RUNNING HEAD: SPEECH INTELLIGIBILITY IN PEDIATRIC TBI POPULATION 1

Speech Intelligibility in Pediatric Traumatic Brain Injury Populations

Sarah Poplawski

Department of Speech-Language Pathology

Seton Hall University

GMSL 6011

Spring 2017
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Introduction

According to the American Speech and Hearing Association (ASHA), a traumatic brain injury

(TBI) is sudden damage to the brain (2017). A TBI can be an open head injury or closed head

injury. An open head injury refers to an injury of the brain being penetrated by object or force,

whereas a closed head injury is caused by a sudden shock to the head without direct penetration

into the brain (ASHA, 2017). Depending on the cause of trauma to the brain, a TBI may result in

two types of damage. The first type is known as primary brain damage and occurs at the time of

impact, including a fracture to the skull, bleeding and/blood clots (ASHA, 2017). The second

type of brain damage is known as secondary brain damage; this is not present or cause of

concern at the time of impact (ASHA, 2017). Secondary brain damage is noted by seizures,

swelling of the brain, and increased blood pressure within the skull.

Every year more than one million TBIs occur in the United States and are a contributing

factor in almost 30% of all injury related deaths (ASHA, 2017). The leading causes of TBI were

identified to be from falls, motor vehicle-related accidents, collision related events and violent

assaults (ASHA, 2017). According to the CDC children aged 0 to 4 years old, and adolescents

between 15 and 19 years old are more likely to sustain a TBI (CDC, 2016). It appears males are

more likely to sustain a TBI than females in these age groups (CDC, 2016). There has been a

60% increase in fall-related TBI seen in emergency departments by children 14 years and

younger (CDC, 2016).

This research takes a glimpse into the effects of traumatic brain injuries in children, with

a focus on speech intelligibility. Morgan and Vogel define speech intelligibility as, the degree to

which a speaker can be understood by a listener (2008). Common motor speech disorders seen in

this population appear from dysarthria, apraxia, neurogenic stuttering, and aphasia. Dysarthria is
SPEECH INTELLIGIBILITY IN PEDIATRIC TBI POPULATIONS 3

characterized by impaired movement of the speech production muscles including the lips,

tongue, vocal folds and the diaphragm. (ASHA, 2017). Characteristics include errors at

diagnosis, and if there are developmental changes over time. The researcher looked at

evaluations and assessment considerations that are made for this population, which leads into

treatments and treatment considerations as well. There is focus on concomitant issues for this

population, in addition to their speech disorder. There is also a section on controversies

surrounding the pediatric TBI population.

Speech Development in Children

Typical Development

The first three years of life are the most significant period of brain development. During

this absolute time, a child begins acquiring speech and language skills (NIDCD, 2010). These

skills develop best in a world with numerous sensory modalities such as sounds, sights and

auditory input from the speech and language of people in the environment. Before speech and

language skills can even begin to develop, other anatomical parts must within typical

development as well (Bernthal, Bankson and Flipsen, 2017). These include the respiratory

system, the larynx, the velopharynx, and the articulators.

The respiratory system consists of the lungs, ribcage, and diaphragm. According to

Bernthal, Bankson, and Flipsen, this system provides the air supply for generating sounds and

coordinates with the larynx to push air out to produce speech sounds (2017). They work together

to provide the upper airway with two types of air flow. The first is a series of pulses of air

created by the action of the vibrating vocal folds (for voiced sounds) and a continuous air flow

that can be used to generate noise energy for the vocal tracts (voiceless sounds) (Bernthal et al.,

2017). The phonatory system is made up of the pharynx and other supporting muscles including
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the vocal folds. As air moves through the vocal folds, they begin to vibrate which allows for

voiced of voiceless speech sounds (Bernthal et al., 2017). The velum, or soft palate, and

associated structures in the velopharyngeal port create the resonant subsystem. These structures

separate the oral and nasal cavity so air can pass from one cavity or both. The articulatory system

comprised of articulators, such as the mandible, tongue, lips and teeth. These system changes are

capable of assuming shapes necessary for vowel and consonant production (Bernthal et al.,

2017).

Although children vary in their development of speech and language skills, there is a

natural progression for mastering these skills, known as milestones. Milestones allow doctors

and other health professionals determine the child is developing typically.

Infants, from birth to 1 month, begin to show first signs of communication when they

learn reflexive noises will provide them with different results, such as food, comfort, and

companionship (NCIDC, 2010). These reflexive noises include crying, burping, coughing and

sneezing. Newborns begin to recognize sounds in their environment, such as the voice of their

mother or primary caretaker (NCIDC, 2010). At two to three months, the infant begins cooing

and gooing, while making velar sounds, or sounds from the back of the mouth. By the time the

infant is four to six months, they have begun to participate. These includes blowing raspberries

with their lips, squealing or growling, and begin to make bilabial sounds (ASHA, 2017). It is also

at this time; the infant begins to recognize basic sounds of their native language. As they grow,

speech sounds sort out into sounds that make up language. (NIDCD, 2010). Between seven and

ten months of age, the child begins to babble, this includes canonical and variegated babbling.

Variegated babbling includes combining different syllables with intonation and stress (ASHA,

2017). By age two, the child should be 50% intelligible to the listener. Based on the Fisher-
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Logemann Test of Articulation Competence (Smith, Hand, Bernthal, & Bird, 1990)., the

developmentally appropriate age of acquisition for phonemes, are demonstrated in the chart

below beginning at age three:

Age Sounds

3 /m/, /h/, /n/, /p/, /w/

4 /g/, /f/, /g/, /k/

5 /b/, /d/, /j/ /ŋ/

6 /l/, /tʃ/, /ʃ/, /r/, /t/

7 / dʒ/, /s/, /v/, /z/, / ʒ/, / θ/

8 /ð/

Evaluations and Diagnosis

There are four common speech disorders seen from the impact of a TBI: dysarthria,

apraxia, aphasia and neurogenic stuttering. These disorders negatively impact a child's speech

production in different ways, including voice production, fluency, articulation, and resonance.

Before evaluating or treating a child for one of these motor speech disorders, it is pertinent to

know the type and severity of the child's brain injury. Two common brain injury evaluations are

the Glasgow Coma Scale and the Ranchos Los Amigos Scale.

Diagnosed by physicians based on a combo of patient reports, clinical presentation and brain

imaging studies (CT scans and MRIs). A mild brain injury is diagnosed by reports given by the

child's parents or caregivers explaining signs and symptoms.

Any
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deficits that resulted from the TBI will be managed collaboratively by medical professionals.

Depending on the needs of the individual, the team often includes and SLP, audiologist, doctors,

nurses, neuropsychologists, OT and PT, social workers, employers/teachers.

Traumatic Brain Injury

Glasgow coma scale.

The Glasgow Coma Scale (GCS) was developed in 1974 (Teasdale, 2014) to provide a

practical method for assessing impair consciousness. It provided the medical professional with a

straight forward approach and use of simple terms to record and communicate their findings. The

scale has become a significant part of care with patients with head trauma. The GCS reflects the

initial severity of trauma, while other assessments are used to demonstrate the injury's evolution.

The GCS helps to guide prognosis for medical professionals regarding their patient.

The GCS based on a 15 point scale for estimating and categorizing the outcomes of brain injury

by social capability or dependence on others. The test measures the motor response, verbal

response and eye opening response using the values displayed in the table below (Teasdale,

2014):

I. Motor II. Verbal III. Eye

Response Response Opening
6- obeys commands 5- Alert and 4- Spontaneous eye
fully oriented opening
5- Localizes to 4- Confused, yet 3-Eyes open to
noxious stimuli coherent, speech speech
4- Withdraws from 3- Inappropriate 2- Eyes open to
noxious stimuli words and jumbled pain
phrases consisting
of words
3- Abnormal flexion 2- Incomprehensible 1-No eye opening
(decorticate sounds
posturing)
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2- Extensor 1-No sounds

response
(decerebrate
posturing)
1-No response

The score found by adding the values of the columns (Teasdale, 2014). The number helps

medical professionals categorize the four possible levels of survival and severity, while a higher

number indicates a less severe injury (Teasdale, 2014). According to Teasdale, a score of 13-15

indicated a mild brain injury, 9-12 indicates a moderate disability, 3-8 is a severe disability and

any score less than three is considered a vegetative state (2014). Teasdale states a persistent

vegetative could be a sign of no brain function (2014).

Rancho Los Amigos scale.

The Racho Los Amigos Scale, often called the "Racho Scale" is used to scale recovery of

function from a traumatic brain injury. It allows for an easy way to describe the person's level of

activity. According to the Encyclopedia of Clinical Neuropsychology, it consists of eight levels

(2008):

(1) no response or coma

(2) generalized response or vegetative state

(3) localized response

(4) confused or agitated

(5) confused, inappropriate, non-agitated

(6) confused-appropriate
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(7) automatic-appropriate

(8) purposeful-appropriate

Each level of the scale comprised of several different characteristic features, as well as

descriptions (2011).

Overview of Treatment.

The speech-language pathologist will assess not only cognitive, communication skills,

but also memory skills (ASHA, 2017) There is also an assessment of the child’s ability to plan,

organize, and attend to details, for much functional skills such as brushing teeth (ASHA, 2017).

A treatment plan develops after the evaluation of the patient. Depending on severity and stage of

recovery the child is in, the treatment can vary.

Early stages of treatment focus on producing a response to sensory stimulation from the patient

(ASHA, 2017). ASHA also suggests helping families cope with the trauma of the child and how

they can interact with the child. Once the individual begins to become more aware, the speech-

language pathologist will focus treatment goals on maintaining attention, reducing confusion and

providing support to the child on what he/she has experienced (2017). Later aspects of treatment

may include improving memory, and problem solving (ASHA, 2017). This will eventually move

to social skills in small groups, which may include community outings to use functional

language and word retrieval (ASHA, 2017).

Depending on the severity of TBI and speech disorder, the child may begin using an

augmentative/alternative communication device (AAC). If the child needs an AAC device,

treatment will include a functional use of the device, as well as education for parents and

families (ASHA, 2017).

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Speech and Language

The patient must complete a formal evaluation performed by a speech-language

pathologist, to be diagnosed. Evaluations include cognitive, communication and swallowing

abilities using a formal and informal measures (ASHA, 2017). An oral exam is completed to

check strength and coordination of muscles that control speech. Understanding and use of

grammar (syntax) and vocabulary (semantics), as well as reading/writing, are assessed through

informal and formal measures (ASHA, 2017). Findings from the speech and language

evaluations are then analyzed to measure the impact the brain injury has on speech and language

skills.

Speech Disorder Characteristics

The brain of a child may take a sudden halt in development when impacted by either an

open or closed TBI (ASHA, 2017). While a pediatric patient may still have the skills necessary

to learn at the time of his/injury, the full impact may not be evident right away. One of the four

subsystems, respiratory, phonatory, resonators and articulatory could affect which may impact

the child's intelligibility.

With any subsystem one of these subsystems not properly working the child's speech will be

affected negatively. When these subsystems are disrupted there may be issues involving, voice,

fluency, articulation and resonance. Four common disorders affect a child's intelligibility after a

TBI. Dysarthria is a motor speech disorder which results from impairment in the movement of

the muscles used for speech production (ASHA, 2017). These include muscles of the lips,

tongue, vocal folds and diaphragm (ASHA, 2017). Acquired apraxia is often coincided with

aphasia and described as distorted, repeated or left out speech sounds or words (ASHA, 2017).
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Neurogenic stuttering is an abnormal dysfluency that derives from damage to the central nervous

system (ASHA, 2017).

Dysarthria

Dysarthria is the most shared and chronic motor speech disorder resulting from traumatic brain

injury in the pediatric population (Morgan, Vodel, 2008). It is caused by a lesion in the brain and

damage to the nervous system. The damage results in impaired movement of the muscles used

for speech production, including the lips, tongue, vocal folds and diaphragm (ASHA, 2017).

Characteristics of speech quality include “slowed” or “choppy” “mumbled” resulting in

difficulties to understand (Morgan, Vogel, 2008). The child may also present with slow rates of

speech, or rapid rates of speech with a “mumbling quality” limited lip, tongue, and jaw

movement due to weakness in articulators. Voice may be affected by atypical pitch and rhythm,

poor in voice quality, or speech that sounds "nasal" or "stuffy" (ASHA, 2017).

Children with dysarthria may exhibit vowel distortion due to impairment of muscles in the

articulatory system. This is caused by decreased range of motion, strength, and coordination of

muscles (Morgan, Vogel, 2008). Researchers took a sample of children and adolescents post-TBI

and measured consonant accuracy (Campbell, Dollaghan, Janosky, Rusiewicz, Small, Dick, &

Adelson 2013). The Percentage of Consonants Correct-Revised (PCC-R) is an articulation

assessment that sampled children from 18 months of age through adolescence. It reflected the

number of consonants produced correctly, meaning they cannot be omitted or substituted, about

a total number of consonants the child produced in a conversational speech sample (Campbell et

al., 2013). The study found that normal-range PCC-R scores were higher in children injured after

60 months of age than children injured at a younger age (Campbell et al., 2013). This may be due
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to skills developing at the time of injury, if the range of motion and coordination of muscles are

not developed at the date of damage, this skills may not develop post injury.

Evaluation of Dysarthria.

To diagnose a child with dysarthria, a speech-language pathologist will look at the movement of

lips, tongue, and face as well as breath support for speech and voice quality through an oral

mechanism exam (ASHA, 2017). The evaluation will also include an examination of speech

production in a variety of context. Some formal assessments included the Frenchay Dysarthria

Assessment and Dysarthria Examination Battery (ASHA, 2017). These evaluations allow the

speech-language pathologist to see how each system to working to produce speech.

Treatment of Dysarthria.

There are two common types of intervention for communication abilities in pediatrics

with traumatic brain injury. They are perceptually-based therapy and instrumentally-based

biofeedback (Morgan, Vogel, 2008)

Perceptually-based therapy is an intervention using traditional drill exercise without

instrumentation in the absence of feedback other than auditory feedback and is used in the

absence of instrumentation (Morgan, Vogel, 2008). These exercises include movement of lips

and tongue to increase the rate, strength, range and co-ordination of muscles used to support

articulation; drill breathing exercises to increase respiratory/breath support for speech and

voicing drills to enhance the loudness of phonation (Morgan & Vogel, 2008). ASHA states that

children with dysarthria must be treated to work on slowing rate of speech, improving breath

support, so the child can speak louder, strengthen muscles, increase tongue, and lip movement,

improving speech sound production so that speech is more clear (2017).

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Instrumentally-based biofeedback approaches include interventions that utilize

instruments to provide visual or auditory biofeedback to the child (Mogan & Vogel, 2008).

ASHA also suggests determining if a child can generate adequate respiratory support for speech

have a child blow bubbles in a cup of water through a straw (ASHA, 2017).

Teaching compensatory strategies using visual cues such as pacing boards, volume thermometer,

visuals that will remind the child when to take a breath. Creating a signal for when the child

could not be understood and need him/her to repeat, videotape the child talking and let the child

critique his/her speech to improve self-monitoring; children with severe dysarthria may benefit

from AAC devices.

Acquired Apraxia of Speech

When a child develops apraxia due to damage to the brain, it is called acquired apraxia (Shelat,

2016).

Signs and symptoms of acquired apraxia include, distorted, repeated or left out speech

sounds or words (ASHA, 2017). The child will have difficulty putting words together in the

correct order or struggling to correctly produce a word. There may appear to be difficulty using

longer words, either all the time or sometimes (Shelat, 2016). Other types are buccofacial or

orofacial apraxia, which according to Shelat, is described as an inability to carry out movements

of the face on demand (2016). Movements of the face that are unable to be performed include

due to motor impairment of articulators include licking the lips, sticking out tongue or whistling

(Shelat, 2016). Due to the damage, apraxia may affect several of the body’s subsystems

including, phonatory, and articulatory.

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Evaluations of Acquired Apraxia.

Evaluations to assess acquired apraxia in pediatrics with TBI include standardized

language and intellectual tests (Shelat, 2016). Assessment is completed using both standard and

nonstand measures (ASHA, 2017). According to ASHA, a comprehensive evaluation for case

history, oral mechanism examination, hearing screening, speech sound assessment at the single

word level and spoken language evaluation and literacy assessment (2017). A comprehensive

oral mechanism/motor control speech examination is critical for differentiating apraxia from

dysarthria (ASHA, 2017). We want to be able to know if speech sound disorders are from muscle

weakness or lack of coordination with the speech subsystem for production.

Treatments of Acquired Aphasia.

Research has shown that treatment of acquired apraxia of speech in the child is most

effective when it incorporates the principles of motor learning (Knock, Ballard, Robin &

Schmidt, 2000). The child with apraxia need a significant amount of practice with many

repetitions for each target, however, to be sure there is no fatigue therapy should be short,

including breaks and regular sessions (Knock et al., 2000). Once the child begins to work

towards a new target; the best practice use blocked practice (Knock et al.,2010). A blocked

practice is when a child repeats the same word or utterance many times in a row. After many

repetitions, the child can begin a transition to random practice (Knock et al., 2010). Random

practice refers to a child practicing different targets in a row in a random order.

The amount of feedback is necessary for the child. It is recommended to provide frequent

feedback (after each trial) and transition to providing feedback less frequently once the child

begins to self-monitor (ASHA, 2017). It is also imperative to time feedback appropriately. When
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the child started to learn new target, start by giving immediately and then transition to delaying

feedback a few seconds, so the child has time to process and judge for him/herself (ASHA).

Acquired Stuttering

A less common speech disorder children may face after a TBI is neurogenic or acquired

stuttering (Lundgren, Estabrooks & Klein, 2010). Neurogenic stuttering is acquired secondary to

a TBI due to lesion or damage to the brain and central nervous system (Lundgren et al., 2010).

There has been a lack of research regarding this phenomenon due to the challenges

distinguishing it from apraxia, dysarthria, and aphasia. According to Lungden, Estabrooks and

Klein, there are six characteristics of neurogenic stuttering (2010). These include: dysfluencies

on grammatical words at a similar rate of occurrence; repetitions, prolongations, and blocks that

occur in all positions of words; consistency in stuttering behavior across speech tasks; the child

does not appear anxious over the stuttering behavior; secondary including facial grimacing, fist

clenching, and eye blinking are rarely present; adaptation effect is not observed (Lundgren et al.,

2010). Stuttering-like dysfluencies are sometimes a component of motor speech disorders, which

often make it hard to diagnose acquired stuttering. For example, apraxia of speech is often

associated with repetitions of phonemes, just as stuttering is (Lungden et al., 2010). There are

often acquired aphasia secondary to TBI which may cause disfluency due to word retrieval errors

that may portray themselves as stuttering.

Evaluations of Neurogenic Stuttering.

To evaluate a child for neurogenic stuttering, it is pertinent that the speech-language pathologist

can separate these characteristics from other disorders that have similarities. One study looked at

a group male pediatric TBI patients for speech fluency to discriminate it from other speech

deficiencies (Penttila, Korpijaakko, 2015). Eight guiding principles need to be analyzed during
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evaluation including the total number of syllable does not include repetitions due to word search;

total number of syllables does not include interjections, discourse particles or interrupted words;

stuttering types are repetitions, blocks, and prolongations; durations of stutter is measured as a

sequence consisting of several features of stuttering and ending when the target word is uttered;

discourse particles may be stuttered by do not transform information; multiple dysfluency types

on a single words; and in the repetition task, count only syllables given in the sentence (Penttila,

Korpijaakko, 2015). This task needs to be assessed on different cognitive levels including

sentence repetitions, spontaneous speech, and narrative discourse. The speech samples are

recorded and orthographically transcribed for accurate analysis (Penttila, Korpijaakko, 2015).

Neurogenic Stuttering Treatment.

A speech-language pathology will work with the child to control the acquired stutter. Treatment

will include ways to minimize the stutter when they speak. The speech-language pathologist will

give the child skills to speak slowly, regulate breathing or gradually progress from single-

syllable responses to more complex sentences (NIDCD, 2010).

Concomitant issues

Speech motor disorders are not the only disorders that affect children after a traumatic brain

injury. This population may experience physical problems, sensory deficits, behavioral deficits,

cognitive deficits and swallowing disorders (ASHA, 2017). These deficits could affect the child's

ability to function dependently, social skills and returning to school.

Physical Deficits.

Some physical deficits’ the pediatric TBI population may experience may be short term

or long term depending on severity. Physical deficits may include loss of consciousness,
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headaches, dizziness, nausea/vomiting, reduced muscle strength or paralysis (ASHA, 2017). This

population may also experience impairment in movements or lack of coordination in other parts

of the body, not including oral motor muscles (ASHA, 2017)

Behavioral Deficits.

A study looked at disruptive behaviors and disruptive symptoms in a pediatric population

after severe traumatic brain injury (Gerring, Grados, Slomine, Christensen, Salario, Cole & Vasa,

2009). It was found that children had a higher risk of symptoms associated with oppositional

defiant disorder (ODD) and conduct disorder (Gerring et al., 2009). These symptoms including

changes in experiencing and powerful emotions, agitation, combativeness, anxiety and stress,

and a reduced frustration tolerance. The researchers also looked into this population pre-injury

and found that while some displayed these behaviors before the injury, some participants only

displayed these after the injury (Gerring et al., 2009). This may be due to lack of socialization,

and other physical difficulties the child is experiencing post-injury.

Language Deficits.

Pediatric traumatic brain injuries can result not only in motor speech disorders but also other

communication and language deficits. This population may suffer from language processing

difficulties which can negatively impact their performance in school (Catroppa & Anderson,

2003). Catroppa and Anderson studied the correlation between language skills and length of time

post-TBI (2003). After 24 months of recovery, participants still displayed significant language

deficits (Catroppa & Anderson, 2003).

Due to cognitive deficits, post-TBI, the child may exhibit a lack of appropriate pragmatic

abilities (Bosco, Parola, Sacco, Zettin & Angeleri, 2017). Depending on the site of lesion and
SPEECH INTELLIGIBILITY IN PEDIATRIC TBI POPULATIONS 17

severity of the injury, the child may experience executive function and theory of mind may be

impaired. This impairment could display deficits in social communication such as turn-taking,

initiating conversation and maintain the topic of conversation (Bosco et al., 2017).

Swallowing Deficits.

Dysphagia, a swallowing disorder, may result from TBI due to a weakness of muscles in

mouth and throat (ASHA, 2017). Dysphagia can impact feeding and swallow in any phases of

the feeding process and includes atypical eating and drinking behaviors (ASHA, 2017).

Dysphagia is not limited to one phase of the swallow, which includes the oral preparation stage,

oral transit phase, pharyngeal phase and esophageal phase (ASHA, 2017). Signs and symptoms

may include coughing or choking, breathing difficulties while eating, gagging, noisy or wet

vocal quality while after feeding and prolonged feeding times (ASHA, 2017).

A study from the University of Queensland in Australia looked at the incidence of

dysphagia in the pediatric TBI population (Morgan, Ward, Murdoch, Brownwyn & Murison,

2003). Results found that dysphagia was prevalent in 68% of the severe TBI population, 15% of

the moderate TBI population and only 1% of mild populations (Morgan et al., 2003).

Controversies

Traumatic brain injury is often described as the leading cause of disability in children,

however there proves to lack of data to support this claim. Currently, there are no population-

based studies of the outcomes of TBI among children to provide national estimates of TBI-

related speech intelligibility disorders (CDC, 2015). Many researchers found that there was a

lack of research on the pediatric brain injury population. Some possible reasons include a lack of

understanding of the characteristics of a natural history of dysarthria association with this

SPEECH INTELLIGIBILITY IN PEDIATRIC TBI POPULATIONS 18

population. The lack of diagnostic classification system for children precluding the development

of well-targeted intervention programs (Morgan and Vogel, 2008).

Researchers have also found that there is a belief stating the “younger” a child is the more

elasticity not better regarding brain injury. The younger the child, the less likely they may be to

develop skills (Schnadower, Vazquez, Lee, Dayan, & Roskind, 2007).

Discussion

Sample Size

The research used for this review all used relatively small samples of populations. Research

investigating consonant accuracy in pediatrics only used a sample of 56 children (Campbell et

al., 2013). Although brain injuries are common, the general rules had only a small number left

for the study. A look into acquired stuttering had a sample size of 15, and all were male (Penttila,

et al., 2014). Research into acquired apraxia of speech only used a sample size of two, and both

of these participants were males (Knock et al., 2000).

Sample sizes were not representative of the typical population. They were small and relied on

mostly male participants.

Research Design

Research into speech intelligibility disorders used in this review all used longitudinal studies.

The populations were looked at anywhere from days after the brain injury, up until two years

post injury. This allowed researchers to see how children recovered from the injury. While some

of the children in the sample gained many skills back, there were some that were unable to gain
SPEECH INTELLIGIBILITY IN PEDIATRIC TBI POPULATIONS 19

any back. Part of this was due to severity of TBI and other concomitant issues that preceded over

speech disorders. Part of this was due to nature of rehabilitative care post injury.

Each study checked for reliability and validity. Assessments were used that were standardized

and verified by research assistants randomly to transcribe speech samples taken by researchers.

Every study was peer reviewed and published in reputable medical journals.

Future Research

Future research needed for the majority of studies used for this review. This was due to inclusive

and exclusive measures that created for small population sizes, and medically sensitive needs

post injury.

According to Dr. Rachel Berger, a member of the Child Protection Team at the Children’s

Hospital of Pittsburgh, research is lacking for the pediatric population because many

pediatricians are not working in the emergency room (2016). These pediatricians are working on

a pediatric floor, and doctors are typically seeing adults are now treating these patients (Berger,

2016). Problems begin to emerge because the correct medical professionals are not seeing these

patients as they come in and are unaware of the developmental issues a child might face, even

from a mild concussion based on the age of development.

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ASHA. (2016). Traumatic Brain Injury (TBI). Retrieved February, 2017, from

http://www.asha.org/public/speech/disorders/TBI/

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Bernthal, J. E., Bankson, N. W., & Flipsen, P. (2017). Articulation and phonological disorders:

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Bosco, F. M., Parola, A., Sacco, K., Zettin, M., & Angeleri, R. (2017). Communicative-

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Adelson, P. D. (2013). Consonant Accuracy After Severe Pediatric Traumatic Brain

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Gerring, J. P., Grados, M. A., Slomine, B., Christensen, J. R., Salorio, C. F., Cole, W. R., &

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