabulary skills would not only learn novel vocabulary words but would retain more vocabulary from books that depict images and experiences similar to their cultural background.

Method
Research Design
An adapted alternating treatments design was used to investigate the acquisition and retention of novel vocabulary words. In an alternating treatments design, a single baseline of behavior is followed by an experimental condition in which two or more interventions are rapidly alternated (Barlow & Hayes, 1979). In applied research, rapid means that each time clients are seen, they receive an alternate treatment. The adapted alternating treatments design differs from the standard alternating treatments design in that each intervention is associated with a unique set of

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instructional items (Sindelar, Rosenberg, & Wilson, 1985). For this investigation, instructional sets of words from two storybooks (i.e., African American book and Caucasian book) served as unique instructional items. An initial baseline (i.e., the pretest) was completed in which equivalence of performance on the two sets of words was demonstrated, followed by the experimental condition (i.e., vocabulary instruction using alternate books). The independent variable was robust vocabulary instruction, and the dependent variable was word knowledge as measured by E. Dales (1965) classification. His description of word knowledge is based on four stages ranging from no knowledge (i.e., 0 points) to full concept knowledge (i.e., 3 points). Examples of each stage and scoring criteria are shown in Table 1.

Participants
African American children were recruited to participate in the study through child-find (i.e., speech-language screenings, announcements, teacher/parent referrals). Criteria for participation required children to (a) be second-grade students, ages 7.08.0 years; (b) have the ability to appropriately attend by looking at the investigator and materials for approximately 30 min, as judged by participation during eligibility assessments; (c) have hearing abilities within normal limits as measured by a bilateral hearing screening; (d) have visual perceptual abilities within normal limits as measured by the Motor-Free Visual Perceptual Test, Third Edition (Colarusso & Hammill, 2003); (e) have cognitive skills within normal limits as measured by the Test of Nonverbal Intelligence, Third Edition (Brown, Sherbenou, & Johnsen, 1997); (f ) have vocabulary skills that were at least 1 SD below the mean on two standardized tests of vocabulary or at least 2 SDs below the mean on one standardized test of vocabulary; and (g) have no knowledge or only a general sense (i.e., Stage 1 or 2) of target words as measured by performance on the dependent measure.

Measures
Because this investigation uses visual images represented in the two storybooks, the Motor-Free Visual Perceptual
TABLE 1. Criteria for pretest and probes of word knowledge. Level of word knowledge Stage 1 No knowledge. Never heard the word. Stage 2 General sense of word. Heard the word but does not know the meaning. Stage 3 Partial concept knowledge. Recognizes the word in a specific context. Stage 4 Full concept knowledge. Knows the word well. Score 0

Test, Third Edition was administered to assess participants visual perceptual ability. The test assesses the following perceptual tasks: spatial relationships, visual discrimination, visual closure, and visual memory. It employs simple black and white line drawings for stimulus and answer choices. Each item was presented in a multiple-choice format with primarily matching tasks. Participants verbalized the letter of the answer or pointed to a picture to indicate answer choices. The Test of Nonverbal Intelligence, Third Edition was given to assess the participants general intellectual functioning. This assessment is a language-free, motor-reduced, and culture-reduced measure of cognitive performance. The test contains 45 items that require abstract/figural problem solving. The Expressive One-Word Picture Vocabulary Test Third Edition (Brownell, 2000a) was administered to assess participants expressive vocabulary. It consists of a set of 170 color test plates depicting objects, actions, or concepts ordered in difficulty. Responses were elicited by asking, What is this? The Receptive One-Word Picture Vocabulary TestThird Edition (Brownell, 2000b) was given to assess participants receptive vocabulary. It consists of a series of test plates that show four illustrations. Participants were asked to point to the correct picture in response to the examiners instruction, such as Show me dog. The Word Test 2: Elementary (Bowers, Huisingh, LoGiudice, & Orman, 2004) was administered to assess participants expressive vocabulary and semantics knowledge. The test consists of six subtests given orally and assesses the following skills: associations, synonyms, semantic absurdities, antonyms, definitions, and flexible word usage. Eligibility assessments were completed 2 weeks prior to implementation of the study. Hearing screenings, vocabulary assessments, and target word knowledge were completed by graduate students in speech-language pathology and supervised by the first author. The first author also completed all remaining assessments. Seventeen children completed eligibility assessments. Nine children did not meet criteria of having below average vocabulary skills, whereas 2 children did not have motor-visual perceptual abilities that were within normal limits. The remaining 6 children qualified for participation in the study. Parental consent was obtained for a final sample of 5 children.

Criteria Word is unknown or an incorrect definition is given (e.g., Ripped means good ). Child is familiar with the word but cannot define it. Word is only given in a sentence (e.g., I ripped my dress). An example based on a specific context is given (e.g., a piece of paper that is torn) or a synonym is given (e.g., something cut ). A complete definition (e.g., Ripped means torn apart or not together anymore like a piece of paper ).

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Participants included 3 boys (2 were twins) and 2 girls ranging in age from 7.2 years to 8.0 years. All children were African American and were from four different elementary schools in the city. No participant was enrolled in or referred for special education services, and none had repeated a grade. All participants were of low SES as judged by parental report of the childs eligibility for free or reduced lunch in public school. Standardized assessment results are shown in Table 2.

Materials
Storybooks. Two books were chosen on the basis of the following criteria: (a) nonstereotyped portrayals, (b) positive images, (c) lack of derogatory language, (d) accurate historical information and cultural details, and (e) realistic illustrations of Caucasian and African American ethnic groups. Book AMiss Viola and Uncle Ed Lee (Duncan, 1999)featured an African American cultural theme and images of a young boy helping his two neighbors, one as neat as a pin and the other as junky as a pack rat, become friends. Book BSophies Knapsack (Stock, 1988)featured a Caucasian cultural theme and images of a young girl accompanying her parents on an overnight hike and camping trip. To verify similarity of vocabulary and informational ideas presented in each book, analysis of narrative and genre structure was completed in accordance with procedures delineated by Donovan and Smolkin (2001). The books had similar lexical density (i.e., the degree of information contained in a passage) and number of informational ideas (i.e., the amount of implicit and explicit information presented in a clause). Book A contained a lexical density of 3.10 and 1.23 informational ideas. Book B contained a lexical density of 3.60 and 1.31 informational ideas. Because visual images were salient factors in this investigation, a visual content analysis focusing on the artwork, scenery, number of character illustrations, and the number of pages with illustrations was also used to determine equivalence of book type. Books contained a similar number of illustrations (i.e., Book A contained 27 illustrations, and Book B contained 22 illustrations) and characters (i.e., three characters). Book order was randomized with a restriction of no more than two consecutive presentations of the same book, yielding an ABBABAAB schedule.
TABLE 2. Participants standard assessment scores. Participant P1 P2 P3 P4 P5 TONI3 90 95 115 103 107 MVPT3 100 93 99 90 110

Target word selection. Verbs were selected because of their instructional potential (i.e., words could be embedded in a variety of ways to build rich representations of them). Six teachers of children in the second grade reviewed the preliminary set for childrens likely knowledge of the words. Teachers indicated whether children (a) would have a general sense of the word (i.e., could provide an appropriate sentence using the word), (b) would know the word (i.e., could provide a correct definition without using the word), or (c) would not likely know the word. If teachers indicated that children would likely know the word, they were asked to provide possible definitions that typically developing children may produce. The definitions provided by teachers and the first author were used to construct a pilot test. The Macmillan Dictionary for Children (Chumbley, 1989) was used to confirm that definitions maintained the standardized meanings of targeted words. Pilot testing for consistency of definitions and for confirmation that a deep knowledge of the words was unknown to young children representing the geographical makeup of the region was completed with typically developing children ages 6.08.0 years (i.e., 74% Caucasian, 23% African American, and 3% Hispanic/Latino). A final set of 18 words (i.e., 9 from each book) was selected on the basis of pilot test results and Beck et al.s (2002) criteria for Tier 2 words. Six words for which regional children had a general sense (i.e., Stage 2) were assigned to the instructional word set. Words for which children had no knowledge (i.e., Stage 1) were assigned to the control word set. Words for which children were readily familiar (i.e., Stages 3 or 4) were assigned to the commonly known word set. Commonly known words were included to give participants a measure of success. Selected target words appeared only once in each story and did not appear in both books. Target words appear in Table 3.

Procedures
General procedures/data collection. Children participated in a small group session for approximately 30 min twice weekly in a large therapy room in a university speech and hearing center. Sessions occurred over a 4-week period, for a total of eight sessions. A single book reading occurred each session followed by a vocabulary lesson on the instructional word set for that book. Weekly probes were administered

EOWPVT3 80 84 70 79 78

ROWPVT3 93 86 96 89 94

WORD2 81 73 78 82 78

Note. Standard scores are based on a mean of 100. TONI3 = Test of Nonverbal Intelligence, Third Edition; MVPT3 = Motor-Free Visual Perceptual Test, Third Edition; EOWPVT3 = Expressive One-Word Picture Vocabulary TestThird Edition; ROWPVT3 = Receptive One-Word Picture Vocabulary TestThird Edition; WORD2 = The Word Test 2: Elementary.

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TABLE 3. Storybook titles and words. Instructional Commonly Noninstructional words known words control words African American book focus visit notice listen combine sweep Caucasian book collect carry flutter buzz snuggle call prune twinkle trifle crackle sizzle skid

Title (author, year) Miss Viola and Uncle Ed Lee (Duncan, 1999) Sophies Knapsack (Stock, 1988)

Note. Selected words appeared only once in each book and did not appear in both books.

to each participant on a day in which an intervention session had not occurred. Weekly probes included 18 words (i.e., 6 instructional words, 6 commonly known words, and 6 control words). A follow-up test was administered 2 weeks following the conclusion of the investigation. All sessions were videotaped using a Sony 8-mm Handycam video camera recorder. Pretest and probe procedures. Participants were individually administered all probe sessions. The first author initiated the word knowledge assessment with a demonstration of the task and two trial items in the following manner: Sometimes in school you may be asked to give the definition of a word or to tell what a word means. The best way to give a definition is to tell what it is and something about it. For example, if I am asked to define skip, I can say hop, but that isnt a complete definition. A better way to tell about skip is, it is hopping lightly on one foot and then another. That tells what skip is and something about it. Two trial items were then completed, followed by the assessment. Each item in the assessment began with a simple carrier phrase, Tell me all you can about what the word _____ means. The investigator waited 5 s for an initiation of a response before proceeding to the next word. If an incomplete response was given or the word was only provided in a sentence, the participant was prompted to provide more information by the investigator stating, tell me more or what does the word mean that was given in the sentence? Noncontingent verbal praise was delivered on the average of every third response for participation and attention to task. All probes were conducted in the same manner with the exception of order of presentation of words, which was randomized on each probe. Instructional/experimental procedures. Each session began with a storybook reading activity followed by a vocabulary lesson targeting instructional words from the story. Oral and hands-on, experiential activitieswhich encouraged childrens interactions with words were completed in a sequenced set of activities based on features of Beck and McKeowns (2001) Text Talk and Beck et al.s (2002) robust vocabulary program operationalized in the following paragraphs. Book reading procedures. The investigator read one book each session using a modified version of Mauttes (1990)

protocol for adult interactive behaviors during storybook reading. Each book reading session began with preparing children for listening with questions and discussions. The story was introduced with background information about the title and author. During the initial reading of each book, children were encouraged to predict what the story would be about as the investigator flipped slowly through the pages of the book. On subsequent readings, children were asked to recall what the story was about. Following predictions and/or recall, the investigator provided a brief description of the story. To build additional background knowledge and a purpose for listening, children were asked prequestions related to events in the story. During each reading, the investigator pointed to and made comments about illustrations in the book. Each book reading was completed as indicated above; however, fluctuations in book reading times occurred because of participants comments and engagement. The African American book was read an average of 10.25 min (SD = 1.70, range = 812 min). The Caucasian book was read an average of 7.75 min (SD = 1.70, range = 610 min). Vocabulary instruction procedures. Following each book reading activity, a vocabulary lesson targeting the instructional word set (i.e., three words per lesson) was implemented. Each word was contextualized for its role in the story, one at a time, by turning to the page in the book and reading the sentence in which the target word appeared. A child-friendly definition was provided, followed by the creation of a phonological representation in which participants repeated the word. After each target word was presented in this manner, an example was provided in a context different from the story. Three to four activities in which children interacted with and said the target words were completed. These activities consisted of using inferential and evaluative questions, comments about the words, choices between words, relating words to known concepts, and participant provision of examples of targeted words. Each lesson concluded with a reinforcement of the phonological representation by repeating the name of each word. Average instructional time for words was 16.75 min (SD = 2.75, range = 1420 min) for the African American book and 18 min (SD = 2.44, range = 1520 min) for the Caucasian book. Each word received three to four exposures in an instructional session. See the Appendix for an example of an instructional session.

Reliability
Three trained research assistants collected and calculated all reliability data. To ensure consistency of implementation, adherence to the set of sequenced activities delineated in the instructional procedures was assessed for every session. Reliability data were calculated by dividing the total number of agreements between investigator behaviors and scripted items by the number of agreements plus disagreements and multiplying the total by 100. Reliability for words from the African American book was 96% (range = 92% 100%) and 98% for words from the Caucasian book (range = 92% 100%). Data collected to ensure an equivalent number of references to images in storybooks yielded a mean of 10.6 for the African American book and a mean of 10.1 for the Caucasian book.
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Reliability data for probe procedures were obtained for 83% of all probes. Procedures measured included presenting instructions, recording verbatim participant responses, and providing variable reinforcement for attending behaviors. Reliability for probes was calculated at 97% (range = 93% 100%). To evaluate the consistency with which the investigator scored a participants response (e.g., Stage 1, 2, 3, or 4), research assistants rescored all participants responses from videotaped sessions for each of the six probes. The item scores were compared with the original item scores to determine agreement. Interrater agreement for the dependent measure was 100% during the baseline condition and 91% during the experimental condition (range = 90%92%).

African American book (Book A) tended to show a decline (except for Participant 4), whereas word knowledge scores for the Caucasian book (Book B) remained the same or increased over the last probe in the experimental condition.

Discussion
Impact of Robust Vocabulary Instruction
The present findings show support for using an instructional strategy that provides frequent and numerous opportunities for children to think about and use novel words across varied contexts. This type of vocabulary instruction has been suggested as a means for improving word knowledge of children with limited vocabularies (Baker, Simmons, & Kameenui, 1995; Graves, 1986). However, to date, the literature has only documented the effects of robust vocabulary instruction with children considered at risk on the basis of attendance at lower SES schools or on the results of reading and vocabulary subtests on standardized achievement tests (e.g., Iowa Tests of Basic Skills; Hoover, Dunbar, & Frisbie, 2006). Thus, the findings of this investigation extend the current literature by showing that robust vocabulary instruction is effective in developing and maintaining knowledge of novel words in children with below average vocabulary skills as measured by standardized vocabulary assessments. It has been suggested that explicit vocabulary instruction with diverse exposures to novel words may be needed for adequate learning to occur (Carr, 1985; Graves, 1986) and that word learning may be facilitated by more concentrated exposures to words. The results show that a significant change in concept understanding occurred at Probe 3, which suggests that 912 instructional exposures to novel words were effective in developing word knowledge beyond a general sense of words. This outcome converges with that of previous reports in the literature. Specifically, McKeown et al. (1985) found that 12 instructional encounters with words produced greater gains in accuracy of word-definition knowledge. It is generally accepted that vocabulary learning is facilitated by an existing knowledge base such that a larger knowledge base allows one to acquire more vocabulary at a faster rate. All of the children in this investigation had standardized vocabulary assessment scores that are considered below average but to differing degrees. Thus, it may be possible that the variability seen among participants is indicative of the degree of vocabulary knowledge prior to the intervention. Previous studies have shown that children with low vocabulary knowledge made gains in word learning at least as much as children with higher vocabulary. Although no clear distinction is evident among children, the 2 children with the lowest pretest scores (Participants 2 and 3) were among the best vocabulary learners, which contradicts the Matthew effect hypothesis. Childrens productive definitions were used in the present study as a means of evaluating word learning. It has been suggested that definitions, and use of a classification system for categorizing them, can show the incremental manner in which vocabulary develops (Beck et al., 2002; Curtis, 1987). To illustrate, at Probe 3, if full or partial concept knowledge

Results
Participant data are shown in Figure 1. The probe sessions conducted are on the x-axis, and the word knowledge score for each probe is on the y-axis. Each data point represents the word knowledge score results. Using the scoring criteria, participants could earn a word knowledge score of 09 points for each three-item word set (i.e., 0 = no knowledge, 1 = general sense, 2 = partial knowledge, 3 = full knowledge).

Impact of Robust Vocabulary Instruction

As anticipated, on the basis of the results of the pilot study, all 5 children had knowledge of the commonly known words from both books. The data show that participants had a contextual knowledge of the words that was consistent across six probes. At pretest, the groups word knowledge for the instructional word set was low (03) but slightly greater than for the control word set (01). A clear separation in word knowledge began to emerge for instructional word sets at Probe 2 and continued to show an overall accelerating trend across the experimental condition. A change in level existed for all participants by Probe 4. This level reflects Stage 3 and Stage 4 knowledge that was comparable or superior to the commonly known words. A reliable demonstration of experimental control is evident in the replication of effects across all 5 participants. In contrast to the instructional word set, all participants showed marginal increases in word knowledge of one or more words in the control word set. The graphs illustrate an overall flat trend. Examination of participant data showed that the children were able to use the control words correctly in a sentence similar to the text, suggesting Stage 2 knowledge, whereas previously they had no knowledge of the words, suggesting incidental learning to a word recognition level.

Impact of Book Type

The graph shows that participants generally had comparable word knowledge of words for each book before instruction. As a group, no reliable difference in acquisition of novel vocabulary on the basis of book type existed during the intervention. Only Participants 2 and 4 showed a separation in word learning, with an advantage evident for the Caucasian book (Book B). At follow-up, word knowledge scores on the

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FIGURE 1. Participants performance on each word set. P = Participant; Instruct. = instructional; A = African American book; B = Caucasian book.

was not demonstrated, analysis showed children chose not to respond to a word rather than to provide an incorrect definition or use it in sentence (i.e., effect of task). This was an interesting discovery given that it only occurred on words in which recognition of the word (i.e., used in a seemingly

correct sentence) had been demonstrated on a previous probe. These findings suggest that perhaps children in this study were cognizant of the task requirement (i.e., that telling what a word means involves more than using it in a sentence) and chose not to respond if they could not meet the demands
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of the task. Therefore, it could be argued that a nonresponse or incorrect definition on a particular probe is not necessarily evidence of a lack of knowledge of that word. It also means that accurate use of the word is not necessarily an indicator of fully acquired understanding. Inconsistencies in the stage of word knowledge from one probe to the next appeared to demonstrate the different degrees to which word learning had occurred. This finding supports the literature that suggests that vocabulary does not occur in a linear fashion but that words are known in degrees and that development occurs gradually even if children may not show that they know a word (Curtis, 1987; Nagy & Scott, 2000).

Limitations
The results of this research provide guidance for implementing an instructional strategy to facilitate development of word learning in children with below average vocabulary skills. However, several salient limitations of this work warrant discussion. The first involves equivalence of the instructional word set. Although all six words were verbs and met the criteria of being Tier 2 words as suggested by Beck et al. (2002), the type of verb may have had a differential effect on the efficiency of word learning. That is, verbs express actions, processes, and conditions. Examination of the verbs indicates that two of the instructional words from the African American book expressed processes, and the remaining words all expressed actions. The extent to which dissimilar verb types vary in levels of metalinguistic complexity is unknown. Second, although the current investigation showed that the use of productive definitions was effective in detecting incremental changes in word knowledge, the inclusion of a receptive task would have further delineated the multidimensionality aspect of novel word learning in an important way. That is, receptive vocabulary knowledge typically precedes development of expressive knowledge, as individuals often understand more than they can express. Therefore, inclusion of a receptive task may have explicated degrees of word learning that were not evident when there was no apparent growth in childrens productive definitions. In addition, use of an alternate tasksuch as story retelling or examining novel word usagemay have provided a more complete picture of the differential effects of book type. Finally, the small sample of words investigated limits the generalizability of these results. Certainly, children encounter many more novel words on a weekly basis in reading, spelling, and literature activities in school settings. Consequently, it is not known whether a larger number of words that are more representative of the number of words children are exposed to during curricular activities may have provided different results.

Impact of Book Type

The general hypothesis undergirding the second research question was that given an empirically sound method of vocabulary instruction, African American childrens retention of novel words would be facilitated by sociocultural images and experiences that were similar to their own. Analysis of the results indicates that the use of the African American book was not a potent influence in facilitating retention of novel words. Surprisingly, when a book type difference existed (Participants 2 and 5), it was in favor of the book featuring Caucasian images and experiences. This finding is inconsistent with previous research by Smith and Lewis (1985) which indicated that stories depicting African American imagery facilitated more efficient recall than stories depicting Caucasian images among African American children. This discrepancy may be accounted for by the fact that the present study examined word retention, whereas Smith and Lewis investigated story recall. The first plausible explanation is that storybooks merely provide a means of contextualizing novel words. Specifically, the actual importance of the books in relation to the intervention technique may be minimal. However, it is possible that a different intervention explicitly referencing and highlighting the illustrations in the storybooks, or the addition of recall task in which vocabulary was measured by the contextually appropriate use of targeted words in retellings, may have produced different results. Second, it is possible that the prevalence of interracial imagery and multicultural themes found in school textbooks and television media has a desensitizing effect on the perception of racial and ethnic imagery (Bell & Clark, 1998). In an effort to respond to the issue of multiculturalism, school textbooks and media have diversified the racial imagery to reflect the distinct social and cultural traditions associated with culturally different groups in general, and African Americans in particular. A third explanation relates to the selection of words. We cannot rule out a possible confound in the difficulty of words unless the same words are targeted in two books that differ on the basis of sociocultural depictions. For example, words from the Caucasian book may have been easier to recall because the sociocultural content presented (i.e., camping) was distinctive from the reported experiences of the African American participants in this investigation. Thus, a novelty effect could have contributed to learning.

Clinical Implications
The present findings demonstrate the potential impact of robust vocabulary instruction for facilitating vocabulary development in children with below average vocabulary skills. It exemplifies a balanced approach using highly contextualized encounters in association with definitional information for novel words that has been suggested as a means for developing word learning in young children (Carlisle & Katz, 2005; Nelson & Van Meter, 2006). The fact that gains were made over eight sessions occurring twice weekly, for 30 min, speaks to the utility and efficiency of the instructional technique for clinical practice. Speech-language pathologists working in school settings with high caseloads and limited time can easily incorporate robust vocabulary instruction into units that are congruent with educational curricula to facilitate vocabulary development that parallels teacher expectations of vocabulary usage in the classroom.

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References
Anderson, R. C., & Freebody, P. (1983). Reading comprehension and the assessment and acquisition of word knowledge. In B. Hutson (Ed.), Advances in reading/language research: A research annual ( pp. 231256). Greenwich, CT: JAI Press. Apthorp, H. S. (2006). Effects of a supplemental vocabulary program in third-grade reading/language arts. The Journal of Educational Research, 100, 6779. Baker, S. K., Simmons, D. C., & Kameenui, E. J. (1995). Vocabulary acquisition: Curricular and instructional implications for diverse learners. Eugene, OR: National Center to Improve the Tools of Educators. Barlow, D. H., & Hayes, S. C. (1979). Alternating treatment design: One strategy for comparing the effects of two treatments in a single subject. Journal of Applied Behavior Analysis, 12, 199210. Battle, D. E. (1996). Language learning and use by African American children. Topics in Language Disorders, 16, 2237. Beck, I. L., & McKeown, M. G. (2001). Text Talk: Capturing the benefits of read-aloud experiences for young children. The Reading Teacher, 55, 1020. Beck, I. L., & McKeown, M. G. (2007). Increasing young lowincome childrens oral vocabulary repertoires through rich and focused instruction. The Elementary School Journal, 107, 251271. Beck, I. L., McKeown, M. G., & Kucan, L. (2002). Bringing words to life: Robust vocabulary instruction. New York: Guilford Press. Beck, I. L., Perfetti, C. A., & McKeown, M. G. (1982). Effects of long-term vocabulary instruction on lexical access and reading comprehension. Journal of Educational Psychology, 74, 506521. Bell, Y. R., & Clark, T. R. (1998). Culturally relevant reading material as related to comprehension and recall in African American children. Journal of Black Psychology, 24, 455475. Biemiller, A. (2001a). Estimating root word vocabulary growth in normative and advantaged populations: Evidence for a common sequence of vocabulary acquisition. Journal of Educational Psychology, 93, 498520. Biemiller, A. (2001b). Teaching vocabulary: Early, direct, and sequential. American Educator, 25, 2428. Bowers, L., Huisingh, R., LoGiudice, C., & Orman, J. (2004). The WORD Test: A test of expressive vocabulary and semantics. (2nd ed.). East Moline, IL: LinguiSystems. Brabham, E. G., & Lynch-Brown, C. (2002). Effects of teachers reading-aloud styles on vocabulary acquisition and comprehension of students in the early elementary grades. Journal of Educational Psychology, 94, 465473. Brown, L., Sherbenou, R. J., & Johnsen, S. K. (1997). Test of Nonverbal Intelligence (3rd ed.). Austin, TX: Pro-Ed. Brownell, R. (2000a). Expressive One-Word Picture Vocabulary Test (3rd ed.). Novato, CA: Academic Therapy. Brownell, R. (2000b). Receptive One-Word Picture Vocabulary Test (3rd ed.). Novato, CA: Academic Therapy. Bus, A., Van Ijzendoorn, M., & Pellegrini, A. (1995). Joint book reading makes for success in learning to read: A meta-analysis on intergenerational transmission of literacy. Review of Educational Research, 65, 121. Campbell, J. R., Hombo, C. M., & Mazzeo, J. (2000). NAEP 1999 trends in academic progress: Three decades of student performance (National Center for Education Statistics [NCES] Publication No. 2000469). Available from NCES Web site: http://nces.ed.gov/nationsreportcard/pdf/main1999/2000469.pdf. Carlisle, J. F., & Katz, L. A. (2005). Word learning and vocabulary instruction. In J. R. Birsh (Ed.), Multisensory teaching

of basic language skills (2nd ed., pp. 345376). Baltimore: Brookes. Carr, E. (1985). The vocabulary overview guide: A metacognitive strategy to improve vocabulary comprehension and retention. Journal of Reading, 28, 684689. Champion, T. B., Hyter, Y. D., McCabe, A., & Bland-Stewart, L. M. (2003). A matter of vocabulary : Performances of lowincome African American Head Start children on the Peabody Picture Vocabulary TestIII. Communication Disorders Quarterly, 24, 121127. Chumbley, H. A. (Ed.). (1989). Macmillan dictionary for children. New York: Macmillan. Colarusso, R. P., & Hammill, D. D. (2003). Motor-Free Visual Perception Test (3rd ed.). Bethesda, MD: American Occupational Therapy Association. Coyne, M. D., McCoach, D. B., & Kapp, S. (2007). Vocabulary intervention for kindergarten students: Comparing extended instruction to embedded instruction and incidental exposure. Learning Disability Quarterly, 30, 7488. Curtis, M. E. (1987). Vocabulary testing and instruction. In M. G. McKeown & M. E. Curtis (Eds.), The nature of vocabulary acquisition ( pp. 3751). Hillsdale, NJ: Erlbaum. Dale, E. (1965). Vocabulary measurement: Techniques and major findings. Elementary English, 42, 895901. Dale, P. S., Crain-Thoreson, C., Notari-Syverson, A., & Cole, K. (1996). Parentchild book reading as an intervention technique for young children with language delays. Topics in Early Childhood Special Education, 16, 213235. deVilliers, J. G. (2004). Cultural and linguistic fairness in the assessment of semantics. Seminars in Speech and Language, 25, 7390. Donovan, C. A., & Smolkin, L. B. (2001). Genre and other factors influencing teachers book selections for science instruction. Reading Research Quarterly, 36, 412440. Duncan, A. F. (1999). Miss Viola and Uncle Ed Lee. New York: Simon & Schuster. Dunn, L., & Dunn, L. (1997). The Peabody Picture Vocabulary TestIII. Circle Pines, MN: AGS. Elley, W. B. (1989). Vocabulary acquisition from listening to stories. Reading Research Quarterly, 24, 174187. Graves, M. F. (1986). Vocabulary learning and instruction. Review of Research in Education, 13, 4989. Grice, M. O., & Vaughn, C. (1992). Third graders respond to literature for and about Afro-Americans. The Urban Review, 24, 149164. Hargrave, A. C., & Snchal, M. (2000). A book reading intervention with preschool children who have limited vocabularies: The benefits of regular reading and dialogic reading. Early Childhood Research Quarterly, 15, 7590. Hart, B., & Risley, T. R. (1995). Meaningful differences in the everyday experience of young American children. Baltimore: Brookes. Heath, S. B. (1982). What no bedtime story means: Narrative skills at home and school. Language Socialization, 11, 4976. Heath, S. B. (1989). Oral and literate traditions among Black Americans living in poverty. American Psychologist, 44, 367373. Hoover, H. D., Dunbar, S. B., & Frisbie, D. A. (2006). Iowa Tests of Basic Skills. Rolling Meadows, IL: Riverside. Justice, L. M., Meier, J., & Walpole, S. (2005). Learning new words from storybooks: An efficacy study with at-risk kindergarteners. Language, Speech, and Hearing Services in Schools, 36, 1732. Kagan, S. L., & Garcia, E. E. (1991). Educating culturally and linguistically diverse preschoolers: Moving the agenda. Early Childhood Research Quarterly, 6, 417443.
Lovelace & Stewart: Novel Vocabulary Acquisition

177

Mautte, L. A. (1990). The effects of adult-interactive behaviors within the context of repeated storybook readings upon the language development and selected prereading skills of prekindergarten at risk students. Florida Educational Research Council Bulletin, 22, 1232. McKeown, M. G., Beck, I. L., Omanson, R. C., & Perfetti, C. A. (1983). The effects of long-term vocabulary instruction on reading comprehension: A replication. Journal of Reading Behavior, 15, 318. McKeown, M. G., Beck, I. L., Omanson, R. C., & Pople, M. T. (1985). Some effects on the nature and frequency of vocabulary instruction on the knowledge and use of words. Reading Research Quarterly, 20, 522535. Nagy, W. E., & Herman, P. A. (1987). Breadth and depth of vocabulary knowledge: Implications for acquisition and instruction. In M. G. McKeown & M. E. Curtis (Eds.), The nature of vocabulary acquisition ( pp. 89106). Hillsdale, NJ: Erlbaum. Nagy, W. E., & Scott, J. C. (2000). Vocabulary processes. In M. Kamil, P. B. Mosenthal, P. D. Pearson, & R. Barr (Eds.), Handbook of reading research (Vol. 2, pp. 269284). Mahwah, NJ: Erlbaum. National Institute of Child Health and Human Development Early Child Care Research Network. (2005). Pathways to reading: The role of oral language in the transition to reading. Developmental Psychology, 41, 428442. Nelson, N. W., & Van Meter, A. M. (2006). Finding the words: Vocabulary development for young authors. In T. A. Ukrainetz (Ed.), Contextualized language intervention ( pp. 95144). Eau Claire, WI: Thinking Publications. Penno, J. F., Wilkinson, I. A. G., & Moore, D. W. (2002). Vocabulary acquisition from teacher explanation and repeated listening to stories: Do they overcome the Matthew effect? Journal of Educational Psychology, 94, 2333. Reynolds, R. E., Taylor, M., Steffense, M. S., Shirley, L., & Anderson, R. C. (1982). Cultural schemata and reading comprehension. Reading Research Quarterly, 17, 357366. Robbins, C., & Ehri, L. C. (1994). Reading storybooks to kindergartners helps them learn new vocabulary words. Journal of Educational Psychology, 86, 5464. Scarborough, H. S. (2001). Connecting early language and literacy to later reading (dis)abilities: Evidence, theory, and practice. In S. B. Neuman & D. K. Dickinson (Eds.), Handbook for research on early literacy ( pp. 97110). New York: Guilford Press.

Snchal, M. (1997). The differential effect on storybook reading on preschoolers acquisition of expressive and receptive vocabulary. Journal of Child Language, 24, 123138. Snchal, M., & Cornell, E. H. (1993). Vocabulary acquisition through shared reading experiences. Reading Research Quarterly, 28, 361373. Snchal, M., Thomas, E., & Monker, J.-A. (1995). Individual differences in 4-year-old childrens acquisition of vocabulary during storybook reading. Journal of Educational Psychology, 87, 218229. Sindelar, P. T., Rosenberg, M. S., & Wilson, R. J. (1985). An adapted alternating treatments design for instructional research. Education and Treatment of Children, 8, 6776. Smith, R., & Lewis, R. (1985). Race as a self-schema affecting recall in Black children. Journal of Black Psychology, 12, 1529. Stock, C. (1988). Sophies knapsack. New York: Lothrop, Lee, & Shepard Books. Sulzby, E. (1985). Childrens emergent reading of favorite storybooks: A developmental study. Reading Research Quarterly, 20, 458481. Washington, J. A., & Craig, H. K. (1999). Performances of at-risk African American preschoolers on the Peabody Picture Vocabulary TestIII. Language, Speech, and Hearing Services in Schools, 30, 7582. Whitehurst, G. J., Falco, F. L., Lonigan, C. J., Fischel, J. E., DeBaryshe, B. D., Valdez-Menchaca, M. C., et al. (1988). Accelerating language development through picture book reading. Developmental Psychology, 24, 552559. Wolfram, W., Adger, C. T., & Christian, D. (1999). Dialects in schools and communities. Mahwah, NJ: Erlbaum. Wright, R. L. (1983). Functional language, socialization, and academic achievement. The Journal of Negro Education, 52, 314. Received March 21, 2008 Revision received July 17, 2008 Accepted November 13, 2008 DOI: 10.1044/1058-0360(2008/08-0023) Contact author: Sherri Lovelace, Arkansas State University, Department of Communication Disorders, 106 Rose Street, Jonesboro, AR 73567-0910. E-mail: slovelace@astate.edu.

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Appendix Example of an Instructional Lesson

Task Elicit recall Content recall Instructions Point to title and ask whether they remember the name of the story. Scaffold: Read title. Does anyone remember what the story was about? Scaffold: The story is about two people who are opposite, but one wants to become friends. What do we know about Uncle Ed Lee? Scaffold: Hes messy or not very neat. What do we know about Miss Viola? Scaffold: Shes very neat and clean. Read book Elicit recall and phonological representation of words Reinforce definitions by contextualizing word(s) for its role in the story Elicit word meaning Who can remember the three words we learned from this story? Scaffold: notice, combine, focus. Turn to page in book on which word(s) appear. In the story Uncle Ed Lee asked Bradley did he notice Miss Violas bright smile. Who remembers what notice means? Scaffold: Notice means to see or observe. In the story, Bradley wondered how you combine messy and neat. Who remembers what combine means? Scaffold: Combine means to join together. In the story, Bradley heard Uncle Ed Lee talking about Miss Viola, but he did not answer because he was trying to focus on the game. Who remembers what focus means? Scaffold: Focus means to pay close attention to. Tell me the ingredients we combined last week to make our pudding. We combined or joined together milk and pudding mix. Let us look at some Wheres Waldo pictures. You really have to focus to find Waldo. Let us see who can pay the closest attention. When you notice him, say I notice or observe Waldo [give location]. Im going to say a sentence that has a word missing. Notice, combine, or focus will fit in each sentence. Repeat the three possible words at the end of each sentence. The coach needed 10 players, he had 4 second graders and 6 third graders, so he decided to __ both grades to make one team. The thief robbed the house at night so he would not be ___. Because Mary did not __ while cutting the paper, she also cut moms picture. Who can tell me the word that means to see or observe? Scaffold: The word that means to see or observe is notice. Who can tell me the word that means to pay close attention to? Scaffold: The word that means to pay close attention to is focus. Who can tell me the word that means to join together? Scaffold: The word that means to join together is combine.

Reinforce connections between words and meanings

Interactions with all three words

Reinforce phonological representation

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Tutorial

Health Literacy and the Role of the Speech-Language Pathologist

Eva Jackson Hester Regena Stevens-Ratchford
Towson University, Towson, MD

Purpose: This article reviews concepts of health literacy and discusses the role of speechlanguage pathologists in improving the health literacy of individuals with and without communication disorders. Method: A literature review was completed of health literacy definitions, concepts, and health literacy assessment and intervention studies with various populations. A literature review was also conducted regarding health literacy or related studies in the field of speech-language pathology.

Conclusion: There is a paucity of information available on health literacy within the field of speech-language pathology. Suggestions are offered regarding increasing health literacy research and intervention by speech-language pathologists.

Key Words: health literacy, research, assessment, intervention

ealth literacy has become a national health concern that can critically affect the health status of many Americans. Health literacy is the degree to which individuals have the capacity to obtain, process, and understand basic health information and the services needed to make appropriate health decisions (Ratzan & Parker, 2000). Reports indicate that more than 90 million adults have problems comprehending and acting on health information (Institute of Medicine [IOM], 2004). Low health literacy has been associated with increased hospitalizations, poor treatment outcomes, depression, and increased mortality (Ad Hoc Committee on Health Literacy, 1999; Chew, Bradley, Edward, & Boyko, 2004; Mika, Kelly, Price, Franquiz, & Villarreal, 2005). Health literacy is needed to effectively manage health conditions and interact in the health care system, including understanding discussions with physicians, reading health information, participating in research studies, using health care equipment, and comprehending medical prescription labels and their accompanying instructions and precautions. Hence, language and communication are key elements for adequate health literacy because patients use communication skills to access health services, describe and discuss symptoms, answer questions, understand medical instructions, and ask relevant health care questions. Given the importance of communication in the promotion of good health, Healthy People 2010, a federal initiative, has identified improving health communication and health literacy as one of its goals (U.S. Department of Health and Human Services, n.d.). As communication specialists, speech-language and hearing professionals can provide unique insight and contributions

to the health literacy discussion, and especially the Healthy People 2010 research agenda in regard to communication, language, literacy and associated health literacy concepts, assessments, and interventions. The American Speech-LanguageHearing Association (ASHA) emphasizes the vision of making effective communication, a human right, accessible and achievable for all (ASHA, 2008). ASHA further notes that speech-language pathologists can be pivotal in providing insight into how to communicate complex messages to individuals who have limited literacy skills or understanding. ASHA encourages professionals to learn more about health literacy, as understanding health information is vital to a persons well-being (ASHA, 2008). Individuals with speech-language and hearing disorders are at particular risk for low health literacy (ASHA, 2008; Hester & Benitez-McCrary, 2006; IOM, 2004; Mika et al., 2005). However, the speech-language literature contains few studies related to health literacy. Available studies have examined the readability of cleft palate educational materials (Kahn & Pannbacker, 2000), text and reader variables related to understanding health information (Harris, Fleming, & McDougall, 2003), and factors that influence utilization of speech-language pathology services by older adults (Shadden & Raiford, 1984). In addition, some recent studies have examined ways to modify aphasia consumer materials (Brennan, Worrall, & McKenna, 2005; Rose, Worrall, & McKenna, 2003). However, there is clearly a need for more health literacy research in the area of speech-language pathology. Speech-language professionals knowledge of language, literacy, and communication can make a unique contribution

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to the health literacy literature that goes beyond the patientdoctor interactions that have been examined previously (Caris-Verhallen, de Gruijter, Kerkstra, & Bensing, 1999; Dearborn et al., 2006; Dutta-Bergman, 2005; Kaakinen, Shapiro, & Gayle, 2001; Query & Wright, 2003; Tran et al., 2004; Williams, Davis, Parker, & Weiss, 2002). Information on the theoretical constructs of language and communication that underlie literacy, in general, can be applied to expand existing knowledge of health literacy. There are several models available, but pragmatic models that emphasize social use of language (Schneider & Watkins, 1996; Ukrainetz, 2005) and cognitive science models that include syntax and semantics (Ebbels, van der Lely, & Dockrell, 2007; Haynes & Shulman, 1998; Shapiro, 1997; Stone, 2004) have been frequently noted. For example, a pragmatic model may be applied to study variations in communicative intentions used during providerpatient interactions. While patients ability to ask questions and provide information has been related to improved health outcomes (IOM, 2004; Kreps, 2006; Street, 2003), systematic studies are needed to support this position. Investigations of questioning and other communicative intentions may reveal additional information to improve patients communication skills within the health care context. Likewise, examining the syntactic complexity of written consumer health care materials may provide information to improve the readability levels of written materials given to patients. Reports indicate that the syntactic complexity of both oral and written statements provides comprehension challenges for older adults, a population identified as having low health literacy (Champley, Scherz, Apel, & Burda, 2008; G. Davis & Ball, 1989; Harris, Rogers, & Qualls, 1998). Therefore, the purposes of this article are to (a) discuss various definitions and concepts related to health literacy, (b) provide information on existing health literacy assessments, (c) describe health literacy characteristics in populations identified as having low or inadequate health literacy, (d) review language and communication studies related to health literacy, and (e) propose theoretical frameworks for speech-language and hearing professionals to become involved with health literacy research, assessments, and interventions.

that are necessary to function in health care systems (JAMA: Health Literacy Lacking, 1999; Ratzan & Parker, 2000). In contrast, Nutbeam (1998) has proposed a broader, more comprehensive definition that encompasses both environmental and individual factors. This definition of health literacy has been adopted by the World Health Organization (WHO) and is presented here: Health literacy represents the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health. Health literacy means more than being able to read pamphlets and successfully make appointments. By improving peoples access to health information and their capacity to use it effectively, health literacy is critical to empowerment. (Nutbeam, 1998, p. 357) Nutbeams definition emphasizes function and the concept of empowerment, and stresses that people must have access to health care as well as health information. In this more encompassing meaning of health literacy, health consumers are expected to be active participants in their health care and to effectively use the system and its resources. This definition suggests that health care providers need to move beyond just providing information to initiating the process of empowerment (Mika et al., 2005). Communication specialists can add to the process of empowerment by teaching patients and clients about the skills that facilitate health communication. Nutbeam (2000) further expanded the concepts of health literacy and proposed a continuum of health literacy skills that includes three levels: functional, communicative/interactive, and critical health literacy. Level 1, functional health literacy, involves communication of health information and use of the health system. This level emphasizes improved knowledge of health risks, services, and compliance with health care recommendations. Information at this level is directed more toward population benefit rather than individual benefit. Activities used at this level may involve distribution of pamphlets and brochures to promote participation in mass screenings. Typically, approaches at this level do not include providerpatient interaction. Social outcome measures would include improved quality of life and functional independence. Expected health outcome measures would include reduced morbidity and disability (Nutbeam, 2000). Level 2, communicative/interactive health literacy, involves improvement of individuals to act independently in taking responsibility for their health care. At this level, the focus is on development of personal skills in a supportive environment. Expected outcome measures include healthy lifestyle (e.g., food choices and physical activity), effective health services (e.g., provision of services), and healthy environments (e.g., good food supply and restricted access to tobacco and alcohol; Nutbeam, 2000). Finally, Level 3, critical health literacy, refers to the cognitive skills directed toward supporting social, political, and individual actions noted in Level 2. Health education at this level would be directed at improving individual and community potential to respond to social and economic factors that affect health status. Expected health literacy 181

Concepts of Health Literacy

The concept of health literacy originated from concerns regarding low literacy rates of adults in the United States (IOM, 2004). The 2003 National Assessment of Adult Literacy showed that 14% of adults have literacy skills that are below basic, and another 3% are nonliterate (Kutner, Greenberg, & Baer, 2005). A new concern in literacy and health care is the increasing realization that low literacy and poor communication skills can affect health status (Drew, 2002). People with low literacy skills have poorer health outcomes and difficulty accessing health services (Baker, Gazmararian, Sudano, & Patterson, 2000; Chew et al., 2004; Georges, Bolton, & Bennett, 2004; Mika et al., 2005). Knowledge of health care services and communication skills are keys to health literacy. In the simplest terms, health literacy can be understood as the ability to execute the basic reading and numerical tasks

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outcome measures include self-efficacy and health-related knowledge, while social action outcome measures include community participation, community empowerment, and public opinion. In addition, healthy public policy and organizational practice measures would be outcomes at this level (Nutbeam, 2000). To illustrate Nutbeams continuum, consider the individual experiencing aphasia after a stroke. At Level 1, patients with aphasia and their families must be knowledgeable of aphasia signs and the availability of treatment for aphasia. In addition, they must know when and where to find treatment services for aphasia. This knowledge of where services are located and how to access these services would be consistent with functional literacy, in which general information and brochures regarding aphasia are made available to the public. Being able to access the service by making the appointment, arriving for the scheduled appointment, interacting with the provider, and understanding assessment findings would be examples of communicative/interactive health literacy. Critical health literacy would involve lobbying for legislation to maximize reimbursement for aphasia assessment and encouraging both professionals and community support of relevant legislation. This continuum requires application of the cognitive, social, and communication components of health literacy that are noted in the WHO definition of health literacy.

Health Literacy Assessments

There are three health literacy assessments that are frequently used in the health care area: (a) the Test of Functional Health Literacy in Adults (TOFHLA; Nurss, Parker, & Baker, 1995), (b) the Short Test of Functional Health Literacy in Adults (S-TOFHLA; Baker, Williams, Parker, Gazmararian, & Nurss, 1999), and (c) the Rapid Estimate of Adult Literacy in Medicine (REALM; T. C. Davis et al., 1993). Table 1 provides specific descriptions of these assessments. These tests have been used for research purposes and also in clinical and community settings (IOM, 2004). The TOFHLA was developed to measure adult literacy in a health care setting. The test measures reading comprehension and numeracy through a modified cloze procedure. Test takers complete sentences by selecting from a list of words beneath each sentence, yielding a maximum score of 100. Total test scores are

classified under the following health literacy levels: inadequate functional health literacy, marginal, or adequate functional health literacy. The short version, the S-TOFHLA (Baker et al., 1999) does not include the numeracy section and consists of 36 test items. For both test versions, the score is the total number of correct items. The REALM was developed for adults to provide a quick estimate of reading level of common terms in a medical setting and involves only word recognition. The test consists of single words arranged in columns of 1- or 2-syllable words and 3-syllable or larger words, and is for standardized English only (T. C. Davis et al., 1993). Sample items from both tests are contained in Appendix A. Several limitations have been reported with the existing health literacy assessments. A major complaint regarding the TOFHLA is the length of the test (Chew et al., 2004). Other concerns have been expressed regarding difficulty of the reading level for the TOFHLA, S-TOFHLA, and REALM. In addition, grade levels have been reported to be unreliable estimates of health literacy (Chew et al., 2004; IOM, 2004). The REALM has been reported to provide very limited information regarding health literacy in that only single-word recognition is assessed. The IOM (2004) noted that both assessments are limited to print literacy and emphasized that health literacy requires many other skills such as cultural and conceptual knowledge, listening, and speaking. The focus on medical terms only has also been noted as a shortcoming, because other reading materials are included in the health care sector, such as consent and case history forms (IOM, 2004). Finally, neither the TOFHLA nor REALM includes assessment of writing (IOM, 2004). Given the limitations of existing tools, researchers have begun to explore other ways to determine health literacy. Chew et al. (2004) examined predictors of health literacy in a sample of participants in a VA hospital. They developed an assessment tool that consisted of a 16-item questionnaire read orally to participants. A 5-point Likert scale was used, ranging from always to never. These items assessed using the health care system, completing medical forms, and following medication instructions, as well as patientprovider interactions and reading appointment slips. The S-TOFHLA was used for comparison standards in the study (Chew et al., 2004). The purpose of the study was to determine the questions that were the best predictors of health literacy. The results indicated that of the 16 items, the following 3 questions

TABLE 1. Description of frequently used health literacy assessments. Average administration time (in minutes) 22

Test Test of Functional Health Literacy in Adults (TOFHLA; Nurss et al., 1995) Short Test of Functional Health Literacy in Adults (Baker et al., 1999) Rapid Estimate of Adult Literacy in Medicine

Standardization 377 adults 1825 years old; English/Spanish 211 adults (no age given); English/Spanish

Components 50 reading comprehension items; 17 numeracy items; maximum score = 100; health literacy levels: inadequate = 059, marginal = 6074, adequate = 75100 36 reading comprehension items from TOFHLA; health literacy levels: inadequate = 016, marginal = 1722, adequate = 2336 Word recognition lists of 66 common medical terms; scores (066) converted to reading grade levels (08)

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revealed the strongest correlation for predicting inadequate health literacy: How often do you have problems learning about your medical condition because of difficulty understanding written information? How confident are you filling out medical forms by yourself ? How often do you have someone help you read hospital materials? Although this study was limited to men in a VA hospital, the authors noted that the findings are important in that few screening questions may be needed to identify 80% of adult patients with inadequate literacy (Chew et al., 2004). Despite attempts to develop more efficient assessments, the IOM (2004) has noted that additional improvement is needed and has specified that speaking and listening competencies are lacking in current assessment tools. The IOM (2004) indicated that oral language skills are critical concerns for public health care because public health communication relies on oral communication to convey health promotion and wellness information to the public. Health care interactions need to include critical discussions between the health care provider and the patient. These discussions allow the nurse or physician to assess and comprehend symptoms, follow patients experiences of the course of an illness, make and explain diagnoses, and offer options for treatment (IOM, 2004). During these health care encounters, patients tell the story of their particular illness, explain and describe the course of the condition and its symptoms, and ask questions about the diagnosis and intervention process. According to the IOM (2004), current health literacy assessments do not assess the entire spectrum of health literacy, which includes speaking and listening. How can speech-language pathologists begin to address this health literacy assessment problem? There are several possible approaches; however, an initial response could be to develop communication screening questions that could be used with other health literacy assessments. These tools could include self-report measures regarding communication skills used within a health care context based on Likert scale responses. For example, the tool could include such statements as I ask my provider questions concerning my medical condition, and I request clarification of information that I dont understand during health care visits. While self-report measures are valid tools for obtaining individuals perception of their performance, they have limitations because of the subjective nature of the assessment. A second option is to develop oral screening measures using a small number of sensitive questions that could identify patients who may be at risk for using limited health care communication skills. An example of a potentially sensitive question would be How would you let your provider know that you did not understand your diagnosis? Such questions could be used in clinical settings during intake, and notations could be made by staff regarding communication limitations. In that way, health care providers could be alerted to modify their interaction with patients who may not ask questions

or request clarification of information that may not be understood.

Health Literacy Assessment and Intervention Studies With Select Populations

Low health literacy has been reported as a problem in African American, Latino, elderly, and poor populations (IOM, 2004; Mika et al., 2005). Studies of health literacy in these groups have indicated that inadequate health literacy may be a contributor to poor health outcomes for a variety of conditions (Baker et al., 2000; Benson & Forman, 2002; Garbers & Chiasson, 2004; Gazmararian et al., 1999; Georges et al., 2004; Guerra, Krumholz, & Shea, 2005; Nurss et al., 1997). Although limitations of existing health literacy assessments have been noted, the TOFHLA and REALM have been used extensively to assess health literacy in high-risk populations, with particular emphasis on patients with diabetes and cancer. Overall, the results of these studies have indicated that a low percentage of African American patients demonstrated adequate health literacy (Nurss et al., 1997; Sharp, Zurawski, Roland, OToole, & Hines, 2002). Moreover, many patients denied having reading difficulty, which prompted investigators to recommend patient education strategies to address health literacy barriers to health care delivery (Nurss et al., 1997). More recent studies have examined health literacy of Spanish speakers using the Spanish version of the TOFHLA (Garbers & Chiasson, 2004; Guerra et al., 2005). Health literacy as related to knowledge about breast and cervical cancer and cancer screenings has been an area of study with this population involving primarily middle-aged and older women. In general, findings from these studies indicated that women with inadequate health literacy were less likely to have cancer screenings and were, therefore, at higher risk for cancer (Garbers & Chiasson, 2004; Guerra et al., 2005). Studies that have used the TOFHLA and REALM with multicultural groups, including both Hispanic and African Americans, have yielded findings that are fairly consistent with individual groups. Georges et al. (2004) conducted a study of both African American and Latino men and women with an average age of 43 in various primary and acute care settings and found many patients to have marginal health literacy. Georges et al. suggested that patients with marginal health literacy will have difficulty reading, understanding, and interpreting most written health texts and health instructions. Similar results were found in a study that examined the relationship between health literacy and cervical cancer in a group of multiethnic women using the REALM (Lindau et al., 2002). Findings from this study, however, indicated that physicians overestimated their patients literacy levels. In essence, the physicians incorrectly classified reading levels and assumed that patients had higher reading levels than those obtained in the study (Lindau et al., 2002). Reportedly, inadequate health literacy is even more prevalent in older populations (Baker et al., 2000, 2002; Benson & Forman, 2002; Gazmararian et al., 1999; JAMA: Health Literacy Lacking, 1999; Scott, Gazmararian, Williams, & Baker, 2002). Scott et al. (2002) used the TOFHLA to examine

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health literacy and the use of preventive health services in a sample of Medicare enrollees and found that individuals with low health literacy were less likely to get preventive health services such as diabetes and blood pressure screenings. Baker et al. (2000) examined functional health literacy in a sample of older adults and identified reasons that might explain why older age groups demonstrate lower functional health literacy. They suggested that (a) several specific health and behavioral domains could be related to older adults being less educated and having poor reading skills, (b) there is a higher prevalence of dementia or cognitive impairment in older adults, (c) there is also a higher incidence of chronic diseases like hypertension that can result in reduced cognitive function and poor physical and mental health, and (d) older adults tend to have higher rates of hearing and visual impairments that can impede reading and other communication skills that are necessary for everyday literacy as well as health. Several studies have reported that many older adults demonstrate poor reading skills (Gazmararian et al., 1999; Kirsch, Jungebelt, Jenkins, & Kolstad, 1993; Williams et al., 1995). The National Adult Literacy Study findings indicated that the proportion of Americans who read at the lowest reading level (level 1) increased from 16% among those 4554 years old to 26% among those 5564 years old, to 44% among those age 65 and older (Baker et al., 2000, p. S368). Poor reading skills in older adults can be problematic because older people tend to have a higher incidence of chronic disease and a greater need for comprehension of health-related information (Baker et al., 2000). Reading capacities may decline as individuals age because reading encompasses several visual and cognitive abilities that include visual acuity and tracking as well as the abilities to attend and concentrate, to recognize and remember words, phrases, and passages, and to execute other informationprocessing skills. Limitations in any of these capacities may affect the ability to read and comprehend written communication. Visual and cognitive impairments tend to increase with age. Baker et al. (2000) contended that the comprehension of written materials is a complex function that incorporates several cognitive capacities; therefore, reading can be hampered by even mild cognitive impairment. Consequently, the increased incidence of dementia and cognitive impairment among older adults might account for the poorer reading scores that are demonstrated by older adult populations (Baker et al., 2000). Chronic diseases, especially hypertension, may be health factors that negatively affect reading skills. Additionally, diabetes, hypercholesterolemia, and hypertension are health conditions that can lead to cardiovascular disease or stroke; such conditions may, in turn, cause impairments that can impede reading ability. Furthermore, older adults who have hypertensive conditions have a tendency to experience cognitive decline even if they do not experience a stroke (Desmond, Tatemichi, Paik, & Stern, 1993; Glynn et al., 1999; Tzourio, Dufouil, Ducimetiere, & Alperovitch, 1999, as cited in Baker et al., 2000). Depression has also been identified as a factor in decreased cognitive function in older adults. Both poor physical health and depression can affect concentration and the ability to perform complex tasks

such as reading (Baker et al., 2000). Finally, Baker et al. assert that older adults may tend to read less as they grow older and, consequently, experience cognitive decline and poorer reading scores as a result (i.e., the use it or lose it assumption). In their study, Baker et al. (2000) investigated what cognitive, health, and behavioral factors were associated with functional health literacy among elderly persons to determine whether the negative association between age and functional health literacy persists after adjusting for cognitive dysfunction (as measured by the Mini-Mental State Examination [MMSE]; Folstein, Folstein, & McHugh 1975), chronic medical problems, physical functioning, mental health, corrected visual acuity, and self-reported frequency of reading the newspaper. This study defined functional health literacy as the ability to read and comprehend health-related information such as prescription bottles, appointment slips, and instructions for procedures or diagnostic tests (p. S371). The Baker et al. study conducted home interviews in a sample of community-dwelling older adults to collect data on education level, newspaper-reading frequency, health status, and other demographic measures. After administering the S-TOFHLA and the MMSE to the participants, the authors found that the mean S-TOFHLA scores declined 1.4 points for every year increase in age. The results indicated that the differences in newspaper-reading frequency, visual acuity, chronic medical conditions, and health status did not explain the lower literacy of these older participants. Baker et al. concluded that functional health literacy was somewhat lower in older age groups than in younger age groups even when their analyses accounted for differences in cognitive function, reading frequency, health status, and visual acuity. They recommended that future studies prospectively examine functional literacy in relation to cognitive function (Baker et al., 2000). Benson and Forman (2002) further noted that higher education levels do not necessarily preclude low health literacy in the elderly. These researchers administered the TOFHLA to college-educated residents in an affluent retirement community. Results indicated that 30% of the participants in the study had reading comprehension difficulties with test items. The investigators concluded that difficulty with the TOFHLA was age-related and might be affected by both cognitive and physical decline (Benson & Forman, 2002).

Health Literacy and Communication Studies

There have been relatively few health literacy studies in the field of communication disorders; Table 2 summarizes this literature. In an early study, Shadden and Raiford (1984) investigated possible factors that influence utilization of speech-language and audiology services by older individuals. Communication disorders professionals and older persons were asked to describe the factors that they believed had influenced service utilization. Results for the professional sample indicated that about 45% of the communication disorders specialists felt that older persons did not take advantage of their services. Audiologists were more likely than speech-language pathologists to feel that services were not utilized. In contrast, 72% of the older participants felt that

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TABLE 2. Summary of selected health literacy studies in speech-language pathology. Citation Shadden & Raiford (1984) Kahn & Pannbacker (2000) Participants 495 speech-language pathology and audiology professionals; 157 senior citizens Review of cleft palate brochures Study design Descriptive study: service utilization Results/implications Knowledge of availability and accessibility of services impeded utilization for seniors. Average readability level for publications was 11th grade; 50% of adults read at 5th-grade level. Reading levels for brochures need to be decreased. Reading comprehension was improved with modified brochures. Aphasiafriendly principles increase understanding of health information.

Rose et al. (2003)

12 adults with aphasia

Brennan et al. (2005)

Hoffman et al. (2005)

Data analyzed from 12,769 participants in ongoing Medicare Current Beneficiary Survey conducted by Centers for Medicare and Medicaid Services.

Descriptive study: 18 publications from American Cleft Palate Association and 12 publications from ASHA using SMOG and Fry formulas Descriptive study: 4 brochures on stroke, arthritis, osteoporosis, and motor neuron disease; modified brochures using pictures, larger font, and simple syntax; participants reading comprehension compared using original and modified text Inferential study: 9 adults with aphasia; 90 paragraphs from SRA series read by participants under 6 conditions: no modification, simplified vocabulary and syntax, pictures, large print, increased spacing, all modifications combined Descriptive study: people with and without speech and hearing problems regarding dissatisfaction with health care; people with communication problems classified as mild-severe Descriptive study: 114 health care documents collected from individuals living with aphasia, analyzed using readability (Fry, SMOG) and linguistic complexity measures

Greatest reading improvement was with simplified vocabulary and syntax; there was no significant improvement with pictures only.

As communication disability increased, level of dissatisfaction increased. People with communication disability reported dissatisfaction with health care quality, accessibility. Average readability for documents was 9th grade. Low frequency words and complex sentences used. No difference in readability and linguistic complexity when speech-language pathology aphasia materials were compared to health documents.

Aleligay et al. (2008)

Note.

ASHA = American Speech-Language-Hearing Association; SMOG = Simple Measure of Gobbledygook.

they did not take advantage of services offered by health professionals, in general, although 34% of the respondents reported having some type of communication disorder. The most frequently reported reason given by the older participants for not utilizing services was lack of knowledge of available services. The authors concluded that increased public awareness programs regarding communication disorders and service availability should be targeted to older individuals (Shadden & Raiford, 1984). In a more recent investigation, Kahn and Pannbacker (2000) examined the readability of educational materials for clients with cleft lip/palate and their families. In this study, publications from the American Cleft Palate-Craniofacial Association and ASHA were analyzed for readability to predict grade-level difficulty. Results indicated that most of the publications were at the high school reading level. In addition, the more understandable materials were often written by parents, rather than professionals. Kahn and Pannbacker (2000) concluded that more attention should be directed to a lower reading level of educational and instructional materials,

given the low literacy rates among adult readers. Furthermore, it was suggested that parents and nonprofessionals should be involved in the development of consumer materials. In another study, Harris et al. (2003) used authentic healthinformation texts to investigate the effects of frequently asked questions (FAQs) on text comprehension. Results indicated that comprehension performance was positively related to participants familiarity with the health topic, the reading level of the text, and performance on the TOFHLA. Harris et al. (2003) recommended that the spectrum of text and reader variables should be considered when developing consumer materials. Table 2 includes a series of studies that have examined text and reader variables in consumer health materials used by individuals with aphasia (Aleligay, Worrall, & Rose, 2008; Brennan et al., 2005; Rose et al., 2003). These studies recommended modifications in consumer health information that would result in more aphasia-friendly materials. Rose et al. (2003) proposed that aphasia-friendly principles involving the use of simple words and short sentences, 185

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relevant pictures, and large fonts be applied to consumer health materials. In a subsequent study, these aphasia-friendly principles were applied to Internet accessibility by people with aphasia (Egan, Worrall, & Oxenham, 2004). Internet training materials were developed using aphasia-friendly principles. Pre- and posttest Internet skills assessment and attitudinal questionnaires indicated favorable outcomes, with increased levels of independence in Internet use noted for people with aphasia (Egan et al., 2004). While these studies add to our understanding of health literacy, the small participant samples limit the generalizability of the results. In contrast to the limited number of communication disorder studies, there is a larger literature base in health-related fields including health communication, health education, public health, and nursing that examines health care communication issues (Caris-Verhallen et al., 1999; Dearborn et al., 2006; Dutta-Bergman, 2005; Kaakinen et al., 2001; Query & Wright, 2003; Tran et al., 2004; Williams et al., 2002). Many of these studies have investigated communication interactions between health care providers and patients. For example, Kaakinen et al. (2001) used focus group qualitative methods to examine interactions with elderly patients in a sample of 6 nurse practitioners. The results identified communication strategies that facilitated elderly patients compliance with treatment. Such strategies included discussing the clients perceptions of their health and educating the clients using printed materials, drawings, and simple language when speaking with them (Kaakinen et al., 2001). Another study explored gender differences in communication of health information to older adult participants and the participants reaction to the information (Dearborn et al., 2006). Older adults listened to 16 narratives regarding risk factors read by male and female speakers. Results indicated that gender influenced communication effectiveness and participants responses, with female voices showing greater effectiveness and female participants identifying a higher number of risk factors than male participants (Dearborn et al., 2006). Query and Wright (2003) used quantitative and qualitative research procedures to examine the relationships among social support, communication competence, and perceived stress in a sample of older cancer patients and their lay caregivers. Online and paper and pencil data collection procedures were used to obtain participants narratives that described both positive and negative experiences of social support. The results indicated that participants who had good communicative competence reported lower levels of perceived stress and described greater satisfaction with their social support network (Query & Wright, 2003). These findings imply that communication skills are an integral part of being socially connected, and that when older adults have a social support system, they are better able to manage and cope with a serious illness and its related stresses. The results also suggest that communicative competence is associated with health literacy and can facilitate the care-giving process as well as support health care interventions. Intervention programs to improve communication with patients have also been reported. Tran et al. (2004) described a How to Talk to Your Doctor forum to improve patients communication competence through a community-based

intervention program. The program consisted of workshops, written materials, videotapes, and role-playing activities targeted to elderly breast cancer survivors. Evaluation of the program indicated that the program was well received and produced improved self-perceptions of communication competence across diverse settings and participants (Tran et al., 2004). Intervention programs have also focused on improving communication skills of professionals with patients who demonstrate low literacy. Dreger and Tremback (2002) developed a home study program to educate perioperative nurses about how literacy and language barriers negatively affect health care. The study involved intervention strategies for communicating with patients with low literacy using questioning and simple language (Dreger & Tremback, 2002). Although various intervention programs have been used, communication components of health literacy continue to be reported as inadequate and in need of research and development, particularly involving questioning and informing skills during health care visits of minority patients and elderly patients (IOM, 2004; Kreps, 2006; Mika et al., 2005; Street, 2003; Williams et al., 2002). Reports indicate that communication problems may be a factor contributing to health disparities seen in these groups (Cooper & Roter, 2003; Kreps, 2006). Contributions to health literacy from the field of speechlanguage pathology could provide information that both contrasts and extends existing studies in other health-related professions in several ways. First, health literacy in people with communication disorders is an area that has been neglected in general, although there are reports that people with speech-language and hearing problems are among populations at risk for low health literacy and poor health outcomes (IOM, 2004; Mika et al., 2005). Studies of physician interactions with patients with communication disorders would add information to this body of literature. Second, investigations of health literacy skills of clients with communication disorders would provide information concerning intervention needs of these clients. Third, studies that focus on family health literacy and literacy skills are needed to examine how health literacy support systems of clients with severe communication disorders affect their health status. Finally, there is a need for speech-language pathologists to become involved in development of appropriate assessment and effective intervention materials to improve health literacy for clients with and without communication disorders.

A Conceptual Approach to Health Literacy for Speech-Language Pathologists

It seems clear that there is a role in health literacy research, assessment, and intervention for speech-language and hearing professionals. One of the goals of Healthy People 2010 is to strategically increase health communication and improve health literacy (U.S. Department of Health and Human Services, n.d.). In addition, the need for research involving the relationship between health literacy and domains of speaking, listening, and comprehension has been documented, as well as the need for inclusion of oral language in health literacy assessments (Hester & Benitez-McCrary, 2006; IOM, 2004; Mika et al., 2005). Although some

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possible suggestions have been offered in preceding sections of this article, a more conceptually based approach is presented in the following discussion. Using the continuum of health literacy proposed by Nutbeam (2000), a health literacy research, assessment, and intervention framework is proposed for communication disorders specialists. Recall that Nutbeams (2000) continuum involved functional literacy, communicative/interactive literacy, and critical literacy. One can also think of approaches to research, assessment, and intervention along such a continuum. Table 3 provides a conceptual framework for applying Nutbeams health literacy levels to research in communication disorders. For example, Level 1, functional health literacy research, would involve collecting data regarding basic knowledge of how health literacy is related to speaking and listening. This information is important for developing oral language components of health literacy assessments. Potential oral language assessments of health literacy may emphasize regulatory functions of communication including a persons ability to question, inform, agree/disagree, initiate topics, and respond. A pragmatic approach also may assess conversational repair strategies. Research that examines the relationship between oral language and health literacy also may include investigating the relationship between existing health literacy assessments and oral language measures such as the Social Communication subtest of the Functional Assessment of Communication Skills for Adults (FACS; Frattali, Holland, Thompson, Wohl, & Ferketic, 1997). Furthermore, investigations of health literacy may explore and modify tools that are currently used to assess clients with speech-language impairments in investigations. For example, assessment tools such as the Profile of Pragmatic Impairment in Communication (PPIC; Hays, Niven, Godfrey, & Linscott, 2004) may be used with existing health literacy assessments to determine possible correlations between language impairment and health literacy. The FACS-Social Communication subtest and the PPIC may provide information regarding how pragmatic functions such as questioning and informing are related to health literacy assessment and intervention.

Research studies that examine health literacy in relation to communication skills and other functional variables would provide important information that can be useful for a number of health care disciplines as well as provide impetus for interdisciplinary approaches for addressing health literacy concerns. One possible research agenda might be to use an interdisciplinary research team to examine the relations among health literacy, communication skills, and successful aging in samples of minority older adults or in samples of older adults with different types of health conditions. Similarly, interdisciplinary research by educational professionals, speechlanguage pathologists, and other health care providers should address the relationship between literacy, health literacy, communication, and other associated factors that have been suggested as important areas of study (IOM, 2004; Mika et al., 2005). Available studies in health communication and nursing on providerpatient interaction (Dutta-Bergman, 2005; Kaakinen et al., 2001) may provide information for studying pragmatic functions related to health literacy in communication disorders research. Similarly, research collaborations with health educators may expand information from existing studies on screening for low literacy in parents of pediatric patients (Bennett, Robbins, Al Shamali, & Haecker, 2003). This information would be integral to the health care of children with swallowing, hearing, craniofacial, and neurological deficits. Within the field of communication disorders, functional health literacy research would also include further examination of readability and accessibility of consumer materials as conducted in previously mentioned studies (Brennan et al., 2005; Harris et al., 2003; Kahn & Pannbacker, 2000; Rose et al., 2003). These studies have suggested simplification of consumer materials to increase readability and understanding of information concerning communication disorders. Appendix B outlines attributes of effective health communication as noted in the Health Communication section of Healthy People 2010 (U.S. Department of Health and Human Services, n.d.). Specific attributes noted include accuracy,

TABLE 3. Conceptual framework for health literacy research in communication disorders. Levels of health literacy 1: Functional health literacy Focus General information for improved knowledge Potential research questions 1. What are the readability levels of consumer materials on various communication disorders written in English and Spanish? 2. Is oral language related to comprehension of written health materials? 3. Is there a relationship between adult language assessments and existing health literacy assessments? 1. What are the effects of simplifying oral language in conferences with clients and families? 2. Do teach-back techniques improve client understanding of diagnostic findings provided in conferences? 1. How do community workshops/in-service training increase service utilization? 2. Is there a relationship between health literacy and consumer satisfaction?

2: Interactive health literacy 3: Critical health literacy

Personal skill development; improvement of capacity to act on knowledge Community, social, political involvement/ empowerment, public opinion

Note. From Health Promotion Glossary, by D. Nutbeam, 1998, Health Promotion International, 13, pp. 349364. Copyright 1998 by Oxford University Press. Adapted with permission.

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availability, balance, consistency, cultural competence, evidence base, and reach. Few studies have focused on these attributes in consumer materials relevant to communication disorders, with most emphasizing readability of materials; one early study was found regarding accessibility of services. Future research may use the attributes outlined in Appendix B as a guide for developing health literacy assessments and examination of consumer materials related to a variety of communication disorders. In addition, these guidelines provide direction for many areas of research on health literacy. For example, investigations of cultural competence and availability of materials may be areas in need of particular attention for Spanish-speaking populations. Although consumer materials relevant to communication disorders have been written in Spanish, the effectiveness of these materials as a viable source of information to the population has not been studied. According to reports that note both low literacy and low health literacy skills in this population (Garbers & Chiasson, 2004; Guerra et al., 2005; IOM, 2004; Mika et al., 2005), research is needed to address these areas. Level 2, communicative/interactive research and intervention, would include examination of interactions between clinicians and clients and ongoing data collection regarding clients understanding of communication disorders, conferences, and management of these disorders. The study on health care satisfaction by people with communication disorders noted in Table 2 indicated that these patients reported a higher dissatisfaction with the quality of their health care than people without communication disorders (Hoffman et al., 2005). This study targeted older adults, and additional studies are needed with other age groups and disorders. It is noteworthy that suggestions have been offered within the profession on ways to modify interactions with clients; however, research is needed to determine the effectiveness of such modifications as speaking slowly; using teach-back techniques, pictures, and short sentences; and chunking information (ASHA, 2008; Rao, 2007). It is important that these strategies be supported by evidence-based studies. For example, Brennan et al. (2005) found no significant differences in reading comprehension for aphasics when pictures were presented with text. These results suggest that intervention strategies to improve health literacy require an evidencebased approach as with other areas of the profession. Finally, at Level 3, critical health literacy research, assessment, intervention, and education programs could be implemented or expanded to empower clients and families to maximize use of speech-language and hearing services, similar to existing studies that have focused on the health literacy of families of patients (Bennett et al., 2003). Hospital and school work settings allow communication specialists potential access to many different groups of people, as well as opportunities to provide in-service training sessions regarding effective communication skills for the health care setting to parents, maintenance staff, and support personnel who may fall into high-risk groups for limited health literacy (Tran et al., 2004). In addition, studies that explore relationships between consumer satisfaction with services provided by communication disorder specialists and health literacy may provide helpful information about public opinion.

Summary
Health literacy is an area that has received extensive attention from many health-related disciplines. Reports indicate that there is a role for speech-language pathologists in addressing the problem of low health literacy in the country (ASHA, 2008; Hester & Benitez-McCrary, 2006; IOM, 2004; Mika et al., 2005; Rao, 2007). Attention to research, assessment, intervention, and interdisciplinary collaborations by speech-language pathologists could be important in increasing health literacy in the country and possibly improving the health outcomes for many Americans both with and without communication disorders.

References
Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs, American Medical Association. (1999). Health literacy: Report of the Council on Scientific Affairs. Journal of the American Medical Association, 281, 552557. Aleligay, A., Worrall, L., & Rose, T. (2008). Readability of written health information provided to people with aphasia. Aphasiology, 22, 383 407. American Speech-Language-Hearing Association. (2008). Health literacy. Retrieved May 7, 2008, from www.asha.org/members/ slp/healthliteracy. Baker, D., Gazmararian, J., Sudano, J., & Patterson, M. (2000). The association between age and health literacy among elderly persons. Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 55, S368S374. Baker, D., Gazmararian, J., Williams, M., Scott, T., Parker, R., Green, D., et al. (2002). Functional health literacy and the risk of hospital admission among Medicare managed care enrollees. American Journal of Public Health, 92, 12781283. Baker, D., Williams, M., Parker, R., Gazmararian, J., & Nurss, J. (1999). Development of a brief test to measure functional health literacy. Patient Education & Counseling, 38, 3342. Bennett, I., Robbins, S., Al Shamali, N., & Haecker, T. (2003). Screening for low literacy among adult caregivers of pediatric patients. Family Medicine, 35, 585590. Benson, J., & Forman, W. (2002). Comprehension of written health care information in an affluent geriatric retirement community: Use of the Test of Functional Health Literacy. Gerontology, 48, 9397. Brennan, A., Worrall, L., & McKenna, K. (2005). The relationship between specific features of aphasia-friendly written material and comprehension of written material for people with aphasia. Aphasiology, 19, 923929. Caris-Verhallen, W., de Gruijter, I., Kerkstra, A., & Bensing, J. (1999). Factors related to nurse communication with elderly people. Journal of Advanced Nursing, 5, 11061117. Champley, J., Scherz, J., Apel, E., & Burda, A. (2008). A preliminary analysis of reading materials and strategies used by older adults. Communication Disorders Quarterly, 29, 131140. Chew, L., Bradley, K., Edward, J., & Boyko, M. (2004). Brief questions to identify patients with inadequate health literacy. Family Medicine, 36, 588594. Cooper, L. A., & Roter, D. L. (2003). Provider-patient communications: The effect of race and ethnicity on process and outcomes of healthcare. In B. Smedley, A. Stath, & A. Nelson (Eds.), Unequal treatment confronting racial and ethnic disparities in health care (pp. 552593). Washington, DC: National Academy Press. Davis, G., & Ball, H. (1989). Effects of age on comprehension of complex sentences in adulthood. Journal of Speech and Hearing Research, 32, 143150.

188 American Journal of Speech-Language Pathology Vol. 18 180191 May 2009

Davis, T. C., Long, S. W., Jackson, R. H., Mayeaux, E. J., George, R. B., Murphy, P. W., & Crouch, M. A. (1993). Rapid estimate of adult literacy in medicine: A shortened screening instrument. Family Medicine, 25, 391395. Dearborn, J., Panzer, V., Burleson, J., Hornung, F., Waite, H., & Into, F. (2006). Effect of gender on communication of health information to older adults. Journal of American Geriatric Society, 54, 637641. Desmond, D., Tatemichi, T., Paik, M., & Stern, Y. (1993). Risk factors for cerebrovascular disease as correlates of cognitive function in a stroke-free cohort. Archives of Neurology, 50, 162166. Dreger, V., & Tremback, T. (2002). Optimize patient health by teaching literacy and language barriers. Association of PreOperative Registered Nurses (AORN) Journal, 75, 280283. Drew, M. (2002). Literacy, health, and health literacy: State policy considerations [Electronic version]. Focus on Basics, 5, 134. Dutta-Bergman, M. (2005). The relation between health-orientation, provider-patient communication and satisfaction: An individual difference approach. Health Communication, 18, 291303. Ebbels, S. H., van der Lely, H. K. J., & Dockrell, J. E. (2007). Intervention for verb argument structure in children with persistent SLI: A randomized control trial. Journal of Speech, Language, and Hearing Research, 50, 13301349. Egan, J., Worrall, L., & Oxenham, D. (2004). Accessible Internet training package helps people with aphasia cross the digital divide. Aphasiology, 18, 265280. Folstein, S., Folstein, E., & McHugh, P. (1975). Mini-Mental State Examination: A practical method for grading the mental state of patients for the clinician. Journal of Psychiatric Research, 12, 189198. Frattali, C., Holland, A., Thompson, C., Wohl, C., & Ferketic, M. (1997). Functional Assessment of Communication Skills for Adults. Rockville, MD: American Speech-Language-Hearing Association. Garbers, S., & Chiasson, M. (2004). Inadequate functional health literacy in Spanish as a barrier to cervical cancer screening among immigrant Latinas in New York. Preventing Chronic Disease, 1(4), A07. Gazmararian, J., Baker, D., Williams, M., Parker, R., Scott, T., Green, D., et al. (1999). Health literacy among Medicare enrollees in a managed care organization. Journal of the American Medical Association, 281, 545551. Georges, C., Bolton, G., & Bennett, C. (2004). Functional health literacy: An issue in African American and other ethnic and racial communities. Journal of the National Black Nurses Association, 15, 14. Glynn, R., Beckett, I., Herbert, I., Morris, M., Scherr, P., & Evans, D. (1999). Current and remote blood pressure and cognitive decline. Journal of the American Medical Association, 281, 438445. Guerra, C., Krumholz, M., & Shea, J. (2005). Literacy and knowledge, attitudes and behavior about mammography in Latinas. Journal of Health Care for the Poor and Underserved, 16, 152166. Harris, J., Fleming, V., & McDougall, J. (2003, November). Effects of text and reader variables on understanding health information. Poster presentation at the Annual Convention of the American Speech-Language-Hearing Association, Chicago. Harris, J., Rogers, W., & Qualls, C. (1998). Written language comprehension in younger and older adults. Journal of Speech, Language, and Hearing Research, 41, 603617. Haynes, C., & Shulman, B. (1998). Theories of communication development. In C. Haynes & B. Schulman (Eds.), Communication development (pp. 5158). Baltimore: Williams & Wilkins.

Hays, S., Niven, B., Godfrey, H., & Linscott, R. (2004). Clinical assessment of pragmatic language impairment: A generalisability study of older people with Alzheimers disease. Aphasiology, 18, 693714. Hester, E., & Benitez-McCrary, M. (2006, December 26). Health literacy: Research directions for speech-language pathology and audiology. The ASHA Leader, 11(17), pp. 3334. Hoffman, J., Yorkston, K., Shumway-Cook, A., Ciol, M., Dudgeon, B., & Chan, L. (2005). Effect of communication disability on satisfaction with health care: A survey of Medicare beneficiaries. American Journal of Speech-Language Pathology, 14, 221228. Institute of Medicine of the National Academies. (2004). Health literacy: A prescription to end confusion. Washington, DC: The National Academies Press. JAMA: Health literacy lacking in the elderly. (1999). Retrieved June 17, 2006, from www.musc.edu/catalyst/archive/1999/ C02-12jama.htm. Kaakinen, J., Shapiro, E., & Gayle, B. (2001). Strategies for working with elderly clients: Qualitative analysis of elderly client/nurse practitioner communication. Journal of the American Academy of Nurses, 13, 325329. Kahn, A., & Pannbacker, M. (2000). Readability of educational materials for clients with cleft lip/palate and their families. American Journal of Speech-Language Pathology, 9, 39. Kirsch, I., Jungebelt, A., Jenkins, I., & Kolstad, A. (1993). Adult literacy in America: A first look at the results of the National Adult Literacy Survey. Washington, DC: U.S. Department of Education, National Center for Education. Kreps, G. (2006). Communication and racial inequities in health care. American Behavioral Scientist, 49, 760774. Kutner, M., Greenberg, E., & Baer, J. (2005). A first look at the literacy of Americas adults in the 21st century (NCES 2006-470). U.S. Department of Education, National Center for Education Statistics, National Assessment of Adult Literacy. Washington, DC: U.S. Government Printing Office. Lindau, S., Tomori, C., Lyons, T., Langseth, L., Bennett, C., & Garcia, P. (2002). The association of health literacy with cervical cancer prevention knowledge and health behaviors in a multiethnic cohort of women. American Journal of Obstetrics and Gynecology, 186, 938943. Mika, V., Kelly, P., Price, M., Franquiz, M., & Villarreal, R. (2005). The ABCs of health literacy. Family Community Health, 28, 351357. Nurss, J., El-Kebbi, I., Gallina, D., Ziemer, D., Musey, V., Lewis, S., et al. (1997). Diabetes in urban African Americans: Functional health literacy of municipal hospital outpatients with diabetes. Diabetes Educator, 23, 563568. Nurss, J., Parker, R., & Baker, D. (1995). Test of Functional Health Literacy in Adults (TOFHLA). Snow Camp, NC: Peppercorn Books. Nutbeam, D. (1998). Health promotion glossary: Health Promotion International, 13, 349364. Nutbeam, D. (2000). Health literacy as a public goal: A challenge for contemporary health education and communication strategies into the 21st century. Health Promotion International, 15, 259267. Query, J., & Wright, K. (2003). Assessing communication competence in an online study: Toward informing subsequent interventions among older adults with cancer, their lay caregivers and peers. Health Communication, 15, 203218. Rao, P. (2007, May 8). Health literacy: The cornerstone of patient safety. The ASHA Leader, 12(6), pp. 89. Ratzan, S., & Parker, R. (2000). Health literacy: A policy challenge for advancing high quality healthcare. Health Affairs, 22, 147153.

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Rose, T., Worrall, L., & McKenna, K. (2003). The effectiveness of aphasia-friendly principles for printed health education materials for people with aphasia following stroke. Aphasiology, 17, 947963. Schneider, P., & Watkins, R. (1996). Applying Vygotskian developmental theory to language intervention. Language, Speech, and Hearing Services in Schools, 27, 157170. Scott, T., Gazmararian, J., Williams, M., & Baker, D. (2002). Health literacy and preventive health care use among Medicare enrollees in a managed care organization. Medical Care, 40, 395404. Shadden, B., & Raiford, C. (1984). Factors influencing service utilization by older individuals: Perceptions of communication disorders professionals and older respondents. Journal of Communication Disorders, 17, 209224. Shapiro, L. (1997). An introduction to syntax. Journal of Speech, Language, and Hearing Research, 40, 254272. Sharp, L., Zurawski, J., Roland, P., OToole, C., & Hines, J. (2002). Health literacy cervical cancer risk factors, and distress in low-income African American women seeking colposcopy. Ethnicity & Disease, 12, 541546. Stone, C. A. (2004). Contemporary approaches to the study of language and literacy development. In C. A. Stone, E. R. Silliman, B. J. Ehren, & K. Apel (Eds.), Handbook of language and literacy: Development and disorders (pp. 324). New York: Guilford Press. Street, R. L., Jr. (2003). Interpersonal communication skills in health care contexts. In J. O. Greene & B. R. Burleson (Eds.), Handbook of communication and social interaction skills (pp. 909933). Mahwah, NJ: Erlbaum.

Tran, A., Haidet, P., Street, R., OMalley, K., Martin, F., & Ashton, C. (2004). Empowering communication: A community-based intervention for patients. Patient Education and Counseling, 52, 113121. Tzourio, C., Dufouil, C., Ducimetiere, P., & Alperovitch, A. (1999). Cognitive decline in individuals with high blood pressure: A longitudinal study in the elderly. Neurology, 53, 19481952. Ukrainetz, T. (2005). Contextualized language intervention. Greenville, NC: Thinking Publications. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (n.d.). Healthy People 2010. Retrieved June 17, 2006, from www.health.gov/ healthypeople. Williams, M., Davis, T., Parker, R., & Weiss, B. (2002). The role of health literacy in patient-physician communication. Family Medicine, 34, 383389. Williams, M., Parker, R., Parikh, K., Coates, W., & Nurss, J. (1995). Inadequate functional health literacy among patients at two public hospitals. Journal of the American Medical Association, 274, 16771682. Received February 5, 2008 Accepted September 20, 2008 DOI: 10.1044/1058-0360(2009/08-0005) Contact author: Eva Hester, Towson University, Communication Sciences & Disorders, 8000 York Road, Towson, MD 21214. E-mail: ehester@towson.edu.

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Appendix A Sample Test Items

From Test of Functional Health Literacy in Adultsa Your doctor has sent you to have a ________ X-ray. a. stomach b. diabetes c. stitches d. germs You must have an ___________ stomach when you come for _________. a. asthma a. is b. empty b. am c. incest c. if d. anemia d. it Numeracy question related to written directions: If you take your first tablet at 7:00 a.m., when should you take the next one? From Rapid Estimate of Adult Literacy in Medicineb List 1 List 2 Fat Fatigue Flu Pelvic
a b

List 3 Allergic Menstrual

Nurss et al. (1995), reprinted with permission of Peppercorn Books & Press, www.peppercornbooks.com. T. C. Davis et al. (1993), reprinted with permission from the Society of Teachers of Family Medicine, www.stfm.org.

Appendix B Attributes of Effective Health Communication

Accuracy: The content is valid and without errors of fact, interpretation, or judgment. Availability: The content (whether targeted message or other information) is delivered or placed where the audience can access it. Placement varies according to audience and message complexity, and sources range from billboards and mass transit signs to prime-time TV. Balance: Where appropriate, the content presents the benefits and risks of potential actions or recognizes different and valid perspectives on the issue. Consistency: The content remains internally consistent over time and also is consistent with information from other sources (the latter is a problem when other widely available content is not accurate or reliable). Cultural competence: The design, implementation, and evaluation process accounts for special issues for select population groups (e.g., ethnic, racial, and linguistic) and also educational levels and disability. Evidence base: The content is based on relevant scientific evidence that has undergone comprehensive review and rigorous analysis to formulate practice guidelines, performance measures, review criteria, and technology assessments for telehealth applications. Reach: The content gets to or is available to the largest possible number of people in the target population. Reliability: The source of the content is credible, and the content itself is kept up to date. Repetition: The delivery of/access to the content is continued or repeated over time, both to reinforce the impact with a given audience and to reach new generations. Timeliness: The content is provided or available when the audience is most receptive to, or in need of, the specific information. Understandability: The reading or language level and format (including multimedia) are appropriate for the specific audience. Source. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion, Healthy People 2010. Retrieved June 17, 2006, from www.health.gov/healthypeople.

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Tutorial

Establishing a Pedagogical Framework for the Multicultural Course in Communication Sciences and Disorders
RaMonda Horton-Ikard
Florida State University, Tallahassee

Maria L. Munoz
Texas Christian University, Fort Worth

Shurita Thomas-Tate
Florida State University, Tallahassee

Yolanda Keller-Bell
University of Georgia, Athens

Purpose: To provide an overview of a model for teaching a foundational course in multicultural (MC) issues and to demonstrate how it can be modified for use in communication sciences and disorders (CSD) by integrating 3 primary dimensions of cultural competence: awareness, knowledge, and skills. Method: This tutorial begins by establishing the need for a basic foundational course in MC issues for CSD. Next, the authors describe a framework for MC instruction developed in the field of clinical counseling. Finally, the framework

is modified and applied to the implementation of an MC course in CSD. Conclusion: The MC course in CSD can provide a useful foundation for facilitating the cultural competence of students in university training programs that have infused MC material across the American Speech-Language-Hearing Associations 9 content areas. Key Words: multicultural course, pedagogy, training

he cultural landscape of the U.S. population is rapidly changing. There have been substantial increases in various racial, ethnic, and linguistically diverse populations. A recent census profile indicated that by the year 2050, the U.S. minority population will expand by at least 44% (Day, 1996; U.S. Census Bureau, 2008). As the population changes, the number of individuals from culturally and linguistically diverse (CLD) backgrounds requiring the services of speech-language pathologists or audiologists will also increase. However, the number of professionals in the field who feel confident in their abilities to serve CLD populations is very small (Roseberry-McKibbin & OHanlon, 2005). The American Speech-Language-Hearing Association (ASHA) has addressed these issues through a number of broad-based programs that focus on the recruitment and retention of minority students and professionals, multicultural (MC) research, and maintaining and providing resources for ASHA constituents on the importance of MC issues

(ASHA, 1991, 1998). These types of initiatives have resulted in a greater number of communication sciences and disorders (CSD) training programs devoting more attention and effort to MC issues. Recently MC competencies were infused within each of the nine content areas of the knowledge and skills acquisition standards for the certification of speech-language pathologists and audiologists. In the 2005 Standards and Implementation Procedures for the Certificate of Clinical Competence in Speech-Language Pathology, ASHA states the following: Standard III-C: The applicant must demonstrate knowledge of the nature of speech, language, hearing, and communication disorders and differences and swallowing disorders, including the etiologies, characteristics, anatomical/physiological, acoustic, psychological, developmental, linguistic and cultural correlates [italics added]. (ASHA, 2005b)

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In effect, clinicians must demonstrate some level of cultural competence in academic and clinical aspects of the nine core areas of speech-language pathology. Although these standards are currently in effect, courses that specifically address MC issues are not offered at many accredited CSD programs (ASHA, 2005a). The majority of programs use an infusion model to meet standards for MC training, which means that each instructor is expected to embed MC topics or themes along with traditional course content (Stockman, Boult, & Robinson, 2004). Currently, ASHA recommends an integral infusion model to disseminate MC content. Infusion as an integral part of course content means that every aspect of course content considers the cultural context as a relevant variable in the construction of knowledge about that content (Stockman, 2003, 3). This model recognizes that communication is culturally embedded; therefore, academic and clinical learning should be inherently MC (Stockman et al., 2004). Unfortunately, there are several limitations associated with effectively integrating MC issues throughout the curriculum (Stockman et al., 2004). First, with the exception of a small number of textbooks, there are few resources available to guide course and curriculum design for producing culturally competent practitioners within our field. Second, there is little evidence to indicate which instructional practices result in effective infusion. Finally, there is a small percentage of CSD academicians who specialize in MC research and teaching. The majority of clinical and academic instructors may not have MC competence for content in their area of expertise. MC training within the field of CSD is still in its infancy when we compare it with other behavioral sciences and clinical training programs (i.e., psychology, nursing). Scant literature is available regarding the teaching of MC content in our field and the effectiveness with which it prepares culturally competent practitioners. Stockman, Boult, and Robinson (2003) conducted the only investigation of MC training in CSD a survey of Council on Academic Accreditation (CAA) accredited programs in the United States. The results revealed that there are no common priorities for what students need to know regarding MC issues in communication disorders. Although infusion is the preferred model of instruction, we argue that a foundational or core course is necessary for the infusion model to be truly effective. However, the form and function of such a course are still to be determined. Infusion should be supported with a core MC course for three primary reasons. First, a well-designed course will ensure that students receive exposure to important basic concepts (i.e., culture, multiculturalism, diversity, cultural competence, etc.). Such concepts provide a foundation for the integration of themes and practices infused throughout the curriculum (Ridley, Espelage, & Rubinstein, 1997). With a foundational course to support infusion, every member of the CSD faculty remains responsible for specific MC content but is not overwhelmed by the need to provide breadth of topic at the expense of depth. Second, the attainment of MC learning outcomes (and by implication teaching effectiveness) can be evaluated with instruments designed to measure the effectiveness of a course in promoting cultural competence (Gopaul-McNicol & Brice-Baker, 1998;

Pope-Davis & Dings, 1995). Last, a well-designed course will encourage and motivate students to think critically about MC issues and promote generalization to clinical practice. The current tutorial is written for those in our field who would like to develop an effective and meaningful MC course but who may lack the expertise and resources to do so. The purpose of this article is to illustrate how a pedagogical framework developed in a related field can be adapted to define a set of priorities for MC competence and education in CSD. The framework can guide the way we teach MC issues in CSD programs by providing a consistent structure for content and methods that have been proven effective in other academic and clinical training programs (PopeDavis & Coleman, 1997).

Adopting a Pedagogical Framework

The fields of psychology, education, social work, and nursing have developed numerous frameworks for designing and implementing MC programs, curriculum, and courses (Barona, Santos de Barona, Flores, & Guttierrez, 1990; Ridley, Baker, & Hill, 2001; Sue, Arrendondo, & McDavis, 1992). For the purposes of the current tutorial, we focus on a model for MC course development in counseling psychology proposed by Ridley, Mendoza, and Kanitz (1994). The model consists of five components for MC instructional planning: establishing a teaching philosophy, defining learning objectives, choosing topics, implementing instructional practices, and evaluating competency. The first step in the creation of the foundational course is to establish a teaching philosophy. Teaching philosophies are statements of the teachers attitude toward MC issues and training. The teaching philosophy defines the importance that is attached to MC content and issues for the curriculum and clinical training of students. It also articulates the instructors role in facilitating cultural competence. The teaching philosophy guides how instructors will structure classroom culture, discourse, and interactions. After the teaching philosophy has been established, the learning objectives should be clearly defined for the course. Ridley et al. (1997) suggested that instructors need to consider the 10 basic learning objectives outlined in Table 1
TABLE 1. Ridley et al.s (1997) 10 basic learning objectives. No. 1 2 3 4 5 6 7 8 9 10 Learning objectives Students will display culturally responsive behaviors. Students will demonstrate ethical knowledge and practice. Students will demonstrate cultural empathy. Students will critique the literature for cultural relevance. Students will develop culturally relevant theoretical orientations. Students will demonstrate knowledge of normative characteristics. Students will develop cultural self-awareness. Students will demonstrate knowledge of within-group differences. Students will demonstrate the ability to define multicultural concepts and issues. Students will display respect for cultural differences.

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when creating and designing an MC course. The chosen learning objectives should be compatible with the instructors personal philosophy of what MC training should accomplish, which means that not all of the learning objectives will be important to all instructors. Once the teaching philosophy is established and the learning objectives have been identified, the instructor is faced with the challenge of deciding what topics should be addressed within the course. A review of the MC counseling and health literature indicates that the following topics are addressed most frequently in MC courses: rationale for MC training, racism, power and prejudice, assessment and diagnosis, service delivery and intervention strategies, MC counseling research and racial identity development, ethical issues in MC counseling, and normative group information (HolcombMcCoy & Myers, 1999; Ridley et al., 2001; Toporek & Reza, 2001). The instructional strategies used to accomplish the learning goals and to disseminate information on the chosen topics for MC courses from other arenas have included didactic methods, technology-assisted training, reading and writing assignments, conducting research projects, experiential exercises, participatory learning, modeling/observational learning, and introspection activities (Amatrano, Callaway, & Stickel, 2002; Chen & Treacy, 1996; Mio & Barker-Hackett, 2003). Experiential exercises generally involve service and clinical projects with targeted nonmainstream populations. Participatory learning may include clinical case interaction with individuals from nonmainstream populations. Modeling/ observational learning often takes on the form of role-play activities that replicate real-life clinical situations with grand round discussion formats. Introspection activities involve the use of activities such as journal writing and reaction papers. The final component of Ridley et al.s (1994) model is the evaluation of competency. Research in MC counseling and education has demonstrated that administration of MC course evaluations and surveys is an effective method for measuring outcomes of training culturally competent service providers (Constantine & Ladny, 2000). Evaluations and surveys measure achievement of learning objectives and effectiveness of instructional strategies. MC evaluations and surveys can also provide baseline and objective data about changes in student attitudes and awareness about MC issues, and help determine whether students demonstrate increased levels of knowledge for the topics covered in the course (Arthur & Januszkowski, 2001; Constantine & Ladny, 2000; Gopaul-McNicol & Brice-Baker, 1998; Lester, 2000; Ponterotto, Alexander, & Grieger, 1995). The field of CSD has much in common with counseling psychology. Each of the components of MC instruction proposed by Ridley et al. (1994) can be easily adapted for use in CSD. However, some modification was necessary to parallel the nomenclature and organizational framework within CSD. Specifically, we suggest integrating the three dimensions of competency acknowledged by ASHA as critical for developing cultural competence: awareness, knowledge, and skills (ASHA, 1983, 1985, 2004, 2005a). Awareness refers to the ability of the clinician to develop a positive orientation toward MC perspectives and to recognize how personal biases and values might interact with

service delivery for speech and language disorders. Knowledge refers to the clinicians understanding of issues of great relevance to individuals from CLD backgrounds and his or her understanding of sociocultural factors that influence cross-cultural communication. The skills dimension refers to specific clinical abilities that will be necessary for speechlanguage pathologists to provide culturally appropriate and relevant services to individuals from the CLD population. In the following section, we discuss how Ridley et al.s (1994) model has been adapted to guide the development and implementation of an MC course in CSD. An excerpt from a course syllabus is provided in Appendix A to demonstrate the link between the pedagogical framework and the course format. In addition, Appendixes B, C, D, and E provide additional resources that were used throughout the teaching of the MC course.

An Example of an MC Course in CSD

Over the past 4 years, we have implemented a core MC course in different CSD programs that infuse MC content throughout the general curriculum. The MC course described below was taught during the 2nd year of a 2-year masters program. The instructors for the course were from minority backgrounds and carried out research agendas focused on CLD populations. Ridley et al.s (1994) model was useful for guiding the development of the MC course used in this example. However, it is important to note that the CSD model described here differs from Ridley et al.s original model in that the five components integrate awareness, knowledge, and skills (see Figure 1). We view the model as interactive and specifically designed to address course development issues in CSD.

Component 1: Teaching Philosophy

Several key beliefs reflect the teaching philosophy that guided the development of the MC course. The teaching philosophy acknowledged that it was important for students to achieve the following items: 1. Have an understanding of the historical and cultural legacies of U.S. minority groups as a context for understanding unique and shared cultural experiences. 2. Develop culturally sensitive attitudes toward all individuals. 3. Gain theoretical knowledge and expertise on the impact of sociocultural factors on communication development. 4. Become experienced with delivering services to individuals who come from a variety of CLD backgrounds. In articulating the teaching philosophy, one of the unique issues that instructors have to contend with when teaching the MC course is managing student attitudes concerning the relevance of MC training to CSD. According to Clark (2002), few graduate programs provide pedagogical training within their own discipline, and fewer still provide guidance in how to incorporate an MC perspective. As instructors in the field of CSD who teach MC content, we face a dual challenge. We are required to try and increase cultural awareness and disseminate information regarding the skills and

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FIGURE 1. A pedagogical model for multicultural training in communication sciences and disorders.

knowledge necessary for providing services to an increasingly diverse population. Often, these two tasks must be accomplished without the benefit of formal training in pedagogical issues. Unlike other content areas within our field, MC training deals with critiques of well-established social systems and personal beliefs and values. This challenge requires the instructor to address a number of social, economic, and political factors that students may find uncomfortable. High levels of student discomfort may increase the likelihood of anxiety or resistance. Students may exhibit anxiety or resistance to the content addressed in an MC course as well as the process of MC education (Deal & Hyde, 2004). A student is expected to examine his or her cultural beliefs and then integrate and apply this information in clinical situations as a beginning speech-language pathologist or audiologist. Therefore, it is critical for instructors to consider these factors in establishing a teaching philosophy for the course and to develop appropriate interpersonal skills for dealing with student anxiety and resistance (Deal & Hyde, 2004). Student resistance and anxiety about MC education is a phenomenon that has been recognized in other professions, such as social work, psychology, and education. Many of the interpersonal strategies used in these professions can be

adapted for the field of CSD (Clark, 2002; Deal & Hyde, 2004; Higgenbotham, 1990). The theme underlying these strategies is to create supportive classroom environments, establish positive relationships with students, and provide a foundation for the discussion of sensitive issues. At the beginning of the course, the instructor should discuss how his or her experiences in society have influenced his or her teaching, learning, discourse styles, and professional philosophies (Young & Tran, 2001). Students are frequently expected to share such personal information within a classroom but may be reluctant to do so because they fear being judged as privileged, racist, or naBve by the instructor or their peers (Deal & Hyde, 2004). Knowing that the instructor is willing to share this information may decrease a students anxiety or reluctance to participate in classroom discussions. Specific issues within multiculturalism should be viewed as a work in progress rather than a time-oriented goal (Young & Tran, 2001). It may be expected that students master specific learning objectives, such as differentiating language differences from disorders. However, areas such as increasing MC awareness may take longer to develop. Depending upon his or her background and beliefs, each student may be
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at a different stage of cultural awareness (Young & Tran, 2001). For example, we have encountered students who state at the outset of the course that culture has had little influence in their lives. However, after class discussions that explicitly define culture, provide examples of cultural differences, and analyze the role of culture in our society, students often express a greater awareness of cultural influences at the end the course. A common complaint from students in MC courses is that the instructor has an agenda. Criticism of a students opinion can be perceived as bias against that particular student or particular ideological viewpoint. This presents a challenge in the classroom, particularly when the instructor strongly disagrees with the students opinion. One suggestion is to reframe and redirect the discussion to common professional issues and goals (Young & Tran, 2001). Instead of debating a students general belief (e.g., racism and stereotyping do not exist in 2008), discuss whether there is test bias in normreferenced test measures and what factors may contribute to test bias. The focus of the discussion is directed toward a common goal (i.e., fair and appropriate assessments measures) but still addresses issues of race and ethnicity. Instructors should also clearly distinguish between their own personal experiences and opinions, evidence-based facts, and the professional requirements of the field when engaging in discussion of such controversial topics. The ethnicity, gender, and sexual orientation of an instructor may influence students perception of their instructor (Alexander-Snow, 2004). Faculty from minority backgrounds may be perceived as being politically correct by White students, whereas students from minority backgrounds may be suspicious of a White instructor (Young & Tran, 2001). Additionally, even within a supportive environment, instructors are still in a position of power. Ultimately, there is a power differential within the classroom. The instructor does have the power to evaluate student performance, a fact that may increase a students reluctance to disagree with the instructor or to express unpopular opinions. These factors underscore the importance of creating and acknowledging ones own experiences and biases. By sharing this information with students, the instructor will enable the students to develop an understanding of how his or her background influences his or her pedagogical approach and treatment of MC topics.

Components 2, 3, and 4: The Integration of Learning Objectives, Topic Selection, and Instructional Strategies for Facilitating Awareness, Knowledge, and Skills
The next three components from Ridley et al.s (1994) model (learning objectives, topic selection, and instructional strategies) are so dependent upon one another that they cannot be discussed separately in describing the course. For this reason, these steps are embedded in the description of course content organized around the three dimensions of competency: awareness, knowledge, and skills. The learning objectives for the course are outlined on the syllabus, and these objectives reflect current ASHA standards (ASHA, 2004, 2005a; see Appendix A). The selection of the course

topics included on the syllabus and the instructional strategies used to disseminate the course content reflected the teaching philosophy previously described while at the same time addressing the learning objectives outlined for the MC course. Awareness Cultural awareness is an important objective in MC instruction. Training that includes awareness provides clinicians with the motivation necessary to deliver culturally competent services. Negative clinical behaviors and practices are unlikely to change unless attitudes and perceptions about CLD populations change (Fazio, 1990). Our teaching of the MC course emphasized the development of cultural awareness through instructional strategies that utilized text and journal readings, as well as discussions and activities, aimed at the following topics: developing self-awareness, examining personal biases, and expanding worldviews. These types of activities involved reflections and critiques of personal beliefs and value systems. As such, one of the first things that we did in the course was to establish ground rules for the course (EdChange & Gorsky, 2008). The ground rules listed in Appendix B served two purposes. First, they informed students that there might be some level of discomfort when discussing the topics to be addressed over the course of the semester. Second, they helped to establish that the classroom was an environment where the discussion of differences would occur in a nonthreatening and nonjudgmental space. Addressing awareness issues at the beginning of the course provides a foundation for the knowledge and skills gained throughout the course (Sue, 2001). At the outset of the course, it is imperative that students become more self-aware and examine their own personal identities. When we talk about culture, many mainstream, middle-class White students find it difficult to imagine themselves as a part of the discussion; any conversation of culture refers to them or the other. To make the discussion relevant to them, we took the time to develop a definition of culture that is inclusive rather than exclusive. We have defined culture as all of the things that make us who we are as a community of people. This may include, but is not limited to, our behaviors, language, rituals, dress, values, and beliefs (Nieto & Bode, 2004). After developing this definition of culture with the students, they are guided to think and write about their own cultural experiences. The next step is for students to develop a concept of multiculturalism. This step facilitates the discussion of diversity as more inclusive of students from a variety of backgrounds (Delpit, 1995). The discussion of multiculturalism and diversity also provides students with the opportunity to acknowledge and discuss similarities and differences in their cultural backgrounds with their classmates. Furthermore, conceptualizing culture and multiculturalism in this manner makes the idea of diversity less foreign to students. Sue (2003) has suggested that as clinicians become more comfortable with themselves, they will become more comfortable accepting differences in their clients. Once students have started developing a greater sense of self, they are ready to begin addressing their personal biases. We start with discussing the idea that we all have biases, and if unchecked, these biases may cause barriers that affect

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the delivery of services (Abreu, 2001). A number of tools have been developed to assess these personal biases (Brown, Parham, & Yonker, 1996; Pope-Davis & Dings, 1995; PopeDavis & Ottavi, 1994; Sue, 1999). However, Taylor and Payne (1994) have provided one that we have found to be particularly effective in examining personal attitudes and perceptions about language and culture. Students are challenged to take ownership of their personal beliefs and therefore responsibility for changing them. For example, one discussion question that might be posed to students is How do cultural biases affect clinical judgment and interpretation of observations? This discussion on personal biases provides a great entry into differentiating stereotypes from established knowledge/information about specific populations. Another way to assist students in increasing their cultural awareness is through providing them with the opportunity to expand their worldview. Many of our students have little experience with persons who they believe to be culturally different from them. One method for helping students to expand their worldview is to have them participate in servicelearning activities (OGrady, 2000). These opportunities can be set up through international student services, public school English as a second language (ESL) programs, and community outreach programs. Students are generally assigned to a person or group of persons to work with over the semester, providing them with some established service (e.g., English conversation partners, tutors, mentor, and advocates). These service-learning opportunities provide students with the opportunity to interact with and develop relationships with people who may not share the same cultural values, assumptions, and beliefs. For students to develop cultural awareness, they need to develop a sense of their cultural self, examine and challenge their personal values and beliefs, and expand their worldview. This can be achieved through a number of methods, but we believe that it needs to be explicitly addressed for students to make the most of the knowledge and skill they are gaining about CLD populations. Appendix C provides a list of resources, including Web sites and books, that will be useful to instructors who are interested in facilitating cultural awareness. Knowledge The instructor who teaches the MC course should select texts, materials, and content that allow students to clearly articulate the framework of the course. Course content for the acquisition of knowledge in the MC core course focused on theoretical perspectives, research frameworks, ASHA position papers, and assessment and treatment literature that specifically addressed the needs of CLD populations. Once again, these topics were chosen on the basis of the learning objectives outlined in the syllabus (see Appendix A) and were consistent with the teaching philosophy. Theoretical perspectives and research frameworks are generally addressed in CSD classes. However, there has not been a model for how this should be addressed in the MC CSD course. Determining what to incorporate related to theoretical perspectives involved reviewing the literature in other training programs similar to speech-language pathology (e.g., counseling, school psychology) to garner what content might be addressed. We identified three primary topics

that were consistent with the teaching of theoretical issues for other behavioral sciences and the learning objectives outlined in the syllabus. These three topics included providing students with content on the (a) historical context for the fields push to MC competence, (b) research methods used to investigate targeted behaviors of minority groups, and (c) frameworks/paradigms for describing disability in minority groups (Holcomb-McCoy & Myers, 1999; Ridley et al., 2001; Toporek & Reza, 2001). The need to understand historical perspectives is important given the social injustices that minorities have faced with regard to education and health care in the United States. It is necessary for students to understand how our field has evolved in terms of knowledge and practices. The ASHA position papers alone are a great resource for clinicians as they work with individuals from CLD populations, but understanding why the papers exist also contextualizes the importance of MC issues. One instructional strategy that can be helpful is the use of a timeline that highlights key historical moments for professionals in the field of speech-language pathology (see Appendix D). These types of descriptions are useful tools for engaging students in discussions concerning the history and legacy of legislation and litigation that played a role in ASHAs creation of many of the position papers that focus on cultural and linguistic diversity (Rhoades, Ochoa, & Ortiz, 2005; Taylor, 1986). The second topic addressed the issue of research methodology that has been used to investigate the language behaviors of CLD populations. This type of critical inquiry enables students to be better consumers of MC research. Instructors can help students identify specific MC methodologies that are used during investigations and compare and contrast methodologies used in investigations concerned with individuals from mainstream populations. For example, over the last decade or so, there has been an increase in the number of studies that employ the use of language sample analysis, dialect density measures, ethnographic assessments, behavioral checklists, and interviews to describe the language behaviors of children from CLD backgrounds (Craig & Washington, 2000; Horton-Ikard & Ellis Weismer, 2007; Jackson & Roberts, 2001; Oetting & McDonald, 2002). By drawing attention to such issues, instructors make it possible for students to recognize culturally appropriate and valid models of MC research. The third issue that was addressed was the identification of frameworks that have been used and are currently used to discuss ability and disability in minority populations. For example, the lecture presentations and discussions for research frameworks specifically focused on teaching students to recognize the deficit, deprivation, and difference models that have been associated with MC research in the behavioral sciences. The deficit model suggests that behavioral differences between racial groups are innate and/or the result of genetic factors that deviate from the norm. The deprivation model suggests that behavioral differences between various racial groups are due to lack of privilege or advantages of the mainstream population. The difference model recognizes the legitimacy and value of cultural differences, and those behaviors that differ from the mainstream are not labeled as disordered or impaired. The presentation of these three types
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of models was discussed in detail with readings from Stockman (1995) and Garcia Coll et al. (1996). Beyond theoretical perspectives, it was important for students to gain knowledge in a number of other areas. Didactic presentations for our courses focused on sociolinguistic and cultural influences; typical language development in simultaneous and sequential bilinguals; normal processes of second language acquisition; linguistic concepts, such as defining the terms accent, dialect, and language; and patterns of language recovery for adults following a neurological insult. In addition, the course content addressed literature on socioeconomic influences on communication and development, special education policies, bilingual education policies, and information on bilingual and special education policies for specific states. Finally, for each of the topics covered, students were provided with additional resources and information. For example, the ASHA Web site was listed as the best resource for accessing information for the position papers. A number of U.S. Department of Education technical reports served as additional resources for students on bilingualism and special education policies. The following-up of lectures, activities, and discussions with additional resources made it possible for students to gather more information on topics that were presented at a basic level during the class time (see Appendix B). Skills As previously discussed, ASHA has published a comprehensive description of the knowledge and skills that speechlanguage pathologists must acquire to provide culturally appropriate services (ASHA, 2004). No single course can prepare students to serve CLD individuals in all areas of communication disorders, as indicated by the ASHA (2004) knowledge and skills document. However, the MC course can provide a platform onto which students can integrate

diversity issues infused in other domain specific courses (e.g., fluency, voice, adult neurogenics, child language development) and address specific issues that speech-language pathologists have felt poorly equipped to handle, such as nonbiased assessment (Kohnert, Kennedy, Glaze, Kan, & Carney, 2003; Kritikos, 2003). The critical MC clinical skills that students must develop include the ability to differentiate a communication difference from a communication disorder and to provide culturally appropriate intervention services. To this end, we address clinical skills within the context of a framework for less biased assessment, and strategies for intervention. The framework and instructional strategies are designed to address specific ASHA-identified knowledge and skills. To assist students in applying knowledge about culturallinguistic diversity to clinical decision making, we conceptualize the assessment process as a five-stage model (see Figure 2): referral, gathering background information, testing, interpretation of results, and recommendations. For each stage, we use available literature, case studies, and in-class activities to transfer knowledge to clinical skill. Students must identify and reduce potential sources of bias to provide culturally and linguistically appropriate services (Taylor & Payne, 1994) as well as appropriately select and utilize alternate assessment practices (Laing & Kamhi, 2003; Leonard & Weiss, 1983; Roseberry-McKibbin & OHanlon, 2005). Step 1: The referral. Most assessments are initiated by a party other than the speech pathologist (i.e., teacher or a doctor). The cultural expectations and experiences, as well as cross-cultural training of the referrer, will influence how he or she interprets an observed communicative behavior. Teachers may interpret certain culturally appropriate discourse patterns as tangential or disorganized (Michaels, 1981), and physicians may interpret another language as jargon

FIGURE 2. Model for least biased assessment of culturally and linguistically diverse populations.

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aphasia (Holland, 1983). We discuss case examples of referrals (within the context of the referrer and referred) and determine how cultural matches/mismatches may have influenced the referral. We emphasize that individuals can be members of a variety of cultural groups and that cultural groups are heterogeneous. Step 2: Gathering background information. We emphasize to students that we cannot make assumptions about an individual on the basis of race, ethnicity, gender, or any number of other cultural variables. Culturally appropriate assessment requires collecting data to identify the patient/clients cultural group memberships, cultural norms (social, communicative, etc.), and linguistic experiences and how they may influence the assessment process. As previously noted, we read Garcia Coll et al.s (1996) article in which the authors describe some sociocultural factors that shape minority childrens developmental trajectories (e.g., social position variables, racism, prejudice, discrimination, segregation, promoting/ inhibiting environments, adaptive culture, child characteristics, family characteristics, and general developmental abilities). Students were given the opportunity to reflect on and discuss the role of these factors in their own lives and predict how they might influence communicative development in children. We discussed the importance of interpreting cognitive and communicative skills/development in relation to known promoting and inhibiting factors. Additionally, we stressed to students the importance of gathering background information on the language(s) and dialect(s) spoken in the home and community. We provided a brief overview of bilingualism and discussed how specific experiences may influence bilingual language development across the lifespan. Case studies provided students with the opportunities to predict how language/dialect background influences the assessment process. Students explored language history and used questionnaires (Muoz, Marquardt, & Copeland, 1999) to learn to identify information critical to the assessment process. Finally, students were taught to identify parental concerns and family history of cognitive or communicative impairment through case study and role play (Restrepo, 1998). Step 3: Testing ( formal and informal). Selection of testing instruments, whether formal or informal, is part of the clinical decision-making process. We emphasized that formal standardized tests should only be used if they are appropriate given the client/patients cultural-linguistic background. Students were given the opportunity to review test manuals to explore the psychometric properties (Hutchinson, 1996), potential sources of bias (Taylor & Payne, 1994), and how responses to specific items may be influenced by culturallinguistic variation (using dialect and language features summarized by Goldstein, 2000). Students reviewed the tests in class, discussed their findings, and prepared handouts on each test for their peers (see Appendix E). During classroom discussions of standardized assessment tools, we included strategies for controlling different sources of bias (linguistic, situational, format; see Taylor & Payne, 1994). We stressed that any deviation from the test format invalidates the norms and that standardized norms may not be appropriate for use with certain linguistic groups. Consequently, this led to discussions about useful alternatives to standardized test

scoresfor example, alternate norms and developmental information (Saenz & Huer, 2003), accepting linguistically appropriate responses (Taylor & Payne, 1994), and conceptual scoring (Pearson, Fernandez, & Oller, 1993). Students were given samples of completed test forms to practice these alternate scoring procedures. In class, we stressed the importance of implementing alternate measurements of communication and cognition, such as dynamic assessment (Pea, Quinn, & Iglesias, 1992), language sample analysis (Craig & Washington, 2000; Gutierrez-Clellen, Restrepo, Bedore, Pea, & Anderson, 2000), and multiple observations in naturalistic settings with a focus on functional communication (Roseberry-McKibbin, 1994). Students read about dynamic assessment tools and models. They then demonstrated the use of dynamic assessment to the class. Additionally, we provided students with language samples from African American English speakers and asked them to calculate dialect density, number of different words, number of words, and amount of complex syntax (Craig & Washington, 2002). We discussed the use of interpreters in clinical practice when a clinician who speaks the individuals language is not available. We described the etiquette of using an interpreter and, when possible, engaged in role-play with a client/ patient, clinician, and interpreter. Step 4: Interpretation of results. Once students have collected all assessment data, they must integrate all data to maximize accuracy in diagnosing a communication disorder. This involves reviewing the data, prioritizing the data, and making inferences about the quality of the data. We utilized case studies so that students could practice sorting the data (e.g., data that indicated a communication difference, and data that indicated a communication disorder). Students then examined the data in each column. For example, a bilingual Spanish-speaking child may have performed below the cutoff for impaired performance on a standardized test but demonstrated no parental concerns, no family history of speech-language delay, and acceptable performance on a language sample analysis (grammatical errors per T-unit, mean length T-unit). One of our readings indicated that these informal measures best differentiated between typically developing and language delayed speakers and, thus, may offset the poor performance on a standardized test (Restrepo, 1998). Step 5: Recommendations. Culturally competent clinicians must integrate available data to recommend (a) an appropriate course of action consistent with an individuals educational and social experience, as well as (b) practice guidelines in speech-language pathology. Recommendations may include no need for therapy, therapy, or a need for further follow-up. Students followed case studies through the five-stage process. They practiced using the data collected to justify their recommendations. Additionally, they identified specific concerns that, rather than indicate a communication disorder, were consistent with cultural-linguistic norms. When the need for treatment is indicated, clinicians must select culturally and linguistically appropriate treatment goals and activities. Unfortunately, research is limited in regard to treatment consideration and CLD populations. We used case studies to assist students in identifying treatment goals that seek to remediate the communicative impairment
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rather than target culturally appropriate linguistic variation. In regards to bilingualism, students practiced selecting the language of treatment for specific goals and predicting the impact of dual language use on development and /or crosslanguage transfer (Bond & Hein, 1985; Gutierrez-Clellen, 1999; Kohnert, Kim, Nett, Kan, & Duran, 2005; Watamori & Sasanuma, 1976, 1978).

Component 5: Evaluation of Competency

The final component of our pedagogical framework addresses the importance of assessing cross-cultural competencies. Given that the teaching of MC content in CSD is a relatively new endeavor, assessment is necessary to evaluate the adequacy of the teaching framework in achieving the actual goal of producing culturally competent professionals. A number of instruments within the MC counseling arena have been designed to assess awareness, knowledge, and skills of mental health professionals (Gopaul-McNicol & Brice-Baker, 1998; Toporek & Reza, 2001). Although some of these instruments contained items general enough in nature to be used outside of the counseling arena, many of them were very specific to counseling and did not address issues that might be relevant for speech-language pathologists. To that end, we adapted Kritikoss (2003) survey for assessing speech pathologists experiences and course work with bicultural individuals. Our MC assessment tool included additional evaluation components related to the topics outlined in each of the above sections. The MC survey elicited information about each students background, academic course work, and clinical experiences with CLD populations. It also asked students to rate their own levels of competency in providing services to CLD populations. Students also completed a traditional end-of-course evaluation of openended questions that solicited feedback on positive and negative aspects of the course. Students who completed the surveys filled out consent forms, and the use of the surveys within this tutorial was approved by the institutional review board. The next section provides a summary of the information obtained from the MC survey and end-of-course evaluations. The MC survey was administered at the beginning and end of each semester that the course was taught. The primary purpose of the survey was to determine whether there were differences in students perceived levels of competency prior to and immediately following completion of the MC course. The following questions were addressed on the pre- and postMC course surveys: 1. With the help of an interpreter, how competent do you feel in assessing the language skills of a person who speaks a foreign language (one you do not use)? 2. How competent do you feel in assessing the language skills of a person who uses a non-Standard American English (SAE) dialect? 3. How competent do you feel in understanding the interaction between socioeconomic status and language development and acquisition? A total of 26 out of 30 second-year masters students who were enrolled in the course completed both the pre- and

postsurvey. All of the students who completed the surveys were White women. The background information collected from the surveys indicated that, prior to the beginning of the course, students had completed course work that addressed issues of bilingualisim and dialect at disproportionate rates. More than half of the students had received information on second language acquisition, dialect use and patterns, and differentiating language difference from language disorder. However, this was not the case for content concerning assessment tools for communication patterns in other cultures, differential assessment of bilingual versus monolingual speakers, and differential assessment of SAE and non-SAE speakers. These data suggest that although infusion was occurring at this university training program, the consistency with which specific topics were being addressed was not the same. Beyond describing previous student knowledge about MC issues, the course survey helped to determine the impact of the MC course on students evaluation of their own competency levels. Changes in student perceptions of competency prior to and after enrollment in the MC course were examined using multiple Wilcoxon signed-ranks tests. Table 2 provides a description of the reported pre- and postcompetency levels for the three primary questions listed above. The pre- and postcompetency levels for Question 1 were significantly different, Z(26) = 3.258, p = .001. Students reported greater competency in assessing the language skills of a person who speaks a foreign langauge following completion of the MC course. The pre- and postcompetency levels for Question 2 were significantly different, Z(26) = 3.99, p = .001. Students reported greater competency levels for assessing the language skills of non-SAE speakers following completion of the MC course. The students pre- and postcompetency levels for Question 3 also were significantly different, Z(26) = 3.43, p = .001. By the end of the MC course, students felt more competent in understanding the interaction between socioeconomic status and language. The survey and standard course evaluations have been especially useful in guiding our teaching efforts. For example, the results of the survey indicate that prior to the course, students were receiving some instruction on second language acquisition and dialect use but that the application of that course work in completing differential assessment for such speakers was lacking. Hence, additional time and specific attention were given to designing course lessons that addressed least biased assessment (see Figure 2 and Appendix A).
TABLE 2. Median, range, and mean of students pre- and postcompetency levels (N = 26). Precompetency Question 1 2 3 Mdn 1 2 2 Range 13 13 13 M 1.27 1.50 1.96 Postcompetency Mdn 2 3 3 Range 13 14 24 M 1.88 2.65 2.69

Note. Competency levels were based on a 4-point scale (1 = not competent, 2 = somewhat competent, 3 = competent, 4 = very competent ).

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Student comments also indicate that they would have liked for the course to be offered at the beginning of their program. This information was useful in helping to guide curricular decisions concerning the sequence of course offerings for our respective programs. Instructors who teach a core MC course may find similar types of surveys to be useful in facilitating student awareness about their own competency and guiding course preparation.

Conclusion
The teaching of the core MC course in CSD is a worthwhile endeavor. However, the nature of the content and dissemination of the material is so heavily influenced by the societal and cultural factors that teachers and students bring to the classroom that greater attention needs to be given to this area of instruction. Most CSD training programs have emphasized the importance of students knowing basic content for many of ASHAs big nine areas before other specialized courses are taken. For example, within most programs, it is uncommon for students to take a voice course without having taken an anatomy and physiology course, or a child language disorders course without a course in language development. However, this does not seem to hold true for MC content. The current tutorial has outlined a preliminary model of some primary issues that can be addressed in a core MC course. As discussed here, the core MC course provides a foundation for effective infusion to occur. We have been able to teach our students not only how to assess, treat, and manage clients from diverse backgrounds but also to increase awareness of cultural and societal factors that influence their interactions and opinions of these populations.

References
Abreu, J. (2001). Theory and research on stereotypes and perceptual bias: A didactic resource for multicultural counseling trainers. The Counseling Psychologist, 29, 482512. Alexander-Snow, M. (2004). Dynamics of gender, race, and ethnicity in understanding classroom incivility. New Directions for Teaching and Learning, 99, 2130. Amatrano, I., Callaway, Y., & Stickel, S. (2002, February). Multicultural infusion in the counselor education curriculum: A preliminary analysis. Paper presented at the annual meeting of the Eastern Education Research Association, Sarasota, FL. American Speech-Language-Hearing Association. (1983). Social dialects [Position statement]. Available from www.asha.org/ policy. American Speech-Language-Hearing Association. (1985). Clinical management of communicatively handicapped minority language populations [Position statement]. Available from www.asha.org/policy. American Speech-Language-Hearing Association. (1991). Multicultural action agenda 2000. Asha, 33, 3941. American Speech-Language-Hearing Association. (1998). Students and professionals who speak English with accents and nonstandard dialects: Issues and recommendations [Position statement]. Available from www.asha.org/policy. American Speech-Language-Hearing Association. (2004). Knowledge and skills needed by speech-language pathologists and audiologists to provide culturally and linguistically appropriate services [Knowledge and skills]. Available from www.asha.org/policy.

American Speech-Language-Hearing Association. (2005a). Cultural competence [Issues in ethics]. Available from www.asha. org/policy. American Speech-Language-Hearing Association. (2005b). 2005 standards and implementation procedures for the Certificate of Clinical Competence in Speech-Language Pathology. Available from www.asha.org/about/membership-certification/ handbooks/slp/#Std _ III. Arthur, N., & Januszkowski, T. (2001). The multicultural counseling competencies of Canadian counselors. Canadian Journal of Counseling, 35, 3648. Barona, A., Santos de Barona, A., Flores, A., & Guttierrez, M. (1990). Critical issues in training school pyschologists to serve minority school children. In A. Barona & E. Garcia (Eds.), Children at risk: Poverty, minority status, and other issues in educational equity (pp. 187200). Washington, DC: National Association of School Psychologists. Bond, S., & Hein, S. (1985). Word finding abilities in a bilingual anomic aphasic: A case study. The Journal of Neurological Communication Disorders, 2, 3640. Brown, S., Parham, T., & Yonker, R. (1996). Influence of a crosscultural training course on racial identity attitudes of White women and men: Preliminary perspectives. Journal of Counseling and Development, 74, 510516. Chen, C., & Treacy, M. (1996). Resistance in multicultural courses: Student, faculty, and classroom dynamics. American Behavioral Scientists, 40, 212221. Clark, C. (2002). Effective multicultural curriculum transformation across disciplines. Multicultural Perspectives, 4, 3746. Constantine, M., & Ladny, N. (2000). Self-report multicultural counseling competence scales: Their relation to social desirability attitudes and multicultural case conceptualization abilities. Journal of Counseling Psychology, 47, 155164. Craig, H., & Washington, J. (2000). An assessment battery for identifying language impairments in African American children. Journal of Speech, Language, and Hearing Research, 43, 366379. Craig, H., & Washington, J. (2002). Oral language expectations for African American preschoolers and kindergartners. American Journal of Speech-Language Pathology, 11, 5970. Day, J. (1996). Population projections of the U.S. by age, sex, race, and Hispanic origin: 1995 to 2050. U.S. Bureau of the Census, current population reports (pp. 251130). Washington, DC: U.S. Government Printing Office. Deal, K., & Hyde, C. (2004). Understanding MSW student anxiety and resistance to multicultural learning: A developmental perspective. Journal of Teaching in Social Work, 24, 7386. Delpit, L. (1995). Other peoples children. New York: New Press. EdChange & Gorsky, P. (2008). Guide to setting ground rules. Available from www.edchange.org/multicultural/activities/ groundrules.html. Fazio, R. (1990). Multiple processes by which attitudes guide behavior: The mode model as an integrative framework. Advances in Experimental Social Psychology, 23, 75109. Garcia Coll, C., Lamberty, G., Jenkins, R., McAdoo, H., Crnic, K., Wasik, B., & Garcia, H. (1996). An integrative model for the study of developmental competencies in minority children. Child Development, 67, 18911914. Goldstein, B. (2000). Cultural and linguistic diversity resource guide for speech-language pathologists. San Diego, CA: Singular. Gopaul-McNicol, S., & Brice-Baker, J. (1998). Cross-cultural practice: Assessment, treatment, and training. Toronto, Ontario, Canada: Wiley. Gutierrez-Clellen, V. (1999). Language choice in intervention with bilingual children. American Journal of Speech-Language Pathology, 8, 291302.
Horton-Ikard et al.: Multicultural Instruction in CSD

201

Gutierrez-Clellen, V., & Pea, E. (2001). Dynamic assessment of diverse children: A tutorial. Language, Speech, and Hearing Services in Schools, 32, 212224. Gutierrez-Clellen, V., Restrepo, M., Bedore, L., Pea, E., & Anderson, R. (2000). Language sample analysis in Spanishspeaking children: Methodological considerations. Language, Speech, and Hearing Services in Schools, 31, 8898. Higgenbotham, E. (1990). Designing an inclusive curriculum: Bring all women into the core. Womens Studies Quarterly, 18, 723. Holcomb-McCoy, C., & Myers, J. (1999). Multicultural competence and counselor training: A national survey. Journal of Counseling and Development, 77, 294302. Holland, A. (1983). Nonbiased assessment and treatment of adults who have neurologic speech and language problems. Topics in Language Disorders, 3, 6775. Horton-Ikard, R., & Ellis Weismer, S. (2007). A preliminary examination of vocabulary and word-learning in AfricanAmerican toddlers from low and middle socioeconomic status homes. American Journal of Speech-Language Pathology, 16, 381392. Hutchinson, T. (1996). What to look for in the technical manual: Twenty questions for users. Language, Speech, and Hearing Services in the Schools, 27, 109121. Jackson, S., & Roberts, J. (2001). Complex syntax production of African-American preschoolers. Journal of Speech, Language, and Hearing Research, 44, 10831096. Kohnert, K., Kennedy, M. R. T., Glaze, L., Kan, P. F., & Carney, E. (2003). Breadth and depth of diversity in Minnesota: Challenges to clinical competency. American Journal of SpeechLanguage Pathology, 12, 259272. Kohnert, K., Kim, D., Nett, K., Kan, P. F., & Duran, L. (2005). Intervention with linguistically diverse preschool children: A focus on developing home language(s). Language, Speech, and Hearing Services in the Schools, 36, 251263. Kritikos, E. (2003). Speech-language pathologists beliefs about language assessment of bilingual/bicultural individuals. American Journal of Speech-Language Pathology, 12, 7391. Laing, S., & Kamhi, A. (2003). Alternative assessment of language and literacy in culturally and linguistically diverse populations. Language, Speech, and Hearing Services in the Schools, 34, 4455. Leonard, L., & Weiss, A. (1983). Application of nonstandardized assessment procedures to diverse linguistic populations. Topics in Language Disorders, 3, 3545. Lester, S. (2000). The professional accreditation of conservatorreceptors: Developing a competence-based professional assessment system. Assessment & Evaluation in Higher Education, 24, 407419. Losen, D., & Orfield, G. (2002). Racial inequality in special education. Cambridge, MA: Harvard Education Press. Michaels, S. (1981). Sharing time: Childrens narrative styles and differential access to literacy. Language in Society, 10, 423442. Mio, J., & Barker-Hackett, L. (2003). Reaction papers and journal writing as techniques for assessing resistance in multicultural courses. Journal of Multicultural Counseling and Development, 31, 1219. Muoz, M. L., Marquardt, T., & Copeland, G. (1999). A comparison of the codeswitching patterns of aphasic and neurologically normal bilingual speakers of English and Spanish. Brain and Language, 66, 249274. Nieto, S., & Bode, P. (2004). Affirming diversity: The sociopolitical context of multicultural education. Boston: Allyn & Bacon. Oetting, J., & McDonald, J. (2002). Methods for characterizing participants nonmainstream dialect use in studies of specific

language impairment. Journal of Speech, Language, and Hearing Research, 45, 505518. OGrady, C. (2000). Integrating service learning and multicultural education in colleges and universities. Mahwah, NJ: Erlbaum. Pearson, B., Fernandez, S., & Oller, K. (1993). Lexical development in bilingual infants and toddlers: Comparison to monolingual norms. Language Learning, 43, 93120. Pea, E., Quinn, R., & Iglesias, A. (1992). The application of dynamic methods to language assessment: A nonbiased procedure. The Journal of Special Education, 26, 269280. Ponterotto, J., Alexander, C., & Grieger, I. (1995). A multicultural competency checklist for counseling training programs. Journal of Multicultural Counseling and Development, 23, 1120. Pope-Davis, D., & Coleman, L. (1997). Multicultural counseling competencies: Assessment, education and training, and supervision. Thousand Oaks, CA: Sage. Pope-Davis, D., & Dings, J. (1995). The assessment of multicultural counseling competencies. In J. Ponterotto, J. Casas, L. Suzuki, & C. Alexander (Eds.), Handbook of multicultural counseling (pp. 287311). Thousand Oaks, CA: Sage. Pope-Davis, D., & Ottavi, T. (1994). Examining the association between self-reported multicultural counseling competencies and demographic variables among counselors. Journal of Counseling and Development, 72, 651654. Restrepo, A. (1998). Identifiers of predominantly Spanish-speaking children with language impairment. Journal of Speech, Language, and Hearing Research, 41, 13981411. Restrepo, A., & Silverman, S. (2001). Validity of the Spanish Preschool Language Scale3 for use with bilingual children. American Journal of Speech-Language Pathology, 10, 382393. Rhodes, R. L., Ochoa, S. H., & Ortiz, S. O. (2005). Assessing culturally and linguistically diverse students: A practical guide. New York: Guilford. Ridley, C., Baker, D., & Hill, C. (2001). Critical issues concerning cultural competence. The Counseling Psychologist, 29, 822832. Ridley, C., Espelage, D., & Rubinstein, K. (1997). Course development in multicultural counseling. In D. Pope-Davis & H. Coleman (Eds.), Multicultural counseling competencies (pp. 131157). Thousand Oaks, CA: Sage. Ridley, C., Mendoza, D., & Kanitz, B. (1994). Multicultural training: Reexamination, operationalization, and integration. The Counseling Psychologist, 22, 227289. Roberts, P., Garcia, L., Desrochers, A., & Hernandez, D. (2002). English performance of proficient bilingual adults on the Boston Naming Test. Aphasiology, 16, 635645. Roseberry-McKibbin, C. (1994). Assessment and intervention for children with limited English proficiency and language disorders. American Journal of Speech-Language Pathology, 3, 7788. Roseberry-McKibbin, C., & OHanlon, L. (2005). Nonbiased assessment of English language learners: A tutorial. Communication Disorders Quarterly, 26, 178185. Saenz, T., & Huer, M. (2003). Testing strategies involving least biased language assessment of bilingual children. Communication Disorders Quarterly, 24, 184193. Stockman, I. (1995, March). The socio-political construction of science: Evidence from language research on African-American children. Paper presented at the W.E.B. Dubois lecture series, Graduate School and University Center, City University of New York. Stockman, I. (2003). A perspective on what multicultural curricular infusion could mean. Available from www.asha.org/ about/leadership-projects/multicultural /faculty/infused.htm. Stockman, I., Boult, J., & Robinson, G. (2003, November). Multicultural content in speech-language pathology and audiology

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curriculum: A survey of ASHA accredited programs. Poster presented at the Annual Convention of the American SpeechLanguage-Hearing Association, Chicago. Stockman, I., Boult, J., & Robinson, G. (2004, July 20). Multicultural issues in academic and clinical education: A cultural mosaic. The ASHA Leader, 20, pp. 67. Sue, D. (1999). Creating conditions for a constructive dialogue on race: Taking individual and institutional responsibility. In J. R. Welsch & J. Q. Adams (Eds.), Cultural diversity: Curriculum, classroom, and climate issues (pp. 1520). Springfield, IL: Illinois Board of Education. Sue, D. (2001). Multidimensional facets of cultural competence. The Counseling Psychologist, 29, 790821. Sue, D. (2003). Multicultural counseling and therapy theory. In J. A. Banks & C. Banks (Eds.), Handbook of research on multicultural education (2nd ed., pp. 813828). New York: Macmillan. Sue, D., Arrendondo, P., & McDavis, R. (1992). Multicultural competencies and standards: A call to the profession. Journal of Counseling & Development, 70, 477486. Taylor, O. (1986). Treatment of communication disorders in culturally and linguistically diverse populations. Austin, TX: Pro-Ed. Taylor, O., & Payne, K. (1994). Culturally valid testing: A proactive approach. In K. Butler (Ed.), Cross-cultural perspectives in language assessment and intervention (pp. 93105). Gaithersburg, MD: Aspen. Toporek, R., & Reza, J. (2001). Context as a critical dimension of multicultural counseling: Articulating personal, professional, and institutional competence. Journal of Multicultural Counseling and Development, 29, 1330.

Umoto, J., & Wong, T. (2000). Multicultural perspectives on the neuropsychology of brain injury assessment and rehabilitation. In E. Fletcher-Janzen, T. L. Strickland, & C. Reynolds (Eds.), Handbook of cross-cultural neuropsychology (pp. 169184). New York: Kluwer Academic/Plenum. U.S. Census Bureau. (2008). Press release CB08-123. Available from www.census.gov/Press-Release/www/releases/archives/ population/012496.html. Watamori, T., & Sasanuma, S. (1976). The recovery process of a bilingual aphasic. Journal of Communication Disorders, 9, 157166. Watamori, T., & Sasanuma, S. (1978). The recovery process of two EnglishJapanese bilingual aphasics. Brain and Language, 6, 127140. Wolfram, W. (1994). Test interpretation and sociolinguistic differences. In K. Butler (Ed.), Cross-cultural perspectives in language assessment and intervention (pp. 106119). Gaithersburg, MD: Aspen. Young, R., & Tran, M. (2001). What do you do when your students say, I dont believe in multicultural education? Multicultural Perspectives, 3, 914. Received November 30, 2007 Accepted October 2, 2008 DOI: 10.1044/1058-0360(2008/07-0086) Contact author: RaMonda Horton-Ikard, Department of Communication Disorders, 407 Regional Rehabilitation Center, Florida State University, Tallahassee, FL 32303. E-mail: rhorton2@fsu.edu.

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Appendix A Course Syllabus for Multicultural Issues in Communication Disorders

Course Description This is a graduate level course intended for students in speech-language pathology, audiology, and related disciplines. Topics will include the following: theoretical rationales for cultural considerations, cultural issues in speech and language development and use, and assessment and treatment practices for children and adults. Learning Objectives 1. Identify frameworks that have been used to examine speech, language, and hearing in mainstream and nonmainstream populations. 2. Articulate a framework for understanding cultural perspectives. 3. Recognize sociocultural influences on language development and acquisition. 4. Apply understanding of sociocultural influences on language development and acquisition to assessment practices in field of specialization. 5. Apply understanding of sociocultural influences on language development and acquisition to treatment practices in field of specialization. Sample Schedule of Topics and Readings Topic Introduction American Speech-Language-Hearing Association (ASHA) position statements Scientific subjectivity Scientific subjectivity Theoretical constructs for examining culture and communication Theoretical constructs for examining culture and communication Cross-cultural interactions Introduction to assessment Introduction to assessment Introduction to assessment Introduction to assessment Assessment: Adults Assessment: Adults Assessment: Children Assessment: Children Assessment: Children Special education Bilingual education Introduction to treatment Reading

ASHA (1983, 1985, 1998) Stockman (1995) Stockman (1995) Garcia Coll et al. (1996) Umoto & Wong (2000) Hutchinson (1996) Taylor & Payne (1994) Wolfram (1994) Goldstein (2000) Roberts et al. (2002) Holland (1983) Gutierrez-Clellen & Pea (2001) Craig & Washington (2000) Restrepo & Silverman (2001) Losen & Orfield (2002) Goldstein (2000) Goldstein (2000)

Appendix B Ground Rules for the Multicultural Course

We recognize that the teaching and learning of multicultural issues and cultural differences can lead to the discussion of topics of a sensitive nature. Therefore, we have established the following ground rules for this course: We ask that you treat each other respectfully and maintain confidentiality on any personal issues or opinions shared in class, and we will do the same. You should complete the assigned readings before the class during which the material will be discussed. Be prepared to describe the readings, as well as provide insight and interpretation about the readings. During classroom discussions, try to speak from your own experience instead of putting your own spin on someone elses experience. Avoid personal attacks on someone elses beliefs and values. You should respectfully ask any questions and make any comments in class that will help you better understand the material. What is clear to us may not make sense to you, so we depend on you for feedback. If you are uncomfortable doing this in class, please make the effort to come see one of us in our office. It is okay to have diverging opinions on controversial topics but always respond critically and analytically to the literature and readings assigned for the course. Please monitor your body language and nonverbal responses as they may convey disrespect in the same manner that words can.

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Appendix C Resources for the Multicultural Course

Textbooks and Further Readings Battle, D. (2002). Communication disorders in multicultural populations (3rd ed.). Boston: Butterworth Heineman. Coleman, T. J. (2000). Clinical management of communication disorders in culturally diverse children. Boston: Allyn & Bacon. Goldstein, B. (2000). Cultural and linguistic diversity resource guide for speech-language pathologists. San Diego, CA: Singular. Lynch, E. W., & Hanson, H. M. J. (2004). Developing cross-cultural competence: A guide for working with children and their families (3rd ed.). Baltimore: Brookes. Rhodes, R. L., Ochoa, S. H., & Ortiz, S. O. (2005). Assessing culturally and linguistically diverse students: A practical guide. New York: Guilford. Wolfram, W., & Schilling-Estes, N. (2006). American English: Dialects and variation (2nd ed.). Oxford, England: Blackwell. Web Site Resources Diversity Web: An interactive resource hub for higher education: www.diversityweb.org / Do you speak American? (PBS special): www.pbs.org /speak / Multicultural Education Pavilion: www.edchange.org /multicultural / Organizations ASHA Office of Multicultural Affairs and Resources: www.asha.org /about / leadership-projects/multicultural / Center for Research on Education, Diversity, and Excellence: http://crede.berkeley.edu /index.html National Association for Multicultural Education: www.nameorg.org / University of California Language Minority Research Institute: http://lmri.ucsb.edu/

Appendix D Example Timeline of Legal and Legislative Decisions Regarding Culturally and Linguistically Diverse (CLD) Populations
ASHA develops and disseminates technical reports, position statements, and knowledge and skills documents as a means to define clinical practice. The documents provide detailed guidelines as to the nature and scope of clinical practice, as well as the types of skills needed by the clinician to provide the services in question. The impetus to develop practice and training guidelines for the provision of speech-language pathology services to CLD populations originated from legal, and subsequently legislative, decisions that legitimized the unique needs of nonmainstream Americans. Legal and Legislative Decisions of Specific Concern to Educators and Speech-Language Pathologists Year 1951 1954 Decision Brown v. Board of Education, Topeka, KS Brown v. Board of Education, Topeka, KS Civil Rights Act of 1964 Hobson v. Hansen Description Brown wanted to enroll his daughter in a nearby White school. With the help of the National Association for the Advancement of Colored People (NAACP), the Browns and other families sued the district to challenge segregation. The Supreme Court ruled that segregation deprived minority children of equal educational opportunities and concluded that separate but equal had no place in the educational system. Separate was not equal and violated the equal protection of the laws guaranteed by the 14th Amendment. Title VI, 42 of the Civil Rights Act prohibits discrimination on the basis of race, color, and national origin in programs and activities receiving federal financial assistance. Suit filed on behalf of African American students enrolled in integrated schools in Washington, DC. The district was using aptitude testing to place students in educational tracks. Tracks were ultimately segregated by race, with African American students in the lower tract and White students in the upper tract. Ruling: The courts found that the tests were not predictive for African American because of dialect and socioeconomic differences and a norming sample composed of White middle-class children. This was the first time norm-referenced tests became associated with segregation, bias, denial of equal educational opportunities, and prejudice. Suit filed on behalf of Mexican American students to prohibit special education placement for children labeled educable mentally retarded (EMR) unless the following criteria were met: hearing held before testing, testing allowed for cultural differences, and retesting after placement.

1964 1967

1968

Arreola v. Board of Education, Orange County, CA

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Appendix E Activity: Review of Norm-Referenced Measures

Learning Objectives 1. 2. 3. 4. Students will Students will Students will Students will evaluate the psychometric properties of a published test. identify test modifications recommended in the manual when assessing individuals from CLD backgrounds. list and explain potential sources of bias for specific CLD groups. suggest modifications in test administration and interpretation to reduce bias for specific CLD groups.

Instructions Students, working in pairs, select one of several tests designed to assess speech and language skills in adults and children. They are instructed to answer the following questions: 1. What is the purpose and underlying rationale for the design of the test? 2. How does this test compare to other measures purported to assess the same thing? 3. Is there evidence that this test accurately identifies/classifies known disorders/impairments? 4. Do the norms represent a variety of performances, or are most of the scores closer toward the middle, rather than the extremes? 5. Do the test makers discuss empirical data (studies beyond the initial norming and standardization) related to the validity of the instrument with children from CLD populations? 6. How well does the normative sample represent the population to which the individual from Hispanic, African American, Asian American, or Native American cultures will be compared? 7. How well does the normative sample represent individuals from different regional and economic backgrounds? 8. Does it mention anything about linguistic diversity, that is, populations of the sample who used African American English or Standard American English? Or populations of the sample who were bilinguals, monolingual Spanish speakers, monolingual English-speaking Hispanics, monolingual English-speaking Asians, and so forth? 9. Create an additional test item that matches the authors rationale of why the specific test content was chosen. Would your test item present any source of bias for any individual from a nonmainstream population?

206 American Journal of Speech-Language Pathology Vol. 18 192206 May 2009