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Nonverbal autism is known as a subset of autism where the person does not speak. While most autistic children eventually begin to speak, there is a significant minority who will remain nonverbal.

Background

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It was formally estimated that 25% to 50% of children diagnosed with autism spectrum disorder (ASD) did not develop spoken language beyond a few words or utterances.[1] More recent research reports that 25-30% of individuals with ASD will not develop functional language. citation here. statement from recent research regarding prevalence of functional language. Despite the growing field of research on ASD, there is not much information available pertaining to people with autism who never develop functional language; that, in fact, nonverbal autistic individuals are considered to be underrepresented in all of autism research.[2] Because of the limited research on nonverbal autism, there are not many validated measurements appropriate for this population. For example, while they may be appropriate for younger children, they lack the validity for grade-school-aged children and adolescents and have continued to be a roadblock for nonverbal autism research.[3] Often in autism research, nonverbal autistic individuals are subgrouped with LFA, categorized by learning at most one word or having minimal verbal language.[2]

Most of the existing body of research in nonverbal autism focuses on early interventions that predict successful language outcomes. Research suggests that acquiring language before age five is a good indicator of positive child development,[4] and the likelihood of acquiring functional language in the future past this age is minimal,[5] that early language development is crucial to educational achievement, employment, independence during adulthood, and social relationships.[1]

Most children with ASD can be diagnosed between age two and three because of their behaviors and lack of social skills. They can also have gastrointestinal problems, seizures, and sleep disorders.[6]

Early predictors

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The causes of nonverbal autism are unknown. However, there appears to be a relationship between joint attention and verbal communication. Joint attention occurs between two individuals when one draws the other’s attention to an object through gesturing (i.e. eye gazing, pointing).[7] The ability to achieve joint attention at an early age plays a significant role in language development, and studies indicate severe lapses in joint attention in children with autism.[7] In one study, researchers suggest that a displayed pattern of delays, absences, or a general impaired response to stimuli (hyporesponsiveness) and a fascination with intense or repetitive stimulation (sensory seeking) is more likely in nonverbal children with autism, suggesting that both hyporesponsiveness and sensory seeking is related to poor communication outcomes in children with ASD.[1]

Potential causes

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The amygdala theory

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There is a growing body of tentative evidence indicating the amygdala's involvement in the development of autism. The amygdala theory of autism focuses on the importance of the amygdala in relation to social functioning and observes that autism is largely a severe impairment of social functioning. The amygdala is thought to be associated with the fight or flight response in animals and its activity is heavily correlated with fear in humans. Additionally, it has been heavily implicated in relation to social functioning in various animal studies. Evidence suggests an amygdala hyperactivity model may be more accurate than one comparing it to a lesion.[8]

Lesion studies have shown that amygdala damage results in severe social impairment among animal models. Vervet monkey mothers with amygdala lesions were shown to be much less caring with their young neglecting and even abusing them.[9] Rats with amygdala ablations become much more docile.[9] Monkeys with lesions to the anterior temporal lobe develop a disorder known as Klüver–Bucy syndrome, characterized by loss of fear, hypersexuality, hyperorality, and an inability to recognize visual objects (often, but not always).[9]

Evidence shows the amygdala accounts for the emotional, oral, and sexual abnormalities listed above.[9] These abnormalities coincide with several characteristics of the diagnostic guidelines for autism, at least passably for an animal model.

Post-mortem analysis of humans shows an increased neuronal density in the amygdala in autism compared to controls, indicating a potential linkage and supporting the hyperactivity model.[9]

Several studies presented subjects with ASD photographs of human eyes and had them report the emotional state of the person in the picture. A smaller amygdala was associated with increased response time but not decreased accuracy.[9] There was also significantly less amygdaloid activation in the brains of those with ASD, than controls. Subjects compensated for this lack of amygdaloid activity with increased activation in the temporal lobe, and are associated with verbally labeling images.[8] This activity is thought to imply less usage of emotional/social cues to identify objects and rather more objective, factually based processing. One may extrapolate from this model that patients with autism may learn that a specific facial configuration represents an emotional state and what that emotional state implies socially, but they may not come to truly understand how that person feels. This supports a theory of mind deficit, or inability to empathize with others – a characteristic symptom of ASD.[citation needed]

Studies conducted specifically on nonverbal autistics[which?] provide similar evidence. Brain studies have shown several amygdaloid impairments among those with ASD. The amygdala in those with nonverbal autism have less volume compared to controls, contain a higher density of neurons suggesting hyperconnection, and show a negative correlation between amygdala size and impairment severity among subjects.[8]

Infantile autism is actually associated with an oversized amygdala, there are developmental theories as to how this may occur. Research on major depressive disorder has shown that excessive activation such as stress or fear leads to allostasis, or degeneration of the neurons involved in creating the phenomenon. Initial hypertrophy results in atrophy and reduction of brain size in the given region.[8] Over time, this occurs in patients with severe depression and they develop a decreased amygdala size. Some scientists[who?] theorize that this is happening early during infancy the autistic brain, accounting for the initial overgrowth and later observed size reduction.[8]

When eye tracking software is employed to record where subjects focus their visual attention on images of human faces, small amygdala volume is associated with decreased eye fixation.[8] Eyes are considered to be especially important for establishing human connection and conveying emotion, thus fixation on them is considered to be a crucial part of identifying people and emotions in a social setting.

In addition to a negative correlation to eye fixation studies showed a smaller amygdala was associated with impairment in nonverbal communication skills as well.[8] This suggests that the amygdala is critical in developing all types of communicative abilities, not just verbal. This suggests the amygdala may play a crucial role in relating to other humans in a way that allows for behavioral mimicry.

Among patients with nonverbal ASD researchers could predict symptom severity based on amygdala activity. Those with the least amygdala activity had the most impaired nonverbal communication abilities, those with the most activity had the strongest communication abilities.[8]

The development of language, similar to the development of most physical skills, relies heavily on mimicry of other humans.[8] ASDs are known to impair one's ability to focus on and relate with people possibly as a result of a damaged amygdala. Nonverbal autistics will often be able to learn more basic communicative skills such as pointing to objects or selecting a picture from a list. These skills are far more simple and do not require the degree of personal connection needed for language development.

It is important to note that these studies must be considered with great caution. Cross-sectional studies can only suggest so much about the pathology of a disorder. Further study, particular longitudinal studies, are needed to gain a more complete understanding.[8] It is also important to recognize that most disorders arise from a complex interworking of the entire brain and restricting a theory to one subsystem would be a mistake, this theory merely suggests how the amygdala may be involved with develop of ASD and provides evidence to support an association.

Language outcomes

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For nonverbal grade school children and adolescents with autism, communication systems and interventions have been implemented to enhance language and communication outcomes. Speech-generating devices such as tablet computers use visual displays for children who lack verbal language, giving them the task of selecting icons indicating a request or need.[10] For adolescents with nonverbal autism, interventions can condition them to learn more advanced operations on speech-generating devices that require more steps (i.e. turning on device, scrolling through pages), which would allow them to enhance their communicative abilities independently.[10]

The picture exchange system (PECS) is a form of spontaneous communication for children with autism in which an individual selects a picture indicating a request.[11] PECS can be utilized in educational settings and at the child’s home. Longitudinal studies suggest PECS can have long-term positive outcomes for school-aged children with nonverbal autism, specifically their social-communicative skills, such as higher frequencies of joint attention and initiation, and duration of cooperative play,[11] which are all important roles in improving language outcomes.

It has also been suggested that a significant stage in acquiring verbal language is learning how to identify and reproduce syllables of words. One study found that nonverbal and minimally verbal children with autism are capable of enhancing their oral production and vocalizing written words by isolating each syllable of a word one at a time.[5] The process of breaking down a syllable at a time and having it visually displayed and audibly available to the child can prompt him or her to imitate and create nonrandom and meaningful utterances.[5]

Most of these studies contain small sample sizes and were pilot studies, making additional research significant to assess whether these findings can be generalized to all age groups of the same population. Furthermore, most studies on nonverbal autism and speech-generating device communication were based on more basic skills, such as naming pictures and making requests for stimuli, while studies in advanced communication is limited.[12]

See also

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References

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  1. ^ a b c Patten, Elena; Ausderau, Karla K; Watson, Linda R; Baranek, Grace T (2013). "Sensory Response Patterns in Nonverbal Children with ASD". Autism Research and Treatment. 2013: 436286. doi:10.1155/2013/436286. PMC 3727194. PMID 23956859.{{cite journal}}: CS1 maint: unflagged free DOI (link)
  2. ^ a b Bardikoff, Nicole; McGonigle-Chalmers, Margaret (2014). "Testing nonverbal IQ in children with Autism Spectrum Disorders". Research in Autism Spectrum Disorders. 8 (9): 1200–7. doi:10.1016/j.rasd.2014.06.007.
  3. ^ Kasari, Connie; Brady, Nancy; Lord, Catherine; Tager-Flusberg, Helen (2013). "Assessing the Minimally Verbal School-Aged Child with Autism Spectrum Disorder". Autism Research. 6 (6): 479–93. doi:10.1002/aur.1334. PMC 4139180. PMID 24353165.
  4. ^ Mayo, Jessica; Chlebowski, Colby; Fein, Deborah A.; Eigsti, Inge-Marie (February 2013). "Age of First Words Predicts Cognitive Ability and Adaptive Skills in Children with ASD". Journal of Autism and Developmental Disorders. 43 (2): 253–264. doi:10.1007/s10803-012-1558-0. ISSN 0162-3257. PMC 4386060. PMID 22673858.
  5. ^ a b c Vernay, Frédérique; Kahina, Harma; Thierry, Marrone; Jean-Yves, Roussey (2017). "Self-paced segmentation of written words on a touchscreen tablet promotes the oral production of nonverbal and minimally verbal autistic children". Journal of Research in Special Educational Needs. 17 (4): 265–73. doi:10.1111/1471-3802.12384.
  6. ^ "What Is Autism? | Autism Speaks". Autism Speaks. Retrieved 2018-10-25.
  7. ^ a b Paparella, Tanya; Goods, Kelly Stickles; Freeman, Stephanny; Kasari, Connie (2011). "The emergence of nonverbal joint attention and requesting skills in young children with autism". Journal of Communication Disorders. 44 (6): 569–83. doi:10.1016/j.jcomdis.2011.08.002. PMID 21907346.
  8. ^ a b c d e f g h i j Nacewicz, Brendon M; Dalton, Kim M; Johnstone, Tom; Long, Micah T; McAuliff, Emelia M; Oakes, Terrence R; Alexander, Andrew L; Davidson, Richard J (2006). "Amygdala Volume and Nonverbal Social Impairment in Adolescent and Adult Males with Autism". Archives of General Psychiatry. 63 (12): 1417–1428. doi:10.1001/archpsyc.63.12.1417. PMC 4767012. PMID 17146016.
  9. ^ a b c d e f Baron-Cohen, S; Ring, H.A; Bullmore, E.T; Wheelwright, S; Ashwin, C; Williams, S.C.R (2000). "The amygdala theory of autism". Neuroscience & Biobehavioral Reviews. 24 (3): 355–64. doi:10.1016/S0149-7634(00)00011-7. PMID 10781695.
  10. ^ a b Achmadi, Donna; Kagohara, Debora M; Van Der Meer, Larah; o'Reilly, Mark F; Lancioni, Giulio E; Sutherland, Dean; Lang, Russell; Marschik, Peter B; Green, Vanessa A; Sigafoos, Jeff (2012). "Teaching advanced operation of an iPod-based speech-generating device to two students with autism spectrum disorders". Research in Autism Spectrum Disorders. 6 (4): 1258–64. doi:10.1016/j.rasd.2012.05.005.
  11. ^ a b Lerna, Anna; Esposito, Dalila; Conson, Massimiliano; Massagli, Angelo (2014). "Long-term effects of PECS on social-communicative skills of children with autism spectrum disorders: A follow-up study". International Journal of Language & Communication Disorders. 49 (4): 478–85. doi:10.1111/1460-6984.12079. PMID 24655345.
  12. ^ Kagohara, Debora M; Van Der Meer, Larah; Ramdoss, Sathiyaprakash; O'Reilly, Mark F; Lancioni, Giulio E; Davis, Tonya N; Rispoli, Mandy; Lang, Russell; Marschik, Peter B; Sutherland, Dean; Green, Vanessa A; Sigafoos, Jeff (2013). "Using iPods® and iPads® in teaching programs for individuals with developmental disabilities: A systematic review". Research in Developmental Disabilities. 34 (1): 147–56. doi:10.1016/j.ridd.2012.07.027. PMID 22940168.


Muteness or mutism (from Latin mutus 'silent') is defined as an absence of speech while conserving or maintaining the ability to understand the speech of others. [1] Mutism is typically understood as an inability to speak on the part of a child or an adult due to an observed lack of speech from the point of view of others who know them such as family members, caregivers, teachers, or health professionals including doctors and speech and language pathologists. Muteness may not be a permanent condition, depending upon etiology (cause). In general, someone who is mute may be mute for one of several different reasons: organic, psychological, developmental/ neurological.[2] For children, a lack of speech may be developmental, neurological, psychological, or due to a physical disability or a communication disorder. For adults who previously had speech and then became unable to speak, loss of speech may be due to injury, disease, termed aphasia, or surgery affecting areas of the brain needed for speech. Loss of speech in adults may occur rarely for psychological reasons.

Treatment or management of muteness depends on what has caused the absence of speech. When there is an absence of speech, a speech assessment is strongly recommended to determine cause and treatment.[3] Treatment of absence of speech is possible in a variety of cases. If the absence of speech is determined to be a permanent condition, a range of assistive and augmentative communication devices are available to aid communication.

Organic causes

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Organic causes of mutism may stem from several different sources. One cause of muteness may be problems with the physiognomy involved in speech, for example, the mouth or tongue.[4] Mutism may be due to apraxia, that is, problems with coordination of muscles involved in speech. [5] Another cause may be a medical condition impacting the physical structures involved in speech, for example, loss of voice due to the injury, paralysis, or illness of the larynx. [6] Neurological damage due to stroke may cause loss or impairment of speech. Neurological damage or problems with development of the area of the brain involved in speech production, Broca's area, may cause muteness. [7] Trauma or injury to Broca's area, located in the left inferior frontal cortex of the brain, can cause muteness. [8] Muteness may follow brain surgery. For example, there is a spectrum of possible neurobehavioural deficits in the Posterior Fossa Syndrome in children following cerebellar tumor surgery.[9]

Psychological causes

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When children do not speak, psychological problems or emotional stress, such as anxiety, may be involved. Children may not speak due to suffering from Selective mutism. Selective mutism is a condition in which the child speaks only in certain situations or with certain people, such as close family members. [10] Assessment is needed to rule out possible illness or other conditions and to determine treatment. [11] Prevalence is low, but not as rare as once thought. [12] Selective mutism should not be confused with a child who does not speak and cannot speak due to physical disabilities. It is common for symptoms to occur before the age of five. Not all children express the same symptoms.

Selective Mutism may occur in conjunction with Autism Spectrum Disorder, or other diagnoses. [13] Differential diagnosis between Selective Mutism and language delay associated with Autism Spectrum Disorder or other disorders is needed to determine appropriate treatment.

Adults who previously had speech and subsequently ceased talking may not speak for psychological or emotional reasons, though this is rare as a cause for adults. [14] Absence or paucity of speech in adults may also be associated with specific psychiatric disorders.[15]

Developmental/Neurological causes

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Absence of speech in children may involve communication disorders or language delays. Communication disorders or developmental language delays may occur for several different reasons. [16][17]

Language delays may be associated with other developmental delays. [18] For example, children with Down syndrome often have impaired language and speech.[19][20]

Children with Autism, categorized as a neurodevelopmental disorder in the DSM-V, often demonstrate language delays. [21] [22] Recent studies have found that children with Autism and language delays are often more able to benefit from treatment services to help build language than was previously believed. [23]

Treatment

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For language delays or communication disorders in children, early assessment is strongly recommended. [24] Language delays may impact expressive language, receptive language, or both. Communication disorders may impact articulation, fluency (stuttering) and other specified and unspecified communication disorders. Treatment focuses on the diagnosed condition. For example, Speech and Language Services may focus on the production of speech sounds for children with phonological challenges. [25] Overall, early intervention for young children with language or other developmental delays is strongly recommended. [26] [27]

For toddlers with language delay who may also have Autism, early intervention services focusing on speech production is strongly recommended. When absence of speech is observed in children who may also be diagnosed with Autism, assessment is also strongly recommended. [28] Intervention services and treatment programs have been specifically developed for children with Autism and language delays. [29] For example, Pivotal Response Treatment is a well-established and researched intervention that includes family participation. [30] Mark Sundberg's Verbal Behavior framework is another well-established assessment and treatment modality that is incorporated into many Applied Behavior Analysis (ABA) early intervention treatment programs for young children with autism and communication challenges.[31]

Treatment for absence of speech due to Apraxia, involves assessment, and, based on the assessment, Occupational Therapy, Physical Therapy, and/or Speech Therapy. [32][33][34]

Treatment for Selective Mutism involves assessment, counseling, and positive supports. [35]

Treatment for absence of speech in adults who previously had speech involves assessment to determine cause, including medical and surgery related causes, followed by appropriate treatment or management. Treatment may involve counseling, or rehabilitation services, depending upon cause of loss of speech. [36][37]

Management

[edit]

Management involves use of appropriate assistive devices sometimes called alternative or augmentative communications. Suitability and appropriateness of modality will depend on users physical abilities and cognitive functioning.[38]

Augmentative or assistive communication technology ranges from elaborated software for iPads to enable complex communication with an auditory component to less technologically involved strategies. For example, a common method involves use of pictures that can be attached to velcro strips to create an accessible communication modality that does not require the cognitive or fine motor skills needed to manipulate an iPad. [39]

Speech-generating devices can help individuals with speech deficiencies associated with medical conditions that affect speech, communication disorders that impair speech, or surgeries that have impacted speech. Speech-generating devices continue to improve in ease of use.[40]

  1. ^ Grippo, J.; Vergel, M. F.; Comar, H.; Grippo, T. (2001 Feb 1-15). "[Mutism in children]". Revista De Neurologia. 32 (3): 244–246. ISSN 0210-0010. PMID 11310279. {{cite journal}}: Check date values in: |date= (help)
  2. ^ Grippo, J.; Vergel, M. F.; Comar, H.; Grippo, T. (2001 Feb 1-15). "[Mutism in children]". Revista De Neurologia. 32 (3): 244–246. ISSN 0210-0010. PMID 11310279. {{cite journal}}: Check date values in: |date= (help)
  3. ^ CDC (2019-01-30). "Language and Speech Disorders in Children | CDC". Centers for Disease Control and Prevention. Retrieved 2020-04-10.
  4. ^ "2 The production of speech sounds". www.personal.rdg.ac.uk. Retrieved 2020-04-11.
  5. ^ "Childhood apraxia of speech - Symptoms and causes". Mayo Clinic. Retrieved 2020-04-13.
  6. ^ "Vocal Cord (Fold) Paralysis". ENT Health. Retrieved 2020-04-19.
  7. ^ "Broca area | Definition, Function, & Facts". Encyclopedia Britannica. Retrieved 2020-04-11.
  8. ^ "Aphasia", The Free Dictionary, retrieved 2020-04-11
  9. ^ Catsman-Berrevoets, Coriene E.; Aarsen, Femke K. (2010-07). "The spectrum of neurobehavioural deficits in the Posterior Fossa Syndrome in children after cerebellar tumour surgery". Cortex; a Journal Devoted to the Study of the Nervous System and Behavior. 46 (7): 933–946. doi:10.1016/j.cortex.2009.10.007. ISSN 1973-8102. PMID 20116053. {{cite journal}}: Check date values in: |date= (help)
  10. ^ "Selective Mutism: Signs and Symptoms". American Speech-Language-Hearing Association. Retrieved 2020-04-13.
  11. ^ Manassis, Katharina (2009-02). "Silent suffering: understanding and treating children with selective mutism". Expert Review of Neurotherapeutics. 9 (2): 235–243. doi:10.1586/14737175.9.2.235. ISSN 1744-8360. PMID 19210197. {{cite journal}}: Check date values in: |date= (help)
  12. ^ Bergman, R. Lindsey; Piacentini, John; McCracken, James T. (2002-08). "Prevalence and description of selective mutism in a school-based sample". Journal of the American Academy of Child and Adolescent Psychiatry. 41 (8): 938–946. doi:10.1097/00004583-200208000-00012. ISSN 0890-8567. PMID 12162629. {{cite journal}}: Check date values in: |date= (help)
  13. ^ Steffenburg, Hanna; Steffenburg, Suzanne; Gillberg, Christopher; Billstedt, Eva (2018-05-07). "Children with autism spectrum disorders and selective mutism". Neuropsychiatric Disease and Treatment. 14: 1163–1169. doi:10.2147/NDT.S154966. ISSN 1176-6328. PMC 5944454. PMID 29765220.{{cite journal}}: CS1 maint: unflagged free DOI (link)
  14. ^ Koźmin-Burzyńska, Agnieszka; Bratek, Agnieszka; Zawada, Karolina; Krysta, Krzysztof; Krupka-Matuszczyk, Irena (2015-09). "Psychogenic speech disorder--a case report". Psychiatria Danubina. 27 Suppl 1: S411–414. ISSN 0353-5053. PMID 26417806. {{cite journal}}: Check date values in: |date= (help)
  15. ^ Cohen, Alex S.; McGovern, Jessica E.; Dinzeo, Thomas J.; Covington, Michael A. (2014-12). "Speech Deficits in Serious mental Illness: A Cognitive Resource Issue?". Schizophrenia research. 160 (0): 173–179. doi:10.1016/j.schres.2014.10.032. ISSN 0920-9964. PMC 4310829. PMID 25464920. {{cite journal}}: Check date values in: |date= (help)
  16. ^ CDC (2019-01-30). "Language and Speech Disorders in Children | CDC". Centers for Disease Control and Prevention. Retrieved 2020-04-19.
  17. ^ "Speech and Communication Disorders". medlineplus.gov. Retrieved 2020-04-20.
  18. ^ Marrus, Natasha; Hall, Lacey (2017-7). "Intellectual Disability and Language Disorder". Child and adolescent psychiatric clinics of North America. 26 (3): 539–554. doi:10.1016/j.chc.2017.03.001. ISSN 1056-4993. PMC 5801738. PMID 28577608. {{cite journal}}: Check date values in: |date= (help)
  19. ^ Martin, Gary E.; Klusek, Jessica; Estigarribia, Bruno; Roberts, Joanne E. (2009-4). "Language Characteristics of Individuals with Down Syndrome". Topics in language disorders. 29 (2): 112–132. ISSN 0271-8294. PMC 2860304. PMID 20428477. {{cite journal}}: Check date values in: |date= (help)
  20. ^ "Speech and Language Resources | National Down Syndrome Congress". Retrieved 2020-04-19.
  21. ^ Volkers, Nancy (2018-45-12 04:45:46). "Untangling the Language Challenges of Autism". The ASHA Leader. doi:10.1044/leader.FTR2.22042017.54. {{cite journal}}: Check date values in: |date= (help)
  22. ^ "Autism Spectrum Disorder: Communication Problems in Children". NIDCD. 2015-08-18. Retrieved 2020-04-19.
  23. ^ Wodka, Ericka L.; Mathy, Pamela; Kalb, Luther (2013-04-01). "Predictors of Phrase and Fluent Speech in Children With Autism and Severe Language Delay". Pediatrics. 131 (4): e1128–e1134. doi:10.1542/peds.2012-2221. ISSN 0031-4005. PMID 23460690.
  24. ^ American Association of Family Physicians (May 2011). "Speech and Language delay in children". American Family Physician.{{cite web}}: CS1 maint: url-status (link)
  25. ^ "Oral Motor Institute". www.oralmotorinstitute.org. Retrieved 2020-04-13.
  26. ^ CDC (2019-12-09). "Why Act Early if You're Concerned about Development?". Centers for Disease Control and Prevention. Retrieved 2020-04-17.
  27. ^ Roberts, Megan; Kaiser, Ann (2015-03-02). "Early Intervention for Toddlers With Language Delays: A Randomized Controlled Trial". Pediatrics. 135. doi:10.1542/peds.2014-2134.
  28. ^ "Study shows that many nonverbal autistic children overcome severe language delays". Autism Speaks. Retrieved 2020-04-17.
  29. ^ Lk, Koegel; Lk, Koegel. "Intervention for Non-verbal and Minimally-Verbal Individuals with Autism: A Systematic Review". doi:10.23937/2469-5769/1510056. ISSN 2469-5769. {{cite journal}}: Cite journal requires |journal= (help)
  30. ^ Lei, Jiedi; Ventola, Pamela (2017-06-20). "Pivotal response treatment for autism spectrum disorder: current perspectives". Neuropsychiatric Disease and Treatment. 13: 1613–1626. doi:10.2147/NDT.S120710. ISSN 1176-6328. PMC 5488784. PMID 28790824.{{cite journal}}: CS1 maint: unflagged free DOI (link)
  31. ^ "Verbal Behavior Therapy". Autism Speaks. Retrieved 2020-04-20.
  32. ^ https://www.apraxia-kids.org/wp-content/uploads/2013/01/BHSM-Fact-Sheet-2.pdf
  33. ^ "Childhood apraxia of speech - Symptoms and causes". Mayo Clinic. Retrieved 2020-04-13.
  34. ^ "Speech-Language Therapy (for Parents) - Nemours KidsHealth". kidshealth.org. Retrieved 2020-04-20.
  35. ^ "Selective mutism". nhs.uk. 2017-10-19. Retrieved 2020-04-20.
  36. ^ Lincoln, Tania M.; Riehle, Marcel; Pillny, Matthias; Helbig-Lang, Sylvia; Fladung, Anne-Katharina; Hartmann-Riemer, Matthias; Kaiser, Stefan (2017-12-05). "Using Functional Analysis as a Framework to Guide Individualized Treatment for Negative Symptoms". Frontiers in Psychology. 8. doi:10.3389/fpsyg.2017.02108. ISSN 1664-1078. PMC 5723417. PMID 29259567.{{cite journal}}: CS1 maint: unflagged free DOI (link)
  37. ^ "Learning to Speak Again After Laryngeal Surgery - Health Encyclopedia - University of Rochester Medical Center". www.urmc.rochester.edu. Retrieved 2020-04-20.
  38. ^ "Families need guidance before buying a communication app for autism". Spectrum | Autism Research News. 2019-04-23. Retrieved 2020-04-14.
  39. ^ "Communication aids for disabled children - Living made easy". www.livingmadeeasy.org.uk. Retrieved 2020-04-14.
  40. ^ "ALS Augmentative Communication Program | Speech-Generating Devices | Boston Children's Hospital". www.childrenshospital.org. Retrieved 2020-04-20.
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